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Vulvar Neoplasms (Part II)

Open AccessPublished:February 22, 2022DOI:https://doi.org/10.1016/j.urology.2022.02.007

      Abstract

      Vulvar disease is common, and urologists are often the first providers to see patients with a vulvar skin condition. Primary vulvar dermatoses can be localized to the anogenital area or a manifestation of more diffuse cutaneous disease. Additionally, secondary dermatoses can develop from exogenous agents and inflammatory vaginitis. Vulvar conditions are challenging to diagnose due to location and different types of skin and mucosal epithelium involved. Herein, we provide an overview of noninfectious inflammatory vulvar dermatoses (Part I) and benign and malignant vulvar neoplasms (Part II), grouped by morphologic findings. We include diagnostic evaluation, workup, and management of these conditions.

      Skin-colored, Red, and White Neoplasms

      Syringomas

      Syringomas are benign adnexal neoplasms derived from eccrine sweat ducts.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      They present as small flat-topped skin-colored to yellowish papules on the vulva. They can be diagnosed clinically and biopsy is confirmatory, revealing characteristic histologic features of sweat duct-like glandular structures.
      • Huang YH
      • Chuang YH
      • Kuo T-t
      • Yang LC
      • Hong HS.
      Vulvar syringoma: a clinicopathologic and immunohistologic study of 18 patients and results of treatment.
      Generally, syringomas are asymptomatic and no treatment is required. If pruritus is associated, laser ablation or excision can be considered.
      • Huang YH
      • Chuang YH
      • Kuo T-t
      • Yang LC
      • Hong HS.
      Vulvar syringoma: a clinicopathologic and immunohistologic study of 18 patients and results of treatment.

      Epidermoid Cysts (EC)

      ECs are common on the vulva, particularly on the hair-bearing keratinized epithelium.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      Rarely ECs can involve the clitoris or labia minora.
      • Sally R
      • Shaw KS
      • Pomeranz MK.
      Benign “lumps and bumps” of the vulva: a review.
      They may occur spontaneously or due to prior surgical procedures or trauma.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      ECs present as firm skin-colored to yellow or white smooth papules (Fig. 1A,B). Rarely they can undergo calcification.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      ECs are asymptomatic unless they become inflamed and leak or rupture, where they can mimic an abscess,
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      Inflamed cysts can be treated with incision and drainage or intralesional triamcinolone injections.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      These measures are not curative, however. Surgical excision can be performed if the cyst is symptomatic or continues to become inflamed.
      • Sally R
      • Shaw KS
      • Pomeranz MK.
      Benign “lumps and bumps” of the vulva: a review.
      Caution should be taken not to surgically excise actively inflamed cysts.
      Figure 1
      Figure 1(A) Multiple epidermoid cysts. (B) Epidermoid cyst. (C) Intradermal nevus. (D) Vulvar vestibular papillomatosis. (E) Genital wart. (F). Differentiated VIN. (G) Squamous cell carcinoma in situ, HPV-related. (Color version available online.)

      Milia

      Milia are small epidermal cysts, measuring 1-2 mm in diameter.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      They are diagnosed clinically and nicking the area with the tip of an 11 blade or a needle will allow for expression of keratin contents. However, they are benign and do not require treatment.

      Acrochordons

      Acrochordons (skin tags) are skin-colored soft, often pedunculated, papules,
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      They tend to involve intertriginous areas and can be seen on the labia minora. Diagnosis is clinical and treatment is not recommended unless they become inflamed or symptomatic.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      Usually, small acrochordons can be treated with cryotherapy or snipping therapy to cut the stalk at the base, but it is important to counsel patients that they tend to recur.

      Intradermal Nevi

      Intradermal nevi are benign melanocytic neoplasms that can appear skin-colored or pink as the pigment is often deeper in the dermis.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      They rarely occur on the vulva.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      They are soft, well circumscribed papules that can be pedunculated and mistaken for acrochordons (Fig. 1C). Treatment is not necessary.

      Vulvar Vestibular Papillomatosis (VVP)

      VVP is a normal anatomical variant, and is the vulvar analog of pearly penile papules.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      These are small slightly elongated to filiform soft papules that can be present as a few lesions or scattered symmetrically over the vestibule from where they arise (Fig. 1D).
      • Sally R
      • Shaw KS
      • Pomeranz MK.
      Benign “lumps and bumps” of the vulva: a review.
      VVP is more pink and less yellow compared to ectopic sebaceous glands (Fordyce spots). It is important to distinguish these from human papillomavirus (HPV) condylomas. As VVP is a normal variant, treatment is not required.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.

