This document provides an overview of vaginal cancer, including: - The main types are squamous cell carcinoma, melanoma, and sarcoma. Squamous cell carcinoma makes up 80-90% of cases. - Risk factors include HPV infection, low socioeconomic status, history of genital warts or abnormal Pap smears. - Vaginal intraepithelial neoplasia (VAIN) is considered a precursor lesion that can progress to invasive cancer. - Treatment depends on the cancer type and stage. It typically involves radiation therapy alone or combined with surgery and/or chemotherapy. The goal is organ preservation when possible.

1. Ca VAGINA
(Anatomy to management)
Dr. BRIJESH MAHESHWARI(JRII)
Moderator: Dr. ARVIND KUMAR/
Dr. AYUSH GARG

2. INTRODUCTION
• The vagina is a muscular dilatable tubular
structure averaging 7.5 cm in length that
extends from the cervix to the vulva.

4. LAYERS OF VAGINA

5. BLOOD SUPPLY

6. LYMPHATIC DRAINAGE

7. INTRODUCTION
• Rare tumor representing only 1-2% of all
gynecologic malignancies .
• 80-90% are metastatic cervix or endometrium.
• Mean age of patients with primary vaginal cancer is
6TH-7TH decade .

8. PREDISPOSING FACTORS
• HPV infection (mostly 16 and 18)
• Low socioeconomic status
• History of genital warts Vaginal discharge or irritation
• Previously abnormal Pap smear .
• Early hysterectomy
• Multiple sexual partners.

9. VAGINAL CANCER PRECURSOR
• Vaginal Intraepithelial Neoplasia (VAIN):-
defined as atypical squamous cells without evidence of
stromal invasion.
• It is hypothesized that vaginal intraepithelial neoplasia
(VAIN) is a precursor lesion to squamous cell carcinoma
of the vagina.

10. VAIN is further classified into
• low grade (VAIN 1) and
• high grade (VAIN 2 to 3).
VAIN 1
Proliferation is limited to
upper 1/3rd of epithelium.

11. VAIN 2
Proliferation of basal layer,
crowding and loss of polarity

12. VAIN 3
• Increased proliferation of
abnormal basal and parabasal
cells replacing full thickness of
epithelium.

13. • The overall incidence of VAIN is estimated to be 0.2 to
0.3 cases per 100,000, with peak incidence found in
women who are 40 and 60 years of age.
• 2% to 20% of patients with VAIN progressing to invasive
vaginal cancer.
• The rate of occult invasive disease in patients with VAIN
3 has been reported to be as high as 28%.

14. TREATMENT FOR VAIN
• In general, women with low-grade VAIN can be offered
close surveillance, as lesions often regress
spontaneously.
• 78% of patients with VAIN 1 or VAIN 2 had spontaneous
regression of disease without
treatment. (Aho et al)
• High-grade VAIN has a higher likelihood of occult
invasive disease and progression to invasive disease
and is typically treated aggressively.

15. Treatment approaches include
– local excision,
– partial or total vaginectomy,(52% to 100%)
– laser vaporization, (48% to 100%)
– electrocoagulation,
– topical 5% fluorouracil administration,(75% to 100%)
– topical 5% imiquimod, (57% to 86%) and
– Radiation. (83% to 100%)

16. Malignant Tumors of the Vagina

18. SQUAMOUS CELL CA
Clinical presentation:-
– 20% of women are asymptomatic at the time of
diagnosis .
– irregular vaginal bleeding(65%)
– Vaginal discharge (10%-15%)
– Other symptoms
• Mass
• Pain
• dysuria, or hematuria.
• tenesmus, constipation, or melena

19. – Located at superior one-third of the vaginal canal
(50% to 83%).
– Tumors may exhibit an exophytic or ulcerative,
infiltrating growth pattern.
– A high proportion of patients have a history of prior
hysterectomy.
– Involvement of the cervix (if present) or vulva at the
time of diagnosis excludes classification as a primary
vaginal cancer.

