Vaginal Carcinoma

This is usually a squamous cell carcinoma involving the posterior wall of upper third of the vagina. It may directly invade the bladder or rectum. Lesions may be ulcerative or exophytic. Those in the upper vagina metastasise in a similar way to cervical carcinoma, eg regional lymph nodes and para-aortic nodes. Those in the middle can invade in either direction. Tumours in the lower third metastasise mainly to inguinal nodes.

Pathology
The distinction between squamous cell carcinoma and adenocarcinoma is important because the two types represent distinct diseases, each with a different pathogenesis and natural history: Approximately 85% of cases are squamous cell vaginal cancer. This initially spreads superficially within the vaginal wall and later invades the paravaginal tissues and the parametria. Distant metastases occur most commonly in the lungs and liver.[1] Approximately 15% of cases are adenocarcinoma. This has a peak incidence between 17 and 21 years of age and differs from squamous cell carcinoma by an increase in pulmonary metastases and supraclavicular and pelvic node involvement.[2] 80% of vaginal carcinoma is metastatic: This may occur from: Urethra Bladder Bartholin's gland Rectum Endometrium Kidney Ovary Endocervix

 Rarely, melanoma and sarcoma are described as primary vaginal cancers. Adenosquamous carcinoma is a rare and aggressive mixed epithelial tumour comprising approximately 1-2% of cases. Clear cell adenocarcinomas plus vaginal adenosis are most often associated with in utero exposure to diethylstilbestrol.

Primary vaginal cancer can only be diagnosed if the cervix is uninvolved or

only minimally involved by tumour obviously of vaginal origin. Where malignancy involves both the cervix and vagina and histology indicates

either origin, then it is conventionally denoted as a cervical carcinoma.

Presentation
Symptoms Vaginal bleeding or bloody discharge may be seen. Advanced tumours may affect the rectum or bladder, or extend to the pelvic wall causing pain or leg oedema. Investigations Colposcopy; because vaginal intraepithelial neoplasia (VAIN) is associated with other genital neoplasias, the cervix (when present) and vulva should be examined carefully. Biopsy. Cervical cytology. Endometrial biopsy. CT scan. Fluorodeoxyglucose-positron emission tomography (FDG-PET) - may be more sensitive than CT scanning.[5] Chest X-ray. Intravenous pyelogram (IVP). Cystoscopy. Sigmoidoscopy.

Staging
International Federation of Gynecology and Obstetrics (FIGO) staging system[6]Stage 0 - squamous cell carcinoma in situ; this disease is usually multifocal and commonly occurs at the vaginal vault. Stage I - the disease is limited to the vaginal wall mucosa. Stage II - the disease involves the subvaginal tissue, but not the pelvic wall. Stage III - the disease extends to pelvic wall. Stage IV - the disease either extends beyond the true pelvis or involves the bladder or rectal mucosa.
Stage IVA - the disease has spread to adjacent organs. Stage IVB - the disease has spread to distant organs.

Management
This depends on the clinical condition of the patient and clinical staging: There is evidence that the majority of women have had a hysterectomy prior to the diagnosis of vaginal cancer.[ Most of this group develop cancers in the upper third of the vagina. For patients with early stage vaginal carcinoma, standard treatment is highly effective. For patients with stages III and IVA disease, radiation therapy alone is standard. For patients with stage IVB disease, current therapy is inadequate and there is no established standard treatment. These patients are rare and should be considered as candidates for clinical trials.

Medical There is some evidence that 5% imiquimod cream may be useful in the treatment of vaginal intraepithelial neoplasia.[9] Treatment leads to complete response in a large number of patients and those with only partial response will require less radical surgery. Reported side-effects were local burning and soreness, but patients did not discontinue treatment. Radiotherapy Combined external beam and internal radiotherapy are used.[10] Surgical Carbon dioxide laser is a safe and effective tool in premalignant disease. Sexual function is not compromised. Stage I and some stage II patients may undergo radical hysterectomy with removal of the upper vagina. There is limited evidence on the feasibility of conservative surgery in women aged under 40 years, wishing to preserve sexual and reproductive function.[11] In one report 4 women are disease-free at 51 months' followup after tumour removal and pelvic lymphadenopathy with subsequent radiotherapy.

Prognosis
Prognosis depends primarily on the stage of disease, but survival is reduced in patients who: Are older than 60 years of age. Are symptomatic at the time of diagnosis. Have lesions of the middle and lower third of the vagina. Have adenocarcinoma rather than squamous cell carcinoma.[12] Have poorly differentiated tumours.[13] The length of vaginal wall involvement has been found to be significantly correlated to survival and stage of disease in squamous cell carcinoma patients