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Vagina

Vagina

Carcinoma of the vagina is one of the rarest gynecologic tumours. The vagina is the primary site in less than one percent of gynecologic malignancies, but may also be involved with metastatic disease or by direct extension from carcinoma of the cervix or vulva. The commonest histology is squamous cell carcinoma.

Diagnosis

Classification Criteria 

  1. Squamous
  2. Adenocarcinoma
  3. Clear Cell Adenocarcinoma (post DES).

Staging

Classification Criteria

Stage IThe carcinoma is limited to the vaginal wall
Stage IIThe carcinoma has involved the subvaginal tissue but tissue has not extended onto the pelvic wall
Stage IIIThe carcinoma has extended to the pelvic wall
Stage IVThe 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.

Staging Diagram

Click image
for larger version

 

Management

​Vaginal Intraepithelial Neoplasia - VAIN

Treatment of these preinvasive lesions is individualized and depends on the extent, location and general medical condition of the patient. Recommended treatment may be local surgical excision, laser therapy under colposcopic control, topical 5-FU, particularly in cases where discrete multifocal lesions are noted, and on occasion partial or total vaginectomy with split thickness skin grafting. On occasion, high vaginal vault lesions and selected other vaginal disease may be suitable for radiotherapy.

Invasive Carcinoma

Carcinoma at the introitus and lower half of the vagina may be amenable to radical vulvectomy and vaginectomy. Patients with lesions inoperable either because of extent or general medical condition may be treated by radiotherapy.

The treatment principles for tumours in the upper half of the vagina are similar to those for cervical cancer: a combination of intracavitary and external beam pelvic irradiation.

Vaginal sarcomas are treated by surgery when possible. Radiation and chemotherapy may be utilized on an individual basis.

Chemotherapy Protocols

Estrogen Replacement Therapy - Site Specific Information

No data exist to show a contraindication for hormone replacement in cervical or vaginal cancer. Many of these patients are young and at high risk for estrogen deprivation related morbidity. It is the feeling of the group that these patients should be encouraged to take estrogen replacement. In the presence of a uterus we recommend continuous estrogen and progestogen with the estrogen at a moderate dose (0.625-1.25 mg Premarin) and the progestogen at a low dose (2.5 mg Provera). Histologic studies have shown that continuous therapy with combined estrogen and progestogen induces an atrophic bland endometrium. This regime may result in some initial bleeding for the first one to two months but in general the women are amenorrheic.

An alternative regime would be to use cyclical estrogen and progestogen. This has the disadvantage of inducing a withdrawal bleed in some patients who have not had total ablation of the endometrium. Hematometra may develop if there is cervical stenosis present leading to abdominal pain or a mass.

Recommendation: Continuous estrogen and progestogen, e.g.:
Premarin; 0.625-1.25mg
Provera 2.5 mg
(note: these small doses of Provera do not seem to have the same deleterious effects on serum lipids as the higher doses.)

In the absence of a uterus there is no theoretical need for progestogen, therefore estrogen alone in usual doses is recommended

Radiotherapy - General Information

Follow-up

Patients should be reminded that it is their responsibility to keep their recommended follow-up appointments. The objectives of the follow-up visits are as follows: 

  1. To determine the patient's immediate response to the treatment employed    
  2. Early recognition and prompt management of treatment related complications    
  3. Early detection of persistent or recurrent disease    
  4. Collection of meaningful data regarding the efficacy of existing treatment policies and their complications so that any appropriate modifications can be instituted

These objectives are best met by having the initial follow-up examination performed by the Agency medical staff. When appropriate, arrangements will be made for follow-up by the referring physician.

Year 1every 3 months
Year2every 4 months
Year 3-5every 6 months
Years 5+annually
SOURCE: Vagina ( )
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