20. PATTERN OF SPREAD
• Radially, enters either into the lumen to form exophytic
masses or through the vaginal wall to invade surrounding
musculature and organs.
• Anterior wall lesion- vesicovaginal septum and/or urethra.
• Posterior wall lesions- rectovaginal septum and involve the
rectal mucosa.
• Advanced disease can extend laterally toward the
parametrium and paracolpal tissues or into the urogenital
diaphragm, levator ani muscles, or pelvic fascia and
eventually to the pelvic side wall.

21. • Distant mets :-
Hematogenous metastasis
lung
liver
and bone.
• the incidence of distant metastasis
– 16% for stage I,
– 31% for stage II,
– 62% for stage III, and
– 50% for stage IV. (Perez et al)

22. PATTERN OF LYMPHATIC SPREAD
• The upper vagina drains into obturator and hypogastric
nodes, similar to cervix.
• The lower vagina drains to inguinal, femoral and external
illiac nodes.
• Posteriorly situated lesion drains into presacral, peri-
rectal nodes.
• Incidence of lymphatic drainage involvement reported is
0-14% in stage I, 21-32% in stage II, 78 % n stage III and
83% in stage IV

23. STAGING

24. DIAGNOSTIC WORKUP
• Complete history and physical examination
.
• Speculum examination and palpation of the vagina
• Bimanual pelvic and rectovaginal examination
• Pap smear, colposcopy, directed biopsies.

25. • Cystoscopy (if needed)
• Proctosigmoidoscopy (if needed)
• Chest X-ray
• IVP
• Barium enema
• Computed Tomography
• MRI
CT of the pelvis is obtained in place of
IVP to assess the renal
parenchyma and also to obtain
information on the extent of local
disease and lymph node status
FIGO
MRI can provide salient treatment planning information by characterizing
extent of invasion and differentiating malignant tumor, which is
isointense to muscle on T1, and hyperintense on T2, from normal structures
and/or fibrosis.

26. • …….
Axial T1-weighted magnetic resonance images of a patient with stage II
squamous cell cancer of the vagina located in the left vaginal fornix with
involvement of the left parametria

27. • MRI is regarded as superior to CT for
staging of gynecologic malignancies
and should be obtained when available.

28. • Positron emission tomography (PET) has
shown efficacy in detecting the extent of primary
tumor and abnormal lymph nodes in vaginal
cancer with higher sensitivity than CT

29. PROGNOSTIC FACTORS
• Stage at time of presentation
• Size of the initial lesion.
• Extent of vaginal canal involvement.
• HPV status
• older age.
• Other possible prognostic factors include
– hemoglobin levels,
– Prior hysterectomy, and
– smoking status.

30. TEATMENT
• Radiation is the treatment of choice.
• Surgery has a limited role.
• surgery is considered beneficial only in carefully selected
patients.
• Typically, amenable lesions are
– small, superficially invasive and well-demarcated, and
localized to the upper vagina.

31. • Wide local excision reserved for carcinoma insitu or small
superficially invasive lesions that are well demarcated
• Stage I tumors of the middle or upper third of vagina
treated with radical hysterovaginectomy and PLND
• Pelvic exenteration. possible for more invasive lesions

32. RADIOTHERAPY
• Radiation is the treatment of choice given the desire for
organ preservation.
• Stage I
• For very small, superficial tumors, brachytherapy alone
can be considered.
• local control rates 62% to 100%.
• However as per some studies (Kanayama et al, Frank
et al.) patients who were treated with local radiation had
more incidence of pelvic recurrence.

33. • With LDR, treatment can be delivered in two applications,
with the first designed to treat the entire vaginal wall and a
second application to cover the tumor volume.
• When HDR brachytherapy is the primary treatment, the
entire length of the vagina is typically treated to a mucosal
dose of 60 to 65 Gy, with an additional mucosal dose of 20
to 30 Gy delivered to the area of tumor involvement

34. • Poorly differentiated or extensively infiltrating
stage I lesions should be treated with a
combination of EBRT and brachytherapy.

