Diagnosis and treatment choices for vaginal cancer

1. Vaginal cancer
Tevfik Yoldemir MD BSc MA PhD
tevfikyoldemir
profdrdrtevfikyoldemir

2. Estimated new gynecologic cancer cases and
deaths in the United States in 2008

4. Surgical management is the mainstay of treatment for VAIN.
• – Wide local excision (5 mm margins) or partial vaginectomy
permits histologic diagnosis and exclusion of invasion.
• Specifically, surgery is indicated if there is any suspicion for
invasion or involvement of the vaginal vault recesses after
hysterectomy, in postmenopausal women or in those who have
failed other therapies.
• Primary closure of the defect can usually be performed.
• – Laser vaporization-similar technique to that described for
vulvar dysplasia as above. Generally well tolerated but side
effect can include adhesions, synechiae, or stricture.

5. • Topical therapies for VAIN dosing, administration, and surveillance:
• – Topical treatment is simple and particularly useful for multifocal disease
that does not involve the lower vagina, but complications can occur from
chemical vulvovaginitis.
• The use of intermittent regimens and several preventive steps can be used
to reduce these side effects.
• – 5-FU cream—Suppositories of 5 % 5-FU are placed in the top of the vagina
at bedtime once per week for 10 weeks. Petroleum jelly should be applied
liberally over the vulva, perineum, and anus to protect these areas.
• A tampon is then placed in the vagina to prevent leakage.
• The tampon is removed and the patient is advised to douche and bath the
next morning to wash the cream out of the vagina.
• – Imiquimod—Recently, several investigators have reported reasonable side
effect profiles and response rates in patients with VAIN using 0.25 mg of 5 %
imiquimod cream intravaginally once weekly for 3 weeks.
• Surveillance for resolution of any lesions and irritation should be performed
8–12 weeks after completion of treatment.

6. VAIN

7. • The majority of primary vaginal cancers are SCC and the peak
incidence occurs in the sixth and seventh decades of life.
– Adenocarcinomas and other histologies are more common in
younger patients.
• The majority of vaginal neoplasms are metastases from other
primary malignancies of the endometrium, cervix, or vulva.
Less commonly, vaginal metastases can occur with non-
gynecologic malignancies
• Despite treatment 3 % of VAIN 1 and 7 % of VAIN 2/3 progress
to invasive cancer (kidney, breast, lung, etc).

8. • Clinical Presentation
• • Painless vaginal discharge and postcoital or postmenopausal
• bleeding are common.
• • Women with lesions involving compression or involvement
• of nearby organs may present with urinary complaints (e.g.,
• dysuria, retention, or hematuria) or even gastrointestinal
• symptoms (e.g., tenesmus, constipation, melena) can occur.
• • Pelvic pain may be associated with advanced disease.
• • The remaining women are asymptomatic (approximately
• 5–10 %) and detected during routine physical examination
• or following abnormal Pap test.

9. Pretreatment Evaluation
• Thorough history and physical with pelvic examination and
visualization of the entire vagina that can be performed under
anesthesia if needed.
• The gross morphology, dimensions, and location of the tumor
including midline proximity and involved structures should be
documented thoroughly during the clinical evaluation.
• Further diagnostic studies also include chest radiograph,
possibly cystoscopy and proctosigmoidoscopy depending on
tumor location, symptoms, and to confirm radiographic evidence
of infiltration of other pelvic organs.
• Although, not used in staging computed tomography (CT),
magnetic resonance imaging (MRI) or PET/CT can be used to
assess lymph nodes and tumor volume for treatment planning.

10. Lymphatic dissemination
• The pattern is dependent on a complex network of efferent
lymphatics in the vagina and varies based on primary tumor
location within the vagina.
○ Lymphatic metastasis from lesions in the upper third of the
vagina spread to pelvic and para-aortic lymph nodes.
○ Tumors in the distal third of the vagina first spread to
inguinofemoral and then pelvic nodes (reported rates are
between 30 and 35 %).

12. SCC Vagina - Patterns of Failure