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Vaginal Squamous Cell Carcinoma

Squamous Cell Carcinoma of the Vagina

Vaginal squamous cell carcinoma is the most common type of primary vaginal cancer, which is overall very rare. Symptomatic patients frequently report painless vaginal bleeding and dysuria. The diagnosis is based on the patient's history, physical exam, and the appropriate studies. To definitively achieve a diagnosis of primary vaginal cancer, other origins must be ruled out.


Presentation

Primary vaginal carcinomas compose approximately 1 to 2% of all malignant gynecologic neoplasms [1] [2]. Squamous cell carcinoma is the most common type of primary vaginal cancer. This malignancy mainly affects women above the age of 60 [3] [4]. Risk factors for primary vaginal cancer include HPV infection, of which subtypes 16 and 18 are common with the former being the most prevalent [5] [6] [7]. Other predisposing factors include high-risk sexual behaviors, smoking, the coexistence of other sexually transmitted infections (STIs), the presence of high-grade vaginal intraepithelial neoplasia (VaIN), history of cervical cancer, low socioeconomic status, and immunosuppression.

The clinical picture is most significant for painless vaginal bleeding [8], which may be found in up to 80% of patients. The bleeding is typically postmenopausal, which is reflective of the age group. However, the bleeding may be in the form of menorrhagia or postcoital bleeding. Other possible manifestations include dysuria, hematuria, vaginal discharge, and pelvic pain. Anterior lesions are consistent with urinary symptoms while posterior masses can cause constipation. A minority of patients will experience vaginal prolapse or report a vaginal mass. Asymptomatic patients with early stages of cancer could be discovered during routine gynecological exams.

The symptoms are averagely present for 6 to 12 months prior to diagnosis. Recognition is delayed since the cancer is rare. The definitive diagnosis, according to the International Federation of Gynecology and Obstetrics (FIGO), is based on confirming that vaginal cancer does not stem from other origins [9]. Also, women with a prior gynecologic cancer should be cancer-free for 5 years to receive a diagnosis of vaginal cancer [1].

The components of the physical exam include visualization of the outside structures such as the labia, inspection of the cervix and particular inspection of the anterior and posterior wall of the vagina with the aid of a speculum, and palpation of the vagina. Masses appear as ulcerating, fungating, or annular.

