Raised vulvar lesions: be aware!

Vulvar melanoma is a rare and deadly cancer in women, and the prognosis is often poor. There are limited studies on the dermoscopic features of vulvar melanoma. Described criteria include the presence of blue, gray, or white colors. Herein we present the clinical and dermoscopic characteristics of a hypopigmented and heavily pigmented nodule in a 92-year-old and an 80-year-old woman. Dermoscopy in the former revealed structureless milky-red to white areas, remnants of brown pigmentation at the base and polymorphic vessels, while the latter displayed structureless blue-gray areas with black dots and peripheral lines at the base. In both cases, histopathology revealed a stage III melanoma. Our two cases along with a review of the literature suggest that the dermoscopic features described for diagnosing cutaneous nodular melanoma, apply also for vulvar melanoma. Clinicians should always raise the suspicion if observing plaques or nodules with a dermoscopic polymorphic vascular pattern and blue-black color on the genitals of postmenopausal women.


Introduction
Vulvar melanoma (VM) is the second most common vulvar malignancy, but represents less than 1% of all melanomas and 1.0% to 2.3% of all melanomas in women [1]. It typically affects postmenopausal women with a peak incidence in the seventh decade of life [1,2]. VM is associated with a poor prognosis. The reported five-year survival rates are less than 60% [3].
It is unclear if the poor prognosis of VM is due to delayed detection or a highly aggressive biological behavior, but early identification and intervention may improve patient outcomes.
Dermoscopy improved the early diagnosis of melanoma, but little is known about the dermoscopy features of melanoma of the vulva [4]. Given the low incidence of VM, most of the information is derived from small retrospective case series and single case reports [1,5].
Vulvar melanoma is a rare and deadly cancer in women, and the prognosis is often poor. There are limited studies on the dermoscopic features of vulvar melanoma. Described criteria include the presence of blue, gray, or white colors. Herein we present the clinical and dermoscopic characteristics of a hypopigmented and heavily pigmented nodule in a 92-year-old and an 80-year-old woman. Dermoscopy in the former revealed structureless milky-red to white areas, remnants of brown pigmentation at the base and polymorphic vessels, while the latter displayed structureless blue-gray areas with black dots and peripheral lines at the base. In both cases, histopathology revealed a stage III melanoma. Our two cases along with a review of the literature suggest that the dermoscopic features described for diagnosing cutaneous nodular melanoma, apply also for vulvar melanoma. Clinicians should always raise the suspicion if observing plaques or nodules with a dermoscopic polymorphic vascular pattern and blue-black color on the genitals of postmenopausal women.

Discussion
Our findings are consistent with the current literature suggesting that VM typically affects woman after the seventh decade of life, is often detected at late stage and has a poor prognosis and outcome (Table 1). Among the clinical features of VM, the data consistently report a nodular polypoid shape and lack of pigmentation in up to 27% of cases [6]. This underlines the need for careful evaluation of both pigmented and non-pigmented vulvar lesions, especially if raised.
Dermoscopy is proven to increase early melanoma detection compared to the naked eye, but its impact on early diagnosis of VM remains to be defined.
In a study by the International Dermoscopy Society, the dermoscopic patterns of a large series of mucosal lesions were analyzed. In that study, the presence of blue, gray, or white colors with or without structureless areas yielded a 100% diagnostic sensitivity for mucosal melanoma, only two cases of VM were included [7]. Among those two, was one amelanotic and revealed polymorphous vessels [8].
Clinically, VM can present as a flat or raised lesion with irregular borders and multiple colors [4,6,7] (Table 2).

Case 2
An 80-year-old Caucasian woman was referred to our skin cancer unit with a rapidly growing nodule on the right side of the labium majus. Clinically an ulcerated, blue-black nodule measuring 3 cm in diameter was seen. Dermoscopy revealed structureless blue-gray areas, black and brown dots, and some streaks at the periphery.
Histopathology revealed a melanoma with a Breslow thickness of 1.2 cm.
At time of diagnosis, inguinal lymph node metastases were present, and she died few months thereafter from metastatic melanoma.

Conclusion
In conclusion, our cases highlight the importance of an inspection of the genital areas especially in postmenopausal woman. The dermoscopic patterns of VM do not differ from melanomas at other body sites. Any pigmented or non-pigmented nodule, dermoscopically exhibiting blue and black or blue-white colors or polymorphic vessels should be carefully evaluated with a very low threshold for biopsy [9].
Based on this data, it appears that the majority of melanomas were at advanced stage at diagnosis.