An overview of disease, diagnosis and treatment
Primary Vaginal cancer is rare, and more aften tumors located in the vaginal wall have spread from other tumor types and locations.
If a tumor is located in the top of the vagina, it can be difficult to differentiate it from a primary cervical cancer, or a recurrence from a previously treated cervical malignancy.
Predominantly vaginal cancers arise from the superficial layer of the internal mucuos membrane (squamous cell carcinoma) in the vagina.
Other more rare tumour types in the vagina are cancers of the glandular tissue (adenocarcinomas), malignant melanomas, or tumors arising from connective tissue or muscles cells in the vaginal wall (sarcoma).
The treatment options for vaginal malignancy are dependent on the tumor type, size and exact location and possible spread. Treatment and follow up for vaginal cancers are often centralized due to the limited number of patients. This allows for specialization among the professionals treating the patients.
Epidemiology
Vaginal squamous cell carcinoma is a rare disease, and the median age of onset is 74 years. Human Papilloma Virus (HPV) infection and smoking predispose to development of vaginal cancer.
Diagnosis
Squamous cell carcinoma is the most common histological type of vaginal cancer. It develops in the squamous cells in the mucous membrane, which lines the internal surface of the vagina. If not treated, the carcinoma may grow deeper into the vaginal wall, and eventually penetrate the vagina and invade e.g. bladder or rectal tissue nearby. The cancer can also spread to distant sites incl. bones, lungs, and liver.
Examinations
Transvaginal Ultrasound
It is a painless examination and can be repeated any number of times. It does not expose the patient to any radiation.
VUL can also be used for visual guidance during tumor biopsi procedures.
Abdominal Ultrasound
Ultrasound examination of the abdomen provides view of the internal organs such as the liver, kidneys, spleen, and to some degree the intestines.
It may visualize, possible tumor spread (metastases) to nearby organs or structures. It can be useful as visual guidance during tumor biopsi procedures.
Blood Tests
Blood tests provide information about the general health condition of a patient.
The test results are important with regard to an upcoming treatment, and usually evaluates haematological status, kidney-, and coagulation function.
Treatment options
Radiation Therapy
Radiation therapy uses high-powered energy beams (usually fotons) to destroy and kill cancer cells. The vaginal tumor and surrounding tissue is irradiated from the outside through the skin (external beam radiation therapy), or from the inside through the vagina (brachytherapy). In a range of patients a combination of the two modalities is recommended for sufficient effect.
During radiation treatment care is taken to protect the surrounding normal tissue such as bladder, rectum, and bowel etc. However, it is often unavoidable that a limited dose affects the surrounding tissue, and consequentially results in side effects of varying degree.
The side effects may be urinary problems, diarrhea, inflammation of the mucous membranes in the vagina, bladder, rectum and bowel, as well as nausea, discomfort/pain, development of scar-tissue in the pelvic area (fibrosis), and swelling af the leg(s) due to lymphoedema. For vaginal cancers the radiotherapy often results in shortening and hardening (due to fibrosis) of the vagina, resulting in sexual disabilities.
Always discuss the riscs and possible treatment options with your radiation oncologist prior to commencing your treatment.
Radiation therapy can be combined with chemotherapy as treatment for vaginal cancer, and this is referred to as chemoradiation treatment.
Surgery
Very small vaginal cancers can be surgically removed. In most cases however, surgical treatment would result in significant morbidity and damage to the pelvic area, as complete removal of the vagina (vaginectomy), as well as other organs e.g. urinary bladder, rectum and lymph nodes, may be necessary. Therefor radiotherapy is often the preferred treatment, even for stage 1 disease.
Making Decisions About Your Care
The choice of therapy for your cancer is an individual decision, and many factors are taken in to consideration, when your doctor(s) discuss the best option(s) with you. These include the type, size and location/spread of the tumor, as well as your age and general health status.
We recommend, that you have a thorough discussion with your doctor(s) about the results upon your diagnosis, the treatment-plan and your chances of recovery (e.g. prognosis).
You are encouraged to include family and/or friends for participation in doctors appointments etc. for improving your/their understanding and remembrance of relevant information, as well as for emotional and physical support during appointments and treatments.
Your doctor can give a detailed explanation of the various therapy options, and has knowledge of the possibility to participate in a clinical trial. Each patient is different and so is their wish upon information needed/wanted prior to making important decisions.
Well designed and conducted clinical trials are essential to determine the effectiveness of a promising new drug or intervention. Many gynaecologic oncology departments have studies open for inclusion during the course of your cancer treatment. Talk to your doctor(s) about your thoughts regarding possible inclusion in a clinical trial now or in the future.
Author: Kristine Madsen, MD, Medical Director NSGO-CTU
