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Lecture 17.3 Neoplastic Diseases of The Vagina
Lecture 17.3 Neoplastic Diseases of The Vagina
narrowing the vagina, thereby preserving vaginal ● The most common symptom of vaginal cancer is
function. abnormal bleeding or discharge.
● Criteria for CO2 laser vaporization include a lesion ● Pain is usually a symptom of an advanced tumor.
that is discrete and easily visible and proof that ● Urinary frequency is also reported occasionally,
invasive cancer has been ruled out. particularly in the case of anterior wall tumors,
● The beam is directed colposcopically. whereas constipation or tenesmus may be reported
● Iodine staining of the vagina can help outline those when the tumors involve the posterior vaginal wall.
areas requiring therapy. ● In general, the longer the delay in diagnosis, the
● Treatment is occasionally performed on an outpatient poorer the prognosis and the more difficult the
basis with a local anesthetic and an analgesic. therapy.
● The intensity of therapy is regulated by adjusting the ● Vaginal cancer is usually diagnosed by direct biopsy
wattage of the laser, most commonly 15 to 20 W of the tumor mass.
carried to a depth of 1.5 to 2 mm. Care must be taken ● Abnormal cytologic findings may prompt a thorough
not to apply the laser too deeply because of the pelvic examination that will lead to diagnosis of
proximity of the bladder and bowel, particularly in vaginal cancer.
older women whose vaginal epithelium may be quite ● It is important during the course of the pelvic
thin. examination to inspect and palpate the entire vagina
● The success rates of laser in treating VAIN vary in the and to rotate the speculum carefully to visualize the
literature but are generally in the range of 60% to entire vagina, because a small tumor may occupy the
85%. anterior or posterior vaginal wall.
● Regular follow-up every 4 months, including a Pap
smear and colposcopy, is required during the first
year and usually 6 to 12 months thereafter.
● The primary disadvantages of laser treatment are the
lack of a pathologic specimen for evaluation of the
adequacy of margins and the fact that the procedure
can be tedious and difficult because of the many folds
and crevices at the vaginal apex.
● Topical chemotherapy, 5% 5-FU cream, can be self-
administered to cover the entire area at risk. It is most
often used for widespread multifocal lesions of HPV-
associated VAIN-1 or VAIN-2.
● The disadvantage of topical therapy with 5-FU cream
is related to the high level of motivation required to
complete therapy. TUMORS OF THE ADULT VAGINA
● The 5-FU cream causes exfoliation and erosion of the A. SQUAMOUS CELL CARCINOMA
vaginal mucosa and can be extremely painful. - The most common vaginal malignancy and accounts
● Wide local excision (upper vaginectomy) is the
treatment of choice for VAIN-3, especially for lesions for 90% of primary vaginal cancers
occurring at the cuff after hysterectomy with a high - The disease occurs primarily in women older than 60
success rate of 84%. - 20% occurs in women older than 80 years
● Upper vaginectomy, however, can result in vaginal - Most squamous cell carcinomas occur in the upper
shortening, which can be ameliorated by the use of third of the vagina
topical estrogen cream and a vaginal dilator (or - Grossly, the tumor appears as a fungating,
frequent intercourse) once healing is complete. polypoid, or ulcerating mass, often accompanied by
a foul smell and discharge related to secondary
MALIGNANT DISEASES OF THE VAGINA infection
- Microscopically the tumor demonstrates the classic
Signs and Symptoms
findings of an invasive squamous cell carcinoma
● Primary vaginal cancers usually occur as squamous infiltrating the vaginal epithelium
cell carcinomas in women older than 60 years. - Treatment of these tumors is based on the size,
● To be considered a primary vaginal tumor, the vaginal tumor stage, and location of the lesion
malignancy must arise in the vagina and not involve - Therapy is limited by the proximity of the bladder
the external os of the cervix superiorly or the vulva anteriorly and the rectum posteriorly
inferiorly. - It is also influenced by the location of the tumor in the
● If this occurs, the tumor is classified as cervical or vagina, which determines the area of lymphatics
vulvar. spread
● Biopsies are mandatory if the cervix is intact in order - Lymphatics of the vagina envelop the mucosa and
to rule out primary carcinoma of the cervix. This is anastomose with lymphatic vessels in the muscularis
also an important therapeutic consideration, insofar as - Those of the mid to upper vagina communicate
the same management techniques apply to small
superiorly with the lymphatics of the cervix and drain
tumors of the upper third of the vagina and cervical
carcinomas. into the pelvic nodes of the obturator and internal
● Tumors of the lower third of the vagina are treated and external iliac chain
similarly to vulvar cancers.
