Vaginal cancer is a rare malignancy representing 1-2% of gynecologic cancers. Most cases are metastatic from cervical or endometrial cancer. Risk factors include HPV infection and prior pelvic radiation. Symptoms include abnormal bleeding and discharge. Diagnosis involves biopsy of any suspicious lesions. Treatment typically involves radiation therapy, with surgery reserved for early stage or recurrent disease. Prognosis depends on stage, with 5-year survival rates of 70-80% for stage I but dropping to 0% for stage IV disease. Recurrence rates after radiation range from 10-45% depending on stage.

1. Vaginal CancerVaginal Cancer
Dr Nabeel YahiyaDr Nabeel Yahiya
Junior resident in RadiotherapyJunior resident in Radiotherapy
Kottayam Medical CollegeKottayam Medical College

2. Vaginal CancerVaginal Cancer
Rare tumor representing only 1-2% of all gynecologicRare tumor representing only 1-2% of all gynecologic
malignanciesmalignancies
80-90% are metastatic80-90% are metastatic
cervix or endometrium.cervix or endometrium.
Metastatic cancer from the vulva, ovaries, choriocarcinoma,Metastatic cancer from the vulva, ovaries, choriocarcinoma,
rectosigmoid, and bladder, renal cell carcinoma, rectosigmoid, and bladder, renal cell carcinoma, melanomamelanoma,,
and breast cancer are less commonand breast cancer are less common
Mean age of patients with primary vaginal cancer is 60-65Mean age of patients with primary vaginal cancer is 60-65
yearsyears

3. IntroductionIntroduction
The vagina is a muscular dilatable tubular structureThe vagina is a muscular dilatable tubular structure
averaging 7.5 cm in length that extends from the cervix toaveraging 7.5 cm in length that extends from the cervix to
the vulvathe vulva

4. RelationsRelations

5. RelationsRelations

6. Layers of vaginaLayers of vagina

7. Blood supplyBlood supply

8. Lymphatic Drainage of VaginaLymphatic Drainage of Vagina

9. LymphaticsLymphatics

10. Vaginal Cancer: PredisposingVaginal Cancer: Predisposing
FactorsFactors
HPV infectionHPV infection
Low socioeconomic statusLow socioeconomic status
History of genital wartsHistory of genital warts
Vaginal discharge or irritationVaginal discharge or irritation
Previously abnormal Pap smearPreviously abnormal Pap smear
Early hysterectomyEarly hysterectomy
Previous pelvic radiation (?)Previous pelvic radiation (?)
In-utero exposure to DESIn-utero exposure to DES

11. Vaginal Cancer precursorsVaginal Cancer precursors
Hallmark of VAINHallmark of VAIN
– cytologic atypia-Pleomorphisim, irreg nuclear contourscytologic atypia-Pleomorphisim, irreg nuclear contours
and chromatin clumpingand chromatin clumping
– Abnormal maturationAbnormal maturation
– nuclear enlargementnuclear enlargement
 10-30% progress to Vaginal Ca10-30% progress to Vaginal Ca

12. Vaginal Cancer precursorsVaginal Cancer precursors
VAIN 1-
Proliferation of basal layer
Koilocytotic atypia
Enlarged pleomorphic nuclei
vacuolated cytoplasm

13. Vaginal Cancer precursorsVaginal Cancer precursors
VAIN 2-
Proliferation of basal layer,crowding
and loss of polarity
Koilocytotic atypia
Enlarged pleomorphic nuclei
vacuolated cytoplasm

14. Vaginal Cancer precursorsVaginal Cancer precursors
VAIN 3
Increased proliferation of abnormal basal
and parabasal cells replacing full
thickness of epithelium

15. Vaginal Cancer precursorsVaginal Cancer precursors
VAIN 3VAIN 3
– usually occurs in upper third of vagina and isusually occurs in upper third of vagina and is
multifocal and diffuse in half the cases.multifocal and diffuse in half the cases.
– 1/3 of patients have a hx/o CIN1/3 of patients have a hx/o CIN
– CIN coexists w/ VAIN in 10-20% of ptsCIN coexists w/ VAIN in 10-20% of pts
– Colposcopic findings are similar to those of CINColposcopic findings are similar to those of CIN
(aceto white epithelium with punctations and(aceto white epithelium with punctations and
mosaic patterns)mosaic patterns)

