Vaginal Cancer

Gynecological Oncology

Clinicals - History

Fact Explanation
Incidental diagnosis on pap smear Primary vaginal cancers are rare but metastatic cancers are common. Squamous cell carcinomas are the commonest histological variant and other variants are clear cell adenocarcinoma and Melanoma. Etiological factors identified are infections such as HPV, HSV, Trichomonas vaginalis,and HIV. Also history of cervical intraepithelial neoplasia (CIN) is considered as a risk factor probably due to association with HPV in both conditions. Diethylstilbestrol is a drug which is implicated as an etiological factor for vaginal cancer. Cigarette smoking, immunosuppressive therapy, chemotherapy, and radiation therapy are also identified as predisposing factors. This is more common in elderly females. Modes of spread are by direct invasion by the tumor, Lymphatic dissemination and hematogenous spread. Incidental diagnosis on pap smear
Primary vaginal cancers are rare but metastatic cancers are common. Squamous cell carcinomas are the commonest histological variant and other variants are clear cell adenocarcinoma and Melanoma. Etiological factors identified are infections such as HPV, HSV, Trichomonas vaginalis,and HIV. Also history of cervical intraepithelial neoplasia (CIN) is considered as a risk factor probably due to association with HPV in both conditions. Diethylstilbestrol is a drug which is implicated as an etiological factor for vaginal cancer. Cigarette smoking, immunosuppressive therapy, chemotherapy, and radiation therapy are also identified as predisposing factors. This is more common in elderly females. Modes of spread are by direct invasion by the tumor, Lymphatic dissemination and hematogenous spread.
Painless vaginal bleeding This is the most common symptom, which could manifest as postmenopausal bleeding Painless vaginal bleeding
This is the most common symptom, which could manifest as postmenopausal bleeding
Itching and vaginal discharge This could be due to infectious lesions involved in the pathogenesis or the malignancy it self. Itching and vaginal discharge
This could be due to infectious lesions involved in the pathogenesis or the malignancy it self.
Urinary symptoms Anterior lesions can spread to involve bladder and can cause urinary symptoms such as dysuria, urgency and hematuria. Urinary symptoms
Anterior lesions can spread to involve bladder and can cause urinary symptoms such as dysuria, urgency and hematuria.
Pelvic pain Compress of nerves due to tumor spread causes pain. Pelvic pain
Compress of nerves due to tumor spread causes pain.
Tenesmus or constipation Posterior lesions invade the rectum and cause these symptoms Tenesmus or constipation
Posterior lesions invade the rectum and cause these symptoms
vaginal mass or vaginal prolapse Only seen if the tumor is very large. vaginal mass or vaginal prolapse
Only seen if the tumor is very large.
Cough, hemoptysis, shortness of breath These pulmonary symptoms are seen once the malignancy spreads to the lungs by blood Cough, hemoptysis, shortness of breath
These pulmonary symptoms are seen once the malignancy spreads to the lungs by blood
Back pain, bone pain These are symptoms due to metastasis to the bone. Back pain, bone pain
These are symptoms due to metastasis to the bone.
Yellowish discoloration of the eyes and sclera, abdominal pain These are symptoms due to metastasis to the liver Yellowish discoloration of the eyes and sclera, abdominal pain
These are symptoms due to metastasis to the liver
Asymptomatic Could be asymptomatic as well and the diagnosis is only made during routine pelvic examination. Asymptomatic
Could be asymptomatic as well and the diagnosis is only made during routine pelvic examination.

