Primary melanomas of the uterine cervix are rare tumors with no more than 60 cases reported in the world literature. Poor prognosis is considered for the neoplasia itself as well as for diagnostic tardiness. There is no standard treatment; however, radical surgery is the treatment cornerstone. Our aim was to present the case of a 34-year-old woman with a primary malignant melanoma in the uterine cervix with affectation of the posterior face of the vagina without metastasis. Total infraelevator pelvic exenteration and adjuvant radiotherapy was performed. The patient was under surveillance for 8 years of followup without evidence of local or distant disease. The majority of case reports found suggests radical hysterectomy as the treatment indicated for these patients. Notwithstanding this, survival is very short when patients are treated in this manner. Based on our results and on those reported in the literature, we propose initial treatment with total pelvic exenteration as optimal management for this neoplasia in its initial form

Almogabar-Villagrán, Erika

Calderón-Salazar, Luz

Cantú de Leon, David

Cetina, Lucely

Perez Montiel, Delia

Villavicencio, Verónica

English

PubMed

Crossref

International Scholarly Research Network
ISRN Obstetrics and Gynecology
Volume 2011, Article ID 683020, 4 pages
doi:10.5402/2011/683020
Case Report
PrimaryMalignant Melanoma of the Uterine Cervix Treated with
Ultraradical Surgery: A Case Report
Luz Caldero´n-Salazar,1 David Cantu´ de Leon,1 Delia Perez Montiel,2
Erika Almogabar-Villagra´n,1 Vero´nica Villavicencio,3 and Lucely Cetina4
1Department of Gynecologic Oncology, Instituto Nacional de Cancerologia, 14080 Me`xico, Mexico
2Department of Pathology, Instituto Nacional de Cancerologia, 14080 Me`xico, Mexico
3Department of Surgery, Instituto Nacional de Cancerologia, 14080 Me`xico, Mexico
4Department of Medical Oncology, Instituto Nacional de Cancerologia, 14080 Me`xico, Mexico
Correspondence should be addressed to David Cantu´ de Leon, dcantu3@yahoo.com
Received 22 August 2010; Accepted 8 September 2010
Academic Editors: R. M. Austin, R.-J. Chen, E. Petru and L. B. Twiggs
Copyright © 2011 Luz Caldero´n-Salazar et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Primary melanomas of the uterine cervix are rare tumors with no more than 60 cases reported in the world literature. Poor
prognosis is considered for the neoplasia itself as well as for diagnostic tardiness. There is no standard treatment; however, radical
surgery is the treatment cornerstone. Our aim was to present the case of a 34-year-old woman with a primary malignant melanoma
in the uterine cervix with aﬀectation of the posterior face of the vagina without metastasis. Total infraelevator pelvic exenteration
and adjuvant radiotherapy was performed. The patient was under surveillance for 8 years of followup without evidence of local
or distant disease. The majority of case reports found suggests radical hysterectomy as the treatment indicated for these patients.
Notwithstanding this, survival is very short when patients are treated in this manner. Based on our results and on those reported
in the literature, we propose initial treatment with total pelvic exenteration as optimal management for this neoplasia in its initial
form.
1. Introduction
Primary malignant melanoma of the cervix constitutes a
rare disease [1–4], representing less than 2% of cases of
malignant melanoma that aﬀects the female genital tract
[1]. It was not until 1960, after the description by Cid
[5] of melanocytic cells in the cervix, when the concept
was accepted of primary melanoma in uterine cervix. It is
considered as a very aggressive neoplasia [6], whose diagnosis
is untimely due to the unusualness of the disease and the
scarce suspicion of the clinician.
At present, there is no consensus on the therapeutic
approach to follow [1, 2, 7]; in the reports found, initial treat-
ment is referred of radical hysterectomy accompanied or not
by radical pelvic lymphadectomy or superior vaginectomy
[1, 2, 6–11].
Although there are no significant statistics, prognosis in
general is poor [2, 9, 11] and unpredictable [1] and is even
worse when early visceral metastases are discovered [11].
In the current literature, there are no more than 60 cases
reported of this entity.
Our purpose is to report the case of a patient with this
neoplasia who was treated with ultraradical surgery followed
by radiotherapy and who has had long-term followup.
2. Case Report
A female patient 34 years of age, Mexican mestizo, nubile.
History of 2 months of abnormal genital bleeding, for which
she was evaluated by abdominal Ultrasound (US) with a
report of uterine myomatosis. Carrying out a gynecological
examination is decided upon, in which a blackish lesion is
observed in the area of the uterine cervix. Thus, a biopsy of
the cervix was taken, which revealed melanoma. The patient
was therefore referred to the National Cancerology Institute
(INCan) in Mexico City in January 2001.
2 ISRN Obstetrics and Gynecology
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Figure 1: Contrast enhanced CT scan of the pelvis showing a solid cervical mass without evidence of direct involvement of bladder or
rectum.
On initial physical exploration at this Institute, cervix-
dependent tumor was noted that extended to the right pelvic
wall, of petraeus consistency, and another at the level of
the anterior wall of the vagina. A new biopsy was taken,
reportingmalignantmelanoma. Chest X-ray, cystoscopy, and
colonoscopy were performed, and reported as normal, in
addition to complete revision of skin and eyes, discarding
other sites of melanocytic lesions. Additionally, a Computed
tomography (CT) was requested, which reported tumor in
the pelvic floor toward the right annex of approximately
8× 6 cm, which displaced the bladder and ureters (Figure 1).
Due to the extension of the lesion, the patient was considered
to be a candidate for exploratory laparotomy, and total pelvic
exenteration was planned, which was performed in March
2001. Reconstruction of the digestive and urinary tracts
was carried out with a terminal colostomy and Bricker ileal
conduit operation, respectively. The final histopathological
report of the surgical specimen obtained demonstrated
malignant melanoma of the cervix of 7.5 × 5 cm, surgical
margins were reported as negative. Intrahospital evolution
was satisfactory, and the patient was discharged on day
10. Adjuvant radiotherapy was administered, 21Gy in three
sessions, concluding in June 2001. The patient has been
under routine surveillance for 8 years, and has only referred
four occasional urinary tract infections, which have been
resolved medically. To the moment of this report, there has
been no evidence of local or distant recurring disease.
3. Pathology
For histopathological studies, the product of the total pelvic
exenteration was received, in which a neoplastic lesion of
the cervix measured 7.5 × 5.5 cm with involvement of the