      Fordyce Spots

      Ectopic sebaceous glands (Fordyce spots) can occur on the vulva as they can occur on the penis and mucosal lips.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      They are common on the labia minora and appear as small yellowish dome shaped papules and can be viewed more clearly when the mucosa is pulled taut. Patients can be reassured these are benign.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.

      Hidradenoma Papilliferum (HP)

      HP is a benign adnexal neoplasm that typically occurs on the labia minora and labia majora as an asymptomatic smooth well-circumscribed skin-colored to erythematous or blue-hued papule or nodule.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      ,
      • Sally R
      • Shaw KS
      • Pomeranz MK.
      Benign “lumps and bumps” of the vulva: a review.
      These lesions can ulcerate. HP is benign but there have been cases of malignant transformation to ductal carcinoma in situ, thus biopsy is recommended.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      ,
      • Hernández-Angeles C
      • Nadal A
      • Castelo-Branco C.
      Hidradenoma papilliferum of the vulva in a postpartum woman: a case report.
      Local excision is curative.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.

      Hidradenitis Suppurativa (HS)

      HS is a chronic inflammatory condition involving the hair follicles, affecting predominantly intertriginous areas. The vulva and inguinal folds are common sites for disease activity.
      • Saunte DML
      • Jemec GBE.
      Hidradenitis suppurativa: advances in diagnosis and treatment.
      There is a wide spectrum of disease presentation, ranging from acne-like erythematous papules and open comedones (blackheads), to nodules and cysts with chronic sinus tracts, ulceration, and swelling with malodorous drainage.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      ,
      • Saunte DML
      • Jemec GBE.
      Hidradenitis suppurativa: advances in diagnosis and treatment.
      When mild, HS can be misdiagnosed as epidermoid cysts, acne, or folliculitis. Diagnosis is usually clinical and treatment depends on severity of disease and includes: topical antibiotics, intralesional steroid injections, surgical excision, laser treatments, oral antibiotics, immunosuppressants, hormonal therapies, metformin, tumor necrosis factor agents and other biologic therapies.
      • Goldburg SR
      • Strober BE
      • Payette MJ.
      Hidradenitis suppurativa: current and emerging treatments.
      Weight loss and smoking cessation are also important for these patients.
      • Saunte DML
      • Jemec GBE.
      Hidradenitis suppurativa: advances in diagnosis and treatment.

      Genital Warts / Condyloma Acuminata

      While infectious diseases are outside the scope of this review, genital warts are important to discuss here as they are common on the vulva and can mimic other neoplastic entities. Genital warts are neoplasms resulting from HPV infection
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      . Genital warts are most common in patients between 16 and 25 years of age but can be seen in any age.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      There are various morphologic variants including flat warts, filiform warts, verrucous appearing warts, and more globular or pigmented warts (Fig 1E).
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      Genital warts are usually asymptomatic but can be associated with irritation and pruritus. Diagnosis is clinical but biopsy can be useful for larger lesions or those recalcitrant to therapy, to exclude SCC. Patients with vulvar warts should undergo evaluation for cervical involvement. Patients should receive HPV vaccination if they have not previously been vaccinated. Treatment modalities include cryotherapy, topical imiquimod or 5-fluorouracil, electrosurgery, laser ablation, and podophyllotoxin.
      • Bertolotti A
      • Milpied B
      • Fouéré S
      • Cabié A
      • Dupin N
      • Derancourt C.
      Local management of anogenital warts in immunocompetent adults: Systematic review and pooled analysis of randomized-controlled trial data.

      Vulvar Intraepithelial Neoplasia (VIN)

