OBSTETRICS AND GYNECOLOGY II Module No.

GYNE ONCOLOGY (VULVA AND VAGINA) 3

Dr. Poblete (INDEPENDENT STUDY) 06 February 2017
muscle is a vestibular bulb, and crura of the clitoris lie deep to the
Lecture Outline ischiocavernosus muscles.
I. Neoplastic Diseases of the Vulva
A. Lichen Sclerosus TABLE 31-1. Histologic Subtypes of Vulvar Cancer
B. Intraepithelial Neoplasia Vulvar carcinomas
C. Paget Disease Squamous cell carcinoma
D. Carcinoma Adenocarcinoma
II. Malignant Diseases of the Vagina Carcinoma of Bartholin gland
A. Intraepithelial Neoplasia Adenocarcinoma
B. Carcinoma Squamous carcinoma
C. Sarcoma Transitional cell carcinoma
LEGEND Vulvar Paget disease
Lecture Powerpoint, PPT 2018, Audio 2018, Book Merkel cell tumors
Verrucous carcinoma
Basal cell carcinoma
CASE 1 Vulvar malignant melanoma
 55 years old, G5P5 (5005) Vulvar sarcoma
 Consulted for vaginal pruritus Leiomyosarcoma
 Smoker Malignant fibrous histiocytoma
Epithelial sarcoma
Malignant rhabdoid tumor
Metastatic cancers to vulva
Malignant schwannoma
Yolk sac tumors

HISTOLOGIC SUBTYPES OF VULVAR CANCER

NEOPLASTIC DISEASES OF THE VULVA
 5% of lower female genital tract neoplasms
 Human papillomavirus (HPV) – noted in almost 70% of patients
with carcinoma of the vulva
o HPV-positive tumors – warty or basaloid appearance
o HPV-negative tumors – keratinized
 Most vulvar malignancies are Squamous Cell Carcinomas
 Most occur in women over 50 years old (Peak 65-75 years old)
o What is the most common cancer? CERVICAL.
o Next what is the net most common? OVARIAN
o Still HPV is the most common causative agent.
 Risk factors for vulvar cancer can be divided into two distinct profiles, which
are age dependent. Vulvar cancers that develop in younger women (<55 y/o)
tend to have the same risk profile as other anogenital cancers. Accordingly,
women with low socioeconomic status, high-risk sexual behaviors, human
papillomavirus (HPV) infection, and cigarette use are disproportionately
affected. These cancers are usually described histologically as being basaloid
or warty and are associated with HPV in 50 percent of cases
 In contrast, older women (55 to 85 years) with late-onset vulvar cancers
typically do not have a history of prior sexually infections and tend not to be
smokers. These cancers are largely keratinizing, and HPV DNA is found in
only 15 percent.
VULVAR ATYPIA
A. SQUAMOUS HYPERPLASIA
 BENIGN
 Hyperplastic dystrophy
 involves the elongation and widening of the rete ridges, which
may be confluent

CLASSIFICATION OF VULVAR ATYPIAS

Squamous hyperplasia (formerly hyperplastic dystrophy), benign.

Squamous cell carcinoma is the most common histologic type
(90%). And common in the post-menopausal women usually mga
40 years old to 55-75 yrs old
 Most vulvar cancers are diagnosed at an early stage (I and II)
 Advanced disease is found mainly in older women, perhaps due to clinical
and behavioral barriers that lead to diagnostic delays
 Vulvar cancer is primarily a disease of elderly women but has been observed
in premenopausal women as well.
VULVA
 The external vulva includes the mons pubis, labia majora and minora, clitoris,
vestibule, vestibular bulbs, greater vestibular or Bartholin glands, lesser
vestibular glands, Skene or paraurethral glands, and urethral and vaginal
orifices. The lateral margins of the vulva are the labiocrural. Vulvar cancer
may involve any of these external structures.
 The internal vulva can be divided into superficial and deep urogenital triangle
compartments. The superficial space of the urogenital triangle is an enclosed
compartment that lies between Colles fascia (superficial perineal fascia) and
the perineal membrane (deep perineal fascia). Within this space lie the
ischiocavernosus muscles laterally, the bulbocavernosus muscles medially,
and the transverse perineal muscle inferiorly. Deep each bulbocavernosus
Hyperkeratosis, acanthosis, and mild inflammation are present
First before going to malignancy, we have to know the pre-
malignant. Bago maging cancer yan. As we all know, may
pinanggagalingan yan. So these are the vulvar atypias. These are
very common.
B. LICHEN SCLEROSUS
 Change in the vulvar skin that often appears whitish
 Microscopically: the epithelium becomes markedly thinned,
with a loss or blunting of the rete ridges
o In some cases, there is also a thickening or hyperkeratosis of
the surface layers
 Small premalignant potential of lichen sclerosus (4.5% risk for
SCCA)
o a risk of lichen sclerosus and squamous cell carcinoma was
4.5%, with an average of 4 years latency between
symptomatic lichen sclerosus and squamous cell carcinoma
o the tumors that develop tend to be clitoral in location and
identifed in patients older than age 40 years

