VAGINAL CANCER

Vaginal cancer represents 1% to 2% of all female genital tract malignancies. The median age at diagnosis is 60 years. Most vaginal cancers are metastatic lesions from other sites, including the cervix, uterus, breast, gestational trophoblastic disease, and the gastrointestinal (GI) tract. 

Primary vaginal cancers are commonly found in the upper one third of the vagina, often in the posterior fornix. There are 4,810 new cases with 1,240 deaths estimated for 2017.

Symptoms include vaginal discharge, vaginal bleeding, tenesmus, pelvic pain, bladder irritation, and pelvic fullness.

If the patient has a history of uterine, cervical,or vulvar cancer,the vaginal lesion is considered a recurrent cancer unless proven otherwise by discriminating pathology or greater than 5 years have intervally passed since prior diagnosis.

Risk factors for vaginal cancer include human papillomavirus (HPV) infection, chronic vaginal irritation, prior treatment for cervical cancer, prior CIN, and a history of in-utero exposure to DES.DES was used from 1940 to 1971. 

Vaginal adenosis and vaginal adenocarcinoma are characteristics of exposure. Other physical representations are a cockscomb cervix. The risk of clear cell carcinoma is 1:1,000 with a history of DES. 

The peak age at diagnosis was 19 years. Surveillance for women who were exposed to DES in utero includes at least yearly gynecologic exams with cervicovaginal cytology (and colposcopy as indicated) to occur indefinitely.

The route of spread is direct, lymphatic, or hematogenous. The route of lym- phatic spread depends on the location of the lesion. If the lesion is in the upper two thirds of the vagina, metastasis is often directly to the pelvic lymph nodes (LNs). If the lesion is in the lower one third of the vagina, metastasis can often be to the inguinal-femoral LNs, and/or to pelvic lymph nodes. Hematogenous spread often occurs late in the disease process.

PRE-TREATMENT WORKUP

The pre-treatment workup is colposcopy of the entire genital tract and physical examination. Diagnosis is via biopsy often guided with colposcopy. It may be necessary to perform an examination under anesthesia with cystoscopy and  proctoscopy.

HISTOLOGY

80% of vaginal cancers are of squamous cell histology.

5% to 9% are adenocarcinomas.

Malignant melanoma represents 2.8% to 5% of vaginal neoplasms. Vaginal melanomas are more often found in the lower one third of the vagina.

Rhabdomyosarcoma is usually found as the botryoid variant of embryonal rhabdomyosarcoma and is the most common malignant tumor of the vagina in infants and children; 90% of patients are younger than 5 years. 

On clinical examination, grape-like edematous masses may protrude from the vagina. The histologic pearl is the presence of a cambium layer beneath an intact vaginal Epithelium.

Vaginal cancer is a rare form of cancer that develops in the cells of the vagina, the canal connecting the uterus to the external genitalia. The exact cause of vaginal cancer is often unclear, but there are several risk factors associated with its development. Here are the causes and symptoms of vaginal cancer:

Causes:

1. Age: The risk of vaginal cancer increases with age, with most cases diagnosed in women over the age of 60.
2. Human papillomavirus (HPV) infection: Certain strains of HPV, particularly HPV types 16 and 18, have been linked to an increased risk of vaginal cancer.
3. Previous cervical cancer: Women who have had cervical cancer in the past are at a higher risk of developing vaginal cancer.
4. Exposure to diethylstilbestrol (DES): DES is a synthetic estrogen drug that was prescribed to some pregnant women between the 1940s and 1970s. Daughters of women who took DES during pregnancy have an increased risk of developing vaginal cancer.
5. Smoking: Cigarette smoking has been associated with an increased risk of vaginal cancer.

Symptoms:

1. Abnormal vaginal bleeding: Unusual vaginal bleeding, such as bleeding after sexual intercourse, between periods, or after menopause, may be a symptom of vaginal cancer.
2. Vaginal discharge: Increased vaginal discharge that may be bloody, watery, or have a foul odor can be a sign of vaginal cancer.
3. Painful urination: Vaginal cancer can cause pain or discomfort during urination.
4. Pelvic pain: Persistent pain or discomfort in the pelvic area, especially during sexual intercourse, may be a symptom of vaginal cancer.
5. Mass or lump: A noticeable mass or lump in the vagina may indicate vaginal cancer.
6. Changes in bowel or bladder habits: In advanced stages, vaginal cancer can affect the nearby organs, leading to changes in bowel or bladder habits, such as constipation or frequent urination.

It’s important to remember that these symptoms can be caused by other non-cancerous conditions as well. However, if you experience any persistent symptoms or notice any unusual changes in the vagina, it is important to consult a healthcare professional for proper evaluation and diagnosis.

Regular pelvic exams, Pap tests, and HPV screenings can help with the early detection of vaginal cancer or any abnormalities in the reproductive system.

FOLLOW-UP

Physical and pelvic examinations are recommended: A Pap smear may help with detection of recurrence but at most annually.

° Every 3 months for the first 2 years

° Every 6 months for the next 3 years

° Annual examinations thereafter

REFERENCES

1. Iversen T, Aalders JG, Christensen A, et al. Squamous cell carcinoma of the vulva: a review of 424 patients, 1956-1974. Gynecol Oncol. 1980;9(3):271-279.
2. Gonzalez Bosquet J, Kinney WK, Russell AH, et al. Risk of occult inguinofemoral lymph node metastasis from squamous carcinoma of the vulva. Int J Radiat Oncol Biol Phys. 2003;57(2):419-424.
3. Klapdor R, Länger F, Gratz KF. SPECT/CT for SLN dissection in vulvar cancer: improved SLN detection and dissection by preoperative three-dimensional anatomical localisation. Gynecol Oncol. September 2015;138(3):590-596.