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Gynae-Oncology > Vaginal Cancer > Flashcards

Vaginal Cancer Flashcards

1
Q

Most vaginal cancerous lesions are…

A

Metastatic from another primary site

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2
Q

Which HPV subtype has been most associated with HSIL and Vaginal cancer?

A

HPV 16

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3
Q

What is the most common histopathological type of vaginal cancer?

A

Squamous cell carcinoma (90%)

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4
Q

What are risk factors for vaginal cancer?

A
  • Age (postmenopausal/eldery, but increasing prevalence amongst younger women due to increased prevalence of HPV)
  • Oncogenic HPV
  • Smoking
  • HIV
  • Immunosuppression
  • Previous pelvic radiotherapy
  • Previous cervical cancer (in 30% cases)
  • DES daughters (clear cell adenocarcinoma)
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5
Q

How does immiquimod treat vaginal HSIL?

A

Immune response modulator
Activates the innate immune response
Subsequently induces pro-inflammatory factors such as interferons
RCT and systematic review have found that it is a safe and effective treatment

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6
Q

What are the management options for vaginal HSIL (VAIN 2 or 3)

A
  • Surgical excision
  • CO2 laser vaporisation
  • Topical fluorouracil
  • Immiquimod
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7
Q

How does vaginal cancer present?

A

Abnormal bleeding
Odorous discharge
Usually painless

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8
Q

How does vaginal cancer spread?

A
  • Direct extension:
  • paravaginal tissue
  • parametria
  • urethra
  • bladder
  • rectum

Lymphatic spread:

  • upper vagina drains to the pelvic lymph nodes including the obturator, internal iliac and external iliac nodes
  • lower 1/3 vagina drains to the inguinal and femoral nodes (groin nodes)

Haematogenous: lung, liver and bone

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9
Q

What is the best imaging modality to detect nodal disease in vaginal cancer (and cervical cancer)

A

PET CT

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10
Q

What is the % risk of VAIN-3 progressing to invasive disease?

A

5-10%

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11
Q

How should LSIL be managed?

A

Observation and repeat smears and colposcopy especially if non-oncogenic strains of HPV.

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12
Q

What are the benefits and risks of surgical excision of HSIL?

A

Benefits:

  • Histological diagnosis (will detect microinvasion)
  • Good for unifocal lesions in upper third of vagina or vault.
  • Recurrence rate 18%

Risks:

  • Injury to adjacent structures (rectum, bladder)
  • Dyspareunia
  • Vaginal shortening and stenosis
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13
Q

What are the benefits and risks of CO2 laser vaporisation management of HSIL?

A

Benefits:

  • Good for multi-focal lesions.
  • Less morbidity c.f. surgical excision.

Risks:

  • No histology; contraindicated if suspicion of cancer.
  • Vaginal shortening and stenosis.
  • Lower HPV clearance rate c.f. imiquimod.
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14
Q

What are the mode of action, benefits and risks of topical fluorouracil management of HSIL?

A

MOA: cytotoxic
Benefits:
- No mutilating adverse effects.
- Can treat entire vagina; good for multifocal lesions
- Avoids risks of surgery and anaesthesia

Risks:

  • Lower efficacy compared with excision or laser.
  • No histology
  • Epithelial disruption, discharge, pain and burning; not severe.
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15
Q

What are the mode of action, benefits and risks of imiquimod management of HSIL?

A

MOA: immune response modulator.

Benefits:

  • Similar regression rates to laser.
  • Superior HPV clearance >50% c.f. laser
  • Avoids risks of surgery and anaesthesia

Risks:

  • No histology
  • Local burning and soreness; not usually severe enough to stop tx.
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16
Q

Discuss the work up and investigations you would organise for a woman you suspect has vaginal cancer:

A

Exam:

  • Colposcopy and biopsy
  • Assess cervix and vulva for tumour
  • May need EUA

Investigations:

  • Biopsies: full thickness as depth of invasion important for staging.
  • MRI pelvis: if clinical assessment difficult.
  • PET-CT: for nodal disease and recurrent disease.
17
Q

Define the FIGO stages for vaginal cancer:

A

Stage I: confined to vagina

Stage II: through vaginal wall, invades paravaginal tissues but not pelvic sidewall.
- No LN or distant spread

Stage III:
- Extends to pelvic sidewall and/or
- Lower one third of vagina and/or
- Blocking flow of urine causing kidney problems
+/- pelvic or groin lymphadenopathy but not distant sites.

Stage IVa: invades bladder or rectum and/or extends beyond the true plevis.
+/- pelvic or groin lymphadenopthy but not distant sites.

Stage IVb: distant mets (lung, bone).

18
Q

How might you manage a woman with stage I vaginal cancer affecting the UPPER vagina?

A

If uterus intact: radical hysterectomy + vaginectomy (1 cm margins) + pelvic lymphadenectomy.

If previous hysterectomy: radical vaginectomy and pelvic lymphadenectomy.

19
Q

How might you manage a woman with stage I vaginal cancer affecting the LOWER vagina?

A

Radical wide local excision (1 cm margins) + groin node dissection.

20
Q

Describe the indications for radiation therapy in the treatment of vaginal cancer:

A
  • Advanced stage
  • Benefit of organ preservation (where 1 cm margins needed could only be achieved by removing bladder or rectum)
    Risks: radiation toxicity
21
Q

What are the principals of treatment for vaginal cancer?

A

Radiotherapy is the mainstay for most cases.
Limited evidence for chemotherapy.

Surgery only indicated in the following circumstances:

1) Stage 1 disease with disease in high vagina - Radical hysterectomy, upper vaginectomy and pelvic lymphadenectomy
2) Laparoscopy to suspend ovaries prior to pelvic radiotherapy in pre-menopausal women
3) Pelvic exenteration if stage IVA disease, particularly if vesicovaginal/rectovaginal fistula
4) Pelvic exenteration if failure of radiotherapy

22
Q

What are the risk factors for vaginal adenocarcinoma?

A
  • DES daughters (clear cell)
  • Wolffian duct remnants (e.g.gartners cyst)
  • Vaginal endometriosis
23
Q

What is the prognosis for vaginal cancer?

A

BAD
5 year survival 52% in SCC

Worse in rarer types of cancer: adenocarcinoma (non-DES), melanoma (10%)

24
Q

What proportion of gynaecological cancers are vaginal cancer?

A

2%

Rare.

25
Q

What proportion of vaginal cancers have had cervical carcinoma or HSIL managed in previous 5 years?

A

30%

Gynae-Oncology (14 decks)

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