GYNECOLOGY

LECTURE: 2.04 Neoplasms of the Cervix, Vulva, and Vagina

LECTURER: Dr. Lilli May C. Teodoro-Cole, M.D.
DATE: March 2, 2017
TRANSCRIBER: Group 9 (Mendoza 09177111614), Medina, Mendoza, Mesina, Miranda
EDITOR: Sarmiento, Hana (09154817560)

OUTLINE Tables 1. Cancer Statistics

I. Cervical Cancer 10 Leading Cancer Sites (Both Sexes)
A. Epidemiology 1. Lung (17,238) 6. Prostate (4,254)
B. Burden of Cervical Cancer
C. Natural History and Risk Factors 2. Breast (14,043) 7. Leukemia (4,202)
D. Seed-Soil-Nutrient Model 3. Colon/ Rectum (8,585) 8. Stomach (3,932)
E. Clinical Presentation 4. Liver (7,629) 9. Thyroid (3,521)
F. Histologic Types 5. Cervix (7,277) 10. Ovary (3,283)
G. Manner of Spread
H. Staging
10 Leading Cancer Sites (Females)
I. Diagnostic Modalities
J. Treatment 1. Breast (14,043) 6. Thyroid (2,766)
K. Modalities of Radiotherapy 2. Cervix (7,277) 7. Liver (1,969)
L. Surveillance 3. Lung (3,965) 8. Leukemia (1,959)
II. Vulvar Cancer 4. Colon/ Rectum (3,848) 9. Corpus (Uterine) (1,777)
A. Mode of Spread 5. Ovary (3,283) 10. Stomach (1,564)
B. Staging
C. Prognosis Those in bold were the ones emphasized during the lecture. She only
D. Management mentioned that if you look at the incidence of cervix CA, it is only half
E. Other Vulvar Malignancies of breast CA’s. It implies there are a lot of breast CA patients.
III. Vaginal Cancer
A. Vaginal Malignancies B. Burden of Cervical Cancer
B. Vaginal Intraepithelial Neoplasia
C. Detection and Diagnosis  Remains a public health concern as it poses a threat to the
D. Management welfare and well-being of women and whole population
E. Malignant Diseases of the Vagina  Affects relatively young women and results in many lost years
F. Primary Vaginal Tumors of life – Leads to the loss of productivity in young women.
G. Least Common Primary Vaginal Tumors  In 2000, about 2.7M age-weighted years of life worldwide
H. Treatment
were lost due to disease
OBJECTIVES: No objectives were given.  Results to orphaned children, households without care takers
References: of children and families- because young women are affected,
Dr. Cole’s Lecture they are at the stage in their life wherein they are just starting
Comprehensive Gynecology to build their families.
Legend: Italicized – quoted from the lecturer; bold – emphasis,  Has significant economic costs and heavy impact on families’
or from references resources. Treatment reaches up to Php 200,000 and that will
not assure you that the patient will be cured
I. CERVICAL CANCER  Affected women lost opportunity to work, preventing other
family members to engage in the same. They have to be
A. Epidemiology accompanied to the hospital so everyday expenses rise.
 Biggest impacts are on poverty, education, and gender
equity
Worldwide:
 Cervical cancer is the second most common cancer  Perpetuates inter-generation and unending cycle of poor
health status to low economic productivity, poor education,
affecting women worldwide (around 500,000 women are
and lack of empowerment among afflicted women and their
diagnosed each year)
families.
 Worldwide, every 2 minutes, a woman dies of cervical cancer
 It is estimated that up to 50-80% of women will acquire HPV
C. Natural History and Risk Factors
infection in their lifetime. Very very common in young women.
 It starts with HPV infection then it becomes low grade cervical
Philippines: squamous intraepithelial lesion (SIL). If left undiagnosed, it
 Cervical cancer is the second leading cause of cancer becomes high grade cervical SIL until it becomes invasive
deaths among women cervical CA. By this time, when you do your speculum exam,
 Incidence starts rising steeply at 35 years old- unique to you will already see a mass in the cervix.
cervical cancer is that it occurs in younger women compared  There is a lot of opportunity for screening. How come when
to ovarian and endometrial cancers that affect 60-70 y/o diagnosed it is already in the advanced stages?
women. Cervical cancer patients are still productive, working, o We do not have a well implemented screening test in
and with small children. our country.
 Disease is usually diagnosed late when patients are at the o Most of the time, we do opportunistic screening for
prime of their lives. Usually at stage 3 (60-70%) despite patients who come in for gynecologic check-up or pre-
presence of screening protocols. natal check-ups (these are the ones we do pap-smears
on)
 56% of Filipino women with cervical cancer die within 5 years.
o High risk patients are not being screened primarily
Around half of those diagnosed with cancer.
because of financial constraints. For example, women