- Lymphatics of the distal third of the vagina drain to - Overall 5-year survival rates for patients with primary
the inguinal nodes and pelvic nodes, similar to the carcinoma of the vagina have been reported to be
drainage of the vulva. approximately 45%
- Posterior wall lymphatics anastomose with the - Stage of the tumor is the most important predictor of
rectal lymphatic system and then to the nodes that prognosis
drain the rectum, such as the inferior gluteal, sacral, - The use of concomitant chemotherapy with radiation
and rectal nodes can be expected to produce improved survival rates
Treatment
- Once vaginal malignancy is established, a thorough B. CLEAR CELL ADENOCARCINOMA
bimanual and visual examination documenting the - Clear cell adenocarcinomas in young women have
size and location of the tumor and assessment of been seen more frequently since 1970 as a result of
spread to adjacent structures (submucosa, vaginal the association of many if these cancers with
sidewall, bladder, rectum) should be performed to intrauterine exposure to DES
determine the clinical stage - Tumors are staged according to FIGO classification
- Cystoscopy or proctoscopy may be helpful to rule - Most tumors (80%) have been diagnosed as stage I
out bladder or rectal invasion or II
- Distant spread may be evaluated by computed - The survival rate is related directly to the stage of
tomography (CT) of the chest, abdomen, and pelvis or the tumor
positron emission tomography (PET) - Surgery is the primary modality because of the
- Early stage vaginal carcinoma without lymph node young age of the patients
involvement (stage I or II) – treated with surgery or - Stage I and early stage II tumors, radical
radiation hysterectomy with partial or complete vaginectomy,
- Young patients with early stage disease and upper pelvic lymphadenectomy, and reconstruction of the
vaginal lesions may be treated with radical upper vagina with split thickness grafts has been most
vaginectomy, parametrectomy, and pelvic common approach
lymphadenectomy - Local excision of the tumor can be performed before
- Radiation therapy – most frequently used mode of irradiation to facilitate local application
treatment and can be used for early and advanced - Local vaginal excision as the sole therapy is not
disease. It is the most common therapy because usually adequate for small tumors because the tumor
most women with vaginal carcinoma are older and frequently recurs
have a poorer surgical risk; radiation is highly - Three predominant histologic patterns:
effective o Tubulocystic cell pattern
- Pelvic exenteration – used to treat advanced o Solid pattern
disease in the absence of lymph node metastasis, but o Papillary pattern
it is usually reserved for patients with localized - Older patients (>19 years) have been found to have
recurrence after radiation a more favourable prognosis in comparison to
- Cisplatin-based chemotherapy with concurrent younger patients (<15 years)
radiation – improved outcomes in squamous lesions - There is more favourable outcome for those with the
of the cervix tubulocystic pattern of adenocarcinoma, the most
- Stage I vaginal carcinoma may be treated with frequent histologic pattern found in older patients
brachytherapy alone, without external beam therapy - Prolonged follow-up is necessary for these patients
- For more advanced lesions, a combination of because recurrences have been reported as long as
external beam and brachytherapy is used 20 years after primary therapy
- Those with maternal history of DES use survive
Brachytherapy – a procedure that involves placing longer
radioactive material inside your body; sometimes
called internal radiation. C. MALIGNANT MELANOMA
(mayoclinic.org)
- Vaginal melanomas are rare and highly malignant
- 2-3% of primary vaginal cancers
- External radiation therapy with megavoltage
- Most common presenting symptoms are vaginal
equipment is initially used to shrink the tumor
discharge, bleeding, and a palpable mass
- The size and extent of the radiation field will be
- Lesions appear as darkly pigmented, irregular
determined by the presence or absence of nodal
areas and may be flat, polypoid, or nodular
disease, as determined by the pretreatment PET ot
- The average age of women is 57 years
CT scan
- Tends to metastasize early via the bloodstream and
- The brachytherapy will bring the total dose to
lymphatics, to the iliac or inguinal nodes, lungs,
between 7000 and 8500 cGy
liver, brain, and bones
- Poorer prognosis than those with vulvar melanoma
Survival
probably because of the delay in diagnosis
APPENDIX