Vaginal Carcinoma

Squamous cell carcinoma usually involves posterior wall of upper third of vagina and may directly invade bladder or rectum.
Lesions may be ulcerative or exophytic.

• Those in the upper vagina metastasise in a similar way to cervical carcinoma e.g. regional lymph nodes and para-aortic nodes.
• Those in the middle can invade in either direction.
• Tumours in lower third metastasise mainly to inguinal nodes.

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

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 most often associated with in utero exposure to diethylstilbestrol.
80% vaginal carcinoma is metastatic.

Metastatic adenocarcinoma may occur from:

• Urethra
• Bladder
• Bartholin's gland
• Rectum
• Endometrium
• Kidney
• Ovary
• Endocervix

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 cervix and vagina and histology indicates either origin, then it is conventionally denoted as a cervical carcinoma.

Incidence

Primary vaginal cancer is the rarest gynaecological cancer. Only 1-2% of all gynaecological cancers.
The National Cancer Data Base (NCDB) in the USA reported that between 1985 - 1994 there were 4,885 cases of primary vaginal cancer.³
More than 90% were epithelial neoplasia with approximately 25% of these in situ lesions only.
Squamous carcinoma was more common as the age of the patient progressed. Adenocarcinomas represented nearly all the carcinomas in the group of patients age < 20 years and were observed less frequently with advanced age.

HIV positive women have more vaginal intraepithelial lesions compared with negative controls.
In a recent study, the incidence of vulvar, vaginal or anal intraepithelial neoplasia was 1.96 per 100 person years for the HIV-infected women and 0.26 per 100 person-years for the control women.⁴

Symptoms

• Vaginal bleeding or bloody discharge may be seen.
• Advanced tumours may affect rectum or bladder, or extend to pelvic wall causing pain or leg oedema.

• Colposcopy; because vaginal intraepithelial neoplasia (VAIN) is associated with other genital neoplasias, the cervix (when present) and vulva should be carefully examined.
• Biopsy
• Cervical cytology
• Endometrial biopsy
• CT
• Chest X-ray
• IVP
• Cystoscopy
• Sigmoidoscopy

This depends on the clinical condition of the patient and clinical staging.⁶ There is evidence that the majority of women have had a hysterectomy prior to the diagnosis of vaginal cancer.⁷ 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 candidates for clinical trials.

Radiotherapy

Combined external beam and internal radiotherapy are used.⁸

Surgical

Carbon dioxide laser is a safe and efficacious tool in the treatment of intraepithelial neoplasia of the vagina (pre-malignant disease). Sexual function is not compromised.

Stage I and some stage II may receive radical hysterectomy with removal of upper vagina.
There has recently been a report showing the feasibility of conservative surgery in women under 40 years, wishing to preserve sexual and reproductive function.⁹ There were only 4 women, but all are disease free at 51 months follow-up after tumour removal and pelvic lymphadenopathy with subsequent radiotherapy.

Prognosis depends primarily on the stage of disease, but survival is reduced in patients who are:

• Older than 60 years of age
• Symptomatic at the time of diagnosis
• Have lesions of the middle and lower third of the vagina
• Adenocarcinoma rather than squamous cell carcinoma¹⁰
• Have poorly differentiated tumors¹¹
• The length of vaginal wall involvement has been found to be significantly correlated to survival and stage of disease in squamous cell carcinoma patients¹²