35. • Stage II
• primary treatment for stage II disease is radiation, most
commonly as a combination of EBRT followed by vaginal
brachytherapy; chemotherapy is typically considered.
• EBRT 45-50.4Gy.
• Boost to tumor volume with BT to total dose of 75-80Gy

36. • Stages III and IVA
• Treated with a combined modality approach of radiation
and chemotherapy.
• Pelvic EBRT, followed by additional parametrial boost.
• Minimum tumor dose of 75 to 80 Gy.
• If brachytherapy is not feasible because of extensive
tumor infiltration of the rectovaginal septum or bladder, a
shrinking field technique have been used to deliver
additional dose to the primary lesion.

37. • The overall cure rate for patients with
stage III disease ranges from 30% to 50%.
Stage IVA carries a worse prognosis.

38. INDICATIONS OF ADJUVENT RT
• Margin positive.
• Node positive.
• Stage 2 onwards
• Inadequate surgery.

39. Role of Combined Chemotherapy
and Radiation
• The control rate in the pelvis for stages III and IV
patients is relatively low.
• About 70% to 80% of the patients have persistent
disease or recurrent disease in the pelvis, in spite of
high doses of external beam RT and brachytherapy.
• Failure in distant sites does occur in about 25% to 30%
of the patients with locally advanced tumors

40. • Agents such as 5-FU, mitomycin-C, and cisplatin have
shown promise when combined with RT
• Advanced cervical cancer has improvement in
locoregional control, overall survival, and disease-free
survival for patients receiving cisplatin-based
chemotherapy concurrently with RT

42. RADIOTHERAPY TECHNIQUES
• At time of simulation, it is helpful to identify the distal
tumor margin with a radio-opaque marker.
• When available, fusion of diagnostic pelvic MRI or PET-
CT to the treatment planning CT can assist in defining
the tumor.
• If inguinal nodes are to be treated, a “frog leg” position to
expose the groin region can be considered.

43. • EBRT delivered through AP:PA portals or using 4 field
“box technique”
• Treatment fields are designed to ensure coverage of the
vagina and common iliac, external iliac, hypogastric, and
obturator lymph nodes.

44. FIELD BORDERS
• Upper border L5-S1 or L4-L5( if positive lymph nodes)
• Inferior border at introitus to ensure coverage of entire
vagina or 4 cm distal to most caudal aspect of vaginal
tumor
• Lateral border 1.5-2cm lateral to pelvic brim
• Anterior- anterior to pubic symphysis
• Posterior- posterior to junction of S2/S3 interspace

46. • The border should be extended accordingly to
include the inguinal nodes

47. Portal for pelvic RT and
elective groin coverage
Portal for groin
coverage with
palpable inguinal
nodes

48. CONFORMAL RADIOTHERAPY
• The gross tumor volume (GTV) is defined as the extent of gross
disease found on clinical examination, as well as palpable lymph
nodes and suspicious lymph nodes and regions seen on CT, MRI,
and/or PET.
• CTV = The GTV is expanded by 1 to 2 cm, which also includes the
entire length of the vagina, paravaginal tissue up to the pelvic
sidewall, and bilateral pelvic lymph nodes.
• PTV = CTV + 1cm

49. BRACHYTHERAPY
• Intracavitory brachytherapy.
• Interstitial brachytherapy.

50. INTRACAVITARY BRACHYTHERAPY
• As monotherapy can be considered for patients with
VAIN and highly selected patients with minimally
invasive stage I disease.
• Boost after EBRT lesion > 5mm total dose 70-80Gy
• LDR or HDR

51. • Intracavitary Brachytherapy: Low Dose Rate
• vaginal cylinder loaded with cesium-137 radioactive
sources.
• 2-3 cesium sources are placed along the central tandem
of the cylinder, and labia are sutured closed to secure
the implant during the treatment.
• Intracavitary Brachytherapy: High Dose Rate
typically performed using iridium-192

52. INTERSTITIAL
BRACHYTHERAPY
• Any lesions >5 mm in thickness after EBRT should be
considered for interstitial BT,
• candidates for interstitial brachytherapy include
– patients with lesions thicker than 5 mm,
– distal vaginal extension,
– or those with a vagina that is unable to accommodate
standard intracavitary applicators.

