Vagina


 * Epidemiology: || Carcinomas of the vagina are uncommon tumors comprising 1% to 2% of gynecologic malignancies. They can be effectively treated, and when found in early stages, are often curable. The histological distinction between squamous cell carcinoma and adenocarcinoma is important because the two types represent distinct diseases, each with a different pathogenesis and natural history. Squamous cell vaginal cancer (approximately 85% of cases) initially spreads superficially within the vaginal wall and later invades the paravaginal tissues and the parametria. Distant metastases occur most commonly in the lungs and liver. Adenocarcinoma (approximately 15% of cases) has a peak incidence between 17 and 21 years of age and differs from squamous cell carcinoma by an increase in pulmonary metastases and supraclavicular and pelvic node involvement. Rarely, melanoma and sarcoma are described as primary vaginal cancers. Adenosquamous carcinoma is a rare and aggressive mixed epithelial tumor comprising approximately 1% to 2% of cases. 1

Vaginal cancer is rare. Only 1% of women with a cancer of the reproductive system have vaginal cancer. In 2009, an estimated 2,160 women in the United States will be diagnosed with vaginal cancer. It is estimated that 770 deaths from this disease will occur this year. The overall five-year survival rate (percentage of women who survive at least five years after the cancer is detected, excluding those who die from other diseases) for vaginal cancer is around 50%. 2 vaginal cancers occur most commonly on the posterior wall of the upper third of the vagina. 51.7% of primary vaginal cancers occurred in the upper third of the vagina and 57.6% on the posterior wall. Distant metastasis occurs in approximately 23% of patients. 3 || Age. Squamous cell carcinoma most often occurs in women between 50 and 70 years old; approximately half of women with vaginal cancer are older than 60. Human papillomavirus (HPV) infection. Research indicates that infection with this virus is a risk factor for vaginal cancer. HPV is most commonly passed from person to person during sexual activity. There are different types, or strains, of HPV, and some strains are more strongly associated with certain types of cancers. Many types of cancer caused by HPV are associated with precancerous conditions that develop before the cancer. Smoking. Smoking may increase a woman’s risk of developing vaginal cancer. DES**.** Women whose mothers took this drug during their pregnancy between the late 1940s and 1971 have an increased risk of clear cell adenocarcinoma. The average age of diagnosis is 19. Because most women of mothers who took DES are now between 30 and 60, the number of cases has declined. However, the long-term risks of DES exposure are not known. Cervical cancer. Women who have had [|cervical cancer] or cervical precancerous conditions have an increased risk of vaginal cancer. Previous radiation therapy. Women who have had radiation therapy in the vaginal area have an increased risk of vaginal cancer. Hysterectomy. Women who have had a hysterectomy (removal of part or all of the uterus) have an increased risk of vaginal cancer. Pessary use. Long-term vaginal irritation from using a pessary (a device used to keep a sagging uterus in place) can increase a woman’s risk of vaginal cancer. 2 || __Special studies:__ exfoliative cytology cytoscopy proctosigmoidoscopy __Radiographic studies:__ chest radiographs intravenous pyelogram barium enema lymphangiogram CT or MRI of pelvis and abdomen __Lab Studies:__ CBC blood chemistry urinalysis 4 In addition, speculum examination must include rotating the speculum as it is withdrawn so that anterior and posterior wall lesions are found. Exfoliative cytology studies can be used to find early squamous cell lesions, but will not find clear cell adenocarcinoma. Schiller's test (with Lugol's solution) and colposcopy are useful for biopsies for abnormal sites within the vagina. For patients with disease beyond stage II, cytoscopy and proctosigmoidoscopy should be used for metastatic evaluation 5 || moderately differentiated. Primary vaginal carcinoma in situ and invasive carcinoma are sometimes reported in patients as marginal recurrences of the cervical lesions. Verrucous carcinoma is a rarely occuring variant of well-differentiated squamous cell carcinoma. Adenocarcinomas comprise approximately 5% of primary vaginal tumors, usually in older women. Clear cell carcinoma may be found in younger patients. Adenoid cystic carcinoma is very rare. There were only 45 cases on record by 1996. Neuroendocrine small cell carcinoma may occur either in pure form, or associated with squamous or glandular elements. It is usually aggressive and prone to early spread. 5 || Those of the lower portion of the vagina either drain cephalad to the cervical lymph nodes or follow the drainage patterns of the vulva into the femoral and inguinal nodes. The anterior vaginal wall usually drains into the deep pelvic nodes, including the interiliac and parametrial nodes. 5 || Vaginal Stenosis: There is no set way to know when vaginal stenosis will happen. However, the standard pelvic dose will cause stenosis and ulceration. The time frame is during treatment and may last for about 2 months after treatment. 9 || Superior:L4-L5 (includes upper portion of common iliac chain) Inferior: includes entire vagina and pelvic lymph nodes Lateral: includes inguinal and adjacent femoral lymph nodes 10
 * Etiology: || The following factors may raise a woman's risk of developing vaginal cancer:
 * Signs & Symptoms: || The most common symptom of vaginal cancer is abnormal vaginal bleeding. Vaginal bleeding, during or after menopause is not normal and is always a sign of a problem. Other symptoms of vaginal cancer include:
 * Abnormal vaginal discharge
 * Difficulty or pain when urinating
 * Pain during sexual intercourse
 * Pain in the pelvic area (the lower part of the abdomen between the hip bones)
 * Pain in the back or legs
 * Swelling in the legs 2 ||
 * Diagnostic Procedures: || General history and physical exam
 * Histology: || Epidermal carcinoma is 90% of primary vaginal tumors. Most of these are nonkeratinizing and
 * Lymph Node Drainage: || Lyphatics of the upper portion of the vagina drain primarily through the cervical lymph nodes.
 * Metastatic Spread: || Metastatic spread to lung, liver, supraclavicular nodes, and pelvic nodes. 6 ||
 * Grading: || **GX:** The tumor grade cannot be evaluated.
 * G1:** The tumor cells are well differentiated (contains 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). 7 ||
 * Staging: || Staging systems are International Federation of Gynecology and Obstetrics or American joint Committee on Cancer. 6 ||
 * Radiation Side Effects: || Vaginal side effects may include serous discharge, pruritus, and vaginal stenosis. 8
 * Prognosis: || The most significant prognostic factor is clinical stage. More recurrence happens with adenocarcinoma than with squamous cell carcinoma. Non-significant factors include "patient age, extent of mucosal involvement, gross appearance of the lesion, and degree of differentiation and keratinization". Patients with squamous cell carcinoma with local recurrence has an approximately 50% 10year survival rate while those with local recurrence with adenocarcinoma is approximately 20% 10year survival rate. 10 ||
 * Treatments: || Vagina Treatment Borders: __AP/PA__ (Usual dose is to 45-50Gy using 10-18MV with midline block)