16. Vaginal Cancer precursorsVaginal Cancer precursors
Treatment Options for VAINTreatment Options for VAIN
– Excisional Bx for small lesionsExcisional Bx for small lesions
– Partial VaginectomyPartial Vaginectomy
– Laser VaporizationLaser Vaporization
– Electro coagulationElectro coagulation
– Intravaginal 5FU creamIntravaginal 5FU cream
– RTRT

17. PathologyPathology
Invasive squamous cell carcinoma is found in 75% to 95% ofInvasive squamous cell carcinoma is found in 75% to 95% of
primary vaginal carcinomasprimary vaginal carcinomas
The majority of these lesions tend to be nonkeratinizing andThe majority of these lesions tend to be nonkeratinizing and
moderately differentiated.moderately differentiated.
The well-differentiated lesions may demonstrateThe well-differentiated lesions may demonstrate
keratinization, manifested by squamous pearls andkeratinization, manifested by squamous pearls and
intracellular bridgesintracellular bridges
Grossly, these tumors may manifest as nodular, ulcerated,Grossly, these tumors may manifest as nodular, ulcerated,
indurated, exophytic, or endophytic lesionsindurated, exophytic, or endophytic lesions

18. HistologyHistology

19. Histologically, keratinizing, nonkeratinizing, basaloid, warty,Histologically, keratinizing, nonkeratinizing, basaloid, warty,
and verrucous variants have been describedand verrucous variants have been described

20. Vaginal Adenosis and AdenocarcinomaVaginal Adenosis and Adenocarcinoma
Adenocarcinoma is found in 5% to 10% of all vaginalAdenocarcinoma is found in 5% to 10% of all vaginal
cancerscancers
The non–clear cell adenocarcinoma frequently arises in theThe non–clear cell adenocarcinoma frequently arises in the
submucosa.submucosa.
When a biopsy of a vaginal lesion reveals adenocarcinoma,When a biopsy of a vaginal lesion reveals adenocarcinoma,
it is important to look for a primary lesion, such asit is important to look for a primary lesion, such as
endometrial cancer, elsewhereendometrial cancer, elsewhere

21. Vaginal adenosis defines the abnormal presence ofVaginal adenosis defines the abnormal presence of
glandular epithelium in the vagina, which is normally devoidglandular epithelium in the vagina, which is normally devoid
of glandular elementsof glandular elements
The glandular epithelial cells may line glands in theThe glandular epithelial cells may line glands in the
submucosa or cover or replace surface squamous cells andsubmucosa or cover or replace surface squamous cells and
are usually located near the surface epitheliumare usually located near the surface epithelium
adenosis is the most common histological abnormality inadenosis is the most common histological abnormality in
women exposed to DES in utero, it is not strictly confined towomen exposed to DES in utero, it is not strictly confined to
this populationthis population
The classic gross appearance of adenosis is red, velvety,The classic gross appearance of adenosis is red, velvety,
grapelike clusters in the vaginagrapelike clusters in the vagina

22. A large cystic focus of adenosis is seen underneath the stratified squamousA large cystic focus of adenosis is seen underneath the stratified squamous
epithelium of the vaginal surfaceepithelium of the vaginal surface

23. Adenosis is associated with 97% of vaginal clear cell cancerAdenosis is associated with 97% of vaginal clear cell cancer
DES-associated CCA has a predilection for the upper third ofDES-associated CCA has a predilection for the upper third of
the vagina and the ectocervixthe vagina and the ectocervix
The most common histologic pattern is tubulocystic followedThe most common histologic pattern is tubulocystic followed
by a solid pattern.by a solid pattern.
The most common cells noted are the clear cell, hobnail cell,The most common cells noted are the clear cell, hobnail cell,
and endometrioid celland endometrioid cell

24. melanomamelanoma
Malignant melanoma of the vagina represents approximatelyMalignant melanoma of the vagina represents approximately
5% of all vaginal neoplasms and approximately 0.7% of all5% of all vaginal neoplasms and approximately 0.7% of all
melanomasmelanomas
Clinically, these tumors present as pigmented masses,Clinically, these tumors present as pigmented masses,
plaques or ulcerative lesions, most frequently on the distalplaques or ulcerative lesions, most frequently on the distal
one-third of the anterior vaginal wall.one-third of the anterior vaginal wall.
However, they may present in a nonpigmented manner.However, they may present in a nonpigmented manner.
Melanomas may display aggressive biological behavior withMelanomas may display aggressive biological behavior with
early and rapid local and systemic failureearly and rapid local and systemic failure

