GYNECOLOGIC ONCOLOGY
VAGINAL CANCER
The vagina is the hollow structure connecting the outer genitals (vulva) to the cervix (and, by extension, the uterus). In its resting state, the vagina is collapsed, meaning that its inner walls fold up and touch each other. The many bends and folds of the vaginal wall also provide it with the necessary flexibility, so that it can expand and stretch during sexual intercourse and form the birth canal during the vaginal delivery of a fetus (baby). Primary vaginal cancer, that is cancers developing directly from the different cell types of the vagina, is a very rare form of cancer. Similar to vulvar cancer, there are several types of vaginal cancer. For instance, squamous cell carcinomas and melanomas develop from vaginal skin cells, whereas adenocarcinoma grows from glandular cells (usually the Bartholin glands at the opening of the vagina which secrete lubricant during sexual stimulation) and sarcoma grows from connective tissue cells underneath the skin and epithelium. Squamous cell carcinoma is by far the most common type of vaginal cancer (it makes up for as much as 90% of vaginal cancers), while adenocarcinoma accounts for a much lower percentage of vaginal cancers, and melanoma and sarcoma are even rarer still.
Risk Factors
The causes of vaginal cancer are not well understood, but there are several factors that can contribute to and increase the risk of vaginal cancer. These include life style choices such as smoking, (increased) alcohol consumption, and risky sexual behaviors (including early onset of sexual activity and high number of sexual partners). Other risk factors are increased age (above 60 years), a prior history of cancer of the female reproductive system (including Human Papillomavirus, HPV, infection), and a prior history of VAIN (vaginal intraepithelial neoplasia), a precancerous alteration (mutation) of vaginal cells. A suppressed immune system (due to immunosuppressant drugs, such as steroids, or an immunocompromising disease such as HIV) can further also increase the risk of vaginal cancer.
Symptoms
The symptoms of vagina cancers are non-specific and can be similar to a variety of conditions, including other female reproductive cancers (such as cervical cancer). Symptoms of vaginal cancer include a palpable mass in the vagina, irregular vaginal bleeding and discharge, pelvic pain (especially on irritation, such as sex or using a tampon), issues with urination (frequency, urgency) and digestions (constipation). If any such symptoms are noticed and persist, medical follow-up should be pursued.
Diagnosis
The first step in diagnosing vaginal cancer is a pelvic exam. During this, the doctor may be able to feel masses in the vagina on palpation (manual exam, usually done inserting two fingers into the vagina), or see them on inspection with the colposcope (microscope). Further work up to determine whether present masses are benign or malignant (cancerous) includes a biopsy, that is the removal of a small sample of cells from the mass for histological analysis (testing of the molecular properties of the cells in the lab). Imaging (X-Ray, CT, MRI, or PET) and -scopies (camera examination of adjacent structures, such as the rectum, colon or bladder) may be used to visualize the masses further and determine the extent to which they have grown and spread.
Treatments
Surgery is often the primary treatment for small vaginal cancer and recurring or (radiation) therapy resistant vaginal cancers. vaginal cancers. Depending on the size and stage of the cancer, different types of surgeries with different levels of invasiveness may be necessary. If the cancer is small enough and clearly circumscribed (well defined), an excision (removal) of the mass(es) alone may be sufficient. If the cancer is further advanced, a partial or total (radical) vaginectomy or even a removal of most or all of the female reproductive organs and adjacent organs such as rectum, colon or bladder (pelvic exenteration) may be required. These are usually followed by a vaginal reconstruction surgery, during which skin, muscle and nerve grafts are transplanted from other areas of the body (often the abdomen, buttocks of thighs). Primary surgery is also often accompanied by removal of one or several adjacent lymph nodes in the groin or pelvic area (lymphadenectomy). Radiation therapy (internal or external) and chemotherapy can also be used, either alternative to surgery or in conjunction with surgery. If used with surgery, radiation and chemotherapy can be done before surgery to reduce the size of the masses (neoadjuvant) or after the surgery to reduce the risk of recurrence (adjuvant).