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GYNECOLOGY: 2.04 Neoplasms of the Cervix, Vulva, and Vagina (2018B)

diagnosed with cervical CA from the provinces, most of E. Clinical Presentation

the time report no prior history of pap smear or
speculum examination.
 ASYMPTOMATIC: majority of the early stage of the cancer.
There is on and off discharge that women do not attribute to
cancer because this is normal in between cycles.
 Abnormal and foul-smelling vaginal discharge as the
cancer progresses (smells like a dead rat and clings to your
clothes. This is due to the secondary anaerobic infection)
 Abnormal bleeding (very minimal in amount unlike in
myoma or Endometrial CA)
o Contact bleeding (postcoital): classic symptom. When
something hits the mass or cervix, it bleeds.
o Intermenstrual spotting
 Low back pain and unilateral leg edema: usually indicate
advance cases of cervical CA

F. Histologic Types

Figure 1. Natural History of the Cervical Cancer. Long interval from

viral infection to cancer development. It takes around 15-20 years.

Risk Factors are divided into 3 main categories:

1. Host-related factors
Usually secondary to the following:
o Immunosuppression or weakened immune system
o Sexual behavior
 First sexual intercourse at a young age
 Many sexual partners
o High parity or giving birth to many children

2. Exogenous factors
Figure 2. Ectocervix showing Squamous cell CA exemplified by the
o Tobacco smoking
o Co-infection with other STI (herpes simplex, invasion of the mucosa on the left.
chlamydia, gonorrhea)
o Long term (>5 years) use of OCP  Squamous cell CA (85%): this involves the lining of the
ectocervix
3. HPV-related cofactors o Large cell keratinizing
o Type of HPV o Large cell non-keratinizing
 Especially for type HPV16 as it is the most o Small cell squamous cancer
virulent, carcinogenic, and common cause of
cervical CA
 If HPV45 or HPV33 (less carcinogenic),
chances of developing full blown cervical CA is
not that high
o Simultaneous infection with several high risk types
 Concomitant infection with different subtypes
would work synergistically in producing the
cancer.
o High virus load

D. Seed-Soil-Nutrient Model
 For the development of cervical cancer- these three must be Figure 3. Cervical adenocarcinoma showing increased number of
present glands with dysplastic arrangement.
 Seed is HPV
o Even if HPV is the necessary cause (you won’t develop  Adenocarcinoma (10-15%): since columnar cells line the
cervical CA if there is no HPV), NOT ALL HPV infections endocervical canal
will develop cervical CA (~1% only because you also  Less common types:
need the co-factors)
o Adenosquamous
 Soil is cervix o Clear cell CA
 Nutrients are the co-factors (STIs, smoking, OCPs)
o Contribute further to possible development of cervical
CA. Acts as fertilizers.

