The incidence of vaginal caner is 1 per 100,000 women. Many women with vaginal cancer have a prior history of gynecologic malignancy.1
Etiology:
There is a lack of information on the etiology of vaginal cancer due to the rarity of the disease. In general, vaginal cancers are associated with the same risk factors as in cervical neoplasia. Multiple lifetime sexual partners, early age at first intercourse, and being current smoker. Most cases of vaginal cancer are likely mediated by human papillomavirus (HPV) infection.1
Signs & Symptoms:
The signs and symptoms associated with vaginal cancer include2,3:
Abnormal vaginal bleeding
Painful intercourse
Vaginal Discharge
Dysuria
Pelvic pain
Diagnostic Procedures:
Diagnostic procedures for vaginal cancer include2:
History and Physical
Exfoliative cytology
Colposcopy
Biopsy
Cytoscopy
Chest radiograph
Complete blood cell count
Urinalysis
Intravenous pyelogram
Histology:
Epithelial malignant tumors:
Epidermoid carcinoma make up 90% of primary vaginal tumors; most of these are nonkeratinizing and moderately differentiated.2
Nonepithelial tumors
Malignant lymphoma
Malignant lymphoma may be localized to the female genital tract or occur as part of a widespread disease process.
Lymph node drainage:
The lymphatics in the upper portion of the vagina drain primarily via the lymphatics of the cervix; those in the lowest portion either drain cephalad to the cervical lymphatics or follow drainage patterns of the vulva into femoral and inguinal nodes. The anterior vaginal wall usually drains into the deep pelvic nodes, including the interiliac and parametrial nodes.2
Metastatic spread:
Vaginal CA usually starts in the posterior wall of the upper 1/3 of the vagina.1 Vaginal lesions spread to their surrounding tissue such as the paracolpal and the parametrial tissues. Anterior vaginal wall lesions can spread to the vesicovaginal septum, and posterior lesions can invade the rectovaginal septum. Vaginal lesions commonly involve the cervix or vulva, but when they do spread to the cervix or vulva the lesion is not consider primary vaginal cancer. Do to the complexity of the vagina, lymphatic spread can occur to any nodal group, but spread the inguinal nodes is the most common rout of lymphatic invasion. Distance metastasis to the lungs, liver, or supraclavicular nodes is very common in squamous cell lesions.
Grading:
GX: The tumor grade cannot be evaluated.
G1: The tumor cells are well differentiated (contain many healthy-looking cells).
G2: The tumor cells are moderately differentiated (more cells appear abnormal than healthy).
G3: The tumor cells are poorly differentiated (most of the cells appear abnormal).
G4: The tumor cells are undifferentiated (the cells barely resemble healthy cells).5
Staging:
Staging is done by using the International Federation of Gynecology and Obstetrics or American Joint Committee on Cancer staging. It is best when performed jointly by the gynecologic and radiation oncologists while the patient is under general anesthesia.2 Staging for vaginal cancer3
Stage I: Tumor is confined to the vagina, 0.5 to 1.0 cm thick Stage II: Tumor invades the paravaginal tissue but not to the pelvic wall Stage III: Tumor extends to the pelvic wall into muscle, fascia, neurovascular structures, or skeletal portions of the bony pelvis Stage IVA: Tumor invades the mucosa of the bladder or rectum and/or extends beyond the true pelvis
Radiation side effects:
Common side effects during Radiation treatment to the vagina4
Diarrhoea
Irritable bladder (or radiation cystitis), frequency changes
Feeling sick
Bleeding from the vagina after internal radiotherapy
Soreness and redness of the vulva or back passage
Common side effects after Radiation treatment to the vagina4
Changes in bladder and bowl movement frequency or constancy
Leg swelling
Ovaries can stop working, causing an early menopause
Vagina becomes narrower and less stretchy
Vaginal area becomes drier
Prognosis:
The clinical stage is the most important prognostic factor.2 Patient age, extent of involvement, gross appearance, degree of differentiation and keratinizaton do not appear to be significant factors. Compared to squamous call carcinoma, adenocarcinoma has a higher incidence of local recurrence (52% and 20% respectively at 10 years), distant metastasis (48% and 10% respectively), and lower 10-year survival rate (20% versus 50%). Overexpresson of her-2-neu oncogenes in squamous cancer of the lower genital tract is rare, but is associated with aggressive biologic behavior.