Clinicals - Examination

Fact Explanation
Lesion/ mass in the vagina A mass/ lesion or the prolapse of the vagina is seen when the tumour mass is large. The lesion/ mass maybe felt in the digital vaginal examination if exophytic or contact bleeding can be present. In advanced malignancies pelvic structures maybe fixed. Speculum examination will also show masses, lesions, discharges. Lesion/ mass in the vagina
A mass/ lesion or the prolapse of the vagina is seen when the tumour mass is large. The lesion/ mass maybe felt in the digital vaginal examination if exophytic or contact bleeding can be present. In advanced malignancies pelvic structures maybe fixed. Speculum examination will also show masses, lesions, discharges.
Vaginal discharge This could be due to infectious lesions or the malignancy it self Vaginal discharge
This could be due to infectious lesions or the malignancy it self
Genital warts As HPV is an etiological factor, genital warts caused by HPV could be seen in the vicinity. Genital warts
As HPV is an etiological factor, genital warts caused by HPV could be seen in the vicinity.
Rectal masses Direct spread to the rectum may show rectal masses or felt during digital rectal examination. Rectal masses
Direct spread to the rectum may show rectal masses or felt during digital rectal examination.
Lymph node enlargement Lymphatic spread of the malignancy produces lymph node deposits in the inguinal nodes if the malignancy is in the lower third of the vagina as well as the para aortic nodes if in the upper third of the vagina. Lymph node enlargement
Lymphatic spread of the malignancy produces lymph node deposits in the inguinal nodes if the malignancy is in the lower third of the vagina as well as the para aortic nodes if in the upper third of the vagina.
Hepatomegaly/ Ascits Liver metastasis may cause enlarged liver and ascites Hepatomegaly/ Ascits
Liver metastasis may cause enlarged liver and ascites
Bone tenderness Bone metastasis may produce bone tenderness over spine Bone tenderness
Bone metastasis may produce bone tenderness over spine
Jaundice Liver metastasis leads to jaundice. Jaundice
Liver metastasis leads to jaundice.
Pallor Profuse bleeding may be sufficient to cause clinical pallor Pallor
Profuse bleeding may be sufficient to cause clinical pallor
Dullness on percussion and reduced breath sounds in respiratory system examination Lung metastasis leads to these lung signs Dullness on percussion and reduced breath sounds in respiratory system examination
Lung metastasis leads to these lung signs

Investigations - Diagnosis

Fact Explanation
Vaginal colposcopy and biopsy This is done under general anesthesia. As malignant cells lack glycogen unlike healthy vaginal mucosa, they do not stain dark brown with Lugol's iodine . This directs the ares to obtain biopsy. Vaginal colposcopy and biopsy
This is done under general anesthesia. As malignant cells lack glycogen unlike healthy vaginal mucosa, they do not stain dark brown with Lugol's iodine . This directs the ares to obtain biopsy.
Pap smear A routine Papanicolaou smear may identify abnormal cells but first a cervical cancer should be excluded because it's very common than vaginal cancer. Pap smear
A routine Papanicolaou smear may identify abnormal cells but first a cervical cancer should be excluded because it's very common than vaginal cancer.
HR-HPV DNA testing This test can be on vaginal cytologic specimens to evaluate the presence of HPV which could be a causative agent. HR-HPV DNA testing
This test can be on vaginal cytologic specimens to evaluate the presence of HPV which could be a causative agent.

