Vaginal cancer
Overview
The vaginal tube is a muscular tube that connects the opening of the womb (cervix) to the skin folds (vulva) between the legs. It permits blood from your menstrual cycle to flow from your body. It is also the path that newborns take after they are born.
Vaginal cancer is characterized by an abnormal proliferation of malignant (cancerous) cells in the vagina. Abnormal vaginal bleeding is the most prevalent sign of vaginal cancer. Vaginal bleeding during or after menopause may indicate a condition that should be explored with your doctor.
Vaginal cancer definition
Primary vaginal cancer is uncommon, accounting for 1% to 2% of all female reproductive tract malignancies. The vaginal organ is a one-of-a-kind organ with different tissue kinds and planes. It is a 7–10 cm long fibromuscular tube that connects the cervix to the vulva. It is located anterior to the rectum and posterior to the urethra and bladder.
The organ is separated into three sections, which are useful for determining tumor localization and lymphatic outflow. The bottom third lies below the bladder base and prior to the urethra. The top third is at the level of the vaginal fornices, whereas the middle third is next to the bladder base. The vaginal fornices are classified as anterior, posterior, or lateral to the cervix.
The vaginal boundaries, on the other hand, are bordered by comparable histologic cell types from the cervix and vulva. Many disorders that affect the vulva or cervix can also affect the vagina. Vaginal cancer is a rare gynecologic cancer. The diagnosis of primary vaginal cancer is uncommon since the majority of these lesions (about 80% to 90%) are metastatic from another main location.
The majority of these metastases originate in other reproductive organs such as the cervix, endometrial, or ovary, but they can also occur in distant regions such as the colon, breast, and pancreas. When there is a suspicion of primary vaginal cancer, a biopsy should be performed to confirm the diagnosis histologically.
Epidemiology
The incidence of vaginal cancer, which arises predominantly from the vagina, rises with age, with nearly half of patients presenting at or after the age of 70, and 20% at or after the age of 80. Each year, around 3000 people in the United States are diagnosed with vaginal cancer, with approximately 30% dying as a result of this diagnosis. Squamous cell carcinoma is by far the most prevalent of these malignancies.
Vaginal cancer causes
Malignant and premalignant vaginal lesions are infrequent. Cancer of the vaginal organ is a clinically diverse illness. The human papillomavirus (HPV) is a recognized carcinogen for vaginal tumors; however, non-HPV-based carcinogenic mechanisms exist as well. As with cervical cancer, high-risk HPV subtypes can cause malignancies of the head and neck, as well as the vulva or vagina.
According to a 2009 study, HPV prevalence was greater in patients with vaginal cancer than in individuals with vulvar cancer. As with cervical cancer, the HPV16 viral strain was responsible for the majority of HPV-positive individuals in both malignancies.
Diethylstilbestrol (DES), a synthetic estrogen administered to pregnant women to prevent miscarriage and premature labor, has been linked to vaginal clear cell adenocarcinoma in children in the past. Since the routine use of DES was halted in the 1970s, the incidence of this malignancy has reduced. Many of the risk factors for invasive vaginal cancer are the same as those for cervical cancer, such as cigarette use, younger age at sexual beginning, HPV, and many sexual partners.
Pathophysiology
Continuous HPV infection, particularly the HPV16 subtype, has been linked to the long-term development of high-grade squamous intraepithelial lesions (HSIL) and vaginal carcinoma, similar to premalignant cervical lesions and carcinoma of the cervix. VAIN 1 to 3 precancerous lesions have recently been renamed low grade squamous intraepithelial lesion and high grade squamous intraepithelial lesion.
Primary melanomas of the female reproductive system are a rare and dangerous malignancy. The vulva is the most common location (70%) followed by the vagina and, less frequently, the cervix. Tumors of the vagina and/or cervix are significantly linked to high-risk clinicopathologic characteristics such as increased tumor thickness, ulceration, positive surgical margins, lymph node metastases, and poor long-term clinical prognosis, including mortality from the illness.
In a multivariate study, the aggressiveness of non-vulvar tumors in terms of clinical behavior is independent of advanced clinical stage and lymph node metastases. Although KIT mutations (especially in exon 11) are very prevalent, targeted molecular analysis supports an overall low prevalence of oncogenic mutations in our MOGS population.