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GYNECOLOGY: 2.04 Neoplasms of the Cervix, Vulva, and Vagina (2018B)

G. Manner of Spread H. Staging

Figure 4. Manner of spread of Cervical Ca. Note the proximity of the

commonly affected organs.
 Direct extension: Most common. Can go:
o Up into the lower segments of the uterus
o Down into the vagina
o Laterally, posteriorly, anteriorly into the bladder
o Into the parametrium (ligaments surrounding the cervix
like cardinal and uterosacral ligaments)
 If it goes laterally, there is secondary ureter
obstruction. Ureter passes through the parametrium
before reaching the bladder. So in advanced cases,
one common presentation is uremia. Creatinine is
high and imaging shows hydronephrosis and
hydroureter. In such cases a stent or a
percutaneous tube nephrostomy is placed.
Figure 6. Staging of Cervical Cancer (correlate with Table 2).
 Most important predictor of prognosis
 Clinically-staged based on the physical examination
findings: unique for cervical and vaginal cancers
 Depends primarily on the pelvic examination, may be
modified by general PE, chest x-ray, intravenous pyelography
(IVP), or CT scan
 Internal examination during pelvic exam
o Size of the tumor (prognostic factor)
o AP and sagittal measurements
o Feel for the fornices if vagina is involved
 Rectovaginal examination
o Access the parametria by pushing the fundus
downwards at the same time sweep fingers towards the
lateral areas
o To detect involvement of parametria and pelvic side wall
 Studies have shown that lesions >4cm have higher chances
of metastasis to the lymph nodes that’s why 4cm is set as the
cut-off for Stages Ib1 & Ib2.

Table 2. Clinical Stages of Cervical Cancer

5-year
Stage Characteristics
survival
0 Carcinoma in situ (CIN) 100%
I Limited to the cervix
Ia1 Microscopic disease: stromal invasion >95%
≤3mm; lateral spread ≤7mm (diagnosed
only by microscopy)
Ia2 Microscopic disease: stromal invasion
Figure 5. Lymphatic spread of Cervical CA.
>3mm and not >5mm; lateral spread
<7mm (diagnosed only by
 Lymphatic: also common
microscopy)
o Rich lymphatic network from the pelvis going up to
cervical areas Ib1 Macroscopic lesion ≤4cm in greatest 90%
o It follows the course of major blood vessels- common dimension (clinically visible)
illiac, aortic, hilar, and left supraclavicular/ scalene Ib2 Macroscopic lesion >4cm in greatest 80-85%
nodes. dimension (clinically visible)
o It is not uncommon in advanced cases, you will see a II Extension to uterus/parametria/vagina 75-78%
mass in the left anterior supraclavicular area. IIa1 Involvement of upper 2/3 of vagina
o Parametria first area with rich lymphatics. It is an WITHOUT parametrial invasion, =/<4cm
important are where spread initially starts in. greatest diameter
 Hematogenous