upper third of the vagina into anterior vaginal septum.
The neoplasia was polypoid and light brown in color
with necrosis. Microscopically, the neoplasia was formed
by nodules of broad cytoplasmic cells with poorly defined
borders with pleomorphic nuclei with prominent nucleolae.
Figure 2: Microscopic picture showing a medium power view of
the lesion. (HE 10x) in the box Melan A reaction diﬀuse positive.
These areas displayed transition with areas with fascicules of
elongated cells of moderate cytoplasm and similar elongated
nuclei to those described previously (Figure 2).
Immunohistochemical stains were positive for S-100 pro-
tein, Melan A, and HMB 45 in neoplastic cells. CKAE1/AE3
and CEA were negative. No binding activity was found.
A total of 15 pelvic lymph nodes were removed with the
specimen, one of them was positive for disease on H&E, all
the surgical margins were negative.
4. Discussion
Malignant melanomas are generally found in areas of skin
exposed to the sun, but can also be present in nonexposed
sites, such as genital tract and esophagus, among others [8].
Cervical melanoma arises from melanocytic cells of the
cervix; in fact, the cervical epithelium is capable of forming
the complete spectrum of melanocytic lesions, from benign
lentigines to blue nevi to melanoma [10].
ISRN Obstetrics and Gynecology 3
The usual form of presentation of primary melanoma of
the cervix on physical examination is a polypoid exophytic
mass, red, brown, grey, black, or blue in color [6], or a col-
orless in the case of amelanotic melanomas, which constitute
up to 55% of cases at this anatomic site [12], presented with
vaginal bleeding [1, 6, 8, 9]. Age range varies from 20 to
78 years [6], being more common between 60 and 70 years
[1]. Due to that the cervix is an unusual site for this type of
neoplasm, the International Federation of Gynecology and
Obstetrics (FIGO) staging system for cervical cancer is used
[11], rather than the Clark and Breslow scales, because the
FIGO staging system correlates better with the prognosis.
Diagnosis of primary melanoma of the cervix entertains
a high probability of being confused with another entity, due
to the rarity of the disease [9]. Diﬀerential diagnosis between
a primary cervical melanoma and a metastatic tumor is
important because the latter can be part of a metastatic
disease spreading to the cervix [1].
Norris and Taylor criteria are used [13] to distinguish
whether it is a primary malignant melanoma of the cervix [6,
8, 12, 13]: (a) presence of melanin in the cervical epithelium;
(b) absence of melanoma in another site of the body; (c)
presence of binding activity in the cervical epithelium near
the lesion; (d) if metastatic disease is found, it should be
according to the cervical carcinoma pattern.
At the present moment there is no standard treatment
for this disease, while there is no doubt that the surgical
approach is the most usual and radical hysterectomy with or
without pelvic lymphadectomy and/or superior vaginectomy
is reported most frequently [1, 2, 7, 8], some authors enter-
tain doubts concerning survival if pelvic lymphadectomy is
performed [2]. Although there is no enough information
about the real role of negative margins in primary melanoma
of the cervix, the primary surgery should have the purpose
of obtaining negative margins [6]; some authors recommend
2-cm margins as minimum [7, 9].
The role of radiotherapy (RT) has not been well estab-
lished, but it has been demonstrated that RT reduces the
tumor size [1, 8, 11]. The use of adjuvant pelvic RT is
considered in the case of not obtaining a satisfactory surgical
resection margins, when the parametrium is involved, or
when lymph nodes are found to be involved [6]. Despite the
low level of radiosensitivity exhibited by melanoma, the use
of external or intracavitary RT is recommended after surgery,
or palliatively when the tumor is inoperable because of its
own conditions or those of the patient [1, 6, 8, 10].
No chemotherapy regimes have been reported that
substantially may reduce the possibility of recurrence. Dacar-
bazin is utilized in advanced disease, and it has been observed
that up to 20% of patients may have response [6, 7].
It has been proposed that the combination of cisplatin,
bleomycin, and vinblastine can provoke a better response
than the use of solely dacarbazine [1], while in other cases,
the greater eﬀectiveness of combining dacarbazine with
vincristine and carmustine has been reported as well as
immunotherapy utilizing local BCG or the transfusion of
activated lymphocytes [10].
Average survival reported in the world literature of these
patients ranges from 6 months to 14 years. The majority of
them report that they succumb to the disease in the first
3 years after diagnosis [8]. Five-year survival after radical
hysterectomy as only treatment is very low: less than 40% in
stage I and 14% in stage II [1, 14].
The limited experience in the management of these cases,
the unpredictable biological behavior of the disease, and the
great variety of treatments employed render the choice of
an optimal therapy for primary malignant melanoma of the
cervix diﬃcult [4, 7].
In our case, due to the magnitude of the tumor, it
was decided to employ total pelvic exenteration, showing
extraordinary results, because the patient continues to be
alive and disease-free at 8 years of surgery, which is in
contrast importantly with that reported in the literature
after treatment with radical hysterectomy. We propose
consideration of this surgical approach and adjuvant RT for
primary melanoma of the cervix as the initial treatment of
choice.
It is necessary to carry out long-term followup and
biological research to obtain a consensus with regard to the
diagnosis, treatment, and prognosis of the disease [11].
5. Conclusion
Primary malignant melanoma of the cervix is a rare disease
with a poor prognosis, especially if it is not detected in a
timely fashion or if it is not treated correctly. To date, no con-
sensus has been established concerning treatment of primary
melanoma of the cervix, but it is recommended that this
be surgical, procuring the establishment of 2-cm margins,
accompanied by radio- or chemotherapy. The majority of
the case reports found suggest radical hysterectomy as the
treatment indicated for these patients; notwithstanding this,
survival is less than three years in general when managed in
this manner.
Total pelvic exenteration for primary malignant
melanoma of the cervix oﬀers a feasible initial treatment
for these unusual cases. It is necessary initiate collaborative
studies and followup of patients to be able to achieve
establishing a therapeutic approach that may oﬀer the best
results to these unfortunate patients.
Conflict of Interests
The authors declare that they have no competing interests.
All authors read and approved the final paper.
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Primary Malignant Melanoma of the Uterine Cervix Treated with Ultraradical Surgery: A Case Report