Vaginal cancer symptoms
Abnormal vaginal bleeding is the most common presenting sign of vaginal cancer. This is followed by indistinguishable symptoms such as vaginal discharge or dysuria. Pelvic discomfort is frequently a sign of severe illness. The presence of cervical cancer is one of the most essential components of the patient's history.
The most prevalent kind of metachronous malignancy, according to a retrospective investigation, was vaginal cancer. A complete physical exam is required for the evaluation of suspected vaginal cancer, which may include a digital exam, rectovaginal exam, speculum exam, palpation of inguinal nodes, and colposcopy with biopsies.
Vaginal cancer Diagnosis
Biopsies continue to be the gold standard for detecting vaginal cancer. An examination under anesthesia with evaluation of the vaginal fornices and biopsies of the cervix is the best way to do this. However, if the patient is at ease, a clinical assessment can be undertaken. Furthermore, if a patient has a history of preinvasive or invasive cervical cancer, a vaginoscopy is required following abnormal cytology following hysterectomy or radiation therapy. There are no particular test abnormalities that may be used to diagnose vaginal cancer.
Elevated liver function tests can indicate metastatic illness; however, they are not specific. MRI of the pelvis can be used to determine tumor size, local tumor extension, and the presence of lymph node metastases in the staging of vulval and vaginal neoplasms. MRI can also be used to diagnose post-therapeutic alterations and tumor recurrence.
PET-CT scans have little usefulness in the diagnosis of vaginal cancer, and FIGO advocates for the use of sophisticated imaging modalities to guide therapy, such as computed tomography, magnetic resonance imaging (MRI), and positron emission tomography (PET).
The imaging findings, however, may not be utilized to modify or reassign the stage. FIGO examined the use of PET/CT for the evaluation of suspected or known illness in one research (primary or recurrent). In 51% and 36% of the investigations, they documented a change in prognostic perception and intended patient care, respectively.
Treatment for vaginal cancer
In most cases, early vaginal carcinomas are treated with surgery or radiation therapy. Radiation treatment and concurrent delivery of combination chemotherapy are used to treat advanced malignancies. According to a report published in the National Cancer Database, the use of CCRT (combined chemoradiation treatment) for women with vaginal cancer has grown, and it is associated with a considerable improvement. CCRT should be included in vaginal cancer therapy guidelines.
Surgery and/or radiation therapy are the major therapeutic options for stage I vaginal cancer. A broad excision can be utilized to remove a tiny tumor. More intensive surgery is required for high-risk individuals. Radiation therapy for stage I and II malignancies has extremely favorable surgical results. A retrospective analysis was carried out on eleven individuals ranging in age from 35 to 78 years. From April 2010 to June 2015, all patients in the study had radical vaginal cancer surgery.
The participants in the research had an average age of 53.2 years. Ten individuals were diagnosed with stage I vaginal cancer and one with stage II vaginal cancer using the FIGO staging criteria. The majority of the patients had squamous cell histology, although two had neuroendocrine tumors. In eight cases, the carcinoma is restricted to the upper two-thirds of the vagina, and in three cases, it is confined to the bottom one-third of the vagina.
The patients were all subjected to major pelvic surgery. Nine individuals had lymph node dissections; three of these patients had positive nodes. Adjuvant therapy was given to these individuals, as well as those who had positive surgical margins. Six patients did not get adjuvant therapy, five did not need it since they did not match the previously mentioned criteria, and one patient postponed treatment.
Complications and local recurrence were modest, with one patient developing a vesicovaginal fistula and another experiencing local recurrence over a 5- to 67-month follow-up period. At 15 months, one patient was lost to follow-up. The 12-month disease-free survival rate was 88.9%, while the 12-month overall survival rate was 100%.
The most common stage II treatment technique is a mix of brachytherapy and external beam radiation therapy (EBRT). Radical surgery may be used to treat a subset of individuals. In terms of survival, neoadjuvant chemotherapy followed by major surgery is a viable alternative to normal treatment. For stages III-IV A, the most common treatment is a combination of EBRT and brachytherapy, however in some cases, pelvic exenteration or a mixture of irradiation might be employed.