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GYNECOLOGY: 2.04 Neoplasms of the Cervix, Vulva, and Vagina (2018B)
IIa2 Involvement of upper 2/3 of vagina
WITHOUT parametrial invasion, >4cm
greatest diameter
IIb1 Involvement of upper 2/3 of vagina WITH
parametrial invasion
III Extension to pelvic side wall and/or lower 47-50%
third of vagina
IIIa Involvement of lower third of vagina
IIIb Extension to pelvic side wall and/or
hydronephrosis
IV Extension to adjacent organs or beyond 20-30%
true pelvis
IVa Extension to adjacent organs (bladder,
rectum)
IVb Distant metastasis
 The following were emphasized by the lecturer:
o Stage 1 – usually confined to the cervix
o Stage 2 – if it goes beyond the cervix, laterally would be
the parametria (Stage 2b); if it extends to the upper third
of the vagina (Stage 2a)
o Stage 3 – if it extends to the pelvic wall (Stage 3b)
 Presence of hydroureter and/or hydronephrosis
are manifestations. If you cannot attribute
hydronephrosis to other conditions, automatically
it is stage 3b cervical cancer even if the
examination findings do not collaborate with the
presence of hydronephrosis.
 May present with low back pain or hypogastric
pain.
o Stage 4 - involvement of the MUCOSA of the bladder or
rectum (Stage 4a). If it’s submucosa, then it’s not yet
considered as stage 4. If there is distant spread, then it
is considered Stage 4b.
I. Diagnostic Modalities
1. Cervical Punch Biopsy
 For diagnosis
 Unlike in CIN wherein the cervix looks normal, in
cervical cancer when you do your speculum exam
and you already see a mass you don’t need to do
your colposcopy or pap-smear. Directly proceed to
biopsy
 Since the staging is clinical, there are only approved
imaging studies and other evaluation procedures
that are used for staging. There’s no use of high-
tech imaging since the staging is clinical. In low
resource countries, high-tech imaging such as CT
scan is not accessible.
2. Chest X-ray: For lung metastasis
3. Intravenous Pyelography (IVP): For hydronephrosis
4. Cystoscopy: To detect involvement of the mucosa of the
bladder
5. Proctoscopy: To detect involvement of the mucosa of the
rectum
6. CT scan (optional only and not recommended):
Although very accurate in detecting metastasis, it is not
usually done in low resource countries like the Philippines.
In the event that a patient can afford it and metastasis was
seen on the liver through CT, just write it down as (+)
lesion on liver BUT the stage follows what you found in
your clinical exam.
TRANSCRIBER: Trans Group 9 (Mendoza, N- 09177111614) EDITOR: (Hana Sarmiento, 09154817560)
J. Treatment
Figure 7. Extent of the different Subtypes of Hysterectomy.
1. Radical Hysterectomy +/- BSO, BLND
 Selected early stage disease
 Stage IA1 to IIA1 (≤4cm lesion size)
 You may leave the ovaries if patient is young PROVIDED
that the parameters for leaving the ovaries are met. This
is done to preserve hormonal function and prevent
premature menopause.
 There is selection of patients who can still undergo
surgery following stringent criteria. Why? This is because
it is a long procedure that takes 4-6hours, there are a lot
of complications. For those with heart disease or other
medical conditions, we advise chemoradiation.
 Vaginectomy or removal of the upper third of vagina is
included because the cervix is very close to the upper
part of the vagina so you want to assess the upper part if
there’s an extension. If you perform a radical
hysterectomy, it is understood that you also perform a
vaginectomy.
 In hysterectomy, if you perform a bilateral salpingo-
oophorectomy, you have to indicate “+BSO”
 It also includes removal of the parametria (start of the
lymphatic network would be at these areas so
parametrectomy is important) and the ligaments that
attach the uterus at the pelvic wall like the cardinal
ligaments.
 BLND (Bilateral Lymph Node Dissection) is done
because a (+) LN means poorer prognosis
 Why does it take so long to perform the procedure?
Because the limits of your excision would be the ureter
and the bladder so all the fibrofatty tissues adjacent to
the ureter and the bladder are removed. This is why one
of the major complications would be ureterovaginal
fistula and vesicovaginal fistula. You denude the ureter
and the bladder and vascular necrosis is one of its
complications. And because you denervate the bladder,
put an indwelling catheter for 3 weeks to rest the bladder