Inguinal Lymphadenopathy
  • Computed tomography (CT) of the abdomen and pelvis revealed a large tumor replacing the vagina with mild hydronephrosis and diffuse pelvic and inguinal lymphadenopathy.[ncbi.nlm.nih.gov]
Pallor
  • General and systemic examination findings were normal except mild pallor. All routine investigations findings were normal except mild anemia.[omicsonline.org]
Weakness
  • Case Report A 62-year-old postmenopausal female presented to our OPD, MKCG Medical College, Berhampur, India with complaints of intermittent, painless vaginal bleeding associated with weight loss and weakness for last 2 months.[omicsonline.org]
Sepsis
  • The patient developed arm phlebitis, pulmonary fungal infection, and severe rectal bleeding, followed by hypocalcaemia, hypokalemia, vaginal bacterial and fungal infection, with subsequent leg and arm phlebitis, perineal abscess, and sepsis.[pagepress.org]
Bone Pain
  • Skeletal X-rays are performed in patients reporting the bone pain. Surgical staging is typically reserved for certain premenopausal patients who undergo laparotomy prior to radiotherapy.[symptoma.com]
Vaginal Bleeding
  • Symptomatic patients frequently report painless vaginal bleeding and dysuria. The diagnosis is based on the patient's history, physical exam, and the appropriate studies.[symptoma.com]
  • Real help from real people. deleted_user 10/18/2009 Dear all, well i hope am in the right forum here is the case of my mum aged 55. she had her uterus and ovary removed some 15 years ago. since last month she was having slight vaginal bleeding. had a[dailystrength.org]
  • Case Report A 62-year-old postmenopausal female presented to our OPD, MKCG Medical College, Berhampur, India with complaints of intermittent, painless vaginal bleeding associated with weight loss and weakness for last 2 months.[omicsonline.org]
  • Most patients present with abnormal vaginal bleeding. Usually diagnose with punch biopsy; sometimes wide local excision is necessary.[merckmanuals.com]
  • Snapshot A 62-year- old women, gravida 4, para 4, complains of abnormal vaginal bleeding that occurs intermittenly between her predictable menstrual cycles. Vaginal biopsy showed a malignancy and an operation was performed.[medbullets.com]
Vaginal Discharge
  • Other possible manifestations include dysuria, hematuria, vaginal discharge, and pelvic pain. Anterior lesions are consistent with urinary symptoms while posterior masses can cause constipation.[symptoma.com]
  • The risk factors for invasive squamous cell carcinoma of the vagina are the same as those for SIL (VAIN) those were prior vaginal discharge, condyloma acuminata or irritation, prior abnormal cervical/vaginal cytology, prior hysterectomy and rarely reported[omicsonline.org]
  • discharge dyspareunia Evaluation Biopsy most lesions occur in the upper 1/3 of the vagina Treatment planning should be individualized depending upon the location, size, and clinical stage of the tumor surgery raditation chemotherapy Please rate topic[medbullets.com]
  • discharge or bleeding that is not normal for you.[mcancer.org]
  • Some also present with a watery vaginal discharge or dyspareunia. A few patients are asymptomatic, and the lesion is discovered during routine pelvic examination or evaluation of an abnormal Papanicolaou (Pap) test.[merckmanuals.com]
Dysuria
  • Symptomatic patients frequently report painless vaginal bleeding and dysuria. The diagnosis is based on the patient's history, physical exam, and the appropriate studies.[symptoma.com]
  • Patients usually come with symptoms of painless vaginal bleeding or discharge, dysuria or frequency. Most primary vaginal carcinomas are grossly nodular, ulcerative, polypoid and fungating lesion. Size usually varies from clinically occult to 10 cm.[omicsonline.org]
  • […] features May initially be asymptomatic Local pruritus, possibly with burning sensation and pain Reddish, blackish, and/or whitish patches of discoloration Lumps or growths of various shapes, often wart-like lesions or ulcers Vulvar bleeding or discharge Dysuria[amboss.com]
  • Painful urination or dysuria. Painful sexual intercourse or dyspareunia. Pain in the pelvic area. Tumor in the vaginal mucosa.[cancerwall.com]
Dyspareunia
  • […] initially be asymptomatic Local pruritus, possibly with burning sensation and pain Reddish, blackish, and/or whitish patches of discoloration Lumps or growths of various shapes, often wart-like lesions or ulcers Vulvar bleeding or discharge Dysuria, dyspareunia[amboss.com]
  • […] grape-like mass in young girls ( 4 years) can prolapse out of vagina spindle-shaped tumor cells stain positive for desmin Presentation Symptoms abnormal vaginal bleeding may be postcoital, intermenstrual, or postmenopausal. watery vaginal discharge dyspareunia[medbullets.com]
  • Some also present with a watery vaginal discharge or dyspareunia. A few patients are asymptomatic, and the lesion is discovered during routine pelvic examination or evaluation of an abnormal Papanicolaou (Pap) test.[merckmanuals.com]
  • Painful sexual intercourse or dyspareunia. Pain in the pelvic area. Tumor in the vaginal mucosa.[cancerwall.com]
Postcoital Bleeding
  • However, the bleeding may be in the form of menorrhagia or postcoital bleeding. Other possible manifestations include dysuria, hematuria, vaginal discharge, and pelvic pain.[symptoma.com]

Workup

The assessment for women who are symptomatic and those with incidental findings includes the patient's personal and detailed family history [10], a complete physical exam, and the appropriate studies.

Key components of the workup include studies that exclude more common malignancies such as cervical cancer. The Pap smear is a routine cervical cancer screening test that is obtained periodically or when indicated. Abnormal cervical or vaginal Pap test results warrant further investigation with colposcopy, which could rule out the cervical origin and allows visual inspection of the vagina and biopsies if needed. Note that any lesion should be biopsied.