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 OB-GYNE GYNE ONCOLOGY (VULVA AND VAGINA)
 Have you heard about lichen? Anong alam nyong mga lichen?
Lichen simplex chronicus, ano pa? Ano pang mga lichen
lichen? LICHEN SCLEROSUS is placed here because it is a pre-
malignant lesion. Other lichens are usually benign. Actually
benign naman ang lichen sclerosus but it is a predisposing
factor.”
 Since it has a premalignant potential, you have to remind them
to follow-up and apply appropriate management after the
diagnosis.
 Keratinocytes affected by lichen sclerosus show a proliferative phenotype and
can exhibit markers of neoplastic progression.
o Suggests that lichen sclerosus may be a precursor lesion
in some cases of invasive squamous vulvar cancer. Vulvar
cancers that coexist with lichen sclerosus have been
shown to develop in older women, predominate in near
the clitoris, and lack association with VIN 3.
C. VULVAR INTRAEPITHELIAL NEOPLASIA (VIN)
 VIN I – Mild dysplasia (lower third of the epithelium)
 VIN II – Moderate dysplasia (half to two-thirds of the epithelium)
 VIN III – Severe atypia (more than two-thirds of the epithelium) &
Carcinoma-in-situ (full thickness of the epithelium)
o Atypical changes may appear in the vulvar epithelium. These
are usually marked by a loss of the maturation process usually
seen in squamous epithelium, as well as an increase in mitotic
activity and nuclear/cytoplasmic ratio
Carcinoma in situ kailan magiging cancer? Kapag meron nang
INVASION
D. PAGET’S DISEASE
 a rare intraepithelial disorder that occurs in the vulvar skin and
histologically resembles Paget disease in the breast, 7th decade
 Pruritus and tenderness
 Hyperemic, sharply demarcated, thickened, with foci of
excoriation and induration
 “cake-icing effect” – classic, pathognomonic
 Areas of leukoplakia mixed with patches of redness where
excoriation occurred because of intense pruritus
Paget’s disease of the vulva involving the lower half of the left
labium major and labium minor. The white medial portion is
characteristic of “cake-icing effect.” The red medial aspect is
also commonly seen and called “violaceous coloring.”
Paget’s disease of the vulva- “Cake icing effect”- whitish
appearance over a red background. It usually start with pruritus
then thickening.
 Extramammary Paget disease is a heterogeneous group of intraepithelial
neoplasias and when present on the vulva, appears as an eczematoid, red,
weeping area. These are often localized to the labia majora, perineal body, or
clitoral area.
 A histologic classification proposed by Williamson and Brown includes: (1)
primary vulvar cutaneous Paget disease, (2) Paget disease as an extension of
Transcribed By: CLIMACOSA, FRANCISCO, ONTIVEROS
Module 5, Lecture 3
transitional cell carcinoma of the bladder or urethra, and (3) Paget disease as
an extension of an associated adjacent primary cancer such as vulvar, anal, or
rectal cancers. The histologic differentiation of these Paget disease types is
important because the specific diagnosis significantly influences treatment
selection.
 Primary cutaneous vulvar Paget disease displays slow growth.
 Diseased areas should be resected with a wide local excision. Positive
margins occur frequently, and disease recurrence is common regardless of