and give time for the small nerves to regenerate.
 Other types of hysterectomy (refer to Figure 7):
o Subtotal: Removing the corpus only, usually done
in postpartum hysterectomy in an effort to perform
the surgery fast because the patient is bleeding. But
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GYNECOLOGY: 2.04 Neoplasms of the Cervix, Vulva, and Vagina (2018B)
the ideal is to remove everything because a lesion
on the cervix may develop later on and treatment
becomes more difficult.
o Total: Removal of the whole uterus, cervix, and
corpus EXCEPT the parametria (note: BSO not
included)
o Simple: Total hysterectomy is an example
2. Chemoradiation
 Standard of treatment as it can treat all stages
 Concomitant pelvic radiation therapy and chemotherapy
for those who come in as advanced cases
 Role of chemotherapy
o Not the active chemotherapy being given in primary
treatments
o Acts as radiosensitizers to enhance the lethal
effect of radiotherapy (RT)
o Given weekly and simultaneously with the
radiation
o Cisplatin (more common), Carboplatin, 5-
Flourouracil
K. Modalities of Radiotherapy
1. External Radiotherapy
 Treatment planning: you pinpoint the areas that has to
undergo radiation, it sterilizes the parametria and the
lymph nodes
 Given everyday, 5 minutes, 28-30 sessions
 Teletherapy
 Growth in the parametrium and pelvic lymph nodes are
sterilized. Pelvic bone to inguinal area.
 Cobalt (old), Linear Accelerator (new)
2. Internal Radiotherapy
 Central growth in the cervix is addressed
 Brachytherapy
o Intracavitary/Internal Radiation
o You put the radiation inside the cervix, usually done
after the external radiotherapy so the remaining
tumors in the cervix is exposed directly to the
radiation
o Closed procedure: A tandem is placed on the cervix
while two ovoids are placed on the fornices forming
a secure triangle. Vagina is held in place. Radiation
flows once the doctors leave the room so they have
less exposure.
o Place radioactive source in close proximity to
tumor: Iridium now used, previously it was radium
o Isodose curve: 2cm from the instrument will be
exposed to radiation
L. Surveillance
 Pelvic Exam
o Every 3-6 months, cervix is very accessible
 Pap smear
o As a test for recurrence, not for screening to detect
suspicious cells as sign of recurrence
 Imaging
o Ultrasound
o CT Scan
o PET CT Scan
TRANSCRIBER: Trans Group 9 (Mendoza, N- 09177111614) EDITOR: (Hana Sarmiento, 09154817560)
II. VULVAR CANCER
 4% of genital tract malignancies, ranks 4th most frequent
 Arise at multifocal points
 Risk factors:
o HPV-younger patients, associated with VIN
o Associated with history of cervical or vaginal CA
 SCCA- 90% of vulvar CA, increases with age
 Melanoma – 4-5%. This is a highly virulent tumor.
Figure 8. Cancer of the vulva. The lesion is usually exophytic and is seen
as a cauliflower-like lesion involving the labia. Other times it can be
infiltrative with very firm edges.
A. Mode of Spread
 Direct extension
 Hematogenous
 Lymphatic spread depends on site:
o Labia majora- ipsilateral inguinofemoral nodes
o Midline structures- either side of inguinofemoral nodes
o No direct drainage to the pelvic nodes
o If it only involves one side, we only do dissection on one
side. But if it is a central lesion, it goes to both inguinal
and femoral nodes so we have to do bilateral inguinal
node dissection. It doesn’t go directly to the pelvic nodes.
Check inguinal nodes first. If positive, then we consider
possible spread to pelvic nodes.
B. Staging of Vulvar Cancer
This was included in the lecture but was not discussed.
Table 3. The International Federation of Gynecology and
Obstetrics (FIGO) staging system for Carcinoma of the
Vulva
Stage I Tumor confined to the vulva.
Stage IA Tumor confined to the vulva or perineum, ≤
2cm in size with stromal invasion ≤ 1mm,
negative nodes
Stage IB Tumor confined to the vulva or perineum, >
2cm in size or with stromal invasion > 1mm,
negative nodes
Stage II Tumor of any size with adjacent spread (1/3
lower urethra, 1/3 lower vagina, anus),
negative nodes
Stage III Tumor of any size with or without extension
to adjacent perineal structures (lower 1/3
anus, urethra, and vagina); positive
inguinofemoral nodes
Stage IIIA Tumor of any size with positive inguino-
femoral lymph nodes:
 1 lymph node metastasis ≥ 5 mm
 1-2 lymph node metastasis(es) of
< 5 mm
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Stage IIIB  2 or more lymph nodes