Investigations - Management

Fact Explanation
Vaginal colposcopy and biopsy This is done under general anesthesia. As malignant cells lack glycogen unlike healthy vaginal mucosa, they do not stain dark brown with Lugol's iodine . This directs the ares to obtain biopsy. Vaginal colposcopy and biopsy
This is done under general anesthesia. As malignant cells lack glycogen unlike healthy vaginal mucosa, they do not stain dark brown with Lugol's iodine . This directs the ares to obtain biopsy.
Pap smear A routine Papanicolaou smear may identify abnormal cells but first a cervical cancer should be excluded because it's very common than vaginal cancer. Pap smear
A routine Papanicolaou smear may identify abnormal cells but first a cervical cancer should be excluded because it's very common than vaginal cancer.
Full blood count To exclude anemia prior to surgery Full blood count
To exclude anemia prior to surgery
Coagulation studies To exclude any coagulopathy prior to surgery Coagulation studies
To exclude any coagulopathy prior to surgery
Renal function tests ( Serum Creatinine, eGFR, Blood urea nitrogen) To assess the fitness for anesthesia prior to surgery Renal function tests ( Serum Creatinine, eGFR, Blood urea nitrogen)
To assess the fitness for anesthesia prior to surgery
Cystoscopy Done to identify for anterior wall tumors Cystoscopy
Done to identify for anterior wall tumors
Proctoscopy As clinical staging is carried out proctoscopy is done for posterior wall tumors Proctoscopy
As clinical staging is carried out proctoscopy is done for posterior wall tumors
Chest radiography This is done as lung metastasis by hematogenous spread is common Chest radiography
This is done as lung metastasis by hematogenous spread is common
Skeletal x-rays If the patient reports bone pain, then skeletal x-rays are performed to rule out bone metastasis. Skeletal x-rays
If the patient reports bone pain, then skeletal x-rays are performed to rule out bone metastasis.
Computed tomography (CT) scanning of the upper abdomen and pelvis Enlarged lymph nodes, compression of ureters, hydronephrosis, and liver metastasis may be easy to be visualized using CT scan. Computed tomography (CT) scanning of the upper abdomen and pelvis
Enlarged lymph nodes, compression of ureters, hydronephrosis, and liver metastasis may be easy to be visualized using CT scan.
Magnetic resonance imaging (MRI) of the upper abdomen and pelvis Enlarged lymph nodes, compression of ureters, hydronephrosis, and liver metastasis may be easy to be visualized because of excellent soft tissue resolution. Magnetic resonance imaging (MRI) of the upper abdomen and pelvis
Enlarged lymph nodes, compression of ureters, hydronephrosis, and liver metastasis may be easy to be visualized because of excellent soft tissue resolution.
fluorodeoxyglucose positron emission tomography (FDG-PET) scanning As malignant deposits are highly metabolically active, this principle is the basis of using PET scans specially for melanoma fluorodeoxyglucose positron emission tomography (FDG-PET) scanning
As malignant deposits are highly metabolically active, this principle is the basis of using PET scans specially for melanoma
Carcinoembryonic antigen (CEA), cancer antigen–125 (CA-125) Some carcinoma types may cause high levels. Carcinoembryonic antigen (CEA), cancer antigen–125 (CA-125)
Some carcinoma types may cause high levels.
Pap smear After hysterectomy Pap smear is done to assess the recurrence. Pap smear
After hysterectomy Pap smear is done to assess the recurrence.
Colposcopy and biopsy Routine screening is not done but after hysterectomy this is done to assess the recurrence in the vaginal vault. Colposcopy and biopsy
Routine screening is not done but after hysterectomy this is done to assess the recurrence in the vaginal vault.

Management - Supportive

Fact Explanation
Patient education Patient education plays a major role. Especially educated regarding the etiology, nature, course and prognosis, available treatment options and the importance follow up. Patient may be worried on the effect on sexual life following surgery or chemotherapy, radiotherapy. Therefore education regarding this also essential. Patient education
Patient education plays a major role. Especially educated regarding the etiology, nature, course and prognosis, available treatment options and the importance follow up. Patient may be worried on the effect on sexual life following surgery or chemotherapy, radiotherapy. Therefore education regarding this also essential.
Counselling Counselling is also important as it's a malignancy. Sometimes psychiatric referral may be necessary to combat grief, depression as a reaction to the news of malignancy. Counselling
Counselling is also important as it's a malignancy. Sometimes psychiatric referral may be necessary to combat grief, depression as a reaction to the news of malignancy.
Screening Screening is important as a preventive measure and done by Pap smear. Pap smear and HPV testing is recommended for women age 30 and older and negative test results indicate screening every 3 years. Screening
Screening is important as a preventive measure and done by Pap smear. Pap smear and HPV testing is recommended for women age 30 and older and negative test results indicate screening every 3 years.
Vaccination HPV 16 and 18 are responsible for malignancy and vaccination against these viruses are present as a preventive measure. It is recommended for both adolescent girls and boys prior to being sexually active Vaccination
HPV 16 and 18 are responsible for malignancy and vaccination against these viruses are present as a preventive measure. It is recommended for both adolescent girls and boys prior to being sexually active