25. SarcomaSarcoma
LeiomyosarcomasLeiomyosarcomas
endometrial stromal sarcomasendometrial stromal sarcomas
malignant mixed mullerian tumorsmalignant mixed mullerian tumors
rhabdomyosarcomas are the major types of primary vaginalrhabdomyosarcomas are the major types of primary vaginal
sarcomassarcomas

26. The most common of these isThe most common of these is
the embryonalthe embryonal
rhabdomyosarcoma (sarcomarhabdomyosarcoma (sarcoma
botryoides)botryoides)
a highly malignant tumor thata highly malignant tumor that
occurs in the vagina duringoccurs in the vagina during
infancy and early childhoodinfancy and early childhood
(mean age 3 years).(mean age 3 years).
This sarcoma has theThis sarcoma has the
characteristic grosscharacteristic gross
appearance of grape-likeappearance of grape-like
masses that are exophytic andmasses that are exophytic and
can protrude from the vagina.can protrude from the vagina.

27. Lymphomas and small cell carcinomas may also arise in theLymphomas and small cell carcinomas may also arise in the
vagina.vagina.
Small cell carcinomas behave in an aggressive manner,Small cell carcinomas behave in an aggressive manner,
similar to small cell carcinomas arising in other parts of thesimilar to small cell carcinomas arising in other parts of the
bodybody

29. Natural History and Patterns ofNatural History and Patterns of
SpreadSpread
Lesions usually found in the upper vagina on the posteriorLesions usually found in the upper vagina on the posterior
wallwall
50% of Vag Ca ulcerative50% of Vag Ca ulcerative
30% are exophytic30% are exophytic
20%are annular and constricting20%are annular and constricting
Vaginal primary tumors may spread along mucosa to cervixVaginal primary tumors may spread along mucosa to cervix
or vulvaor vulva
Direct extension to bladder, parametria, paracolpos, rectum,Direct extension to bladder, parametria, paracolpos, rectum,
cardinal ligaments, uterosacral ligamentscardinal ligaments, uterosacral ligaments

30. Natural History and Patterns ofNatural History and Patterns of
SpreadSpread
Any of the nodal groups may be involved regardless of theAny of the nodal groups may be involved regardless of the
location of the tumorlocation of the tumor
Inguinal nodes most often involved if lesion is in the lower 1/3Inguinal nodes most often involved if lesion is in the lower 1/3
of the vaginaof the vagina
Clinically apparent inguinal node mets seen in 5-20% ofClinically apparent inguinal node mets seen in 5-20% of
patientspatients
Incidence of pelvic nodes varies with stage and location ofIncidence of pelvic nodes varies with stage and location of
the tumorthe tumor

31. Clinical PresentationClinical Presentation
Abnormal vaginal bleedingAbnormal vaginal bleeding
– 50-75% of patients with primary tumors50-75% of patients with primary tumors
DischargeDischarge
DysuriaDysuria
PainPain

32. Diagnostic Work-upDiagnostic Work-up
Complete history and physicalComplete history and physical
Speculum examination and palpation of the vaginaSpeculum examination and palpation of the vagina
Bimanual pelvic and rectovaginal examinationBimanual pelvic and rectovaginal examination
Pap smear, colposcopy, directed biopsiesPap smear, colposcopy, directed biopsies

33. Diagnostic Work-upDiagnostic Work-up
CystoscopyCystoscopy
ProctosigmoidoscopyProctosigmoidoscopy
Chest X-rayChest X-ray
IVPIVP
Barium enemaBarium enema
Computed TomographyComputed Tomography
MRIMRI

34. Axial T1-weighted magnetic resonance images of a patient with stage IIAxial T1-weighted magnetic resonance images of a patient with stage II
squamous cell cancer of the vagina located in the left vaginal fornix withsquamous cell cancer of the vagina located in the left vaginal fornix with
involvement of the left parametriainvolvement of the left parametria

35. StagingStaging

37. 5 Year Survival5 Year Survival
0
10
20
30
40
50
60
70
80
Stage I Stage I I Stage I I I Stage I V