Blood levels of tumor markers such as CA-125, CA-19-9, tumor antigen-4, and carcinoembryonic antigen should be obtained [10].

Staging of vaginal cancer according to FIGO is based on physical exam findings, chest radiography, cystoscopy, and proctoscopy. Magnetic resonance imaging (MRI) of the abdomen and pelvis, positron emission tomography-computed tomography (PET-CT), and chest computed tomography (CT) evaluate for metastatic disease [10]. Specifically, CT and MRI reveal findings such as an involvement of lymph nodes, metastases to the liver and other organs, hydronephrosis, and ureteral compression. Skeletal X-rays are performed in patients reporting the bone pain.

Surgical staging is typically reserved for certain premenopausal patients who undergo laparotomy prior to radiotherapy.

Treatment

  • In the case presented percutaneous nephrostomy was the only possible treatment of hydronephrosis. In advanced primary SCC (Figo IVA) with nodal involvement palliative treatment is only option.[ncbi.nlm.nih.gov]
  • During 7 week treatment it went away. After brachythetapy it came back. Used like 1 pad per day. Now it's heavier and using 2 "bladder leakage"pads, it is now dark mustard color. I did have a PET scan 3 months post treatments.[community.macmillan.org.uk]
  • A repeat CT scan of the abdomen and pelvis upon completion of her treatment revealed progression of disease with multiple liver metastases and gastrohepatic ligament adenopathy.[ncbi.nlm.nih.gov]
  • The primary treatment for large stage I squamous cell lesions of the vagina is radiotherapy, whereas an equally large sarcoma is best treated by wide local excision alone.[ncbi.nlm.nih.gov]

Prognosis

  • Prognosis is good for lesions in the upper 1/3rd of the vagina.[omicsonline.org]
  • Clinical and histopathologic factors related to prognosis in primary squamous cell carcinoma of the vagina. Int J Gynecol Cancer. 2006;16(3):1201–11. PubMed CrossRef Google Scholar Hildesheim A, Han CL, et al.[link.springer.com]
  • Prognosis The prognosis of vaginal cancer includes factors such as the stage of cancer, tumor size, age, general health condition, recurrence and location of the tumor.[cancerwall.com]
  • Prognosis is significantly dependent on stage.[radiopaedia.org]
  • Vulvar cancer is usually associated with a poor prognosis.[amboss.com]

Etiology

  • Rosenberg SA (eds): AIDS: Etiology, Diagnosis. Treatment, and Prevention. ‏ الصفحة 190 - Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med. ‏ الصفحة 193 - Henson D, Tarone R.[books.google.com]
  • Fistulas in malignant gynecologic disease: etiology, imaging, and management. Radiographics. 2009;29(4):1073–83. PubMed CrossRef Google Scholar Oncology FCOG.[link.springer.com]
  • Vaginal cancer is closely related to vulvar cancer in terms of etiology and histology, but it occurs inside the vagina (typically the posterior third of the vaginal wall), rather than the vulva.[amboss.com]
  • The exact etiology is unknown but there are some predisposing factors i.e., HPV infection, vaginal intraepithelial neoplasia, exposure to DES and radiation.[omicsonline.org]
  • […] some cases, vaginal intraepithelial neoplasia (VAIN) can be found prior to invasive squamous cell carcinoma History of prior hysterectomy in up to 50% of cases Also associated with vaginal or uterovaginal prolapse ( Crit Rev Oncol Hematol 2015;93:211 ) Etiology[pathologyoutlines.com]

