## 3 Results  
In our institution, we had to manage a case with vaginal melanoma. The patient was 70 years old and was diagnosed in June 2020 with the previously mentioned medical condition. In June 2020, the biopsy and imagistic evaluation was carried out. Head, neck, thorax, abdomen CT did not reveal metastatic disease in July 2020, but an MRI showed a vaginal tumor on the left side wall, of 50/32/27 mm in size, without lymph node invasion. In September 2020, the removal of the vaginal tumor (left lateral wall) was performed with limited data regarding resection margins. The initial histopathological exam revealed undifferentiated carcinoma and the immunohistochemical tests showed that tumor cells were diffusely positive for S100; while HMB45 and p16 were positive with moderate intensity in the tumor cells; p63 and CK5/6 were negative in the tumor and the Ki-67 labeling index was approximately 60% (Figures 1 and 2). Thus, the diagnosis of an ulcerated nodular malignant melanoma was established.  
Figure 1: The squamous cell epithelium (in the lower left quadrant), mononuclear cell infiltrate in the subepithelial connective tissue and the tumor proliferation, consisted of sheets of spindle cells, H&E stain, and magnification of \(\times\)100.  
Imagistic evaluation by computed tomography evidenced a lung node with a diameter of 3 mm and a left inguino-femoral lymphadenopathy with a diameter of 35 mm in October 2020. Surgery was performed, consisting of an inguino-femoral lymphadenectomy with the excision of the adenopathy block, in November 2020. The final histopathological examination after the paraffin-embedding of the tissue determined that one of the seven examined lymph nodes had a small area of malignant tumor infiltration, with associated chronic inflammatory infiltrate. Biological, biochemical parameters and tumor markers were within the normal limits. Additionally, the BRAF mutation test was negative.  
One month after the surgery, a positron emission computed tomography examination was performed and bilateral lung nodes, with SUV 18 mm were revealed.  
Our oncology committee decided upon immunotherapy performed with nivolumab, which was initiated in January 2021, conforming to national protocols. Radiotherapy was integrated into pluridisciplinary care and was performed in our department, in 3D conformal technique with 6 MV photons, the total dose of 30 Gy in 10 fractions, was applied with good compliance. Organ at risk dose constraints were evaluated conforming to QUANTEC (Quantitative Analysis of Normal Tissue Effects in the Clinic) (Figure 3) and hospital therapeutic protocols, after the informed consent of the patient was signed.  
Twelve months after immunotherapy was initiated, the patient had a performance index of IP (ECOG) = 1, representing a complete remission of lung lesions without immune toxicities.  
Figure 2: Immunohistochemical profile of the tumor: **(A)** Tumor cells are diffusely positive for S100, magnification \(\times\)200; **(B)** The tumor shows intense, diffuse positivity for HMB45, magnification \(\times\)200; **(C)** p16 is positive with moderate intensity, magnification \(\times\)200; **(D)** p63 is negative in the tumor cell and positive in the squamous epithelium (left upper quadrant), magnification \(\times\)100; **(E)** Tumor cells show negativity for CK5/6, magnification \(\times\)400; **(F)** A Ki-67 labeling index of 60%, magnification \(\times\)400.