Reproductive health

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PREMALIGNANT AND MALIGNANT LESIONS OF THE VAGINA
Specific Learning Outcomes
1. Describe the pathology and management of the premalignant lesions
2. List the risk factors associated with carcinoma of the vagina
3. Describe the classification carcinoma of the vagina
4. Describe the types of carcinomas of the vagina and management
5. Enumerate the associated complications
Preinvasive Disease of the Vagina
Vaginal intraepithelial neoplasia (VAIN)
 As an isolated lesion but multifocal disease is more common
 Natural history thought to be similar to that of
 Cervical intraepithelial neoplasia (CIN)

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 Associated with HPV and condylomatous lesions
 Usually asymptomatic and detected by routine vaginal cytologic studies
Pathology
 Characterized by a loss of epithelial cell maturation
 Associated with nuclear hyperchromatosis and
 Pleomorphism with cellular crowding
 Thickness of the epithelial abnormality designates the various lesions as
 VAIN I, II, or III.
 VAIN III synonymous with carcinoma in situ of the vagina
Diagnosis
 Almost all lesions asymptomatic
 Lesions often accompany HPV infection, so may have vulvar warts

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 An abnormal Pap smear is usually the first sign of disease
 Diagnosis by colposcopic examination of the vagina with a
 Directed biopsy with use of 3-5% acetic acid or Lugol’s iodine
Treatment
 The primary treatment modality is
 Surgical excision or carbon dioxide laser ablation
 VAIN I lesions usually do not require treatment
 Typically regress, are multifocal, and often recur
 VAIN II and III can be treated by laser ablation or excision.
 VAIN III lesions need adequate sampling before ablation
 Total excision if lesion focal
 If multifocal disease is present:
 Total vaginectomy then a split-thickness skin graft vaginal reconstruction or

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 Topical 5 fluorouracil may also be used in treating multifocal
 Approx 80% of patients evidence of regression after one to two courses of treatment
Follow-Up
 Monitor closely every 3–4 months with colposcopic examinations
 Of entire lower genital tract
Cancer of the Vagina
Essentials of Diagnosis
 If asymptomatic, abnormal vaginal cytology.
 Early presentation is painless bleeding from ulcerated tumor.
 Late presentation has bleeding, pain, weight loss, swelling
General Considerations
 Primary cancers of the vagina rare (approx. 3% of gynaecological cancers)

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 Approximately 85% are squamous cell cancers
 Others, in decreasing order of frequency:
 Adenocarcinomas
 Sarcomas
 Melanomas
 Secondary tumours from
 Cervical, endometrial, or ovarian and breast cancers,
 Gestational trophoblastic disease,
 Colorectal, urogenital and vulvar cancers
 Extension of cervical cancer to the vagina probably
 The most common malignancy
 HPV, early hysterectomy, and prior radiation possible risk factors for vaginal cancer
 No specific etiologic agent has been identified.

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Pathology
 Squamous cell carcinoma may be ulcerative or exophytic
 Usually involves the posterior wall of the upper third of the vagina
 But may be multicentric.
 Direct invasion of the bladder or rectum may occur
 Incidence of lymph node metastases directly related to tumour size
 Tumors in the lower third metastasize like cancer of the vulva
 Primarily to the inguinal lymph nodes
 Cancers of upper vagina metastasize like cancer of the cervix
 Lesions in the middle third of the vagina may metastasize to the
 Inguinal lymph nodes or directly to the deep pelvic lymph nodes
 Melanomas and sarcomas of the vagina metastasize like squamous cell cancer,
 Although liver and pulmonary metastases commoner

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 Sarcomas of the vagina occur in children younger than 5 years of age and
 In women in the fifth to sixth decades
 Clear cell adenocarcinomas arise in conjunction with vaginal adenosis and
 Have been associated with diethylstilbestrol (DES) use during pregnancy
 Metastatic adenocarcinoma to the vagina may arise from the
 Urethra, Bartholin's gland, the rectum or bladder,
 The endometrial cavity, the endocervix, or an ovary, kidney or
 It may be metastatic from a distant site
Clinical Findings
 Vaginal cancer is often asymptomatic
 Postmenopausal vaginal bleeding and/or bloody discharge
 Impinge upon the rectum or bladder or extend to the pelvic wall, causing pain or leg edema.

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Table 49–2. FIGO Staging of Carcinoma of the Vagina.
Preinvasive carcinoma
Stage 0 Carcinoma in situ, intraepithelial carcinoma.
Invasive carcinoma
Stage I The carcinoma is limited to the vaginal mucosa.
Stage
II
The carcinoma has involved the subvaginal tissue but has not extended to the pelvic
wall.
Stage
III
The carcinoma has extended to the pelvic wall.
Stage
IV
The carcinoma has extended beyond the true pelvis or has involved the mucosa of the
bladder or rectum. A bullous edema as such does not permit allotment of a case to
stage IV.
Stage
IVA
Spread of the growth to adjacent organs.
Stage
IVB
Spread to distant organs.

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Differential Diagnosis
 Benign tumors from mesonephric (wolffian) or
 Paramesonephric ducts (Gartner's duct cyst)
 An ulcerative lesion
 Direct trauma
 Inflammatory reaction caused by prolonged retention of
 A pessary or other foreign body
 Occasionally, following a chemical burn
 Granulomatous venereal diseases (seldom affect vagina)
 Endometriosis that penetrates the cul-de-sac into the upper vagina
 Cancer of the urethra, bladder, rectum, or Bartholin's gland extending into the vagina

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Treatment
 Pretreatment evaluation may include:
 Chest radiography
 Intravenous pyelography
 Cystoscopy
 Proctosigmoidoscopy
 CT scan of the abdomen and pelvis
 Treatment of patients with invasive vaginal cancer primarily consists of
 Combined external-beam and internal radiation therapy
 In patients in whom coitus is an important factor, surgery should be considered
 Stages I and IIA lesions, radical hysterectomy with an upper vaginectomy
 Principles of treatment of primary adenocarcinoma same as
 Those for squamous cell cancer

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 Sarcoma botryoides,
 A variety of rhabdomyosarcoma
 Usually seen in patients younger than 5 years old
 Primary chemotherapy with vincristine, actinomycin D, and
 Cyclophosphamide plus radiation
 Melanoma treated with radiation, conservative excision, and/or radical surgery
 Epidermoid cancers that recur after primary radiation therapy
 Usually treated by pelvic exenteration
 Also multidrug regimens incorporating cisplatin
Prognosis
 The size and stage of the disease at the time of diagnosis
 Most important prognostic indicators in squamous cell cancers

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The 5-year survival rate is approximately
 Stage I - 77%
 Stage II - 45%
 Stage III - 31%
 Stage IV - 18%
Melanomas
 Very malignant
 Few respond to therapy
 Recurs locally and metastasizes to the liver and lungs
 Chemotherapy and immunotherapy have been used as adjunctive treatment.
Sarcomas
 Propensity for local recurrence and distant metastases
 Prognosis is usually poor

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DR D.K NGOTHO – S/L, RH