Treatments:
Radiation therapy is treatment of choice.2 Surgery is an option, and can be combined with radiation, but more complications are likely. Treatments are divided by stage: Carcinoma in situ
Intracavitary LDR delivering 65-80 Gy to the involved vaginal mucosa
Treat entire mucosa to 50-60 Gy
Stage I
Superficial tumors: intracavitary cylinder covering the entire vagina (LDR to 60 Gy) and boost 20-30 Gy to the tumor area
Thicker lesions localized to one wall: 60-65 Gy (LDR) to the entire vaginal mucosa via cylinder. 15-20 Gy boost
External beam for aggressive lesions only
Stage IIA
20-30 Gy whole pelvis radiation
Parametrial dose with a midline block for a total of 45-50 Gy
Interstital and intracavitary LDR brachytherapy may be used to deliver a minimum of 45-55 Gy 0.5 cm beyond the tumor. 70-75 Gy at depth of tumor
Stage II, III, and IV
External radiation 40 Gy to whole pelvis, and 45-50 Gy to the parametria
Interstital and intracavitary dose to 75-80 Gy to the tumor
Interstital implant to boost of 20-25 Gy. Maximum of 80-85 Gy are delivered to the vaginal mucosa with both modalities
Chemotherapy is used for small cell carcinoma along with these same radiation treatment guidelines. Surgery, intracavitary, and eternal beam radiation are used for clear cell carcinoma. Post radiation recurrences may be treated with surgery. Rhabdomyosarcoma can be treated with surgery, radiation, and chemotherapy.
TD 5/5:
Tolerance doses that within 5 years will cause a minimum 5% complication rate.2
Bladder: 65 Gray (Gy): Bladder contracture and volume loss
Femoral head: 52Gy: Necrosis
Rectum: 60Gy: Severe proctitis, necrosis, fistula, stenosis
Colon: 45Gy: Obstruction, perforation, ulceration, fistula
Small bowel: 40Gy: Obstruction, perforation, fistula
G1: The tumor cells are well differentiated (contain many healthy-looking cells).
G2: The tumor cells are moderately differentiated (more cells appear abnormal than healthy).
G3: The tumor cells are poorly differentiated (most of the cells appear abnormal).
G4: The tumor cells are undifferentiated (the cells barely resemble healthy cells).5
Staging for vaginal cancer3
Stage I: Tumor is confined to the vagina, 0.5 to 1.0 cm thick
Stage II: Tumor invades the paravaginal tissue but not to the pelvic wall
Stage III: Tumor extends to the pelvic wall into muscle, fascia, neurovascular structures, or skeletal portions of the bony pelvis
Stage IVA: Tumor invades the mucosa of the bladder or rectum and/or extends beyond the true pelvis
Common side effects after Radiation treatment to the vagina4
Treatments are divided by stage:
Carcinoma in situ
- Intracavitary LDR delivering 65-80 Gy to the involved vaginal mucosa
- Treat entire mucosa to 50-60 Gy
Stage IStage IIA
Stage II, III, and IV
Chemotherapy is used for small cell carcinoma along with these same radiation treatment guidelines. Surgery, intracavitary, and eternal beam radiation are used for clear cell carcinoma. Post radiation recurrences may be treated with surgery. Rhabdomyosarcoma can be treated with surgery, radiation, and chemotherapy.
Bladder: 65 Gray (Gy): Bladder contracture and volume loss
Femoral head: 52Gy: Necrosis
Rectum: 60Gy: Severe proctitis, necrosis, fistula, stenosis
Colon: 45Gy: Obstruction, perforation, ulceration, fistula
Small bowel: 40Gy: Obstruction, perforation, fistula