      VIN terminology has changed over the years, with the most recent terminology from the International Society for the Study of Vulvovaginal Disease (ISSVD) in 2015 dividing VIN into two subtypes, depending on whether VIN is HPV-dependent (usual type) or HPV-independent (differentiated type).
      • Bornstein J
      • Bogliatto F
      • Haefner HK
      • et al.
      The 2015 International Society for the Study of Vulvovaginal Disease (ISSVD) Terminology of Vulvar Squamous Intraepithelial Lesions.
      HPV-dependent VIN (usual type) occurs due to HPV infection and can be divided into: LSIL (low-grade squamous intraepithelial lesion) or HSIL (high-grade squamous intraepithelial lesion).
      • Bornstein J
      • Bogliatto F
      • Haefner HK
      • et al.
      The 2015 International Society for the Study of Vulvovaginal Disease (ISSVD) Terminology of Vulvar Squamous Intraepithelial Lesions.
      These lesions are usually multifocal and present as skin-colored to red to pigmented flat-topped papules.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      These lesions can occur in the vestibule and on the keratinized vulvar skin. Lesions tend to be asymptomatic. Treatment is recommended for all HSIL
      • Haller H.
      Management of vulvar intraepithelial neoplasia.
      and includes: excision, laser therapy, topical imiquimod. Use of 5-fluoruracil and cidofovir cream has also been reported with some success.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      ,
      • Tristram A
      • Fiander A.
      Clinical responses to Cidofovir applied topically to women with high grade vulval intraepithelial neoplasia.
      HPV-independent VIN (differentiated type or dVIN) develops in the setting of a pre-existing inflammatory vulvar dermatosis, most commonly lichen sclerosus (Fig. 1F).
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      These lesions present differently than HPV-dependent VIN. They are normally solitary and tend to be deeper. They can be fixed papules, plaques or nodules that may have erosion or crust.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      These may be symptomatic and can occur on any area of the vulva. dVIN is more likely to progress to squamous cell carcinoma (SCC) than their HPV-counterparts.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      Thus, in patients with lichen sclerosus or lichen planus with lesions that do not respond to treatment, one must maintain a high index of suspicion for progression to dVIN and consider biopsy of the area. Currently, the standard of care for treatment of dVIN is surgical excision due to the strong association with SCC development.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.

      Squamous Cell Carcinoma (SCC)

      The incidence of vulvar cancer is about 2.6 per 100,000 women per year and SCC is the most common type of vulvar cancer, making up greater than 75% of all vulvar cancers.

      National Cancer Institute Surveillance, Epidemiology, and end results program. Accessed 2022 Feb 1. Available from: https://seer.cancer.gov/statfacts/html/vulva.html

      Vulvar SCC can develop through either VIN pathway above.
      • Deppe G
      • Mert I
      • Winer IS.
      Management of squamous cell vulvar cancer: a review.
      HPV-dependent SCC tends to develop more commonly in younger patients while SCC-independent SCC tends to develop in older patients and have a worse prognosis. SCC an occur as an in situ variant (Fig. 1G) or can be invasive. Biopsy is required to make the diagnosis. The American Joint Committee on Cancer (AJCC) TNM staging system or International Federation of Gynecology and Obstetrics (FIGO) system can be used to stage SCC
      • Olawaiye AB
      • Cotler J
      • Cuello MA
      • et al.
      FIGO staging for carcinoma of the vulva: 2021 revision.
      and current treatment guidelines for vulvar SCC are detailed in the National Comprehensive Cancer Network (NCCN) guidelines to include excision, sentinel node biopsy, and node dissection depending on clinical stage and pathologic findings

      Bradley K, Crispens MA, Frederick P. (Squamous cell carcinoma) vulvar cancer. 2020.

      , which is beyond the scope of this article.

      Basal Cell Carcinoma (BCC)

      BCC is the most frequently diagnosed skin cancer on sun-exposed skin and much less commonly found on the genital skin, representing 2%-8% of all vulvar cancers.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      Vulvar BCC tends to present as a pearly pink or skin colored papule, plaque, or nodule. The area can be ulcerated or can be pigmented.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      BCCs only occur on keratinized vulvar skin and not on mucous membranes, with the labia majora being the most common site.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      Diagnosis is confirmed by biopsy and treatment recommendations include wide local excision or MMS.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.

      Extramammary Paget Disease (EMPD)

      While EMPD is a malignant neoplasm of the vulva, this section is discussed in Part I, as this often clinically mimics a dermatitis.

