Vaginal Cancer Flashcards
Most vaginal cancerous lesions are…
Metastatic from another primary site
Which HPV subtype has been most associated with HSIL and Vaginal cancer?
HPV 16
What is the most common histopathological type of vaginal cancer?
Squamous cell carcinoma (90%)
What are risk factors for vaginal cancer?
- 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)
How does immiquimod treat vaginal HSIL?
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
What are the management options for vaginal HSIL (VAIN 2 or 3)
- Surgical excision
- CO2 laser vaporisation
- Topical fluorouracil
- Immiquimod
How does vaginal cancer present?
Abnormal bleeding
Odorous discharge
Usually painless
How does vaginal cancer spread?
- 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
What is the best imaging modality to detect nodal disease in vaginal cancer (and cervical cancer)
PET CT
What is the % risk of VAIN-3 progressing to invasive disease?
5-10%
How should LSIL be managed?
Observation and repeat smears and colposcopy especially if non-oncogenic strains of HPV.
What are the benefits and risks of surgical excision of HSIL?
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
What are the benefits and risks of CO2 laser vaporisation management of HSIL?
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.
What are the mode of action, benefits and risks of topical fluorouracil management of HSIL?
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.
What are the mode of action, benefits and risks of imiquimod management of HSIL?
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.
Discuss the work up and investigations you would organise for a woman you suspect has vaginal cancer:
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.
Define the FIGO stages for vaginal cancer:
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).
How might you manage a woman with stage I vaginal cancer affecting the UPPER vagina?
If uterus intact: radical hysterectomy + vaginectomy (1 cm margins) + pelvic lymphadenectomy.
If previous hysterectomy: radical vaginectomy and pelvic lymphadenectomy.
How might you manage a woman with stage I vaginal cancer affecting the LOWER vagina?
Radical wide local excision (1 cm margins) + groin node dissection.
Describe the indications for radiation therapy in the treatment of vaginal cancer:
- Advanced stage
- Benefit of organ preservation (where 1 cm margins needed could only be achieved by removing bladder or rectum)
Risks: radiation toxicity
What are the principals of treatment for vaginal cancer?
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
What are the risk factors for vaginal adenocarcinoma?
- DES daughters (clear cell)
- Wolffian duct remnants (e.g.gartners cyst)
- Vaginal endometriosis
What is the prognosis for vaginal cancer?
BAD
5 year survival 52% in SCC
Worse in rarer types of cancer: adenocarcinoma (non-DES), melanoma (10%)
What proportion of gynaecological cancers are vaginal cancer?
2%
Rare.
What proportion of vaginal cancers have had cervical carcinoma or HSIL managed in previous 5 years?
30%
