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Cancer of the Vagina

Primary carcinoma of the vagina is rare and comprises only 1-2% of all female genital malignancies. To be classified as primary vaginal cancer, the lesion must arise in the vagina and must not involve the cervix or vulva. More than 80% of primary vaginal cancers are squamous cell carcinomas, and these squamous cell lesions usually occur in postmenopausal women cancer of the vagina, vaginal cancer, vagina cancer. The nonsquamous cancers tend to occur in younger 

For example, embryonal rhabdomyosarcomas and endodermal sinus tumors usually occur in children younger than 5 years of age, whereas the rare clear-cell adenocarcinoma, epidemiologically related to diethylstilbestrol (DES), is

Epidemiologic factors associated with the occurrence of preinvasive and invasive squamous cell lesions include chemotherapy, chronic vaginal irritation, excessive douching, a history of condyloma acuminatum, immunosuppressive treatment or states, long-term pessary use, low socioeconomic status, neglected prolapse, previous irradiation for cervical cancer, primary hysterectomy for cervical intraepithelial neoplasia (CIN) or for benign disease, and multiple sex partners. No single predisposing

Vaginal Intraepithelial Neoplasia

Vaginal intraepithelial neoplasia accounts for fewer than 1% of lower genital intraepithelial lesions. Women with vaginal intraepithelial neoplasia tend to be one to two decades younger than those with invasive squamous lesions. Vaginal intraepithelial neoplasia is most often associated with prior or coexistent neoplasia of the cervix or vulva. Prior pelvic irradiation, immunosuppression, or a history of HPV are other

Diagnosis

Because patients with vaginal intraepithelial neoplasia are usually asymptomatic, an abnormal Pap test frequently leads to the diagnosis. Rarely, patients may present with postcoital spotting. Colposcopically directed biopsies usually establish the diagnosis. In the patient who has had a hysterectomy, care should be taken to evaluate the pockets sometimes present in the lateral vault

Application of 4-5% acetic acid will cause affected areas to appear white and well demarcated, allowing for target biopsies. Lesions are usually located in the upper one third of the vagina, but because vaginal intraepithelial neoplasia tends to be

Treatment

Proposed treatments for vaginal intraepithelial neoplasia include surgical excision with partial vaginectomy, laser, topical 5-fluorouracil cream, total vaginectomy with split-thickness skin graft, cryotherapy, and radiation therapy. The mainstay of treatment is wide local excision of the affected area or upper vault vaginectomy. The use of dilute vasopressin injection will facilitate surgery. Laser vaporization has been used, but a biopsy of multiple areas should be performed to rule out invasion. Vasopressin injection also facilitates laser vaporization, and the depth of destruction should be limited to 2 mm. Topical administration of 5-fluorouracil cream has yielded cure rates in selected, compliant patients and may be of particular value in

Use of cryotherapy should be discouraged. Two other, less desirable modalities include total vaginectomy with skin grafting and delivering 6,500-8,000 cGy via an intra-cavitary application. Both procedures can lead to stenosis, scarring, and

Invasive Squamous Cell Carcinoma

Primary invasive carcinoma of the vagina accounts for 12% of all gynecologic malignancies. It is a disease of older women, with the peak incidence in the sixth and seventh decades. Only 10% of these carcinomas occur in women younger than 40 years of

 

Staging of Vaginal Carcinoma

Stage 0

Carcinoma in situ; intraepithelial carcinoma

Stage I

Carcinoma limited to vaginal mucosa (wall)

Stage II

Subvaginal infiltration into parametrium, not extending to the pelvic wall

Stage III

Carcinoma has extended to the pelvic wall

Stage IV

Carcinoma has extended beyond the true pelvis or involves mucosa of bladder or rectum

 

Stage IVA

Carcinoma has spread to adjacent organs and/or direct extension beyond the true pelvis

Stage IVB

Carcinoma has spread to distant organs

Modified from International Federation of Gynecology and Obstetrics. Annual report on the results of treatment in gynecological cancer. 22nd edition. Stockholm: FIGO, 1994

Diagnosis

Only about 20% of patients with invasive carcinoma are asymptomatic. Most patients present with abnormal vaginal bleeding or discharge, which may be malodorous. Less frequent complaints include dysuria, urgency, constipation, and pain, all usually occurring with more advanced disease. The upper one third of the vagina is involved in 4050% of cases in reported series.