Management - Specific

Fact Explanation
Treatment of vaginal intraepithelial neoplasia (VAIN) As in any malignnacy, treatment of vaginal cancer depends on the stage and size of the cancer,
histological type of cancer, contraindications for available treatment options. Patient's preference also plays a big role. Pap smear and colposcopy can be used to follow up but. topical chemotherapy therapy, laser treatment, brachytherapy may also be used. Sometimes, surgery is used to remove the lesion.
Treatment of vaginal intraepithelial neoplasia (VAIN)
As in any malignnacy, treatment of vaginal cancer depends on the stage and size of the cancer,
histological type of cancer, contraindications for available treatment options. Patient's preference also plays a big role. Pap smear and colposcopy can be used to follow up but. topical chemotherapy therapy, laser treatment, brachytherapy may also be used. Sometimes, surgery is used to remove the lesion.
Treatment of Stage 0 (VAIN 3 or CIS) Laser vaporization, local excision, and brachytherapy, topical chemotherapy with 5-FU cream and topical immunotherapy with imiquimod may be used. If there's recurrence, surgery with partial vaginectomy may be needed Treatment of Stage 0 (VAIN 3 or CIS)
Laser vaporization, local excision, and brachytherapy, topical chemotherapy with 5-FU cream and topical immunotherapy with imiquimod may be used. If there's recurrence, surgery with partial vaginectomy may be needed
Treatment of Stage I Radiation therapy with brachytherapy or external beam radiation is effective for squamous cell carcinomas. Partial or radical vaginectomy are also options and if the cancer is in the upper vagina, radical hysterectomy with bilateral radical pelvic lymph node removal, and radical or partial vaginectomy is done. Treatment of Stage I
Radiation therapy with brachytherapy or external beam radiation is effective for squamous cell carcinomas. Partial or radical vaginectomy are also options and if the cancer is in the upper vagina, radical hysterectomy with bilateral radical pelvic lymph node removal, and radical or partial vaginectomy is done.
Treatment of stage II Combination of brachytherapy and external beam radiation is used. Radical surgery (radical vaginectomy or pelvic exenteration), chemotherapy, chemoirradiation may also be used to treat stage II disease. Treatment of stage II
Combination of brachytherapy and external beam radiation is used. Radical surgery (radical vaginectomy or pelvic exenteration), chemotherapy, chemoirradiation may also be used to treat stage II disease.
Treatment of Stage III or IVA Surgery is not attempted as the spread is uncertain. Treatment is with both brachytherapy and external beam radiation. Chemotherapy combined with radiotherapy will provide a better outcome. Treatment of Stage III or IVA
Surgery is not attempted as the spread is uncertain. Treatment is with both brachytherapy and external beam radiation. Chemotherapy combined with radiotherapy will provide a better outcome.
Treatment of stage IVB Symptomatic improvement is seen with radiotherapy and chemotherapy is also useful. Treatment of stage IVB
Symptomatic improvement is seen with radiotherapy and chemotherapy is also useful.
Treatment of recurrent cancer If the cancer was previously treated with surgery, radiation therapy is given and vice versa if the previous treatment is radiation. Treatment of recurrent cancer
If the cancer was previously treated with surgery, radiation therapy is given and vice versa if the previous treatment is radiation.
Treatment of Vaginal melanoma Surgery is the main treatment for vaginal melanoma. Treatment of Vaginal melanoma
Surgery is the main treatment for vaginal melanoma.