      Acquired Lymphangiectasia (AL)

      AL, previously referred to as lymphangioma circumscriptum, occurs due to the obstruction of lymphatics. This results in vulvar edema or grouped vesicular-appearing papules that are firm to palpation.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      They are often translucent but can be hemorrhagic or erythematous. AL can arise in the setting of disruption of lymphatics by radiation, lymph node dissection, or surgery for pelvic malignancies or from underlying inflammatory disorders such as Crohn's disease.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      ,
      • Stull CM
      • Rakita U
      • Wallis L
      • Krunic A.
      Successful treatment of acquired vulvar lymphangiectasia with 1% polidocanol sclerotherapy.
      Treatment is challenging as AL tends to recur. Surgical excision, laser therapy, sclerosing agents, and topical agents such as imiquimod have all been utilized with varying degrees of success.
      • Stull CM
      • Rakita U
      • Wallis L
      • Krunic A.
      Successful treatment of acquired vulvar lymphangiectasia with 1% polidocanol sclerotherapy.
      ,
      • Marous MR
      • Mercurio MG.
      Lymphangioma circumscriptum as an untoward consequence of hidradenitis suppurativa surgery.
      Lymphedema therapists who have experience in genital lymphedema management can be useful resources for these patients.

      BROWN, BLUE, AND BLACK NEOPLASMS

      Angiokeratomas

      Angiokeratomas are benign vascular papules composed of dilated vessels that can appear dome-shaped or warty.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      They are small, dark blue to red to black, and commonly found on the labia majora (Fig. 2A).
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      Angiokeratomas are asymptomatic but if irritated, can bleed. Treatment is not indicated unless lesions are irritated, and electrocautery is usually the treatment of choice.
      • Sally R
      • Shaw KS
      • Pomeranz MK.
      Benign “lumps and bumps” of the vulva: a review.
      Angiokeratomas are sometimes mistaken for nevi clinically but upon close inspection, they are vascular and tend to be more diffusely distributed, though they can be solitary.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      Figure 2
      Figure 2(A) Angiokeratomas. (B). Seborrheic keratosis. (C) Melanocytic nevus. (D) Melanotic macule. (E) Vulvar melanosis in the setting of lichen sclerosus. (Color version available online.)

      Seborrheic Keratoses (SK)

      SKs are benign neoplasms of keratinocytes. These are not comprised of melanocytes (pigment cells), however they can mimic pigmented neoplasms such as nevi and melanoma due to their appearance.
      • De Giorgi V
      • Massi D
      • Salvini C
      • Mannone F
      • Carli P.
      Pigmented seborrheic keratoses of the vulva clinically mimicking a malignant melanoma: A clinical, dermoscopic-pathologic case study.
      Additionally, because of their often warty appearance, one needs to rule a diagnosis of HPV-related genital warts or VIN. However, SKs tend to be solitary while HPV-related lesions are usually multiple.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      SKs can be tan, brown, or black and tend to be raised and often verrucous in appearance (Fig. 2B). Dermoscopy is a useful tool for determining whether a brown or black lesion is and SK or a melanocytic neoplasm and if in doubt, biopsy can confirm the diagnosis. No treatment is required for SKs.

      Pigmented Genital Warts and VIN

      HPV-related genital warts and VIN can also be brown or black. These conditions are discussed under “skin-colored neoplasms”.

      Kaposi Sarcoma (KS)

      KS is a vascular malignancy with several types, all of which are related to human herpes virus type 8 infection.
      • Errichetti E
      • Stinco G
      • Pegolo E
      • Patrone P.
      Primary classic kaposi's sarcoma confined to the vulva in an HIV-negative patient.
      Lesions can occur on the vulva though this is an infrequent site.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      KS presents as a red to purple papule, nodule, or plaque and diagnosis is confirmed by biopsy.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      Patients must be worked up for other cutaneous or extracutaneous involvement and treatment depends on whether KS is localized or systemic.
      • Régnier-Rosencher E
      • Guillot B
      • Dupin N.
      Treatments for classic Kaposi sarcoma: a systematic review of the literature.
      Additionally, treatment depends on whether the patient has HIV-related KS or non-HIV related KS. Treatment of localized lesions consist of excision, cryotherapy, intralesional chemotherapy, radiation, laser therapy, as well as topical alitretinoin or imiquimod.
      • Régnier-Rosencher E
      • Guillot B
      • Dupin N.
      Treatments for classic Kaposi sarcoma: a systematic review of the literature.

