184Vaginal Cancer

CHARACTERISTICS

•   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 lymphatic 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.

•   The most important prognostic factor is stage of disease. Age is also an important factor. Melanomas and sarcomas have the worst prognosis. Lesions of the distal vagina tend to have a worse prognosis than proximal lesions. Size less than 3 cm has a better prognosis than if larger than 5 cm. LN status also confers prognosis, with a 5-year survival (YS) of 33% for positive LNs compared to 56% for negative LNs.

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 185proctoscopy. These procedures may also help with initial staging. Chest x-ray, intravenous pyelography (IVP), cystoscopy, proctoscopy, and barium enema are FIGO-approved diagnostic studies. CT, MRI, and PET imaging may assist in evaluating extent of disease and aid in treatment planning.

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.

•   Leiomyosarcoma can also be found, and this can occur in women with a prior history of radiation therapy (XRT).

STAGING

Staging continues to be clinical, closely following cervical cancer parameters (Tables 2.30A–D).

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