Chapter 2 - Vagina

CARCINOMA OF THE VAGINA Primary growths of the vagina are rare; secondary growths are more common, especially extension from cervical cancer, and metastatic deposits may appear disease elsewhere in the body. CLINICAL FEATURES - the patient is usually menopausal and - complains of bleeding and discharge - if the bladder is involved = pain and dysuria - old women often believe or affect to believe that all bleeding is from haemorrhoids - an early tumour can easily be missed if it is obscured by the blade of the speculum HISTOLOGY Eighty-five per cent are squamous carcinomas, occurring in women over 60, the remainder include melanoma, sarcoma, adenocarcinoma and clear cell carcinoma, all of which tend to be associated with middle-aged or even young women. SITE AND SPREAD Tumours of the lower third have a much poorer prognosis than those of the upper and middle thirds, partly because spread to the danger to bladder. CLINICAL STAGING Stage 0 intraepithelial carcinoma – should be curable with the use of colposcopy. Stage I confined to the vaginal wall – 70-80% Stage II invading subvaginal tissues – 30-40% Stage III extension to the pelvic wall – 20-40% Stage IV extension to other viscera – 0-30% Prognosis depends on the stage, wihich depends on when the patient goes to her doctor, and on the position in the vagina. The lower third with its much quicler lumphatic spread is the least favourable. TREATMENT In stage 0 growths, good results have been obtained with local application of 5fluorouracil cream. For stage I onwards, radiotherapy is the usual treatment (indications of radiotherapy): 1. it can be applied at any stage 2. it is more readily available than skilled radical surgery 3. the patients are often elderly and poor surgical risks. Radical surgery: (radical hysterectomy, vaginectomy, lumphadenectomy) is claimed to give good results in experienced hands, and a cure rate of over 80% has been achieved for stage I. In stage IV where radiotherapy is only palliative, surgery which includes some form of exenteration is the better treatment if the patient is fit and the gynaecologist has the necessary experience. In the past, stilboestrol was adninistered in pregnacies had an increased risk of developing vaginal adenoisis and vaginal carcinoma in adolescence and early adult life.