vaginal cancer

Question 1

is vaginal cancer common or rare

Answer 1

rare

Question 2

age for vaginal cancer

Answer 2

most commonly >65 but can also be seen in young women mothers using diethylstilbestrol -estrogen therapy (however this is rarely used0

Question 3

causes of vaginal cancer

Answer 3

STI's
CIN (cervical intraepithelial neoplasia)
HPV (6and11)
use of dethyistillbeterol (estrogen therapy mothers used from the 1940's-1970's)
smoking 
previous pelvic XRT

Question 4

Vagina connects what 2 structures

Answer 4

cervix to the vulva and the external structures

Question 5

vagina is located ____ to the bladder and ____to rectum

Answer 5

post, ant

Question 6

what are the functions of the vagina

Answer 6

Produces acidic pH secretions to prevent growth of bacteria and yeast
Produces mucus during sexual stimulation for lubrication
Acts as a canal to the exterior during child birth

Question 7

spread in vaginal cancer

Answer 7

Direct extension to the parametrium, bladder or rectum

Distant spread to liver and lungs

Question 8

where is vaginal cancer most common (what part of the vagina)

Answer 8

Most common in the post upper ⅓

Question 9

most common presentation of vaginal cancer

Answer 9

most commonly asymptomatic at diagnosis

Question 10

s&s of advanced vaginal cancer

Answer 10

Abnormal bleeding
Vaginal discharge
Painless mass
Constipation
Painful urination
Hematochezia

Question 11

diagnosis of vaginal cancer

Answer 11

FNA used for palpable inguinal l/n

Question 12

most common histology of vaginal cancer, second most common?

Answer 12

most common is SCC then malignant melanoma

Question 13

staging for vaginal cancer

Answer 13

Stage I:Limited to vaginal mucosa
Stage II: Extension to submucosa and parametrium but not to pelvic side walls
Stage III: Extension to pelvic side wall
Stage IV: Bladder, rectum or other distant mets
uses FIGO staging

Question 14

use of surgery in the treatment of vaginal cancer

Answer 14

Less common now due to devastating functional results

Now used for recurrence

Question 15

use of chemo in vaginal cancer

Answer 15

May be used adjuvantly in combo w/ XRT for stages IIB, III & IV

Question 16

What chemo agents are used

Answer 16

cispltinum

Question 17

when is XRT used in the treatment of vaginal cancer

Answer 17

Used as primary for stage IIB- IV and adjuvant for stage I-IIA following brachy

Question 18

CT scanning limits for vaginal cancer

Answer 18

CT Scan Limits:
Sup= L3/L4
Inf= 5cm inf of ischial tuberosities

Question 19

shielding for vaginal cancer treatment

Answer 19

5HVL midline shielding introduced at approx. 4000cGy to protect the rectum and bladder while still treating the parametrium
Shielding of the small bowel and femoral heads

Question 20

target volume for XRT treating the upper 1/3 of the vagina

Answer 20

Upper ⅓= Same as for cervix

Question 21

target volume for XRT treating the lower 2/3 of the vagina

Answer 21

GTV is entire length of vagina
All pelvic l/n
Inguinal and femoral l/n

Question 22

Field borders XRT

Answer 22

Sup= L4/L5 (to cover external iliac l/n) OR L2/L3 (to cover common iliac l/n)
Inf= Introitus (cover entire vagina)
Lat= 2cm lat to pelvic brim

Question 23

Drainage of the upper 2/3 of the vagina

Answer 23

FOLLW CERVICAL DRAINAGE paracervical- internal iliacs, external iliac, common iliac, paraaortic, cisternal chyli, thoracic duct

Question 24

drainage of the lower 1/3 of the vagina

Answer 24

Follow vulvar drainage and include femoral and inguinal Ln

Question 25

use of brachytherapy in vaginal cancer indications

Answer 25

Alone or in combo with EBRT of stage I tumours As a boost post EBRT for stage II-III As palliative tx for stage IV

Question 26

dose LDR/ PDR bratty

Answer 26

Sole Treatment: 60Gy at 0.5Gy/hr | Boost: After EBRT 45-50Gy should be to a dose of 20-25Gy at 0.5Gy/hr

Question 27

dose HDR bratty

Answer 27

Sole Treatment: 30-36Gy/5-6 | Boost: After EBRT 45-50Gy delivered in 16.5Gy fractions in 3 fractions