Treatment guidelines for Carcinoma of the Vagina. 10 || || **__ References __** 1. [|www.cancer.gov/cancertopics/pdq/treatment/vaginal/HealthProfessional/page2.com] Accessed Febuary 2, 2010. 2. [|www.cancer.net/Cancer+Types/Vaginal.com] Accessed Febuary 1, 2010 3. Chao KS, Perez CA., Brady LW. Radiation Oncology- Management Decisions. 2nd edition. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002 4. Perez CA, Brady LW, eds. //Principals and Practice of Radiation Oncology//, 3rd ed. Philadelphia: Lippincott-Raven. 1998. 5. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002 6. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002 7 . AJCC Cancer Staging Manual, Sixth Edition (2002) // published by Springer-Verlag New York, [|//www.cancerstaging.net//]////.// Accessed February 1, 2010. Table 1 8. Gunderson and Tepper. Clinical Radiation Oncology. 2nd Edition. Philadelphia, PA: Churchill Livingstone.2007. 9. Khan. Treatment Planning in Radiation Oncology. 2nd Edition. Philadelphia, PA: Lippincott, Williams & Wilkins; 2007. 10. Chao KS, Perez CA., Brady LW. //Radiation Oncology - Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2002. 11. Hand CM, Kim SJW, Waldow SM. Overview of radiobiology. In: Washington CM, Leaver D, eds. //Principles and Practice of Radiation Therapy//. 2nd ed. St. Louis, MO: Mosby; 2004:80-81. 12. Treatment plans and treatment planning photos courtesy of the University of Colorado Hospital, 2010.
 * TD5/5: || According to Washington and Leaver, et. al. the main organs of interest in the treatment fields for vaginal would be rectum, bladder and urethra and possibly intestine. The TD5/5 for rectal tissue is 6000 cGy which could result in ulceration or stricture. The tolerance dose for small bowel is much lower at 4500 cGy. Intestine exposed to 45 Gy or higher could result in sequelae of ulcer, perforation of hemorrhage. Bladder and urethra TD5/5 is 6000 cGy which could result in contracture or strictures. 11 ||
 * Treatment Plans and Fields || Treatment plan and initial treatment fields used in 2010 on a patient with vaginal cancer at the University of Colorado Hospital. Note how the inferior field borders are below the obturator foramen and the ischial tuberosities in order to ensure inclusion of the introitus of the vagina. 12