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  1. ANDROUTSOPOULOS GEORGIOS, TERZAKIS EMMANOUIL, IOANNIDOU GEORGIA, TSAMANDAS ATHANASIOS, DECAVALAS GEORGIOS. Vaginal Primary Malignant Melanoma: A Rare and Aggressive Tumor. Case Reports in Obstetrics and Gynecology [online] 2013 December, 2013:1-6 [viewed 26 August 2014] Available from: doi:10.1155/2013/137908
  2. AULT K. A.. Cervical Cancer Prevention: Better Tests, Better Tools, and More Equitable Outcomes. JNCI Journal of the National Cancer Institute [online] December, 103(18):1352-1353 [viewed 26 August 2014] Available from: doi:10.1093/jnci/djr330
  3. BANSAL M., LI Z., ZHAO C.. Correlation of Histopathologic/Cytologic Follow-up Findings With Vaginal ASC-US and ASC-H Papanicolaou Test and HPV Test Results. American Journal of Clinical Pathology [online] December, 137(3):437-443 [viewed 25 August 2014] Available from: doi:10.1309/AJCP9TO1OMXLDDPI
  4. BERIWAL SUSHIL, HERON DWIGHT E, MOGUS ROBERT, EDWARDS ROBERT P, KELLEY JOSEPH L, SUKUMVANICH PANITI. High-dose rate brachytherapy (HDRB) for primary or recurrent cancer in the vagina. Array [online] 2008 December [viewed 26 August 2014] Available from: doi:10.1186/1748-717X-3-7
  5. BHALODIA JIGNASA N., KAPAPURA DHIREN V., PAREKH MALAY N.. Primary Small Cell Neuroendocrine Carcinoma of Vagina: A Rare Case Report. Pathology Research International [online] 2011 December, 2011:1-3 [viewed 25 August 2014] Available from: doi:10.4061/2011/306921
  6. BILLOW MEGAN, JAMES REBECCA, RESNICK KIMBERLY, HIJAZ ADONIS. An unusual presentation of a urethral diverticulum as a vaginal wall mass: a case report. Array [online] 2013 December [viewed 25 August 2014] Available from: doi:10.1186/1752-1947-7-171
  7. BLANCHARD P., MONNIER L., DUMAS I., MORICE P., PAUTIER P., DUVILLARD P., AZOURY F., MAZERON R., HAIE-MEDER C.. Low-Dose-Rate Definitive Brachytherapy for High-Grade Vaginal Intraepithelial Neoplasia. The Oncologist [online] December, 16(2):182-188 [viewed 26 August 2014] Available from: doi:10.1634/theoncologist.2010-0326
  8. CARUSO ANITA, VIGNA CRISTINA, MAGGI GABRIELLA, SEGA FABIO, COGNETTI FRANCESCO, SAVARESE ANTONELLA. The withdrawal from oncogenetic counselling and testing for hereditary and familial breast and ovarian cancer. A descriptive study of an Italian sample. Array [online] 2008 December [viewed 26 August 2014] Available from: doi:10.1186/1756-9966-27-75
  9. DASARI PAPA, RAJATHI S, KUMAR SURENDRAV. Colposcopic evaluation of cervix with persistent inflammatory Pap smear: A prospective analytical study. CytoJournal [online] 2010 December [viewed 25 August 2014] Available from: doi:10.4103/1742-6413.67112
  10. DHOREPATIL BHARATI, LADDA DIPAKKUMAR, RAPOL AARTIU. Rare case of primary mucinous adenocarcinoma of vagina. J Can Res Ther [online] 2013 December [viewed 25 August 2014] Available from: doi:10.4103/0973-1482.119366
  11. DRESANG L. T.. Colposcopy: An Evidence-Based Update. The Journal of the American Board of Family Medicine [online] 2005 September, 18(5):383-392 [viewed 25 August 2014] Available from: doi:10.3122/jabfm.18.5.383
  12. GRAHAM JANICE E, MISHRA AMRITA. Global challenges of implementing human papillomavirus vaccines. Array [online] 2011 December [viewed 25 August 2014] Available from: doi:10.1186/1475-9276-10-27
  13. HAMPL MONIKA, HUPPERTZ EDUARD, SCHULZ-HOLSTEGE OLAF, KOK PATRICK, SCHMITTER SARAH. Economic burden of vulvar and vaginal intraepithelial neoplasia: retrospective cost study at a German dysplasia centre. Array [online] 2011 December [viewed 26 August 2014] Available from: doi:10.1186/1471-2334-11-73
  14. HUSSAIN N., MURALA K. S., WEBSTER D.. Abnormal vaginal bleeding. InnovAiT: Education and inspiration for general practice [online] 2014 April [viewed 25 August 2014] Available from: doi:10.1177/1755738014530892
