Vaginal cancer

Question 1

Vaginal cancer typically presents in what age group?

Answer 1

70% of primary vaginal malignancies are detected in women ≥60 yo.

Question 2

What 3 lifestyle risk factors are associated with increased incidence of
vaginal cancer? How common is HPV detected?

Answer 2

Increased risk of vaginal cancer is associated with the # of lifetime sexual
partners, early onset of intercourse, and current smoking.

HPV DNA is detected in 64%–91% of invasive vaginal cancers.

Question 3

What % of cancers involving the vagina are not primary vaginal cancers?

Answer 3

∼75% of malignancies involving the vagina originate at other sites.

Question 4

What is the most common histology for vaginal cancer? What are 5 other
rare vaginal cancer histologies?

Answer 4

Squamous cell carcinoma is the most common primary vaginal histology.
Melanoma, sarcoma, lymphoma, adenocarcinoma, and clear cell adenocarcinoma are much more rare.

Question 5

Increased risk for clear cell adenocarcinoma is linked with what exposure?

Answer 5

In utero exposure to the synthetic estrogen diethylstilbestrol (DES) is linked with an increased risk for clear cell adenocarcinoma.

Question 6

What type of vaginal sarcoma is most common in adults? In children?

Answer 6

Adults: leiomyosarcoma

Children (≤6 yo): embryonal RMS (i.e., sarcoma botryoides)

Question 7

If an elderly woman has had a hysterectomy d/t early-stage cervical
cancer, is it reasonable to continue PAP smear screening of the vaginal
vault?

Answer 7

Yes. Though the value of continued screening is not proven, PAP smears of
the vaginal vault in elderly women who have had hysterectomy for
invasive/preinvasive cervical cancer seems reasonable given the increased
risk for vaginal cancer.

Question 8

What is the nodal drainage of the upper two-thirds of the vagina? Of the
lower one-third of the vagina?

Answer 8

The upper two-thirds of the vagina drain to the obturator, internal, external, and common iliac nodes. The lower one-third of the vagina may drain to the inguinofemoral nodes.

Question 9

What are 4 common presenting Sx of vaginal cancer? What 2 additional
Sx may suggest locally advanced Dz?

Answer 9

Vaginal cancer may present with bleeding, discharge, pruritus, and dyspareunia. Pain or change in bowel/bladder habits may suggest locally
advanced Dz.

Question 10

Where in the vagina is vaginal cancer most often located?

Answer 10

Vaginal cancer is most often found in the post wall, sup one-third of the
vagina (the speculum must be rotated to ensure exam of this region).

Question 11

What staging exams/studies contribute to the FIGO stage?

Answer 11

Exams/studies that contribute to the FIGO stage include clinical exam of the
pelvis and vagina (possibly under anesthesia), cystoscopy, and proctosigmoidoscopy in women with locally advanced Dz, CXR, LFTs, and alk phos.

Question 12

What imaging studies can be obtained but are not required in order to
assign an FIGO stage?

Answer 12

Advanced imaging such as CT, MRI, and PET do not contribute to the
FIGO stage (but still should be used to assess the Dz extent and plan
therapy).

Question 13

What is the AJCC 8th edition/FIGO staging for vaginal cancer?

Answer 13

T1a/I: Tumor confined to the vagina, measuring ≤2 cm
T1b/I: Tumor confined to the vagina, measuring >2 cm
T2a/II: Tumor invading paravaginal tissues but not to pelvic sidewall,
measuring ≤2 cm
T2b/II: Tumor invading paravaginal tissues but not to pelvic sidewall,
measuring >2 cm
T3/III: Tumor extending to the pelvic sidewall and/or involving the lowerthird
of the vagina and/or causing hydronephrosis or nonfunctioning
kidney
T4/IVA: Tumor invading the mucosa of the bladder or rectum and/or
extending beyond the true pelvis (bullous edema is not sufficient evidence
to classify a tumor as T4)
N1/III: Pelvic or inguinal LN mets
MI/IVB: DM

Question 14

A vaginal cancer is never considered a vaginal primary if it involves either
of what 2 structures?

Answer 14

Cancer involving the vulva or cervix is never considered to be a vaginal
primary (even if the bulk of Dz lies in the vagina).

Question 15

When working up a presumed vaginal cancer primary, what other 3 sites
should be evaluated for synchronous in situ or invasive Dz?

