Vaginal melanoma

　　1. Etiology

　　Vaginal melanoma is believed to originate from melanocytes in the vaginal mucosa, which are derived from neural crest cells during embryogenesis. Melanocytes can be found in the vaginal mucosa of 3% of adult women. During the migration process from the neural crest to the epidermis, melanocytes become lost in the vaginal mucosa, and these ectopic melanocytes become the source of vaginal melanoma development.

　　2. Pathogenesis

　　The growth patterns of vaginal melanoma mainly include three types: superficial spreading type, nodular type, and freckle-like type. According to morphology, melanoma cells can be divided into nevus-like cells, epithelioid cells, spindle cells, or mixed cells. The tumor cells may be diffusely distributed or aggregated into clumps, and some can invade the mucosal epithelium. The morphological features of the tumor cells are diverse, with large nuclei, prominent nucleoli, and common atypical nuclear division figures and tumor giant cells. Brownish-black pigment granules can be seen in the cytoplasm. For pigment-free tumors, Fontana staining, S-100, and HMB-45 immunohistochemical staining can assist in diagnosis. Occasionally, the交界 activity of vaginal malignant melanoma cells can be seen, which suggests primary vaginal mucosal tumor.

　　Common complications of vulvar melanoma: vulvar ulcer with infection. Immunohistochemical staining. The combined immunohistochemical staining of melanoma cell antigens such as Keratin, Vimentin, S-100, and HMB-45 is helpful for the diagnosis and differential diagnosis of melanoma. Tissue culture of pigment-free melanoma can also produce melanin. Histopathological examination. Monoclonal antibody HMB-45 has high sensitivity and specificity for melanoma, and immunohistochemical staining with it can assist in pathological diagnosis. Some normal tissue margins should be included when excising living tissue.

　　1. The location and gross appearance of the tumor:Melanoma can occur at any site in the vagina. Most literature reports that the tumor is often located in the lower third of the vagina (accounting for 58% to 66%), with the anterior wall being more common (accounting for 45%). The tumor diameter ranges from 0.2 to 10 cm, with solitary lesions being more common. The color of the lesions varies from brown to black, and there may also be pigment-free lesions. The morphological changes are diverse, presenting as flat black spots, nodular, polypoid, cauliflower-like, papillary, or ulcerative on the surface.

　　2. Clinical symptoms:The most common symptoms are vaginal bleeding (80%), vaginal discharge (7%), or vaginal mass (13%). A few patients are asymptomatic and vaginal abnormalities are found during physical examination. Some vaginal discharge may appear as black water-like, known as 'black string'. The time from the onset of symptoms to the time of examination and evaluation of treatment ranges from 2 days to 4 months, with an average of 2.4 months. Bloody, foul-smelling purulent discharge may occur with infection, and late symptoms may include lower abdominal坠痛, difficulty in urination and defecation.

　　Vaginal melanoma has typical clinical manifestations. Vaginal lesions can be found during gynecological examination, making clinical diagnosis relatively easy. For suspicious cases, core biopsy or excision of the full-thickness lesion for pathological examination can be performed, with the surgical margin including 1-2 cm of normal vaginal mucosa to prevent tumor spread during biopsy. After rapid frozen section examination of the excised tissue is confirmed, the surgical scope can be expanded according to the situation. Cytological smear examination of the vagina can help in the rapid diagnosis of the disease, showing non-epithelial malignant tumor cells without melanin granules. HMB-45 immunohistochemical staining can assist in diagnosis for those without melanin granules.

　　Prognosis

　　Survival rate and prognostic factors of vaginal melanoma:

　　1. Survival rate:Vaginal melanoma is a highly malignant tumor. Due to the rich lymphatic network of the vagina and the tendency to hematogenous metastasis, early patients often have metastasis. The 5-year survival rate is low, and Table 1 lists the 5-year survival rates reported by some authors regarding vaginal melanoma.