metastases ≥ 5 mm
 3 or more lymph nodes
metastases < 5 mm
Stage IIIC Positive node(s) with extracapsular spread
Stage IV Tumor invades other regional (2/3 upper
urethra, 2/3 upper vagina), or distant
structures
Stage IV A  Tumor invades other regional
structures (2/3 upper urethra, 2/3
upper vagina), bladder mucosa,
rectal mucosa, or fixed to pelvic
bone
 Fixed or ulcerated inguino-femoral
lymph nodes
Stage IV B Any distant metastasis including pelvic
lymph nodes
C. Prognosis of Vulvar Cancer
STAGING is the most important predictor of prognosis.
 Stage I – 71.4%
 Stage II – 61.3%
 Stage III – 43.8%
 Stage IV – 8.3%
 Other prognostic factors:
o Lesion size
o Lymph node involvement
o Vascular space involvement – indicates potential
spread to other parts of the body
o Tumor thickness
o Perineural invasion
D. Management of Vulvar Cancer
1. Surgery
o Radical wide excision - <2cm all around the lesion but
the depth should be up to the level of the fascia (this
differentiates radical from simple excision)
o Vulvectomy
 Simple vulvectomy – hemivulvectomy; Simple: up
to the subcutaneous tissue only.
 Radical vulvectomy with bilateral groin
(inguinofemoral) node dissection. Radical: you
have to remove all the fatty tissues until the fascia is
visible. Wound dehiscence is the most common
complication. We prevent them from defecating
because it will soil the lesion and it will lead to
infection.
Figure 9. Partial v. Radical vulvectomy
Figure 10. Radical Vulvectomy Specimen. The inguinal nodes and the
femoral nodes are contained in the lateral areas, the lesions behind
should have a 2 cm margin because even if the skin is normal looking,
it’s involved in cancer already so make sure you have an adequate
margin when you do vulvectomy.
2. Radiation Therapy with Chemotherapy (Chemoradiation)
– for non-operable patients, tumor is shrunk before surgery
E. Other Vulvar Malignancies
1. MELANOMA – from junctional nevi, labia minora or
clitoris
2. BARTHOLIN’S GLAND CARCINOMA- 1-2%
o Posterolateral to labium majus, involving the lower
part of the vulva
o HPV infection – major risk factor
o In older women, make sure you palpate because
sometimes it is no longer an abscess but a
carcinoma.
3. BASAL CELL CARCINOMA- 2%
o More common in older women
o Slow-growing, may metastasize to lymph nodes of
the groin
4. VERRUCOUS CARCINOMA
o Exophytic
o Affects essentially postmenopausal women
5. SARCOMA (Epithelioid sarcoma)
o Distal extremities of young adults (women, child-
bearing age)
o Painless, rapidly enlarging tumor
o extremely rare
6. GRANULAR CELL MYOBLASTOMA
o mesodermal origin
III. VAGINAL CANCER
A. Vaginal Malignancies
 Vaginal Intraepithelial Neoplasia (VaIN) – histologic
appearance similar to cervix, not as common.
o When the patient has CIN or VIN, make sure to look into
the vaginal also. It could be multifocal because the effect
of the HPV is not only limited to one area of the lower
genital tract, so you could have CIN, VIN, and VaIN.
 VaIN I – mild dysplasia
 VaIN II – moderate dysplasia
 VaIN III – severe dysplasia, ca in –situ
o VaIN-1 is classified as a low-grade squamous
intraepithelial lesion, whereas VAIN-2 and VAIN-3 are
grouped as high-grade squamous intraepithelial lesions.
 Vaginal Cancers

