Vaginal

• True / False: most malignancies of vagina are due to invasion from nearby tumours (cervix, vulva)

  • true: most malignancies are due to invasion from nearby tumours (cervix, vulva)
• Peak incidence: 50 - 60 years (sixth - seventh decade)
• Epidemiology:

  • mean age: 65 +/- 14 years
  • increasing incidence in younger women due to HPV
  • vaginal or utero - vaginal prolapse
• True / False: vaginal cancer incidence rates were highest for African American women

  • true: incidence rates were highest for African American women
• Etiology:

  • most common cause: HPV
  • previous cervical cancer
  • in utero exposure to DES (diethylstilbestrol)
  • previous hysterectomy
  • smoking → 2 x risk of vaginal cancer
  • HIV
• Pathology:

  • squamous cell = most common
  • adenocarcinoma
  • more likely to spread than squamous cell carcinoma
• Natural history:

  • commonly involves superior 1 / 3 of vaginal canal
  • exophytic, infiltrating growth pattern
  • anterior wall → vesicovaginal septum or urethra
  • posterior wall → rectovaginal septum or rectal mucosa
  • advanced: parametrium, levator ani muscles, pelvic fascia, pelvic sidewall
  • distant mets: lung, liver, bone
• vaginal intraepithelial neoplasia (VAIN)→ precursor lesion to SCC of vagina

  • VAIN 1: low grade, changes limited to upper 1 / 3 epithelium
  • VAIN 2: changes to lower 2 / 3 epithelium
  • VAIN 3: changes to full thickness of epithelium, carcinoma in situ
• True / False: in vaginal cancers, the lateral walls are less frequently involved

  • true: the lateral walls are less frequently involved
• Presentation:

  • abnormal bleeding from vagina (between menstrual periods)
  • abnormal vaginal discharge (smells foul, blood)
  • lump in vagina
  • changes in bladder and bowel habits
• Diagnostic tests:

  • history and physical:
  • pelvic exam
  • may do DRE and Pap test
  • colposcopy
  • biopsy = gold standard for diagnosis
  • imaging (may use endovaginal gel)
  • CT
  • MRI
• Prognostic indicators:

  • most important: stage
  • early stage = more favourable
  • SCC - most favourable
  • location of tumour
  • middle and lower 1 / 3 vagina + back wall = less favourable prognosis
  • present with symptoms = less favourable
  • younger age = more favourable
  • advantage with earlier hysterectomy
• Routes of spread:

  • local
  • bladder
  • cervix
  • rectum
  • paracolpial tissues = vascular and connective tissues along vagina
  • lymphatics
  • hematogenous: lung, liver, bone
  • after lymph node involvement - rare and late
• Lymphatics:

  • upper 1 / 3
  • vagina → para cervical nodes → internal iliac → common iliac → para aortic → cisterna chyli → thoracic duct
  • middle 1 / 3
  • vagina → internal iliac → common iliac → para aortic nodes → cisterna chyli → thoracic duct
  • lower 1 / 3
  • vagina → superficial inguinal nodes → external iliac → common iliac → para aortic → cisterna chyli → thoracic duct
• Staging FIGO:

  • stage 0: carcinoma in situ
  • stage 1: confined to vagina
  • stage 2: paravaginal tissues, no extension beyond pelvic side walls
  • stage 3: extension to pelvic side walls
  • stage 4: spread beyond true pelvis
  • 4A: bladder and rectal mucosa, extension beyond true pelvis
  • 4B: distant mets
• N stage:

  • N0(I+): isolated cells in regional node (< 0.2 mm)
  • N1: pelvic or inguinal lymph nodes mets
• Management overview:

  • goals: cure, vaginal preservation
  • chemo: used as primary if unfavourable factors
  • cervix is primary site
  • large lesion
  • downstage before radical surgery
• Stage 1 and 2 management (early stage):

  • RT:
  • brachy (small and superficial) - interstitial or intracavitary
  • EBRT (large) + intracavitary brachy
  • surgery:
  • radical hysterectomy + lymphadenectomy
  • may preserve ovarian and sexual function
• Stage 3 and 4 management (late stage):

  • definitive RT = primary treatment
  • Stage 3 and 4A:
  • unresectable: interstitial + intracavitary brachy + EBRT
  • if resectable: primary pelvic exenteration + pelvic lymphadenectomy or neoadjuvant chemo RT
  • stage 4B:
  • palliative EBRT + concurrent chemo
• Concurrent chemo RT:

  • chemo = cisplatin or 5 FU
  • overall survival benefit of chemo - minimal
  • greatest in stage 2 - 4
• Surgery:

  • early stage (limited to vaginal mucosa): definitive surgery
  • preserve ovarian and sexual function
  • eliminate risk for radiation induced malignancy
  • if upper vagina:
  • if intact uterus: radical hysterectomy, vaginectomy + 1 cm margin, pelvic lymphadenectomy
  • if lower vagina:
  • radical wide local excision + 1 cm margin, bilateral groin node dissection
  • if stage 4 + vesical or rectal vaginal fistula:
  • bilateral inguinofemoral lymphadenectomy if distal 1 / 3 vagina involved
  • relapse (central after RT): salvage surgery
• Radiation:

  • benefit: organ preservation
  • volume: entire vagina, paravaginal area to pelvic side wall, common iliac, internal iliac, external iliac, obturator, presacral, inguinal (if distal 1 / 3 vagina)
  • dose: 45 - 50.4 Gy / 25 - 28 fr
  • primary tumour receives total: 70 - 80 Gy
  • if no brachy for boost, can use IMRT to boost
  • energy: 15 MV
  • fields: 4 field or AP / PA
• EBRT upper 1 / 3 vagina field borders:

  • AP / PA:
  • sup: L5 / S1
  • inf: bottom of obturator foramen
  • lat: 1.5 cm lat of pelvic brim
  • Lat:
  • ant: mid pubic symphysis
  • post: S2 / S3
  • if lower 1 / 3 vagina:
  • length extended inferiorly to include inguinal nodes
• Brachy:

  • indicated: primary and recurrent vaginal cancer
  • HDR: Ir - 192
  • intracavitary: 60 - 65 Gy + 1 - 2 Gy boost
  • interstitial: 70 - 85 Gy total
  • side effect: radiation vaginitis
• Acute RT toxicity:

  • diarrhea
  • anal mucositis
  • vaginal mucositis
  • radiation vaginitis
• Chronic RT toxicity:

  • rectovaginal or vesicovaginal fistula
  • stricture in rectum or vagina
  • vaginal stenosis and shortening
  • cystitis
  • proctitis
• Prognosis: average = 47%

  • localized = 67%
  • regional = 52%
  • distant = 19%