Vaginal carcinoma.

Vaginal cancer comprises of malignant changes in cells of the vagina differentiated based on the cell layer from which the disease develops. Over 95 percent develop from changes in the top layer of the mucous membrane (squamous cell carcinoma). The remaining cancers include adenocarcinomas (cancer of the glandular tissue), malignant melanomas (black skin cancer) or arise from connective tissue or muscles cells in the walls of the vagina (vaginal sarcoma).

Cancer that begins in your vagina (primary vaginal cancer) is rare and the causes are still largely unknown. Risk factors include infections with Human Papillomavirus (HPV), early sexual intercourse, promiscuity and smoking. Vaginal cancer often causes symptoms at a late stage. Patients usually notice slight bleeding or increased or aberrant discharge.

Epidemiology

Vaginal cancers are rare. Every year, approximately 0.6-1 in 100,000 women develop vaginal squamous cell carcinoma. The median age of onset is 74 years. If the affected person is younger, the disease is usually caused by an infection with human papilloma viruses.

Diagnosis
The diagnosis of vaginal cancer is often an incidental finding at a routine gynecological check-up. If aberrant cells are seen in the removed cell smear during the microscopic examination, an additional colposcopy will be carried out. In addition, a tissue sample (biopsy) can be taken and examined microscopically by a pathologist.

Most malignant tumors in the vagina have there origine in neighboring organs and spread to the vagina. So if the cervix is ​​affected, the tumor is considered cervical cancer; if the vulva is affected at the same time, it is qualified as vulvar cancer. This distinction is important for the choice of therapy, so the diagnosis focusses on establishing if a tumor other than vaginal cancer is present.

Examination methods

If vaginal cancer is suspected, the doctor can carry out the following examinations:

• Medical history and physical status with tactile examination
• Ultrasound examination of the vagina from the inside, the liver and the kidneys
• Analysis of the urinary tract and intestine (cystoscopy, proctoscopy).

Additional examinations, like X-ray of the lungs and/or magnetic resonance imaging of the pelvis, can determine whether the tumor has spread to other organs. If location at the abdominal region is suspected, a computed tomography of the abdomen can also be carried out. Based upon the results of these examinations it is decided which treatment is the most suitable one. 

Colposcopy is used to detect vaginal disorders. For the examination, the doctor unfolds the vaginal walls with a metal spatula, the speculum, and positions a special examination microscope (colposcope) in front of the vagina. Colposcopy allows your doctor to magnify the surface of your vagina and cervix 6 to 40 times. The smallest areas of abnormal cells, tumors and bleedings become visible.

Sonography (transvaginal ultrasound examination) The ultrasound examination of the internal genital organs is carried out with the help of an ultrasound probe that is inserted into the vagina (transvaginal sonography). The transvaginal ultrasound examination is painless and can be repeated any number of times because it does not expose the patient to radiation.

Sonography (abdominal ultrasound examination) The ultrasound examination of the abdomen provides an insight into the internal organs such as the liver, kidneys, spleen and intestine. It provides information about additional tumor location in these organs.

Treatment options 

Surgery. Small vaginal cancers can be surgically removed without significant damage. In case of extensive tumors, however, the operation can take up considerable proportions, even up to complete removal of the vagina (vaginectomy), as well as other organs such as the urinary bladder and/or the intestine. If affected, nearby lymph nodes in the abdomen and pelvis must also be removed. For this reason, radiation therapy is often preferred, even in stage I.

Radiation therapy uses high-powered energy beams, such as X-rays, to kill cancer cells. It kills rapidly growing cancer cells, but may also damage nearby healthy cells, causing side effects. The impact of radiation therapy depends on the radiation's intensity and where it's aimed at. Radiation can take place from the outside (external radiation, percutaneaously) or from the inside (internal radiation, vaginal brachytherapy). It can be carried out alone, in combination with chemotherapy or in addition to surgery (adjuvant). Because vaginal cancer is a rare disease, there have been few studies on the efficiency of combined chemoradiation. It is often used especially for locally advanced tumors in the hope that this will improve the patient's prospects.

Making decisions about your care:

The choice of therapy is an individual decision depending in particular on the location and size of the tumor(s), your age and general health status. It is important that you talk to your doctor in detail about the findings and the chances of recovery (prognosis) of your illness. Get a detailed explanation of the various therapy options and find out the possibilities of participating in a clinical trial. Well-designed, well-conducted clinical trials are the only way to determine the actual effectiveness of a promising new drug or intervention that is being studied.

The tremendous advances in the treatment of childhood cancer are a direct result of their participation in clinical trials. As more than 60 percent of children with cancer participate in clinical trials, whereas only 3% of adults with cancer do. The success of cancer therapy in children relates directly to this participation rate. For this reason, we recommend, if possible, participation in a clinical trial.

Should participation in clinical trials be the NEW standard of care for women with vulva cancer?

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