Vaginal Cancer (28/5/13)

Front 1

% of all gynaecologic malignancies that primary vaginal cancer comprise

Back 1

1-2%

- usually primary cervical or vulvar
- more likely metastatic than primary (cervix, endometrium, colon/rectum)"

Front 2

common patterns of spread of vaginal cancer

Back 2

- local extension
- lymphatic spread

Front 3

lymphatic drainage sites of vagina

Back 3

- any node in the pelvis, groin, or anorectal area may drain any part of the vagina

- mainly: external, internal, and common iliac LNs
- posterior vagina may drain to: inferior gluteal, presacral, or perirectal LNs
- distal 1/3 of vagina: superficial and deep inguinal LNs"

Front 4

blood supply of vagina

Back 4

- anterior division branches of internal iliac
- uterine
- vaginal
- middle rectal
- internal pudendal"

Front 5

rate of progression from VaIN to invasive vaginal cancer

Back 5

~2%

Front 6

Where in the vagina do most vaginal cancers develop?

Back 6

upper 1/3

Front 7

How is vaginal cancer staged?

Back 7

- clinically
- vaginal Bx
- P/E
- ECC (r/o primary cervical)
- endometrial Bx (r/o primary endom. CA)
- cystourethroscopy
- proctosigmoidoscopy
- CXR"

Front 8

5-year survival rate of vaginal cancer, all stages

Back 8

- 45-68%

- stage I: 85-92%
- stage II: 68-78%
- stage III/IV: 13-58%"

Front 9

factors predicting poor prognosis for vaginal cancer

Back 9

- advanced stage
- large tumour size
- adenocarcinoma cell type
- older age"

Front 10

treatment options for stage I vaginal cancer

Back 10

- surgery: radical vaginectomy and pelvic lymphadenectomy
- radiation
- brachytherapy alone"

Front 11

common sites of distant metastases for vaginal cancer

Back 11

- liver
- lungs
- bones"

Front 12

What is included in the triad of symptoms suggestive of pelvic side wall involvement?

Back 12

- sciatic pain
- leg edema
- hydronephrosis

Front 13

gross appearance of verrucous carcinoma

Back 13

- warty, fungating mass that grows slowly and pushes into rather than invades contiguous structures

Front 14

What treatment is contraindicated for verrucous carcinoma?

Back 14

- radiation treatment
- usually resistant to radiation
- may transform into SCC after radiation"

Front 15

adenocarcinomas that may metastasize to the vagina

Back 15

- endometrial
- cervical
- ovarian
- breast
- pancreas
- kidney
- colon

- if primary, likely from vaginal adenosis"

Front 16

Which type of vaginal adenocarcinoma is associated w/ in utero DES exposure?

Back 16

- clear cell
- treated like SCC - good outcomes
- median age of onset is 19
- bimodal? early 26 yo with DES and late 71yo with no DES exposure. - netherlands 1997.

Front 17

What was DES used for clinically?

Back 17

- prevention of miscarriage

Front 18

most common malignancy in the vagina in infants and children

Back 18

- embryonal rhabdomyosarcoma (sarcoma botryoides = most common subtype)

- almost exclusively in girls < age 5"

Front 19

appearance of sarcoma botryoides

Back 19

- ""bunches of grapes""
- multiple polyp-like structures
- or solitary growth w/ a nodular, cystic, or pedunculated appearance"

Front 20

treatment for sarcoma botryoides

Back 20

- before 1972, pelvic exenteration
- gradually shifted to:
- primary chemotherapy
- conservative surgery to excise residual disease if necessary"

Front 21

risk factor for developing vaginal leiomyosarcoma

Back 21

- previously treated w/ pelvic radiotherapy for cervical cancer
- most common vaginal sarcoma in adults.
still very rare only 138 case reports published.

Front 22

what embryological structures contribute to form the vagina?

Back 22

both the mullerian ducts and the urogenital sinus.

Front 23

Are local invasion and lymphatic spread common in vaginal cancer

Back 23

Yes. - Any node in pelvis, groin or anorectal area may drain any part of the vagina. ext internal and common iliac LN are primary sites.

Hematogenous spread is rare

Front 24

What % of vag cancers are SCC

Back 24

70-80%

Front 25

What are the risk factors for vag Ca

Back 25

1. HPV Infection
2. earlly intercourse
3. multiple sexual partners
4. smoking

Front 26

What is the most common complaints presenting Vag Ca

Back 26

- Vaginal bleeding, pelvic pain and increased vaginal discharge.
- most cancers develop in upper third of vagina.
- previous hyst are more likely to have lesions in upper vag.(70%) than those without prior hyst (36%)

Front 27

How is vaginal cancer staged?

Back 27

Clinically

Front 28

What is the 5 year survival rate for vag Ca

Back 28

45-60% for all stages.
Stage I - Carcinoma limited to vag wall - 85%
Stage II - involves the subvaginal tissue but has not extended to pelvic wall. - 78%
Stage III - Extension to pelvic sidewall. 58%
Stage IV - beyond true pelvis
IVA - invades bladder/rectal mucosa +/- direct extension beyond pelvis. 58%
IVB - distant organs.

Front 29

Treatment for stage I

Back 29

Surgical resection or radiation therapy

Front 30

Treatment for stage II

Back 30

surgical or radiation but tailored to individual and surgeon

Front 31

Treatment for stage III

Back 31

External beam rads alone or in combo with brachytherapy. chemo as adjunct to rad sensitivity may be given.

Front 32

What is general followup in BC

Back 32

Year 1 every 3 months
Year 2 every 4 months
Year 3-5 every 6 months
Years 5+ annually

Front 33

Treatment for recurrent disease?

Back 33

Limited if already had rads. exent

Front 34

What is the triad of pelvic wall disease?

Back 34

sciatic pain
leg edema
hydronephrosis

survival is poor
5 year is 20% for local recurrence
4% for metastatic recurrence.

Front 35

Verrucous Carcinoma

Back 35

Warty fungating mass that grows slowly, pushing into rather than invading surrounding structures.
- May coexist with SCC - need to biopsy if concerned.
- local recurrent likely but mets to LN rare.
- resistant to rads, need surgical ressection

Front 36

What is vaginal adenosis

Back 36

- results from exposure to DES in utero.
- presence of subepithelial glandular structures lined by mucinous columnar cells resembling endocervical cells.
- residual glands of mullerian origin.
- Clinically appear as red glandular spots or patches.

Front 37

What is the classical microscopic finding of Yolk Sac tumor (endodermal sinus tumor)

Back 37

Schiller-Duval body - a papilla with a single central vessel.