Case Report: Two cases of primary malignant melanoma of the female genital tract and literature review.

Primary malignant melanoma of the cervix (PMMC) is an exceptionally rare and aggressive malignancy with a poor prognosis. Due to its rarity, there are no standardized treatment guidelines. This case report presents two patients with PMMC, contributing to the literature through a novel treatment approach and literature review. Both patients presented with vaginal bleeding: one postmenopausal without obvious cervical pigmentation, the other premenopausal with a brown, friable cervical mass. Histopathology confirmed PMMC in both. The first patient underwent radical surgery without adjuvant therapy and died from recurrence 36 months later. The second patient received radical surgery, adjuvant chemotherapy, and bevacizumab maintenance, followed by a combination of carboplatin, dacarbazine, and Tislelizumab for pulmonary metastases, achieving significant tumor regression after two cycles. A review of nine reported cases treated with PD-1/PD-L1 inhibitors revealed that radical surgery was performed in 90% of patients, yet 80% did not receive chemotherapy or radiotherapy, and most (80%) still experienced disease progression with immunotherapy, underscoring its limited efficacy. PD-L1 expression, assessed in only three cases (all negative), did not reliably predict response. In conclusion, PMMC remains a formidable clinical challenge with high recurrence rates despite surgery. Response to immune checkpoint inhibitors is inconsistent, but multimodal strategies integrating surgery, chemotherapy, anti-angiogenic agents, and immunotherapy may offer clinical benefit and warrant further investigation to improve outcomes in this aggressive disease.