Vaginal Premalignant Diseases
• Vaginal intraepithelial neoplasms (VAIN) are due to HPV infection and occur through abrasions from sexual intercourse or tampon use. It is almost always associated with CIN, but its malignant potential is less than CIN. VAIN can be a vaginal extension of CINs or a satellite lesion. Because it is thought to have similar factors.
• VAIN lesions are asymptomatic. Since they are associated with active HPV infection (HPV 16), cases may complain of vulvar warts or odorous vaginal discharge caused by vaginal warts. They are usually located in the upper part of the vagina 1:3.
• It should be scanned with a smear and is usually diagnosed after an abnormal Pap smear. If there is VAIN, the smear will also be positive. However, colposcopic examination and biopsy provide definitive diagnosis.
Treatment
► While a conservative approach consisting of observation is recommended in VAIN I, local excision or CO2 laser ablation is preferred according to the location and number of the lesion in high-grade (VAIN2-3) cases. Cryotherapy should never be used in the vagina for ablation of high-grade VAIN cases. On the other hand, cautery can only be performed on superficial lesions.
VAGINAL CANCER
• Primary vaginal cancer is very rare and constitutes 1-2% of all genital cancers. Most cases are metastatic. Metastases originate from the cervix, endometrium, colorectal, ovary, and vulva, in order of frequency. In addition, choriocarcinomas frequently metastasize to the vagina. Bladder and rectum tumors can directly invade the vagina.
Vaginal Squamous Cell (Epidermoid) Carcinoma
• It is the most common primary vaginal cancer and 80-90% of primary vaginal cancers are squamous cell carcinoma. It is typically a disease of postmenopausal women.
etiology
► Vaginal cancer is thought to be related to HPV, just like cervical cancer.
► The incidence of vaginal squamous cell cancer is very high in patients who have received pelvic radiotherapy for cervical cancer before.
► VAIN lesions are also premalignant and may progress to 3-7% invasive vaginal cancer.
► Chronic irritation due to prolonged use of vaginal pessary may also be associated with vaginal cancer.
Clinic
► It most commonly involves the 1:3 upper part of the posterior wall of the vagina. 14% are asymptomatic; however, painless vaginal bleeding and discharge are the most common symptoms in progressive cases.
Diagnosis
► Routine scanning is not suitable; however, annual smear follow-up should be performed in patients with cervical or vulvar neoplasia. If there is a vaginal lesion, it is placed as a result of biopsies taken from the lesion or suspicious areas with Lugol's solution from places that do not hold dye. All vaginal cancer cases should be evaluated for metastatic disease.
Spread
► It first and most frequently spreads directly to neighboring organs, followed by metastasis to lymph nodes and distant organs. Spread to the lungs, liver and bones by hematogenous route occurs at a later stage.
Staging
Primary vaginal cancers are clinically staged
FIGO Staging (Clinical)
Stage 1----The cancer is limited to the vaginal wall
Stage 2---The subvaginal tissue is involved but has not reached the pelvic wall
Stage 3---The pelvic wall is involved
Stage 4---- Tumor beyond the true pelvis or tumors that have spread to the bladder/rectal mucosa
4a ----Involvement of the bladder and/or rectum mucosa and/or tumor directly extending beyond the true pelvis
4b -----Metastasis to distant organs
Presence of bullous edema in the bladder does not make the case as Stage IV.
Vaginal cancer has no microinvasive stage.
Lymph node metastasis and lymphovascular area involvement have no role in staging of vaginal cancer.
Clinic
► The main treatment is radiotherapy. However, surgery can also be applied in selected cases.
Adenocarcinoma
• Primary adenocarcinoma is extremely rare and the most common vaginal adenocarcinoma is metastatic (most commonly in the endometrium, but also in the cervix, ovary, colon, breast, kidney, pancreas, and stomach).
• Primary adenocarcinomas develop from areas of vaginal adenosis, especially in patients with intrauterine diethylstilbesterol (DES) exposure, and may also develop from endometriotic foci, periurethral glands and Wolf duct remnants. Compared to squamous cell cancers, it is observed in younger women and has a worse prognosis.
• Vaginal adenosis and clear cell adenocarcinoma; DES prevents squamous metaplasia of the glandular columnar epithelium originating from the Müller duct, which forms the upper 2:3 part of the vagina in female fetuses. Thus, the upper part of the newborn's vagina has columnar epithelium, which should not normally be present, and this phenomenon is called vaginal adenosis. Vaginal adenosis is actually a benign lesion, but it needs close follow-up because it can cause malignant change at puberty with the effect of endogenous estrogens and cause especially clear cell adenocarcinoma. Vaginal adenosis is present in 90% of clear cell adenocarcinomas, which occur mostly in the ectocervix or 1:3 upper-anterior wall of the vagina.
Malignant Melanoma
• It is 3%-S of vaginal cancers. Genital melanomas are most frequently observed in the vulva (70%) and are observed in the vagina (21%) and cervix (9%), respectively. They are highly aggressive tumors that metastasize by hematogenous route in the early period. The mean age of the patients is 58 years. They are most commonly located in the lower 1:3 of the vagina.
Vaginal Sarcomas
• They are very rare. While the most common leiomyosarcoma or fibrosarcoma in adults; rhabdomyosarcoma (botryoid sarcoma) is most common in newborns and childhood.
• It should definitely be considered in childhood vaginal bleeding. The lower part of the vagina 2:3 originates from its anterior wall. In treatment, chemotherapy is given first.
The most common sites of botryoid sarcoma in the genital area
- Most common in the vagina during infancy and childhood
- Most common in the cervix in the reproductive age
- Most common in the uterine corpus in the postmenopausal period
Endodermal Sinus Tumor
• They are very rare tumors seen under 2 years of age. They are the most common vaginal tumors in early childhood. It originates from the posterior wall of the vagina. Its prognosis is quite poor.
Pregnancy and Vaginal Cancer
Pregnancy is not considered in the first and second trimesters. Radical hysterectomy + upper vaginectomy + bilateral pelvic lymph node dissection is performed. Postoperative adjuvant chemotherapy is given.
If the pregnancy is large and the vagina is severely involved, the uterus is evacuated by hysterotomy or a cesarean section is performed and appropriate chemotherapy is given. Surgery is preferred if there is only upper vaginal and/or cervical involvement.