38. Natural History and Patterns ofNatural History and Patterns of
FailureFailure
Stage IStage I
– 10-20% pelvic recurrence, 10-20% distant10-20% pelvic recurrence, 10-20% distant
Stage IIStage II
– 35% pelvic recurrence, 22% distant35% pelvic recurrence, 22% distant
Stage IIIStage III
– 25-45% pelvic recurrence, 23% distant25-45% pelvic recurrence, 23% distant
Stage IVStage IV
– 58% pelvic recurrence, 30% distant58% pelvic recurrence, 30% distant

39. primary vaginal carcinomas treated with definitive RT, theprimary vaginal carcinomas treated with definitive RT, the
10-year actuarial disease-free survival (DFS)10-year actuarial disease-free survival (DFS)
94% for stage 094% for stage 0
75% for stage I75% for stage I
55% for stage II55% for stage II
32% for stage III32% for stage III
0% for those with stage IV.0% for those with stage IV.

40. ManagementManagement
Radiation therapy is the preferred treatmentRadiation therapy is the preferred treatment
for most carcinomas of the vaginafor most carcinomas of the vagina
Surgical therapySurgical therapy
– Early stage lesionEarly stage lesion
– Irradiation failuresIrradiation failures
– Non-epithelial tumorsNon-epithelial tumors
– Stage I Clear cell adenocarcinomas in youngStage I Clear cell adenocarcinomas in young
womenwomen

41. ManagementManagement
SurgerySurgery
– Wide local excision reserved for carcinoma insitu or smallWide local excision reserved for carcinoma insitu or small
superficially invasive lesions that r well demarcatedsuperficially invasive lesions that r well demarcated
– Stage I tumors of the middle or upper third of vaginaStage I tumors of the middle or upper third of vagina
treated with radical hysterovaginectomy and PLNDtreated with radical hysterovaginectomy and PLND
– Stage I tumors of the lower third of vagina which mayStage I tumors of the lower third of vagina which may
encroach on the vulva treated with radicalencroach on the vulva treated with radical
vulvovaginectomy and bilat. groin node dissectionvulvovaginectomy and bilat. groin node dissection
– Pelvic exenteration possible for more invasive lesionsPelvic exenteration possible for more invasive lesions

42. ManagementManagement
Stage IStage I
– Usually managed with RTUsually managed with RT
– Superficial lesions (<5mm) may be treated with vaginalSuperficial lesions (<5mm) may be treated with vaginal
cylinder covering the entire vaginacylinder covering the entire vagina
– Thicker lesions may be treated with vaginal cylinder +Thicker lesions may be treated with vaginal cylinder +
single plane implantsingle plane implant
– EBRT reserved for aggressive lesions (infiltrating orEBRT reserved for aggressive lesions (infiltrating or
poorly differentiated)poorly differentiated)

43. RT…RT…
Selected patients with superficial tumors brachytherapySelected patients with superficial tumors brachytherapy
alone by vaginal cylinders.alone by vaginal cylinders.
60-70Gy 0.5 cm surface LDR60-70Gy 0.5 cm surface LDR
Additional 20-30Gy to tumor aloneAdditional 20-30Gy to tumor alone
HDR, 21-25Gy in 3-5 fractionsHDR, 21-25Gy in 3-5 fractions
Additional 21-25Gy to tumorAdditional 21-25Gy to tumor

44. RT..RT..
Combination of ICA and IBT in lesions thicker than 5mmCombination of ICA and IBT in lesions thicker than 5mm
Vaginal cylinder delivers 45Gy LDR or 21-25Gy by HDR 0.5Vaginal cylinder delivers 45Gy LDR or 21-25Gy by HDR 0.5
cm vaginal mucosacm vaginal mucosa
Additional therapy with interstitial BT to tumor volumeAdditional therapy with interstitial BT to tumor volume
25-35Gy LDR25-35Gy LDR

45. Stage 1 RT..Stage 1 RT..
Combination of EBRT n BT for more aggressive stage 1 withCombination of EBRT n BT for more aggressive stage 1 with
greater infiltration and poor differentiationgreater infiltration and poor differentiation
Recent trend towards combinationRecent trend towards combination
Possible under estimation of submucosal disease or nodalPossible under estimation of submucosal disease or nodal
statusstatus

46. Stage 2Stage 2
Radiation is the primary optionRadiation is the primary option
EBRT + BTEBRT + BT
EBRT 45-50.4GyEBRT 45-50.4Gy
Boost to tumor volume with BT to total dose of 75-80GyBoost to tumor volume with BT to total dose of 75-80Gy