Answer 15

When working up a presumed vaginal cancer primary, always evaluate for
synchronous cervical, vulvar, and/or anal Dz.

Question 16

What are 3 appropriate Tx options for vaginal intraepithelial neoplasia
(VAIN)?

Answer 16

Surgical excision, laser vaporization, and topical 5-FU are all appropriate
Tx for VAIN.

Question 17

VAIN is multifocal in what % of pts?

Answer 17

Up to 60% of pts with VAIN have multifocal Dz. Close f/u is essential

Question 18

In general, what is the preferred definitive Tx modality for vaginal
cancer?

Answer 18

Although Sg may be appropriate for early, stage I lesions, definitive RT is
generally the preferred Tx modality (as morbidity is less compared with
radical Sg).

Question 19

What are the estimates of 5-yr pelvic Dz control and DSS for stages I, II,
and III–IVA vaginal cancer managed with definitive RT?

Answer 19

For vaginal cancer managed with definitive RT, 5-yr pelvic Dz control is 86%, 84%, and 71% for FIGO stages I, II, and III–IVA, respectively. 5-yr
DSS is 85%, 78%, and 58%, respectively. (Frank SJ et al., IJROBP 2005)

Question 20

Is concurrent CRT a reasonable consideration in advanced-stage vaginal
cancer?

Answer 20

Yes. Extrapolating from the cervical, vulvar, and anal cancer literature,
concurrent CRT (typically, cisplatin-based) is reasonable to consider for
advanced-stage vaginal cancer (i.e., stages III–IVA).

Question 21

Is vaginal cylinder brachytherapy alone (without EBRT) appropriate in
any vaginal cancer pts?

Answer 21

Possibly. Although whole pelvis EBRT combined with brachytherapy is
generally preferred, vaginal cylinder brachytherapy alone may be acceptable
for pts with VAIN or very early stage I vaginal cancer <5-mm thick.

Question 22

What brachytherapy technique is commonly required for stages II–III
vaginal cancer (in addition to EBRT Tx)? How important is it to include
brachytherapy?

Answer 22

1. Interstitial brachytherapy needle implants are commonly required to
   achieve adequate brachytherapy dose coverage for stages II–III vaginal cancers (the depth–dose characteristics of intracavitary applicators are not favorable enough to treat deep lesions).
2. Recently published SEER analysis (Orton A et al., Gynecol Oncol 2016)
   compared pts with primary vaginal cancer treated with EBRT alone
   vs. EBRT with brachtherapy. All FIGO stages benefited with a reduced
   rate of death by more than 20%.

Question 23

Describe the regions that are targeted in whole pelvis RT for vaginal
cancer.

Answer 23

A whole pelvis field for vaginal cancer typically targets the common,
internal, and external iliac nodes, obturator nodes, and the entire vagina (or 3
cm below the Dz extent). If the lower-third of the vagina is involved, then the
inguinal nodes may be targeted as well (as per vulvar or anal cancer).

Question 24

What are the appropriate EB and cumulative (EB + brachytherapy) RT
doses for vaginal cancer?

Answer 24

Whole pelvis (+/– inguinal nodes) EB doses are typically 45–50 Gy →
brachytherapy boost to a total dose of 65–75 Gy. 70–80 Gy has been
recommended when RT alone (without chemo) is used.

Question 25

Among pts who fail following definitive RT, what % have LR as a component of their relapse?

Answer 25

∼75% of pts with relapse following definitive RT for vaginal cancer will
experience LF. (Frank SJ et al., IJROBP 2005)

Question 26

What are the 5- and 10-yr grades 3–4 toxicity rates following definitive
RT for vaginal cancer?

Answer 26

Grades 3–4 toxicity rates are 10% and 17% at 5 and 10 yrs, respectively, following RT for vaginal cancer. (Frank SJ et al., IJROBP 2005)

Question 27

What are the 4 most common grades 3–4 late effects following definitive
RT for vaginal cancer?

Answer 27

Following definitive RT for vaginal cancer, proctitis (requiring transfusion), rectal fistula, SBO, and hemorrhagic cystitis are the most common grades 3–4 toxicities.

Question 28

What common late effect may limit sexual function as well as f/u for vaginal cancer?

Answer 28

Vaginal stenosis is very common following RT for vaginal cancer. All pts
should use a vaginal dilator