Figure 1. Vaginal melanoma: histopathological pictures.

DISCUSSION
Melanoma is a highly metastatic, highly aggressive tumour of melanocytes that most frequently develops in the skin but can also occur in the eyes and mucous membranes to a much lower level. One percent of all melanomas are mucosal, and 18 percent of them develop in the vulvovaginal areas. Even more infrequently, between the ages of 60 and 80, just 0.46 instances per million women are diagnosed with vaginal melanoma each year [2]. As in our instance, vaginal melanomas are typically located in the lower portion of the anterior vaginal wall. There are no clear identifiable causes of vaginal melanomas, and the literature does not show any appreciable variations among racial or ethnic groups [1]. The cellular microenvironment and interactions between any of these have been implicated in proposed mechanisms of its pathogenesis and etiological variables, however these hypotheses are at best [6].
Our patient’s clinical symptoms included myalgias, arthralgias, weariness, a palpable mass in the genital area, pain, and 2 weeks’ worth of foetid transvaginal haemorrhage. According to the bibliography, genital bleeding (80%) and a palpable mass (15%), genital secretions (25%), and local pain (10%) are among the symptoms of vaginal melanoma [1,3]. Vulvar and vaginal melanomas have beginnings that are typically missed by routine examination, with the anatomical location of the lesion being the primary factor in the late diagnosis and poor prognosis of these lesions. [4], Any discoloured growth in the vagina with complaints of vaginal bleeding should be believed to be melanoma since the growth is typically blue-black or blackish with plaques or ulceration [3].
Most patients have advanced disease when they are first diagnosed [1]. Vaginal melanomas are diagnosed using a combination of histological analysis and visual inspection. When the protein S-100, Melan A, and HMB-45 markers are positive, the diagnosis is confirmed by pathological investigation using IHC of the biopsy sample [1]. Histologically, there are three main forms of vaginal melanomas: epithelioid (which accounts for 55% of cases), spindled, and mixed [2]. The big, spherical cells of the epithelioid type have a lot of eosinophilic cytoplasm. They have peppered moth nuclei, which are vesicular nuclei with coarse, uneven chromatin and peripheral condensation. The most typical locations for this cell type in melanomas are nodular and superficial spreading. The pigment is distributed erratically, there is dermal fibrosis, and the inflammatory infiltrate is varied (brisk, non-brisk, or nonexistent) in the stromal compartment [4]. In order to identify the tumor’s Breslow depth, the quantity of mitoses, the kind of ulceration, the presence of microsatellites, and the look of the tumour margins, a thorough pathological investigation should also be carried out [1], as described in the case of our patient.
Prognostic variables and treatment regimens for vaginal melanoma are not well characterised because there are not enough patients to conduct randomised clinical studies.
The American Joint Committee on Cancer’s tumour, node, and metastases and the International Federation of Obstetrics and Gynaecology systems are currently used to stage primary vaginal melanoma, but the evidence from various studies suggests that the AJCC stage, tumour size, and lymph node status are the main prognostic factors. Poorer outcomes were linked to AJCC stage III, tumour size 3 cm, and lymph node involvement. In general, MM has a 10-to-20% 5-year overall survival rate compared to 93% for CM.
Additionally, the vaginal melanoma 5-year survival rate is less than 15% [5]. In appropriate circumstances, surgery is the go-to treatment because it’s linked to a higher overall survival rate. Quality of life and patient preferences are crucial in determining the extent of surgery, as is the case with our patient, who refused extensive surgery. However, the radicality of the surgery had no discernible impact on outcomes. Routine groyne or pelvic lymphadenectomy is not advised for individuals without signs of clinical or radiological involvement due to the low rate of regional lymph node metastases; instead, prognosis is the key consideration [5]. In the absence of lymph node metastases, local excision of recurrence results in a 50% 5-year disease-free survival rate [1]. If surgical resection is not possible, lymphatic invasion, regional extension, or as a palliative measure, radiotherapy may be utilised as a neoadjuvant treatment [4]. Immune checkpoint inhibitors or targeted therapy are the preferred first-line treatments for metastatic or incurable vaginal melanoma in the context of driver mutations. Nivolumab and ipilimumab combination therapy or anti-PD1 monotherapy with pembrolizumab or nivolumab are the recommended starting regimens for advanced stages (stage III-IV), respectively. This was the treatment of choice for our patient [2,4]. Agents including dacarbazine, iterleukin-2, and interferon alpha-2b have showed promise in extending survival [2].
According to evidence, cytotoxic therapy mostly employs dacarbazine, temozolomide, cisplatin, and paclitaxel as neoadjuvant or palliative care [2,4]. It is worthwhile to investigate topical imiquimod as an adjuvant treatment further [6]. Adjuvant chemotherapy (dacarbazine) or the combination of targeted therapy (ipilimumab) and radiotherapy have also been mentioned in the literature, with promising outcomes, in addition to surgical excision.