Vagina Cancer. Diagnosis
Invasive Squamous Cell Carcinoma
Primary invasive carcinoma of the vagina accounts for 12% of all gynecologic malignancies. It is a disease of older women, with the peak incidence in the sixth and seventh decades. Only 10% of these carcinomas occur in women younger than 40 years of age. Squamous cell lesions constitute 80-90% of all invasive malignancies.
Stage 0 : Carcinoma in situ; intraepithelial carcinoma
Stage 1 : Carcinoma limited to vaginal mucosa (wall)
Stage 2 : Subvaginal infiltration into parametrium, not extending to the pelvic wall
Stage 3 : Carcinoma has extended to the pelvic wall
Stage 4 : Carcinoma has extended beyond the true pelvis or involves mucosa of bladder or rectum
Stage 4A : Carcinoma has spread to adjacent organs and/or direct extension beyond the true pelvis
Stage 4B : Carcinoma has spread to distant organs
Modified from International Federation of Gynecology and Obstetrics. Annual report on the results of treatment in gynecological cancer. 22nd edition. Stockholm: FIGO, 1994
Diagnosis
Only about 20% of patients with invasive carcinoma are asymptomatic. Most patients present with abnormal vaginal bleeding or discharge, which may be malodorous. Less frequent complaints include dysuria, urgency, constipation, and pain, all usually occurring with more advanced disease. The upper one third of the vagina is involved in 4050% of cases in reported series. Involvement of the distal third of the vagina may be noted in as many as one third of patients. Posterior wall involvement is more common than lateral or anterior locations. Tumors usually appear exo-phytic or ulcerated. Most gynecologists use FIGO clinical staging (see the box). To rule out adjacent organ primary cancers, staging pelvic examination with biopsies under anesthesia may be indicated.
Once the histologic diagnosis is made, cystoscopy and proctoscopy are indicated in patients with large tumors. Chest X-ray and intravenous pyelography or computed tomography with intravenous and oral contrast usually aid in treatment planning, particularly with clinical stage II or more advanced disease. Magnetic resonance imaging may help in differentiating between fibrotic tissue and tumor infiltration. The use of tumor markers, such as squamous cell carcinoma antigen, has been suggested to assist in surveillance, but these markers are expensive, and few data are available to support their sensitivity or specificity.
Some researchers have recommended surgical evaluation of adjacent nodes for treatment planning. Lymphatics from the upper vagina probably drain in a manner similar to that of the cervix, whereas those from the lower vagina are assumed to drain in a manner similar to that of vulvar lesions. The lymphatic drainage of the vagina is complex and consists of an extensive intercommunicating, interconnecting network. Because of the rarity of vaginal tumors, meaningful surgical studies of lymph node metastasis have not been performed. Lymphangiography may be a less costly and morbid technique for assessing lymph node involvement, particularly in obese patients.