47. Stage 3 n 4Stage 3 n 4
EBRT + BTEBRT + BT
IMRTIMRT

48. Role of Chemotherapy and RadiationRole of Chemotherapy and Radiation
The control rate in the pelvis for stages III and IV patients isThe control rate in the pelvis for stages III and IV patients is
relatively lowrelatively low
about 70% to 80% of the patients have persistent disease orabout 70% to 80% of the patients have persistent disease or
recurrent disease in the pelvis, in spite of high doses ofrecurrent disease in the pelvis, in spite of high doses of
external beam RT and brachytherapyexternal beam RT and brachytherapy
Failure in distant sites does occur in about 25% to 30% ofFailure in distant sites does occur in about 25% to 30% of
the patients with locally advanced tumorsthe patients with locally advanced tumors

49. Therefore, there is a need for better approaches to theTherefore, there is a need for better approaches to the
management of advanced disease such as the use ofmanagement of advanced disease such as the use of
concomitant chemoradiotherapyconcomitant chemoradiotherapy
Agents such as 5-FU, mitomycin-C, and cisplatin haveAgents such as 5-FU, mitomycin-C, and cisplatin have
shown promise when combined with RTshown promise when combined with RT
Advanced cervical cancer has improvement in locoregionalAdvanced cervical cancer has improvement in locoregional
control, overall survival, and disease-free survival forcontrol, overall survival, and disease-free survival for
patients receiving cisplatin-based chemotherapypatients receiving cisplatin-based chemotherapy
concurrently with RTconcurrently with RT
This was interpolated in to therapy of vaginal cancer.This was interpolated in to therapy of vaginal cancer.

50. Radiation Therapy TechniquesRadiation Therapy Techniques
EBRT delivered through AP:PA portals or using 4 field “boxEBRT delivered through AP:PA portals or using 4 field “box
technique”technique”
It should ensure coverage of vagina common illiac, externalIt should ensure coverage of vagina common illiac, external
illiac, hypogastric, and obturator nodeilliac, hypogastric, and obturator node

51. Field bordersField borders
Upper border L5-S1 or L4-L5( if positive lymph nodes)Upper border L5-S1 or L4-L5( if positive lymph nodes)
( some authors 2cm above lower border of SI joint)( some authors 2cm above lower border of SI joint)
Inferior border at introitus to ensure coverage of entireInferior border at introitus to ensure coverage of entire
vagina or 4 cm distal to most caudal aspect of vaginal tumorvagina or 4 cm distal to most caudal aspect of vaginal tumor
Lateral border 1.5-2cm lateral to pelvic brimLateral border 1.5-2cm lateral to pelvic brim
Anterior- anterior to pubic symphysisAnterior- anterior to pubic symphysis
Posterior- posterior to junction of S2/S3 interspacePosterior- posterior to junction of S2/S3 interspace

53. Inguinal nodes should be electively covered (4500-5000cGy)Inguinal nodes should be electively covered (4500-5000cGy)
for tumors of the lower 1/3 of vaginafor tumors of the lower 1/3 of vagina
Additional 1500cGy (4-5cm depth) delivered for palpableAdditional 1500cGy (4-5cm depth) delivered for palpable
inguinal nodesinguinal nodes

54. Radiation Therapy TechniquesRadiation Therapy Techniques
Portal for pelvic RT and
elective groin coverage
Portal for groin coverage
with palpable inguinal
nodes

55. Portal to include inguinal nodesPortal to include inguinal nodes

56. EBRT doseEBRT dose
45-50.4 Gy IN 25-28 fractions45-50.4 Gy IN 25-28 fractions
Boost depend on size n site of lesionBoost depend on size n site of lesion
Vaginal apex > 5mm EBRT OR IBT boostVaginal apex > 5mm EBRT OR IBT boost
< 5mm - ICA< 5mm - ICA

57. Mid and distal s treated with IBTMid and distal s treated with IBT
If extensive disease treated with EBRTIf extensive disease treated with EBRT
Total dose of 70-80GyTotal dose of 70-80Gy

58. BrachytherapyBrachytherapy
Intracavitary brachytherapyIntracavitary brachytherapy
VAIN and highly selective minimally invasiveVAIN and highly selective minimally invasive
Boost after EBRT lesion < 5mm total dose 70-80GyBoost after EBRT lesion < 5mm total dose 70-80Gy
LDR or HDRLDR or HDR