Epidemiology

  • Diagnostic criteria and microbial and epidemiologic associations. Am J Med. ‏ الصفحة 193 - Henson D, Tarone R. An epidemiologic study of cancer of the cervix, vagina, and vulva based on the Third National Cancer Survey in the United States.[books.google.com]
  • Comparing mortality of vaginal sarcoma, squamous cell carcinoma, and adenocarcinoma in the surveillance, epidemiology, and end results database Talayeh Ghezelayagh; Jose Alejandro Rauh-Hain; Whitfield B.[mgh-ita.org]
  • ., genital lichen planus ( hypertrophied skin with purple lesions) Etiology : unclear (hormonal, immunological, and/or infectious factors are believed to play a role) Epidemiology : postmenopausal women and, less commonly, prepubescent girls Clinical[amboss.com]
  • Epidemiology Incidence Vaginal cancer is a rare cancer in the UK, accounting for around 1% of all gynaecological cancers. [ 1 ] HIV-positive women have more vaginal intraepithelial lesions compared with negative controls.[patient.info]
Sex distribution
Age distribution

Pathophysiology

  • Definition / general Primary squamous cell carcinoma arising in vagina without involvement of surrounding structures, such as cervix or vulva Pathophysiology In some cases, vaginal intraepithelial neoplasia (VAIN) can be found prior to invasive squamous[pathologyoutlines.com]

Prevention

  • Treatment, and Prevention. ‏ الصفحة 190 - Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med. ‏ الصفحة 193 - Henson D, Tarone R.[books.google.com]
  • Preventive Services Task Force. Available online at . Accessed 6/16/15. Moyer, VA on behalf of the U.S. Preventive Services Task Force. (2012 June 19). Screening for Cervical Cancer: U.S. Preventive Services Task Force Recommendation Statement.[labtestsonline.it]
  • Vulvo-vaginal cancers: risks, evaluation, prevention and early detection. Obstet Gynecol Clin North Am. 2007;34(4):783–802. x. PubMed CrossRef Google Scholar Frumovitz M, Gayed IW, et al.[link.springer.com]
  • Vaccines that prevent some types of HPV infection are available. Exposure to miscarriage prevention drug.[mayoclinic.org]
  • Researchers are still investigating the causes of vaginal cancer and ways to prevent it. There is no way to completely prevent the disease, but by following the advice above, risks can be minimized.[medicalnewstoday.com]

References

Article

  1. Kim HG, Song YJ, Na YJ, Choi O-H. A Case of Vaginal Cancer with Uterine Prolapse. J Menopausal Med. 2013;19(3):139-142.
  2. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics, 2002. CA Cancer J Clin. 2005;55(2):74–108.
  3. Benedet JL, Bender H, Jones H, 3rd, Ngan HY, Pecorelli S. FIGO Committee on Gynecologic Oncology. FIGO staging classifications and clinical practice guidelines in the management of gynecologic cancers. Int J Gynaecol Obstet. 2000;70(2):209-262.
  4. Iavazzo C, Vorgias G, Vecchini G, Katsoulis M, Akrivos T. Vaginal carcinoma in a completely prolapsed uterus. A case report. Arch Gynecol Obstet. 2007;275(6):503–505.
  5. Ferreira M1, Crespo M, Martins L, Félix A. HPV DNA detection and genotyping in 21 cases of primary invasive squamous cell carcinoma of the vagina. Mod Pathol. 2008;21(8):968-972.
  6. Koyamatsu Y, Yokoyama M, Nakao Y, et al. A comparative analysis of human papillomavirus types 16 and 18 and expression of p53 gene and Ki-67 in cervical, vaginal, and vulvar carcinomas. Gynecol Oncol 2003;90(3):547–551.
  7. Kiyahu MT, Shibata D, Arnheim N. Detection of human papillomavirus in formalin-fixed, invasive squamous carcinomas using the polymerase chain reaction. Am J Surg Pathol 1989;13(3):221–224.
  8. Creasman WT. Vaginal cancers. Curr Opin Obstet Gynecol. 2005;17(1):71–76.
  9. Hacker NF, Eifel PJ, van der Velden J. Cancer of the vagina. Int J Gynaecol Obstet. 2012;119(Suppl 2):S97–S99.
  10. Kim JY, Lee KA, Kim BG, Bae DS, Lee JW. Vaginal cancer with multiple liver and pulmonary metastases that achieved long-term survival. Obstet Gynecol Sci. 2013;56(6):416-419.

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Last updated: 2019-06-28 09:34