Vaginal

Question 1

Histological types of vaginal cancer- what is most common?

Answer 1

SCC most common (>80%)

Adenocarcinoma (10%)

Sarcoma
Melanoma
Small cell
Lymphoid
Carcinoid

Question 1

Median age of dx for vaginal SCC cancer

Answer 1

65years

Question 2

Frequency of vaginal cancer

Answer 2

Rare
<3% of all gynae cancers
6000 pa in USA

Question 3

Risk factors for vaginal cancer

Answer 3

Similar to cervical

current Smoking
HPV (75%)
- life time number of sexual partners
- early age at first intercourse
DES exposure (clear cell Adeno)
alcohol consumption
prev RT (controversial)

Question 4

What type of mucosa is the vagina

Answer 4

stratified squamous non keratinising

Question 5

What is the lymphatic drainage of the upper third of the vagina

Answer 5

Internal and external iliac, common iliac nodes
parametrial nodes
obturator nodes

Question 6

What is the lymphatic drainage of the middle third of the vagina

Answer 6

Drains to both lymphatic pathways of upper and lower vagina;

Upper: parametrial, obturator, pelvic (external and internal and common iliac) nodes

Lower: inguinal , external iliacs

Question 7

Where does vaginal cancer commonly metastasise to?

Answer 7

Para-aortic lymph nodes
Lungs, liver, Bone

Question 8

What HPV subtypes are specifically implicated in Vaginal cancer?

Answer 8

HPV 16 and 18

Question 9

What % of gynae cancers is vaginal cancer? How does it rank compared to other gynae cancer?

Answer 9

3% of all gynae cancers

4th most common gynae malignancy

Question 10

What is the most common location of vaginal cancer?

Answer 10

Posterior wall, superior third of vagina

(the speculum must be rotated to ensure exam of this region).

Question 11

Are the majority of vaginal cancers primary or metastatic?

Answer 11

approx 75%

often arising from the endometrium, cervix, vulva, ovary, breast, rectum and kidney.
Vaginal metastases may occur by direct extension (eg, cervix, vulva, endometrium) or by lymphatic or hematogenous spread (eg, breast, ovary, kidney).

Question 12

Presenting symptoms of vaginal cancer

Answer 12

Vaginal bleeding (typically post coital)

Vaginal discharge

Vaginal mass

Local extension of disease
- Urinary symptoms (frequency, dysuria, haematuria)
- GI symptoms (tenesmus, constipation, Malena)

Pelvic pain

Question 13

How should a vaginal cancer be classified if it has occurred within 5 years of a previous gynae malignancy?

Answer 13

If vaginal cancer is diagnosed <5 years after previous gynaecologic malignancy, then new diagnosis should be categorised as a recurrence of the original

Question 14

Increased risk for clear cell adenocarcinoma is linked with what exposure?

Answer 14

In utero exposure to the synthetic estrogen diethylstilbestrol (DES) is linked with an increased risk for clear cell adenocarcinoma.

Question 15

What type of vaginal sarcoma is most common in adults? In children?

Answer 15

Adults: leiomyosarcoma

Children (≤6 yo): embryonal RMS (i.e., sarcoma botryoides)

Question 16

A vaginal cancer is never considered a vaginal primary if it involves either
of what 2 structures?

Answer 16

Cancer involving the vulva or cervix is never considered to be a vaginal
primary (even if the bulk of Dz lies in the vagina).

Question 17

What are 3 appropriate Tx options for vaginal intraepithelial neoplasia
(VAIN)?

Answer 17

Surgical excision, laser vaporization, and topical 5-FU are all appropriate
Tx for VAIN.

Question 18

VAIN is multifocal in what % of pts?

Answer 18

Up to 60% of pts with VAIN have multifocal Dz. Close f/u is essential

Question 19

In general, what is the preferred definitive Tx modality for vaginal
cancer?

Answer 19

Although Sg may be appropriate for early, stage I lesions (upper third vagina, <2cm)
, definitive RT is
generally the preferred Tx modality (as morbidity is less compared with
radical Sg).

Question 20

What brachytherapy technique is commonly required for stages II–III
vaginal cancer (in addition to EBRT Tx)? How important is it to include
brachytherapy?

Answer 20

1. Interstitial brachytherapy needle implants are commonly required to
   achieve adequate brachytherapy dose coverage for stages II–III vaginal cancers (the depth–dose characteristics of intracavitary applicators are not favorable enough to treat deep lesions).
2. SEER analysis (Orton A et al., Gynecol Oncol 2016)
   compared pts with primary vaginal cancer treated with EBRT alone
   vs. EBRT with brachtherapy. All FIGO stages benefited with a reduced
   rate of death by more than 20%.

Question 21

What common late effect may limit sexual function as well as f/u for vaginal cancer?

Answer 21

Vaginal stenosis is very common following RT for vaginal cancer. All pts
should use a vaginal dilator

Question 22

What is stage I vaginal cancer

Answer 22

Vagina confined

Stage Ib <2cm
Stage Ib >2cm

Question 23

What is stage II vaginal cancer?

Answer 23

Invading paravaginal tissue, but not PSW (muscle, fascia, neurovas, bone)

IIA <2cm
IIB >2cm