53. • Applicator Selection:-
• Template systems available includes
– Syed-Neblett template,
– the modified Syed-Neblett, and
– the MUPIT (Martinez Universal Perineal Interstitial
Template
• These systems consist of a perineal template, a vaginal
cylindrical obturator, and hollow guides for loading
radionuclide sources.
• Goal is to cover GTV with 1-2 cm margin

56. • ,././

57. • …/./.
Anterior localization film of an interstitial implant used to treat a
deeply invasive stage I lesion. Isodose curves representing dose
rates and the tumor volume have been superimposed

58. • …..
Lateral localization film of an interstitial implant showing
its position relative to the bladder and rectum. Isodose
curves representing dose rates and the tumor volume
have been superimposed

60. • Treatment Toxicities
• Acute Toxicity
– Increased urinary frequency,
– urgency, and
– dysuria.
– Hemorrhoids
• Late Toxicity
– rectovaginal or
– vesicovaginal fistulas,
– strictures in the rectum or vagina,
– premature menopause from radiation exposure to
the ovaries,
– or cystitis,
– proctitis, or
– necrosis of the soft tissue or bone

61. PATTERNS OF FAILURE
• Most treatment failures occur within 5 years
• Local recurrence is the most common pattern of
treatment failure.
• The rate of locoregional recurrence ranges from
– 10% to 20% for stage I
– 30% to 40% for stage II.
– advanced disease often have persistent disease
despite treatment, up to 68%

62. MELANOMA
• Malignant melanoma of the vagina represents
approximately 4% of all vaginal neoplasms and
approximately 0.7% of all melanomas.
• Clinically, these tumors present as pigmented masses,
plaques or ulcerative lesions, most frequently on the distal
one-third of the anterior vaginal wall.
• However, they may present in a nonpigmented manner.
• Melanomas may display aggressive biological behavior with
early and rapid local and systemic failure

63. • Treatment Option
– wide local excision,
– radical surgery,
– radiation and
– chemotherapy, or
– a combination of modalities
• Overall survival is poor 5-20%

64. SARCOMA
• Sarcomas represent 3% of all primary vaginal cancers.
• Compared to other vaginal cancers, sarcomas tended to
be larger, with decreased likelihood of lymph node
involvement.
• vaginal sarcomas had a 69% greater risk of cancer
related mortality when compared to squamous cell
carcinoma.

65. • The major types of primary vaginal sarcomas are
– Leiomyosarcomas
– endometrial stromal sarcomas
– malignant mixed mullerian tumors
– Rhabdomyosarcomas.(most common)
a highly malignant tumor that occurs in the
vagina during infancy and early childhood
(mean age 3 years).
This sarcoma has the
characteristic gross appearance
of grape-like masses that are
exophytic and can protrude from
the vagina

66. • Generally treated with a combination of surgery,
RT, and chemotherapy
• Vincristine, Dactinomycin, Cyclophosphamide
(VAC) X 1- 2 years effective adjuvant treatment
for stage 1 dz
• Local excision + interstitial/intracavitary RT +
systemic chemo has replaced radical pelvic
surgery as therapy of choice

67. Clear Cell Adenocarcinoma
• Incidence is between 0.14 to 1.4/1000 women exposed to DES
• Median age at diagnosis 19 years ( bimodal -26yr and 71yr)
• Lesions found mainly in the upper 1/3 of the anterior vaginal
wall
• 90% of patients with early stage disease (I and II) at diagnosis.
• It is a common histologic abnormality in women who have been
exposed to DES in utero, presenting in up to 95% of such
women.

68. • Surgery for stage I lesions has advantage of ovarian
preservation and better vaginal function following skin
graft
• Vaginectomy, radical hysterectomy PLND, paraaortic
LNBx (frozen section of distal margin)
• Intracavitary or transvaginal radiation can be used for
small lesions
• More extensive lesions: EBRT

69. SUMMARY
• Superficial stage I lesions may be treated with
brachytherapy or radical hysterovaginectomy
• Stage II-IVA treated with WPRT and brachytherapy
• Role of chemotherapy in advanced SCCA presently
unknown
• Pelvic failures and distant metastases occur in 1/2 of pts
with advanced diseases