      Melanocytic Nevi

      Melanocytic nevi can be found on any area of skin including the vulva. Nevi can be skin colored or pink (typically intradermal nevi) or brown to black macules or papules (Fig. 2C). They are most commonly seen on the labia majora, labia minora, and clitoral hood.
      • Murzaku EC
      • Penn LA
      • Hale CS
      • Pomeranz MK
      • Polsky D.
      Vulvar nevi, melanosis, and melanoma: an epidemiologic, clinical, and histopathologic review.
      Atypical melanocytic nevi of the genital type (AMNGT) are a benign subtype of melanocytic nevi that tend to occur in young white women in the early 20s.
      • Murzaku EC
      • Penn LA
      • Hale CS
      • Pomeranz MK
      • Polsky D.
      Vulvar nevi, melanosis, and melanoma: an epidemiologic, clinical, and histopathologic review.
      If a pigmented lesion is clinically atypical appearing or the patient reports a history of changes or symptoms, biopsy is indicated. Dermoscopy is a useful tool that can help determine whether nevi have clinically concerning features, aiding the clinician in deciding whether a biopsy is indicated. Common vulvar nevi are benign.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      ,
      • Murzaku EC
      • Penn LA
      • Hale CS
      • Pomeranz MK
      • Polsky D.
      Vulvar nevi, melanosis, and melanoma: an epidemiologic, clinical, and histopathologic review.

      Melanotic Macule / Vulvar Melanosis

      Melanotic macules are brown to black macules or patches that can be isolated (Fig. 2D) or occur as multiple lesions in a more confluent pattern, where they are known as vulvar melanosis (Fig. 2E). Melanotic macules are flat lesions that most often occur on mucous membranes and modified mucous membranes.
      • Edwards Libby
      • Lynch PJ.
      Genital Dermatology Atlas and Manual.
      Vulvar melanosis accounts for most pigmented vulvar lesions.
      • De Giorgi V
      • Gori A
      • Salvati L
      • et al.
      Clinical and dermoscopic features of vulvar melanosis over the last 20 years.
      While vulvar melanosis can develop in any patient, it is more commonly seen arising in the setting of longstanding LS. Additionally, a hormonal role has been implicated in the development of vulvar melanosis.
      • De Giorgi V
      • Gori A
      • Salvati L
      • et al.
      Clinical and dermoscopic features of vulvar melanosis over the last 20 years.
      Diagnosis is often made clinically but if any atypical features are identified, a biopsy should be performed as melanoma is a consideration in the clinical differential. Vulvar melanosis is a benign condition and no treatment is indicated.
      • De Giorgi V
      • Gori A
      • Salvati L
      • et al.
      Clinical and dermoscopic features of vulvar melanosis over the last 20 years.
      Studies have shown that over time these lesions do not undergo malignant transformation and patients can be reassured.
      • De Giorgi V
      • Gori A
      • Salvati L
      • et al.
      Clinical and dermoscopic features of vulvar melanosis over the last 20 years.

      Vulvar Melanoma

      Following SCC, melanoma is the second most common vulvar malignancy, accounting for around 10% of vulvar malignancies.
      • Murzaku EC
      • Penn LA
      • Hale CS
      • Pomeranz MK
      • Polsky D.
      Vulvar nevi, melanosis, and melanoma: an epidemiologic, clinical, and histopathologic review.
      Vulvar melanomas can present as macules, papules, plaques, or nodules that tend to have irregular colors and borders. Because vulvar melanoma is diagnosed later than other cutaneous melanomas, they are often associated with symptoms of bleeding, pruritus, irritation, and even lymphadenopathy at time of diagnosis.
      • Murzaku EC
      • Penn LA
      • Hale CS
      • Pomeranz MK
      • Polsky D.
      Vulvar nevi, melanosis, and melanoma: an epidemiologic, clinical, and histopathologic review.
      The most frequent vulvar location for melanoma is the labia majora, followed by labia minora and clitoral hood, but melanoma can arise on any epithelial or mucosal surface.
      • Murzaku EC
      • Penn LA
      • Hale CS
      • Pomeranz MK
      • Polsky D.
      Vulvar nevi, melanosis, and melanoma: an epidemiologic, clinical, and histopathologic review.
      All patients with suspicion for melanoma should undergo biopsy that adequately samples as much of the lesion as possible.
      • Murzaku EC
      • Penn LA
      • Hale CS
      • Pomeranz MK
      • Polsky D.
      Vulvar nevi, melanosis, and melanoma: an epidemiologic, clinical, and histopathologic review.
      Vulvar melanomas have a poor prognosis overall and therapies depend on depth of invasion including surgical excision, chemotherapy, and immunotherapy.
      • Leitao MM.
      Management of Vulvar and Vaginal Melanomas: current and future strategies.

      Conflicts of Interest

      None

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