the surgical margin status. If invasive disease is suspected, radical partial
vulvectomy is warranted by extending the deep margins to the perineal
membrane.
VULVAR ATYPIA: CLINICAL PRESENTATION
 Variety of signs and symptoms
 Irritation or itching is common
 Diffuse whitish change to the vulvar skin which appears thin with
scarring and contracture
 Areas of squamous hyperplasias (formerly called hyperplastic
dystrophy without atypia) also appear as whitish lesions in
general, but the tissues of the vulva usually appear thickened
and the process tends to be more focal or multifocal than diffuse
 Fissuring of the skin is often present with excoriation
 May also appear as white, red, or pigmented areas on the vulva
 >50%: Long-term pruritus or lump/mass on vulva- sometimes 10
years na yung pruritus
 Indolent, extends slowly, metastasizes fairly late
 70% arise on the labia (more commonly labia majora)
Most common symptom of vulvar atypia is PRURITUS. Sometimes
merong fissuring.
Due to scratching na-aalter yung skin
 Women with VIN and vulvar cancer commonly present with pruritus and a
visible lesion. However, pain, bleeding, and ulceration may also be initial
complaints. Clinicians may also contribute to delays by providing medical
treatment for up to 12 months before obtaining a biopsy or considering
referral.
 Colposcopic examination of the vulva, termed vulvoscopy, can direct biopsy
site selection.
 Other clinical entities may present similarly and include preinvasive
neoplasia, infection, chronic inflammatory disease, and granulomatous
disease. Thus, the goal of evaluation should be to obtain an accurate and
definitive pathologic diagnosis.
VULVAR ATYPIA: DIAGNOSTIC METHODS
 Cytologic smear (Pap smear) – presence of ulceration “to
document and to be sure.
o Cytologic evaluation (Pap smear) of the vulva has not proved
helpful, in part because the vulvar skin is thick and keratinized
and does not shed cells as readily as the epithelium of the
vagina and cervix.
o In some cases, particularly if there is ulceration of the vulva, a
cytologic smear can be helpful diagnostically
o When do you use this? For? Cervical cancer. But in terms of
VULVAR CANCER, PAPSMEAR is also good. If there are cases
na may ulceration, you can actually swab and saline solution.
That may help kasi madaming cells na makikita doon.”
o tongue depressor moistened with normal saline or tap water
is scraped over the surface portion of the vulva to be sampled
 Biopsy of the vulva – Keyes dermal punch biopsy
o 3- to 5-mm diameter punch is used
o Keyes punch biopsy - the punch is then rotated and
downward pressure applied so that a disk of tissue is
circumscribed. When the entire thickness of the skin has been
incised, the specimen is elevated with forceps and removed
with a sharp scissors.
o This one you need to remember. Kapag sa VULVA, you need
to do KEYES PUNCH BIOPSY
o Biopsy must be done “if you see any change, you need to do
biopsy”
o One-third of patients with carcinoma in situ will present with
pigmented lesions, emphasizing the importance of a biopsy
to establish the diagnosis
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OB-GYNE GYNE ONCOLOGY (VULVA AND VAGINA) Module 5, Lecture 3