　　2. Tumor recurrence:The prognosis of vaginal melanoma is extremely poor after recurrence and metastasis. Reid reported that the recurrence rate of the disease is 62.3%, 40.7% is local recurrence in the vagina, 19.7% is regional recurrence (pelvic, vulvar, bladder, and urethra), and 39.5% is distant metastasis. The lung is the most common site of metastasis, and most patients with distant metastasis also have recurrent disease in the pelvis.

　　Although the prognosis of patients after recurrence is extremely poor, active treatment can still enable some patients to survive for a long time. Treatment methods can include surgery, radiotherapy, radiotherapy + surgery, and chemotherapy. Chung reported a case of recurrence 28 months after initial treatment, where the patient underwent vaginal surgery, radical vulvectomy, and lymph node dissection in the inguinal and pelvic regions, and was tumor-free for 12.75 years at the time of the literature report. Davis reported a case of vaginal melanoma that recurred after 9 months and 12 months of initial treatment, with large resection performed each time. The patient was tumor-free for 16 years at the time of the literature report. Reid reported 15 cases of vaginal melanoma patients, 5 of whom received radiotherapy, 2 for the treatment of recurrence, 2 recurrent cases received high-dose fractionation therapy, 1 underwent hysterectomy and total vaginal excision after radiotherapy, and the patient was tumor-free for 22 months at the time of the literature report. Another case also achieved 75% local control. Stellato reported a case of vaginal melanoma patient who developed lung metastasis 5 months after radical surgery, where the patient received fotemustine (fotenustine) and DTIC combined chemotherapy for 8 courses, with interferon therapy as an adjuvant.

　　Prognostic factors related to tumor survival include: the size of the tumor, the thickness of the tumor, the mitotic index of the tumor, and the staging of the tumor.

　　3. Analysis of prognostic factors

　　Tumor size:The size of the tumor is related to the survival of the patient. Reid reported that there was a significant difference in the comparison between those with a tumor diameter of 3cm (P=0.024).

　　Tumor marker examination, immunohistochemical examination, histopathological examination, and electron microscopy observation.

　　X-ray, ultrasound, CT, MRI and other examinations are performed to understand the extent of pelvic involvement and whether there is metastasis to common sites such as the lung, liver, and brain.

　　1. The indirect immunofluorescence marking of human melanoma serum on melanoma tissue, when the antiserum dilution is 1:2, the highest positive rate can reach 89%.

　　1. Using Vacca double PAP immunoenzyme marking method to determine, when the antiserum dilution is 1:400, 82.14% shows a positive reaction.

　　2. Melanogen test: After melanogen is excreted by the kidney, it is oxidized to make the urine dark brown, known as black urine. If ferric chloride, potassium dichromate, and sulfuric acid are added to the urine, it can promote its oxidation, and then add sodium nitrate, the urine turns purple; first add acetic acid, then add sodium hydroxide, the urine turns blue.

　　Firstly, dietary therapy for vaginal melanoma

　　1. Sweet and Sour Cucumber

　　Take 300g of fresh and tender cucumber, 50g of sugar, 30g of vinegar, 1 clove of garlic, and a little salt. Wash the cucumber, slice it, salt it, squeeze out the water, mix sugar, vinegar, and monosodium glutamate into sauce, pour it over the cucumber, and then add the mashed garlic and mix well. Suitable for cancer patients with poor appetite.

　　2. Longan Meat Porridge

　　Take 15g of longan meat, 3 to 5 red dates, and 100g of glutinous rice, cook them into porridge and eat as desired. Suitable for cancer patients with insufficient Qi and blood, and those with weak bodies.

　　3. Vinegar Egg

　　Pour 150ml of vinegar into a bowl, add a cleaned egg, soak for 48 hours, stir with a chopstick after the eggshell softens. Each vinegar egg yolk is taken 5 to 7 times. Take one dose in the morning on an empty stomach each day (you can mix it with water when taking it).

　　Use warm water 3 to 5 times. If the eggshell is completely softened, it is best to swallow it all at once when taking the medicine. Rinse the mouth with warm water after taking the medicine to prevent tooth acidification and calcium loss. It is suitable for the recovery period of tumor patients.

　　4. Sanqi Yuanhu Garlic Paste

　　Ingredients: 10 grams of Sanqi powder, 10 grams of Yuanhu powder, 50 grams of garlic.

