Cancer of the Vagina. Diagnosis. Treatment
Because patients with vaginal intraepithelial neoplasia are usually asymptomatic, an abnormal Pap test frequently leads to the diagnosis. Rarely, patients may present with postcoital spotting. Colposcopically directed biopsies usually establish the diagnosis. In the patient who has had a hysterectomy, care should be taken to evaluate the pockets sometimes present in the lateral vault areas. During inspection, the speculum blade should be withdrawn slowly and rotated in the partially open position to allow visualization of the entire vaginal tube.
Application of 4-5% acetic acid will cause affected areas to appear white and well demarcated, allowing for target biopsies. Lesions are usually located in the upper one third of the vagina, but because vaginal intraepithelial neoplasia tends to be multifocal, potential lesions in the lower vault should be identified. The lesions may be flat, slightly raised, or warty and granular. Keratinization may obscure any vascular pattern, mosaic, or punctuation. In the postmenopausal patient, lesions are sometimes not easily identified. Topical estrogen for several weeks may help mature vaginal mucosa and allow for easier detection on reexamination. Lugol’s solution may be helpful in determining the extent or location of lesions.
A mixture of 1% lidocaine and vasopressin, injected with a small-gauge spinal needle, will provide local anesthesia for the few patients who need it. The biopsy is often facilitated by grasping tissue adjacent to the lesion with a skin hook and pulling the tissue toward the surgeon. Adequate specimens can be obtained with small, alligator-jaw forceps.
Treatment
Proposed treatments for vaginal intraepithelial neoplasia include surgical excision with partial vaginectomy, laser, topical 5-fluorouracil cream, total vaginectomy with split-thickness skin graft, cryotherapy, and radiation therapy. The mainstay of treatment is wide local excision of the affected area or upper vault vaginectomy. The use of dilute vasopressin injection will facilitate surgery. Laser vaporization has been used, but a biopsy of multiple areas should be performed to rule out invasion. Vasopressin injection also facilitates laser vaporization, and the depth of destruction should be limited to 2 mm. Topical administration of 5-fluorouracil cream has yielded cure rates in selected, compliant patients and may be of particular value in immunosuppressed patients with HPV-associated vaginal intraepithelial neoplasia or in patients who have had previous irradiation. The 5% cream is applied in several regimens, such as every night for 7-10 days with a 2-week break or every week at night for 10 weeks. Caveats to ensure patient compliance and minimize morbidity include inserting one quarter to one third of the applicator high in the vagina before retiring, using a tampon, and protecting the vulva from irritation by use of petroleum jelly.
Use of cryotherapy should be discouraged. Two other, less desirable modalities include total vaginectomy with skin grafting and delivering 6,500-8,000 cGy via an intra-cavitary application. Both procedures can lead to stenosis, scarring, and the rare formation of fistulas.