o In addition, reddish nodules may also be foci of Paget disease
as well as of carcinoma in situ. Paget disease often has a
reddish eczematoid appearance. It should be reemphasized
that these conditions cannot be accurately diagnosed from
their clinical appearance, and biopsies are needed.
the sweat glands of the vulva or Bartholin gland carcinoma may
be present
 Rule out presence of breast and GI malignancy
o Breast mammography, Stool occult blood
 Wide local excision
o remove the full thickness of the skin to the subcutaneous fat
o “You have to remove the complete thickness with an
appropriate margin”
 Topical Imiquimod cream as a nonsurgical therapy
 Surgical procedures for the treatment of invasive vulvar neoplasia include
wide local excision (WLE), radical partial vulvectomy, and radical complete
vulvectomy.

MALIGNANT DISEASE OF THE VULVA

 Delay of 2-16 months following onset of symptoms
to diagnosis

What vulvar lesion or vaginal lesion, is bluish, violacious that

you will NOT do biopsy?? What lesion?? Bluish, with a history
of hydatidiform mole. Basta TROPHOBLASTIC LESION, DO
NOT DO BIOPSY.

 Vulvoscopy
o Vulva is soaked with 3-percent acetic acid for 5 minutes
to allow adequate penetration into the keratin layer  this
aids identification of acetowhite areas and abnormal
vascular patterns, which are characteristics of vulvar SQUAMOUS CELL CARCINOMA
neoplasia.  90% of primary vulvar malignancies
o Lesions may be raised, ulcerated, pigmented, or warty,  appear as raised, flat, ulcerated, plaque-like, or polypoid
and biopsies of the most suspicious appearing areas are masses on the vulva
obtained..
 arising in a bed of lichen sclerosis

VULVAR ATYPIA: TREATMENT

 Topical steroids
o 0.05% clobetasol propionate ointment – first line therapy
o Topical steroids can be used for atrophic conditions of the
vulva, can be used anywhere from nightly to twice weekly for
up to 12 weeks and then used to re-treat
 Topical calcineurin inhibitors (TCIs)
o TCIs pimecrolimus and tacrolimus
 Testosterone and Progesterone creams
o For women who fail clobetasol and TCIs, some advocate the
use of hormonal creams, although results from small clinical
trials using testosterone and progesterone creams have been
mixed
 Symptom relief of itching
o local measures to diminish irritation (cotton underclothes,
avoidance of strong soaps and detergents, avoidance of Staging – Surgical-Pathologic
synthetic undergarments)
o Topical fluorinated corticosteroids,
o Burow’s solution (5% solution of aluminum acetate) is
frequently used as a wet dressing to help control irritation and
itching
o Doak tar, 3%, in petrolatum (USP) or in 1% hydrocortisone
ointment is useful for severe cases

“If you will not perform biopsy, you may actually try na mag topical
steroids muna. You may use Fluticasone, then let your patient
come back maybe after 4 weeks.”

“Testosterone and progesterone creams - cost efficient. So pag

mga matanda na, maputi na, you may give estrogen creams”

“Itching is a red flag, kasi minsan din a sila makatulog, ano nalang
ginagawa sa gabi? Nagkakamot nalang. You have to inform then
to use mild soap, yung type of panty, steroids can actually address
the itchiness pero pag sobrang severe, you may give also anti-
histamine.”

A. Treatment – VIN
 Once the diagnosis of VIN has been established by biopsy,
therapy is performed to eradicate the area containing the
neoplasia
 VIN may spontaneously regress
 Local excision
o Laser therapy of the atypical area may be used for younger
patients who do not have raised lesions
 HPV Vaccination – explored for treatment of VIN III
 “What’s the HPV type??? Type 16 and 18”
B. Treatment – PAGET’S DISEASE
 The major importance of Paget disease of the vulva is the
frequent association with other invasive carcinomas. Squamous
cell carcinoma of the vulva or cervix or an adenocarcinoma of
 In the clinical staging system, lymph node status was assessed
clinically and incorporated into the stage. Enlarged or clinically
suspicious lymph nodes were assigned a higher stage, regardless
of disease status documented at surgery. Clinically negative
nodes were assigned an earlier stage, which was upheld even if
they were found to harbor metastasis after surgical removal and
pathologic examination.
”Remember pala, Cervical cancer- clinically staged,
Treatment: Chemoradiation.”

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OB-GYNE GYNE ONCOLOGY (VULVA AND VAGINA) Module 5, Lecture 3

“Ovarian, endometrial, vulvar, Vaginal cancer- open na yan.  Sarcoma

Surgically staged. Ooperahan with wide local incision”  Granular Cell Myoblastomas

Natural History, Spread, and Prognostic Factors A. Bartholin Gland Carcinoma

 Lymphatic route for initial metastases  Adenocarcinomas that constitute approximately 1% to 2% of
o Lymphatics from clitoris directly to deep pelvic lymph nodes vulvar carcinomas. “So yung vulvar carcinoma ay 5%, 1-2% of
o Unusual to find metastasis in pelvic lymph nodes without that ay ito”
metastasis in inguinal lymph nodes  Enlargement of bartholin gland in a postmenopausal woman
 Vulvar carcinomas less than 2 cm in diameter and depth of commonly more than 40 years old.
invasion less than 1 mm (3-mm thickness) rarely metastasize to  Radical vulvectomy with bilateral inguinofemoral
regional nodes lymphadenectomy is the treatment of choice- “usually
 Unilateral vulvar tumors (>2 cm from midline) usually metastasize tatanggalin because of the risk for malignancy”
to ipsilateral inguinofemoral nodes only
 the vulvar area is rich in lymphatics, with numerous cross
connections
 Prognosis in vulvar cancer is primarily related to lesion size, lymph
node status, and stage
 The risk of lymph node groin metastases is related to tumor
differentiation, lesion thickness, lymphovascular space
involvement, patient age, and tumor size
 The deep pelvic nodes do not become involved with metastatic
vulvar cancer unless the inguinofemoral nodes are affected
 5-year survival rate with negative nodes is more than 95%
o One positive node – 94%
o Two positive nodes – 80%
o Three or more positive nodes – 12%