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GYNECOLOGY: 2.04 Neoplasms of the Cervix, Vulva, and Vagina (2018B)
B. Vaginal Intraepithelial Neoplasia (VaIN)
 Previous CIN (1 to 3 %) and VIN – field defect (increases
risk of squamous neoplasia in the lower genital tract)
 Multifocal, vaginal apex
 Risk factors:
o STDs – HPV, HSV, HIV
o Prior radiation, immunosuppressive and chemotherapy
C. Detection and Diagnosis
 Pap Smear
o Sometimes an incidental finding on Pap smear. If you
don’t find a lesion on the cervix, make sure to do a
detailed examination on the vagina. Sometimes, it is in
the fornix.
o When you see a normal cervix but an abnormal pap
smear, make sure that you do a detailed examination of
the vagina as well.
 Vaginal cytology
 Colposcopy
 Biopsy – done when a lesion is visible
D. Management
 The choice of treatment depends largely on the number of
lesions, their location, and the level of concern for possible
invasion.
 Wide excision
o From Lentz: is the treatment of choice for VAIN-3,
especially for lesions occurring at the cuff after
hysterectomy. Upper vaginectomy, however, can
result in vaginal shortening, which can be
ameliorated by the use of topical estrogen cream
and a vaginal dilator (or frequent intercourse) once
healing is complete.
 Carbon Dioxide Laser
o From Lentz: It vaporizes the abnormal tissue without
shortening or narrowing the vagina, preserving
vaginal function.
 5-Fluorouracil Cream – not available in the country.
 Regular follow-up
o Every 4 months with Pap-smear and colposcopy
E. Malignant Diseases of the Vagina
 Symptoms: abnormal bleeding or discharge; urinary
frequency; constipation and tenesmus; pain late symptom
 Primary vaginal CA – rare, <2%
 Most vaginal CA metastatic – from cervix and endometrium,
less common from ovary, rectosigmoid, choriocarcinoma
 If the tumor grows posteriorly causing compression of the
rectum, the patient could present with constipation but if it
spreads into the anterior vaginal wall going into the urinary
bladder, the patient could present with altered urinary
frequency, hematuria. There could already be vaginal
mucosal involvement.
F. Primary Vaginal Cancer
 DIAGNOSTIC CRITERIA: The malignancy must arise in
the vagina and not involve the cervix os or the vulva.
o If it primarily arises in the vagina, make sure that the
cervix and vulva is not involved. Even though the lesion
is smaller than the vulva but it crosses the hymen, the
hymen separates the vulva from the vagina that is
labeled as vulvar cancer.
TRANSCRIBER: Trans Group 9 (Mendoza, N- 09177111614) EDITOR: (Hana Sarmiento, 09154817560)
o If the cervix is involved, even though the involvement is
smaller than the vagina, it is categorized as cervical
cancer.
o The reason is because primary vaginal cancer is RARE.
 Very rare, >2%
 Most vaginal malignancies are metastatic, primarily from the
cervix and endometrium. Less commonly, ovarian and
rectosigmoid carcinomas, as well as choriocarcinoma,
metastasize to the vagina.
 If you have cancer in the other side like the endometrium,
cervix, vulva, label it as a metastasis, a satellite lesion of
those cancer. Look 1st in these areas because primary
vaginal cancer is rare.
 Same management techniques for small tumors of the Upper
3rd of the vagina (cervix) and lower 3rd of the vagina (vulva).
If the tumor grew at the upper 3rd, it’s managed as cervical
cancer but if it’s in the lower 3rd of the vagina, it’s managed
as vulvar cancer.
Figure 10. FIGO Staging System for Vaginal CA
 Lymphatic Drainage System of the Vagina:
o Muscularis (very rich in lymphatics)
o Middle to upper vagina – lymphatics of the cervix drain
to pelvic nodes
o Distal third of vagina – inguinal nodes then pelvic nodes
G. Least Common Primary Vaginal Cancers
The following were lifted from Lentz because the lecturer did not
elaborate on the definition. Just remember that the most common
primary vaginal cancer is Squamous Cell CA.
1. ENDODERMAL SINUS TUMOR
- An endodermal sinus tumor, a type of adenocarcinoma,
is a rare germ cell tumor that usually occurs in the ovary.
- The tumor secretes a-fetoprotein, which provides a
useful tumor marker to monitor patients treated for these
neoplasms.
- Approximately 69 cases of this unusual malignancy
originating in the vagina of infants, predominantly those
younger than 2 years, have been reported. The tumor is
aggressive, and most patients have died.
2. SARCOMA BOTRYOIDES
- Embryonal Rhabdomyosarcoma; Sarcoma botryoides
is a rare sarcoma that is usually diagnosed in the vagina
of a young girl.
- Rarely does it occur in a young child older than 8 years,
although cases in adolescents have been reported.
- The most common symptom is abnormal vaginal
bleeding, with an occasional mass at the introitus. The
Page 7 of 8
GYNECOLOGY: 2.04 Neoplasms of the Cervix, Vulva, and Vagina (2018B)