　　Preparation: Wash and dry the Sanqi and Yuanhu, grind them into fine powder and mix well. Clean the purple garlic, chop it into garlic paste, mix it with the Sanqi and Yuanhu powder, and add an appropriate amount of warm water if necessary, stir into a paste, and it is ready.

　　Effects: Activate blood circulation and Qi, anti-cancer and analgesic.

　　Administration: Twice a day, morning and evening.

　　5. Turmeric and Yujin Honey Drink

　　Ingredients: 60 grams of turmeric, 30 grams of yujin, 30 grams of honey.

　　Preparation: Wash and dry the turmeric and yujin, slice them, put them in a pot with water, soak for a while, boil for 30 minutes, filter off the dregs, and add honey when the juice is warm. Mix well and it is ready.

　　Effects: Promote Qi and blood circulation, anti-cancer and analgesic

　　Administration: Twice a day, morning and evening.

　　Secondly, what is good for the body to eat when suffering from vaginal melanoma

　　1. It is advisable to eat more foods that enhance the immune system: turtle, tortoise, sea turtle, sandworm, crucian carp, shark, water snake, shrimp, white flower snake, crucian carp, mulberry, fig, litchi, walnut, loofah, chive, soy sauce, olive, almond, luffa, etc.

　　For infections and ulcers, it is recommended to eat sheun grass, limpet, needlefish, loach, hilsa, chrysanthemum flower, rapeseed, taro, mung bean, adzuki bean, malan head, etc.

　　After surgery for vaginal melanoma, the body loses energy and blood, so it is advisable to eat more tonifying and nourishing foods such as jujube, longan, mung bean, glutinous rice, litchi, mushroom, carrot, quail egg, lotus root powder, beans, etc.

　　4. It is recommended to eat more foods that have an anti-vulvar tumor effect, such as sesame seeds, almonds, wheat, barley, loofah, black-bone chickens, cuttlefish, green snakes, pork pancreas, chrysanthemum, umeboshi, peaches, lychees, chenopodium, chicken blood, eels, abalone, crabs, horseshoe crabs, sardines, clams, and tortoises.

　　Third, Foods to Avoid for Vaginal Melanoma

　　1. Avoid foods that are considered to cause heat, such as mutton, shrimp, crabs, eels, salted fish, and blackfish.

　　2. Avoid spicy foods and drinks such as chili, Sichuan peppercorns, green onions, garlic, and white wine.

　　3. Avoid caffeine and other stimulating beverages.

　　4. Avoid eating foods containing carcinogens, such as vegetables containing strong carcinogens like nitrites, moldy foods, preserved, smoked, grilled, and fried foods.

　　First, Surgical Treatment

　　Vaginal melanoma was previously considered a tumor resistant to radiotherapy and chemotherapy, and therefore surgery has become the main treatment option for patients who can be operated on. It is generally believed that the treatment of vaginal lower segment lesions is similar to that of vulvar cancer, while cancer in the upper segment of the vagina requires more extensive resection.

　　Second, Chemotherapy (Radiotherapy)

　　1. Chemotherapy

　　Malignant melanoma was previously considered a radioresistant tumor, and conventional fractionated radiotherapy was ineffective.

　　2. Chemotherapy and Immunotherapy

　　The chemotherapy effect of vaginal melanoma is poor, and commonly used drugs include DTIC (triazine imidazole), vincristine (VCR), lomustine (CCNU, ethyl cyclohexyl nitrosourea), cisplatin (DDP), and others. The route of administration can be intravenous administration or high selective pelvic artery catheterization.

　　Three, Drug Treatment

　　BDPT regimen:

　　1. Carmustine (BCNU):150mg/㎡ intravenous infusion, on the first day, once every 6-8 weeks.

　　2. Dacarbazine (DTIC):200-220mg/㎡, intravenous infusion on days 1-3, once every 3-4 weeks.

　　3. Cisplatin (DDP):25mg/㎡, intravenous infusion on days 1-3, once every 3-4 weeks.

　　4. Tamoxifen:10mg, twice daily, taken orally.