Medical Oncology
The use of chemotherapy in vaginal cancer is very new, with the majority of the study based on data from cervical cancer treatment. Treatment with cisplatin or 5-fluorouracil has shown some success in several situations. Following a recent retrospective assessment that shown an optimistic increase in overall and disease-free survival rates, chemoradiation can be considered in the care plan of vaginal cancer.
Despite the fact that it was a small study with only 71 patients, it found a substantial difference in overall survival and disease-free survival rates between women who got radiation alone vs those who had chemoradiation as their initial therapy (three-year overall survival of 56 percent versus 79 percent and three-year disease-free survival of 43 percent versus 73 %)
Surgical Oncology
In stage I lesions that are amenable to hysterectomy with upper vaginectomy and lymph node dissection, surgical therapy might be explored. These lesions should ideally be found at the apex of the vaginal posterior fornix. Lower lesions might be tackled with vulvovaginectomy, however owing to its complexity and consequences, this technique is not commonly used.
To avoid the negative consequences of radiation-induced menopause, ovarian transposition can be provided before final radiation therapy to young women with vaginal cancer who require radiation as main treatment. Laparoscopic or extraperitoneal excision of large lymph nodes might be offered in some circumstances as part of the staging and treatment planning process.
Radiation Oncology
Radiation is the cornerstone of treatment for this disease in the vast majority of patients, particularly in the late stages. Radiation treatment is a mix of external beam radiation therapy (EBRT) and intracavitary irradiation, often known as brachytherapy (ICRT). The primary benefit of radiation is organ preservation. According to the standard of care, EBRT to the pelvis covers the external iliac and obturator nodes. If the tumor is in the distal vagina, the inguinal nodes may also be included.
The ideal or lower threshold dosage, which has been demonstrated to enhance results, is 70 Gy. The Korean Radiation Oncology Group studied primary radiation treatment for vaginal cancer in a retrospective analysis. The research looked at those who had primary radiation with or without treatment.
The patients who survived the trial had a median follow-up period of 77.6 months and a median survival time of 46.9 months. The overall 5-year survival rate was 68%, the cancer-specific survival (CSS) rate was 80%, and the progression-free survival (PFS) rate was 68%. A hysterectomy and a diagnosis of CSS at an early FIGO stage were both good markers of CSS.
Differential Diagnosis
Vaginal cancer has a wide differential diagnosis, which might include abnormalities that are not characteristic of the reproductive system. Sexually transmitted illnesses like herpes simplex and syphilis can create lesions that look like cancer. Vaginal trauma can also cause bleeding akin to vaginal cancer.
Vaginal atrophy can sometimes be accompanied by vaginal hemorrhage. Polyps, Gartner duct cysts, Bartholin gland cysts, and vaginal adenosis are examples of benign vaginal lumps. When assessing if a lesion is a primary vaginal carcinoma, oncologists must rule out cervical and vulvar cancer. Colorectal cancer metastatic lesions have also been documented.
Vaginal cancer survival rate
Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis depends on the following:
- The stage of the cancer (whether it is in the vagina only or has spread to other areas).
- The size of the tumor.
- The grade of tumor cells (how different they look from normal cells under a microscope).
- Where the cancer is within the vagina.
- Whether there are signs or symptoms at diagnosis.
- Whether the cancer has just been diagnosed or has recurred (come back).
Complications
Complications from vaginal cancer therapy are determined by a variety of variables. The variables might be classified as treatment-based or patient-based. The amount of radiation, kind of surgery, and type of chemotherapy are all treatment-related parameters. Age, hormonal state, and personal cleanliness are all patient-specific considerations. Radiation effects can include edema, erythema, and mucositis with or without ulceration. Typically, these side effects subside within a few months of medication.
Conclusion
Vaginal cancer is a form of cancer that primarily affects women. Women over the age of 60 are more likely to develop this form of cancer. Women who carry the human papillomavirus (HPV) are more likely to develop vaginal cancer.
Because vaginal cancer frequently has no visible signs, it is typically advanced by the time it is identified. As a result, it is critical to have frequent well-woman checks, which can occasionally detect vaginal and cervical cancer before symptoms appear. Treatment for vaginal cancer is determined on the type of cell, stage of cancer, and age. A young lady who has not yet had children may be subjected to a particular sort of therapy in order to preserve her fertility.