 The incidence of Bartholin gland carcinomas peaks in women in their mid-

60s.
 Soft, distensible tissue normally surrounds these glands, and tumors may
reach considerable size before patients develop symptoms.
 Dyspareunia is a common first complaint.
 Bartholin gland enlargement in a woman older than 40 years and recurrent
cysts or abscesses warrant a biopsy or excision. Similarly, all solid masses
require fine-needle aspiration or biopsy to establish definitive diagnosis.
 Bartholin gland carcinomas tend to spread into the ischiorectal fossa and have
a propensity for lymphatic spread into the inguinal and pelvic lymph nodes.
Therapy includes a radical partial vulvectomy with inguinofemoral
lymphadenectomy.
 Postoperative chemoradiation has been shown to reduce the likelihood of
local recurrence for all stages. If the initial lesion impinges on the rectum or
Management
anal sphincter, preoperative chemoradiation can be used to avoid extensive
 En bloc dissection of radical vulvectomy plus inguinal and pelvic surgery.
lymphadenectomy
o Mainstay of treatment in vulvar cancer
o 2-cm margin B. BASAL CELL CARCINOMA
o Goal of Radical vulvectomy: remove the primary lesion to the  2% of vulvar carcinomas, MC in elderly women
depth of perineal fascia with a 2-cm circumferential margin  Treatment: Wide local excision of the ulcerated lesion
 Lymph nodes resected via separate incision  If the surgical resection margins are free of tumor, the disease is
o Well-lateralized lesions less than 1 cm from midline – modified cured
radical vulvectomy with ipsilateral inguinofemoral lymph
node dissection
o Central lesions – bilateral lymph node dissection
 If (+) inguinal nodes – pelvic radiation therapy (instead of pelvic
lymph node dissection) is done
o 2-year survival rate
 Radiotherapy – 68%
 Pelvic node dissection – 54%
 Lymph node dissection still cornerstone for groin
 Advanced vulvar tumors encroaching on the urethra or anus:
Radiation followed by wide radical excision and enhanced with
combined use of chemotherapy and radiation

Technique of Radical Vulvectomy

 On the vulva, BCC is characterized by pigmentation, pruritus, and a clinical
appearance often mimicking other dermatopathologies such as eczema,
psoriasis, or intertrigo.
 The literature suggests that local trauma and advancing age may contribute to
the development of BCC in these sites.
 Basal cell carcinoma should be removed by wide local excision using a
minimum surgical margin of 1 cm. Deep margins of 1 cm should also be
obtained. Lymphatic or distant spread is rare. However, local recurrences may
occur, particularly in tumors removed with suboptimal resection margins.

C. VERRUCOUS CARCINOMA
 A special variant of squamous cell cancer
 Appear as a large condylomatous mass on the vulva
OTHER VULVAR MALIGNANCIES  Treatment: Wide local excision and tumor-free margins
 Radiotherapy is contraindicated
 Bartholin Gland Carcinoma
 Basal Cell Carcinoma
 Verrucous Carcinoma
 Melanoma