A rare case of primary malignant melanoma of cervix,”

Management of primary melanoma of the female urogenital tract,”

Melanoid pigmentation of the endocervix: a neurogenic visceral argument,” Annales d’anatomie pathologique,

Melanomas of the vagina,”

Primary malignant amelanoticmelanomaofthefemalegenitaltract:reportoftwo cases and review of literature,”

Primary malignant melanoma of cervix—a case report,”

Primary malignant melanoma of the cervix. Case report,”

Primary malignant melanoma of the uterine cervix: case report and review of the literature,”

Primary malignant melanoma of the uterine cervix: case report with world literature review,”

Primary malignant melanoma of the uterine cervix: report of a case diagnosed by cervical scrape cytology and review of the literature,”

W a s e f ,J .K .R o b e r t s ,a n dG .R .D i x o n ,“ P r i m a r y malignant melanoma of the cervix uteri,”

http://doaj.org/search?source=%7B%22query%22%3A%7B%22bool%22%3A%7B%22must%22%3A%5B%7B%22term%22%3A%7B%22id%22%3A%22a1afdd0ea2194e4593a87858787f8c59%22%7D%7D%5D%7D%7D%7D

Primary Malignant Melanoma of the Uterine Cervix Treated with Ultraradical Surgery: A Case Report

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