Once the histologic diagnosis is made, cystoscopy and proctoscopy are indicated in patients with large tumors. Chest X-ray and intravenous pyelography or computed tomography with intravenous and oral contrast usually aid in treatment planning, particularly with clinical stage II or more advanced disease. Magnetic resonance imaging may help in differentiating between

Treatments

Most vaginal carcinomas are best treated with radiation therapy. Patients with occult or smaller than 1-cm, stage I, superficial lesions could be considered for radical surgery. Select patients with a lesion in the upper third of the vagina may be candidates for radical hysterectomy, vaginectomy, and bilateral pelvic lymph node dissection. Patients with positive nodes should receive external beam irradiation through appropriately designed ports, particularly if more than three nodes are involved. Patients with

For other patients with locally advanced squamous cell cancers, individualized radiation therapy is administered. Generally used is 4,000 cGy to the whole pelvis with a 5,000- to 6,000-cGy total parametrial dose, along with a combination of interstitial and intracavitary insertions to deliver a total dose of 7,500-8,000 cGy to the vaginal lesion and 6,500 cGy to parametrial and

Survival for patients with stage I vaginal cancer has been reported to range from 72% to 90%, and survival for stage II is around 55%. Approximately 45% of patients with stage III cancer will be 5-year survivors. Patients with stage IVA cancer have a

Diethylstilbestrol and Adenocarcinoma of the Vagina

The rare primary adenocarcinoma of the vagina usually occurs in postmenopausal women. These lesions may arise from residual glands of müllerian origin. Metastatic lesions (from breast, bowel, cervix, endometrium, and ovary) should be

Exposure in utero to DES has been epidemiologically associated with vaginal clear-cell adenocarcinoma since 1971. The registry for this disease now includes more than 600 cases, although millions of women were treated with DES during pregnancy, starting in the

Benign Anomalies

Adenosis and vaginal epithelial changes, present in as many as 50% of women who were exposed to DES before 18 weeks of gestation, include large transformation zones extending to the vagina, cervical collars, hypoplastic cervices, pseudopolyps, and vaginal septa. As the patient grows older, these

The immature squamous metaplasia noted on colposcopy can lead to overzealous treatment. Among the progeny of women exposed to DES, fewer than 10% with biopsies of these areas will have significant intraepithelial neoplasia. Women with

Exposure to DES may place women at a small, but statistically significant, risk for developing breast cancer. The possibility of an

Sarcoma

Embryonal rhabdomyosarcomas (sarcoma botryoides) occurs almost exclusively in children younger than 5 years old. These children usually have vaginal bleeding or discharge, and grapelike, gray-red masses may

Perioperative chemotherapy (vincristine, dactinomycin, cyclophosphamide) offers a survival advantage with various sarcomas. Thus, instead of exenteration, patients are probably best treated with preoperative combination chemotherapy, followed by

In adults, leiomyosarcomas and mixed miillerian tumors are the most common tumors. As with similar sarcomas of other organs, mitotic counts are important in assessing malignant potential. Surgical excision of these tumor masses, with removal of adjacent organs, is the primary therapy. Adjuvant cisplatin with ifosfamide for mixed miillerian tumors and doxorubicin hydrochloride with

Melanoma

About 150 cases of primary vaginal melanoma have been reported. The average age of patients is about 58, and patients present with bleeding, discharge, or a mass. Dark lesions of the vagina should be excised. These neoplasms most commonly occur in the

Radical surgery (radical hysterectomy with radical vaginectomy or exenteration) may