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OB-GYNE GYNE ONCOLOGY (VULVA AND VAGINA)
“This is verrucous parang warty like lesion, it is condylomatous. For
this one, radical incision, tatanggalin mo din”
D. MELANOMA
 The most frequent non-squamous cell malignancy of the vulva
 Second most common malignant neoplasm of vulva
 5% of vulvar carcinomas
 Arises from a lesion containing a junctional or a compound
nevus
 Pigmented and raised, may be ulcerated
 Pruritus, bleeding, enlargement of pigmented are
 Most occur on the labia minora or clitoris “so where is the most
common area for melanoma? Clitoris or labia. Remember that”
 Radical local excision with a margin of 2 cm for thin lesions (up
to 7 mm) and 3 to 4 cm for thicker lesions for well-circumscribed
melanomas
o Clark level I or II – wide local excision
 Lymphadenectomy is prognostic than therapeutic
 Often misdiagnosed as undifferentiated squamous cell cancers
(especially when amelanotic)
Transcribed By: CLIMACOSA, FRANCISCO, ONTIVEROS
Module 5, Lecture 3
 Malignant vulvar melanoma will most commonly arise from the labia minora,
labia majora, or clitoris.
 Three histologic subtypes of vulvar melanoma have been described:
superficial spreading melanoma (SS), nodular melanoma (NM), and acral
lentiginous melanoma (AL).
E. SARCOMA
 less than 3% of vulvar cancers ”it is very rare”
 Leiomyosarcomas are the most common histologic subtype
found
 Surgical removal of the primary tumor is the treatment of choice
 Chemotherapeutic considerations
F. GRANULAR CELL MYOBLASTOMAS
 extremely rare tumor that is almost invariably benign but
morphologically shows pleomorphism
 tumor appears as a solitary, firm, non-tender, slowly growing
nodule in the subcutaneous tissue of the vulva
 Local excision is generally sufficient therapy
PREMALIGNANT DISEASE OF THE VAGINA
VaIN (Vaginal Intraepithelial Neoplasia)
 Premalignant changes in the vagina occur less frequently than
comparable lesions in the cervix and vulva.
 VAIN – term used to describe these histologic changes
 Generally asymptomatic
 Observed in patients who have undergone previous therapy
for intraepithelial disease of the cervix.” It is very important to
observe if there is the history of CIN.”
 VAIN usually occurs in the upper half of the vagina or along the
vaginal cuff suture line
 Diagnosis: Biopsy (Kevorkian or Eppendorf punch biopsy
forceps)
 HPV 16 – most common associated with vaginal dysplasia
 3-7% progress to invasive carcinoma despite treatment
 Chronic vaginal irritation- (Mechanism not well understood)
MANAGEMENT – VAIN
 Principles of management: rule out and prevent invasive disease
and preserve vaginal function
 VAIN can be treated by excision, laser, 5-FU, or Imiquimod
o Excision is often used for VAIN-3
o Laser treatment is generally used for discrete lesions once
invasion has been ruled out
o 5-FU and Imiquimod cream are used to treat diffuse,
multicentric, low-grade disease
MALIGNANT DISEASE OF THE VAGINA
 Primary cancer of the vagina is rare and constitutes less than 2%
of gynecologic malignancies
 Most vaginal malignancies are metastatic, primarily from the
cervix and endometrium
 Most common histologic type of primary vaginal cancer is
squamous cell carcinoma
SQUAMOUS CELL CARCINOMA
 HPV infection
o HPV 16 in 2/3 of cases
 1/3 have history of cervical dysplasia or cervical cancer more
than 5 years earlier. “always ask if the patient had a previous
abnormal smear”
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OB-GYNE GYNE ONCOLOGY (VULVA AND VAGINA) Module 5, Lecture 3

 Median interval between cervical disease and development of o Upper 3rd – common iliac, presacral, hypogastric nodes
vaginal cancer – 14 years
o 16% had history of prior radiation

Screening
 Examine lateral “horns” of upper vaginal vault in patients with
history of hysterectomy “usually diba pag ni-IE mo, you will feel
a donut, yung cervix. Pero pag nag post-hysterectomy na, SLIT-
CUT lng mafeel mo”
 Pap smear
o Continued in women with history of cervical dysplasia/cancer
(increased risk) whether or not they may have had a
hysterectomy
 Development of vaginal cancer is possible even in women with
a history of hysterectomy for a benign disease