Question 28

bratty types for vaginal

Answer 28

May use LDR iridium wire interstitial implants and afterloading implant techniques for either PDR or HDR

Question 29

PDR/HDR indications

Answer 29

Therefore limited to tumours where the PTV will not be more than 1cm from the surface Typically used for lesions that have been completely excised or for flat superficial tumours For those w/ a high risk of nodal disease, EBRT should also be considered adjuvantly

Question 30

treatment stage 1 vaginal cancer

Answer 30

Primary brachy w/ possible adjuvant brachy mucosal boost and/or EBRT pelvic boost) Superficial tumours may be treated with only intracavitary cylinder covering the entire vagina with 60Gy and an additional mucosal boost of 20-30Gy EBRT should be reserved for very aggressive lesions to supplement intracavitary- whole pelvis treated with 10-20Gy w/ additional parametrial dose should be delivered w/ a midline 5 HVL block shielding the brachy volume to give a total dose of 45-50Gy to the parametric

Question 31

treatment stage 2 a vaginal cancer

Answer 31

Stage IIA: (Primary brachy w/ adjuvant pelvic EBRT and possible brachy boost) Requires a greater EBRT dose- whole pelvis to 20-30Gy w/ additional parametrial dose w/ midline block for a total dose of 45-50Gy

Question 32

stage 2b-4 vaginal cancer treatment

Answer 32

Stage IIB-IV: (Primary EBRT with adjuvant brachy and possible brachy boost) For advanced tumours 40Gy whole pelvis and 55-60Gy total parametrial dose w/ midline shielding w/ intracavitary brachy for a total tumour dose of 75-80Gy and parametrial dose of 65Gy An interstitial implant boost of 20-25Gy is sometimes used w/ pts w/ extensive parametrial infiltration

Question 33

most important prognostic indicator

Answer 33

stage

Question 34

prognostic indicators

Answer 34

``` stage Age Extent of mucosal involvement Degree of differentiation Histology ```

Question 35

how long is the vagina

Answer 35

7.5cm

Question 36

anterior vaginal wall drainage

Answer 36

deep pelvic nodes (including inter iliac and parametrical LN)

Question 37

what LN is most often involved in lower 1/3 vagina

Answer 37

inguinal LN

Question 38

what type of test can detect early SCC but not CCA (clear cell carcinomas)

Answer 38

exfoliative cytology

Question 39

which is more likely to recur SCC or adenocarcinoma

Answer 39

adenocarcinoma

Question 40

which vaginal cancer histology is worst

Answer 40

non epithelial cancers (ex: sarcoma, melanoma)

Question 41

preferred treatment for vaginal cancers

Answer 41

XRT

Question 42

CCA (clear cell carcinoma) is mostly associated with what risk factor

Answer 42

mothers having used diethylbestorol

Question 43

treatment for when LN are palpable

Answer 43

additional 15Gy should be given with 10-18Mv and 2 cm bolus should be used

Question 44

interstitial bratty sources

Answer 44

cs137 ra226 Ir192

Question 45

ages for vagonal cancer

Answer 45

can be >65 (SCC) | OR LESS commonly in younger Pt (15-29) for clear cell carcinoma

Question 46

where do most vaginal cancers arise

Answer 46

upper 1/3 of the vagina

Question 47

tumours in the apex of the vagina are associated with what in majority of cases?

Answer 47

60% are associated with hysterectomy- most likely because the apex of the vagina is close to cervix

Question 48

lYMPHATIC DRAINAGE OF VAGINAL APEX

Answer 48

follows cervical lymphatics drainage | Parametric- pelvic- common iliacs- paraortics-s'clav

Question 49

lymphatic drainage of the posterior pelvic wall

Answer 49

drain to Sup and inf gluteal Ln

Question 50

lymphatic drainage of lower 1/3 of vagina

Answer 50

can follow vulvar drainage- inguino and femoral Ln

Question 51

most common presentation

Answer 51

is most commonly diagnosed asymptomatic

Question 52

MOST COMMON PATHOLOGY

Answer 52

SCC 80-90%

Question 53

what treatment modality is not typically used? and why?

Answer 53

surgery- as the loss of function is devastating to the patent, its only used for recurrence of tumour