59. LDR ICB was performed using a vaginal cylinder loaded withLDR ICB was performed using a vaginal cylinder loaded with
Cs-137Cs-137
Usually 2-3 Cs are placed along central tandemUsually 2-3 Cs are placed along central tandem
Vaginal colpostat alone can also be used for fornicial tumorsVaginal colpostat alone can also be used for fornicial tumors

60. HDR-ICB is typically performed using Ir-192HDR-ICB is typically performed using Ir-192
EBRT 45-50.4Gy followed by HDR 20-28Gy in 3-4 fractionsEBRT 45-50.4Gy followed by HDR 20-28Gy in 3-4 fractions

61. ApplicatorsApplicators

62. Applicators..Applicators..
Shielded Cylindrical ApplicatorShielded Cylindrical Applicator

63. Interstitial brachytherapyInterstitial brachytherapy
ICB not suitable > 5mmICB not suitable > 5mm
Vaginal cylinder fails to deliver sufficient coverage toVaginal cylinder fails to deliver sufficient coverage to
paravaginal tissueparavaginal tissue
Boost after EBRTBoost after EBRT

64. IBT..IBT..
Routine preoperative assessment under anaesthesia toRoutine preoperative assessment under anaesthesia to
assess diseaseassess disease
If MRI is available it s superior to assess the thicknessIf MRI is available it s superior to assess the thickness
Patient is positioned in dorsal lithotomy positionPatient is positioned in dorsal lithotomy position
A speculam and digital examination allows assessment ofA speculam and digital examination allows assessment of
vaginal width, tumor size and location, amount and thicknessvaginal width, tumor size and location, amount and thickness
of residual parametrial or paravaginal diseaseof residual parametrial or paravaginal disease

65. IBT..IBT..
A sterile set up is used at time of insertionA sterile set up is used at time of insertion
A foley catheter is placed for bladder drainageA foley catheter is placed for bladder drainage
Radio opaque markers can be kept for tumor delineationRadio opaque markers can be kept for tumor delineation

66. Templates..Templates..
Template systems are available to secure the position ofTemplate systems are available to secure the position of
needles in the target volumesneedles in the target volumes
Syed- NebletteSyed- Neblette
Modified Syed- NebletteModified Syed- Neblette
Martinez-Universal Perineal ImplantMartinez-Universal Perineal Implant

67. IBT..IBT..
These system consist of a perineal template, a vaginalThese system consist of a perineal template, a vaginal
cylinder obturator, and hollow guides for loading radionuclidecylinder obturator, and hollow guides for loading radionuclide
sources.sources.
So through opening in the template needles can be insertedSo through opening in the template needles can be inserted
Goal is to cover GTV with 1-2 cm marginGoal is to cover GTV with 1-2 cm margin

70. IBT..IBT..
It s optimal to place needle under image guidanceIt s optimal to place needle under image guidance
Laparoscopic. CT, USG, MRILaparoscopic. CT, USG, MRI
TRUSTRUS
With MRI n CT 3D Image based brachytherapy can be doneWith MRI n CT 3D Image based brachytherapy can be done
Increasing tumor control and decreasing toxicityIncreasing tumor control and decreasing toxicity

72. Anterior localization film of an interstitial implant used to treat a deeply invasive stageAnterior 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 beenI lesion. Isodose curves representing dose rates and the tumor volume have been
superimposedsuperimposed

73. Lateral localization film of an interstitial implant showing its position relative to theLateral localization film of an interstitial implant showing its position relative to the
bladder and rectum. Isodose curves representing dose rates and the tumorbladder and rectum. Isodose curves representing dose rates and the tumor
volume have been superimposedvolume have been superimposed

74. TRUS GUIDEDTRUS GUIDED

75. MRI BASED PLANNINGMRI BASED PLANNING

76. IBTIBT
HDR is preferredHDR is preferred
Limiting exposure to care givers and ability to optimize doseLimiting exposure to care givers and ability to optimize dose
distribution by 3D image based planningdistribution by 3D image based planning
Permanent implant with Au-198 n I-125 reported in elderlyPermanent implant with Au-198 n I-125 reported in elderly
patientspatients