  15. HYACINTH HYACINTH I., ADEKEYE OLUWATOYOSI A., IBEH JOY N., OSOBA TOLULOPE, MEDEIROS RUI. Cervical Cancer and Pap Smear Awareness and Utilization of Pap Smear Test among Federal Civil Servants in North Central Nigeria. PLoS ONE [online] 2012 October [viewed 26 August 2014] Available from: doi:10.1371/journal.pone.0046583
  16. JIN X. W., LIPOLD L., SIKON A., ROME E.. Human papillomavirus vaccine: Safe, effective, underused. Cleveland Clinic Journal of Medicine [online] December, 80(1):49-60 [viewed 26 August 2014] Available from: doi:10.3949/ccjm.80a.12084
  17. JIN X. W., SIKON A., YEN-LIEBERMAN B.. Cervical cancer screening: Less testing, smarter testing. Cleveland Clinic Journal of Medicine [online] December, 78(11):737-747 [viewed 26 August 2014] Available from: doi:10.3949/ccjm.78a.11033
  18. KUMAR A, SRIVASTAVA U. Role of routine laboratory investigations in preoperative evaluation J Anaesthesiol Clin Pharmacol [online] 2011, 27(2):174-179 [viewed 25 August 2014] Available from: doi:10.4103/0970-9185.81824
  19. LIU X, YUE Y, ZONG S. Post-hysterectomy vaginal cuff cancer secondary to HPV infection and CIN: A case report Pak J Med Sci [online] 2013, 29(4):1068-1070 [viewed 26 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3817789
  20. MADELEINE M. M., DALING J. R., SCHWARTZ S. M., CARTER J. J., WIPF G. C., BECKMANN A. M., MCKNIGHT B., KURMAN R. J., HAGENSEE M. E., GALLOWAY D. A.. Cofactors With Human Papillomavirus in a Population-Based Study of Vulvar Cancer. JNCI Journal of the National Cancer Institute [online] 1997 October, 89(20):1516-1523 [viewed 25 August 2014] Available from: doi:10.1093/jnci/89.20.1516
  21. MCLACHLAN J. A. Commentary: Prenatal exposure to diethylstilbestrol (DES): a continuing story. International Journal of Epidemiology [online] 2006 July, 35(4):868-870 [viewed 25 August 2014] Available from: doi:10.1093/ije/dyl140
  22. MIYAMOTO DAVID T., VISWANATHAN AKILA N., GLYNN SHARON A.. Concurrent Chemoradiation for Vaginal Cancer. PLoS ONE [online] 2013 June [viewed 26 August 2014] Available from: doi:10.1371/journal.pone.0065048
  23. MOSS E L. The role of CA125 in clinical practice. Journal of Clinical Pathology [online] 2005 March, 58(3):308-312 [viewed 25 August 2014] Available from: doi:10.1136/jcp.2004.018077
  24. MURAKAMI N., KASAMATSU T., SUMI M., YOSHIMURA R., TAKAHASHI K., INABA K., MOROTA M., MAYAHARA H., ITO Y., ITAMI J.. Radiation therapy for primary vaginal carcinoma. Journal of Radiation Research [online] December, 54(5):931-937 [viewed 26 August 2014] Available from: doi:10.1093/jrr/rrt028
  25. NORDIN K. Coping style, psychological distress, risk perception, and satisfaction in subjects attending genetic counselling for hereditary cancer. [online] 2002 September, 39(9):689-694 [viewed 26 August 2014] Available from: doi:10.1136/jmg.39.9.689
  26. OLIVEIRA RAFAEL, BóCOLI MAYRA COELHO, SALDANHA JOãO CARLOS, MURTA EDDIE FERNANDO CANDIDO, NOMELINI ROSEKEILA SIMõES. Primary Small Cell Carcinoma of the Vagina. Case Reports in Obstetrics and Gynecology [online] 2013 December, 2013:1-4 [viewed 26 August 2014] Available from: doi:10.1155/2013/827037
  27. PALMER J. R.. Prenatal Diethylstilbestrol Exposure and Risk of Breast Cancer. Cancer Epidemiology Biomarkers & Prevention [online] 2006 August, 15(8):1509-1514 [viewed 25 August 2014] Available from: doi:10.1158/1055-9965.EPI-06-0109
  28. SONODA L. A., ROSENHECK R. E., TIERNEY K., MUDERSPACH L. I., PALMER S. L., SENIKOWICH M., LIN Y. G.. Novel application of a fecal management system for vaginal use in radiotherapy- associated rectovaginal fistula. Palliative Medicine [online] December, 27(1):91-93 [viewed 26 August 2014] Available from: doi:10.1177/0269216312443582