Signs and Symptoms

 Painless vaginal discharge, often bloody – most frequent
 Postcoital or postmenopausal bleeding
 Urinary symptoms (pain, frequency)
o More common than in cervical cancer because of neoplasms
that are lower in the vagina are close to the vesicle neck Prognostic Features
 Compression of bladder at earlier stage  Age at time of diagnosis
 Tenesmus – associated with posterior lesions o ”the older the patient the poorer prognosis”
 5-10% asymptomatic o Performance status
 Similar to those of cervical cancer  Tumor histology
o Vaginal melanomas and sarcomas – poorest prognosis
Diagnostic Considerations compared to squamous cell and adenocarcinomas
 Adequate pelvic examination (under anesthesia if necessary)  Stage, tumor location, tumor size (>4 cm)
 Vaginal colposcopy – in patients with abnormal Pap smear and  5-year survival
no gross abnormality o Stage I – 64-90%
 “You know what colposcopy is? It’s just a big microscope na o Stage II – 31-80%
parang magnifying glass, it is called COLPOSCOPE na para mag o Stage III – 0-79%
magnify. yun lang ganun lang sya.” o Stage IV – 0-62%
 Metastatic carcinoma to vagina is seen much more often than  But if there is a lesion on the Distal vagina had poorer prognosis
primary disease than those in proximal vagina
o 84% from genital sites
 Cervix 32% Management
 Endometrium 18%  VAIN – usually vaginal apex
o 16% GI tract, breast  Radical surgery may be used to treat low-stage tumors, primarily
of the upper vagina, in younger patients
Staging o Wide local excision, Total vaginectomy, Radical
o Lesions 0.5 cm or less
 Surgery preferred
 Local therapy (conservative approach)
o Thicker than 0.5 cm
 Total vaginectomy and lymphadenectomy
 Radical hysterectomy and upper vaginectomy for women
with no history of prior hysterectomy
 Pelvic EBRT and interstitial implants
 Brachytherapy
 Radiation therapy is the most frequently used modality for the
treatment of squamous cell carcinoma of the vagina
 Concurrent chemoradiation should strongly be considered

CLEAR CELL ADENOCARCINOMA

 6% of vaginal cancers
 April 1970, Herbst and Scully reported 7 cases of primary vaginal
adenocarcinoma between ages 15-22
o Mothers have been treated with DES
o DES – Nonsteroidal synthetic estrogen used to support high risk
pregnancy and reduce fetal wastage
 Lower risk of cancer among women whose mothers began
DES after 12th week of pregnancy
 Clear cell adenocarcinoma is often associated with
prenatal DES exposure. Prognosis is improved if the patient
is older than 19 years, the tumor has a predominant
tubulocystic tumor pattern, and the disease is low stage.
Those with a positive DES maternal history have a better
prognosis.
 Better prognosis if patient is older than 19 years old,
predominantly tubulocystic pattern, and lower stage

Management
 Local therapy for small, stage I clear cell adenocarcinoma
o If the tumor is smaller than 2 cm in diameter
o invades less than 3 mm
Patterns of Spread o predominantly of the tubulocystic histologic type
 Metastasizes by direct extension, lymphatic dissemination,  Pelvic nodes should be sampled and be free of tumor
hematogenous spread “because the vagina is very vascular  Overall 5-year survival rate of treated patients is 80%
diba?”
 Lymphatic drainage of vagina:
o Lower 3rd – drain into femoral and external iliac nodes MALIGNANT MELANOMA
o Middle 3rd – hypogastric nodes  Rare and highly malignant

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OB-GYNE GYNE ONCOLOGY (VULVA AND VAGINA) Module 5, Lecture 3

 2% to 3% of primary vaginal cancers

 Most common presenting symptoms are vaginal discharge,
bleeding, and a palpable mass
 Common in postmenopausal women
 Treatment usually consists of surgery with wide excision of the
vagina and dissection of the regional nodes

OTHER VAGINAL CARCINOMAS

VAGINAL ADENOCARCINOMAS ARISING IN
ENDOMETRIOSIS
 Endometrioid adenocarcinomas of the vagina may occur
through the malignant transformation of endometriosis, often
associated with the use of unopposed estrogen or tamoxifen

VAGINAL TUMORS OF INFANTS AND CHILDREN

 Endodermal Sinus Tumor (Yolk Sac Tumor)
o occur in children younger than 2 years. They secrete α-
fetoprotein and are usually treated by multiagent
chemotherapy, followed by surgical excision.
 Sarcoma Botryoides (Embryonal Rhabdomyosarcoma)
o occurs primarily in children younger than 8 years. It is treated
by a multimodality approach using multiagent
chemotherapy with surgical removal and occasionally
irradiation
 Pseudosarcoma Botryoides

REFERENCES
Comprehensive Gynecology
Trans batch 2018

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