77. Management of rare histologiesManagement of rare histologies
Small Cell CarcinomaSmall Cell Carcinoma
Poor prognosis (85% die in first year)Poor prognosis (85% die in first year)
– Reasonable local control may be obtained with surgery orReasonable local control may be obtained with surgery or
irradiation followed by systemic chemoirradiation followed by systemic chemo
– EPEP
– Cyclophosphamide, Adriamycin, Vincristine (CAV) X 12Cyclophosphamide, Adriamycin, Vincristine (CAV) X 12
cycles (some prior to initiation of RT)cycles (some prior to initiation of RT)
– Doses of RT similar to SCCADoses of RT similar to SCCA

78. ManagementManagement
RhabdomyosarcomaRhabdomyosarcoma
– Generally treated with a combination of surgery, RT, andGenerally treated with a combination of surgery, RT, and
chemotherapychemotherapy
– Vincristine, Dactinomycin, Cyclophosphamide (VAC) X 1-Vincristine, Dactinomycin, Cyclophosphamide (VAC) X 1-
2 years effective adjuvant treatment for stage 1 dz2 years effective adjuvant treatment for stage 1 dz
– Local excision + interstitial/intracavitary RT + systemicLocal excision + interstitial/intracavitary RT + systemic
chemo has replaced radical pelvic surgery as therapy ofchemo has replaced radical pelvic surgery as therapy of
choicechoice

79. Sarcoma BotryoidesSarcoma Botryoides

80. Sarcoma BotryoidesSarcoma Botryoides
Strap cell

81. ManagementManagement
Malignant LymphomaMalignant Lymphoma
< 1% of extra nodal lymphoma< 1% of extra nodal lymphoma
– Cyclophosphamide, adriamycin, vincristine, prednisoneCyclophosphamide, adriamycin, vincristine, prednisone
(CHOP) X 6 cycles most often used(CHOP) X 6 cycles most often used
– Followed by RTFollowed by RT

82. Clear Cell Adenocarcinoma andClear Cell Adenocarcinoma and
DES ExposureDES Exposure
Incidence is between 0.14 to 1.4/1000 women exposed toIncidence is between 0.14 to 1.4/1000 women exposed to
DESDES
Median age at diagnosis 19 yearsMedian age at diagnosis 19 years
Lesions found mainly in the upper 1/3 of the anterior vaginalLesions found mainly in the upper 1/3 of the anterior vaginal
wallwall
90% of patients with early stage disease (I and II) at90% of patients with early stage disease (I and II) at
diagnosisdiagnosis

83. ManagementManagement
Clear Cell AdenocarcinomaClear Cell Adenocarcinoma
– Surgery for stage I lesions has advantage of ovarianSurgery for stage I lesions has advantage of ovarian
preservation and better vaginal function following skinpreservation and better vaginal function following skin
graftgraft
– Vaginectomy, radical hysterectomy PLND, paraaorticVaginectomy, radical hysterectomy PLND, paraaortic
LNBx (frozen section of distal margin)LNBx (frozen section of distal margin)
– Intracavitary or transvaginal radiation can be used forIntracavitary or transvaginal radiation can be used for
small lesionssmall lesions
– More extensive lesions: EBRTMore extensive lesions: EBRT

84. Clear cell adenocarcinomaClear cell adenocarcinoma

85. FAVORABLE FACTORS IN SURVIVAL OFFAVORABLE FACTORS IN SURVIVAL OF
PATIENTS WITH CLEAR CELLPATIENTS WITH CLEAR CELL
ADENOCARCINOMAADENOCARCINOMA
Low stageLow stage
Older ageOlder age
Tubulocystic PatternTubulocystic Pattern
Small tumor diameterSmall tumor diameter
Reduced depth of invasionReduced depth of invasion
Negative nodal metsNegative nodal mets
Positive ho/o DESPositive ho/o DES

86. MelanomaMelanoma
Wide local excisionWide local excision
Radical surgeryRadical surgery
RadiationRadiation
Overall survival s poor 5-20%Overall survival s poor 5-20%

87. SummarySummary
Superficial stage I lesions may be treated with RT or radicalSuperficial stage I lesions may be treated with RT or radical
hysterovaginectomyhysterovaginectomy
Stage II-IVA treated with WPRT and brachytherapyStage II-IVA treated with WPRT and brachytherapy
Role of chemotherapy in advanced SCCA presentlyRole of chemotherapy in advanced SCCA presently
unknownunknown
Pelvic failures and distant metastases occur in 1/2 of pts withPelvic failures and distant metastases occur in 1/2 of pts with
advanced dzadvanced dz

88. The EndThe End