Vagina

General [1] -History -Physical, Including careful pelvic/bimanual examination Special Studies [1] -Exfoliative cytology (CCAs may not be detected) -Colposcopy and directed biopsies (including Schiller’s test) -Biopsies and examination under anesthesia to determine extend -Cystoscopy -Proctosigmoidoscopy
 * **Epidemiolgy:** || Adenocarcinomas comprise approximately 5% of primary vaginal tumors and are found more frequency in older women between the ages of 50-70 years. Clear cell adenocarcinoma of the vagina may be found in young patients. Leiomyosarcomas comprise 68% of vaginal sarcomas in adults, whereas rhabdomyosarcomas comprise less than 2%. Rhabdomyosarcomas represents 90% of cases occurring in children under 5 years of age. [1] ||
 * **Etiology:** || The cause for vaginal cancer is unknown but risk factors include having the HPV virus, chronic irritation of the vaginal mucosa, hysterectomy and in utero exposure to the synthetic estrogen diethylstilbestrol. [1] ||
 * **Signs & Symptoms:** || Abnormal vaginal bleeding is the presenting symptom in 50% to 75% of patients with primary vaginal tumors. Vaginal discharge is common. Dysuria and pelvic pain may also be present particularly when the tumor has spread to adjacent organs. [1] ||
 * **Diagnostic Procedures:** || (Taken from Table 38-1)

Radiographic Studies [1] Standard Chest Radiographs Intravenous pyelogram Complementary Barium enema Lymphangiogram Computed tomography or magnetic resonance imaging scans of pelvis and abdomen

Laboratory Studies [1] -Complete blood cell count -Blood chemistry -Urinalysis 1. An important clinical evaluation is a bimanual pelvic and rectal examinations [1] 2. Exfoliative cytology studies are used to detect early squamous cell lesions. [1] 3. Patients with stage II invasive vaginal carcinoma should be evaluated with cystoscopy and proctosigmoidoscopy. [1] 4. Computed tomography, and magnetic resonance imaging or the pelvis and abdomen are also used to evaluate these patients. [1] || Squamous cell carcinoma – Most Common Type about 70% of vaginal cancers occurring in the epithelial lining of the vagina. [1] The medical term VAIN (vaginal intraepithelial neoplasia) is used to describe a pre-cancerous condition; replacing the dysplasia designation. There are 3 types: VAIN1, VAIN2, and VAIN3, with 3 indicating furthest progression towards true cancer. [1] Adenocarcinoma About 15% of vaginal cancers are adenocarcinomas, typically developing in women > 50.[1] Clear cell adenocarcinoma, (a special type) occurs more in young women exposed to diethylstilbestrol (DES) in utero.[1] Melanoma About 9% of all vaginal cancers are melanomas, affecting the lower or outer portion of the vagina. [1] Sarcoma Up to 4% of vaginal cancers are sarcomas that form deep in the wall of the vagina, not on its surface.
 * **Histology:** || There are several types of vaginal cancer.

Several types of vaginal sarcomas. [1] 1) Rhabdomyosarcoma (most common Sarcoma) most often found in children &  rare in adults. [1]  2) Leiomyosarcoma more often in adults. Age >50. [1] ||
 * **Lymph node drainage:** || Lymphatic drainage of the vagina can involve any nodal group; however the typical drainage path is listed below.

Upper vagina

Lower vagina

Anterior vagina

Drain primarily through the cervix lymph path

Can either drain superiorly to the cervical lymph path or drain into the femoral and inguinal nodes

The lower 1/3 of the vagina most commonly drain to the inguinal nodes

Drain into the deep pelvic, interiliac and parametrial nodes

Positive inguinal and/or pelvic nodes vary with the primary tumor location and stage of the disease. || GX: The tumor grade cannot be evaluated. G1: The tumor cells are well differentiated (contain 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). [2] ||
 * **Metastatic spread:** || Occurs in approximately 23% of patients, most commonly to the lungs, liver or supraclavicular nodes.[1] ||
 * **Grading:** || Grading:
 * **Staging:** || AJCC or FIGO staging matrix is used.

TX: The primary tumor cannot be evaluated. T0: There is no evidence of cancer in the vagina. Tis (FIGO 0): The tumor is carcinoma in situ, an early cancer found only in one layer of cells that has not spread to nearby tissue. T1 (FIGO I): The tumor is in the vagina and has not spread through the vaginal wall or to other parts of the body. T2 (FIGO II): The tumor has spread through the vaginal wall and surrounding tissue, but not to the walls of the pelvis. (FIGO IIA): Subvaginal infiltration, not into the parametrium. (FIGO IIB): Parametrial infiltration, not extending to pelvic wall. T3 (FIGO III): The tumor has spread to the pelvic wall. T4 (FIGO IV): The tumor has spread to the bladder, rectum, or other areas of the body.

NX: The lymph nodes cannot be evaluated. N0: Cancer has not spread to the regional lymph nodes. N1: Cancer has spread to the regional lymph nodes.

MX: Metastasis cannot be evaluated. M0: The cancer has not metastasized. M1: There is metastasis to another part of the body.[1,2] || Surgical treatment for vaginal cancer is wide local excision or total vaginectomy with vaginal reconstruction. This is only reserved for localized carcinoma in situ or superficially invasive tumors. Chemotherapy is not common in the treatment of vaginal cancer.
 * **Radiation side effects:** || Fatigue, skin reddening, rectal ulceration or proctitis, cystitis, vaginal necrosis or stenosis, leg edema, burning with urination due to skin reaction or infection. [1] ||
 * **Prognosis:** || ==== The prognosis of vaginal cancers depends on several factors. These include the stage of the cancer, age, size and grade of the tumor. However, the stage of the vagina cancer at the time of presentation plays a key factor in the prognosis of the disease. The survival rate decreases as the stage of the disease increases. The survival rates for stage I disease ranges from 60% to 85%. Whereas, survival rates for stage IV disease is 0% to 25%. [1,3] ==== ||
 * **Treatments:** || ** Surgery **
 * Chemotherapy **

**Radiation Therapy** The radiation therapy is the most common treatment implemented for vaginal cancer. Both external beam radiation therapy and brachytherapy are used as part of the treatment. This combination treatment technique has been shown to improve overall survival rates.

The external beam radiation therapy is delivered to the whole pelvis, which covers the vaginal tumor, entire vagina, and the pelvic lymph nodes. Treatment techniques include a four field with an anterior and posterior field, two lateral fields or intensity modulated radiation therapy. A standard treatment field extends superiorly to the L5-S1 interspaces and inferiorly to the extent of the vagina. The lateral treatment borders are 1.5cm to 2.0cm lateral to the pelvic brim. The doses of external beam radiation therapy used are 45Gy to 50Gy and high dose rate brachytherapy boost of 18Gy. The IMRT dose is 64-70Gy. [1,3] || Bladder < 65Gy Small Bowel < 45Gy Rectum < 60Gy Femoral Head & Neck < 52Gy Colon < 45Gy || [2] [] Last updated March 22, 2012. Accessed June 18, 2012. [3] Hoppe TR, Phillips LT, Roach M. //Leibel and Phillips Textbook of Radiation Oncology//. 3rd Ed. Philadelphia, PA: Saunders, Elsevier; 2010. || Figure 1. Vaginal brachytherapy. [3] Back to Week 5
 * **TD 5/5:** || **Normal Tissue Tolerances (Whole Organ)** [3]
 * **Reference** || [1] Chao C. //Radiation Oncology Management Decisions//. 2nd ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2002.