tumor grossly will resemble a cluster of grapes forming

multiple polypoid masses. 4. Atypical proliferation and disorderly maturation of squamous
cells involving more than 2/3 of the cervical mucosa is correctly
3. CLEAR CELL ADENOCARCINOMA classified as:
- Clear cell adenocarcinomas in young women have been A. CIN I
seen more frequently since 1970 as a result of the B. CIN II
association of many of these cancers with intrauterine C. CIN III
exposure to DES. D. Invasive carcinoma
- Therapeutic considerations are similar to those for
squamous cell carcinoma, taking into account the young 5. The most common malignant tumor of the adult cervix:
age of the patients undergoing therapy. Cervical clear A. SCC
cell adenocarcinomas are treated in the same manner B. Sarcoma botryoides
as primary cervical carcinomas. C. Clear cell adenocarcinoma
D. Adenosquamous carcinoma
4. MELANOMA
- Vaginal melanomas are rare and highly malignant. Only 6. A 45 y/o woman complained of post-coital bleeding of 3
approximately 2% to 3% of primary vaginal cancers are months duration. On pelvic exam, cervix was noted to be
melanomas. enlarged 6x5cm, friable and nodular. The most appropriate next
- The most common presenting symptoms are vaginal step in the management would be:
discharge, bleeding, and a palpable mass. A. Pap smear
B. HPV DNA test
5. SQUAMOUS CELL CARCINOMA C. Colposcopy
- 90%, most common D. Cervical punch biopsy
- Although reported in women in their 30s, the disease
occurs primarily in women older than 60, and 20% are 7. The etiologic agent in the development of cervical cancer is:
older than 80 years. A. HPV
- Most squamous cell carcinomas occur in the upper B. HSV
third of the vagina, but primary tumors in the middle C. HIV
and lower thirds may also occur. D. Syphilis
- Grossly, the tumor appears as a fungating, polypoid, or
ulcerating mass, often accompanied by a foul smell and 8. The standard treatment in cervical cancer is:
discharge related to a secondary infection. A. Chemoradiation
- Microscopically, the tumor demonstrates the classic B. Radical hysterectomy
findings of an invasive squamous cell carcinoma C. Chemotherapy
infiltrating the vaginal epithelium. D. Immunotherapy

H. Treatment 9. Which of the ff. statements are consistent with the current
 Chemoradiation and/or Surgery (selected cases) recommendations on the frequency of cervical cancer
screening?
REVIEW QUESTIONS A. Combination of cervical cytology and HPV DNA
1. A 48-year old G3P3 (3003) sought consult because of post- screening is not recommended for women 30 years and
coital bleeding. Speculum and I/E revealed a 6x5x3 cm fungating older
cervical mass. Parametria is smooth and pliable. What is the B. Women younger than 30 years old should undergo
clinical stage? annual cervical cytology screening
A. Ia C. Women younger than 30 years old should undergo
B. Ib1 cervical cytology screening every 3 years
C. Ib2 D. Women aged 30 years and older who have 2
D. IIa consecutive negative cervical cytology screening test
results and who have no history of CIN 2 or CIN 3 are
2. Cervical carcinoma that has involved the upper third of the not immunocompromised may extend screening interval
vagina is staged as: to every 5 years
A. Stage Ib
B. Stage Ia 10. Not true about HPV
C. Stage II A. Types 6,8 majority of cancer cases
D. Stage III B. Long term persistence of HPV developed into
neoplasia
3. Lichen sclerosus et atrophicus of the vulva represents which C. Identified 100 types
of the ff: D. 13 carcinogenic types
A. Hyperplasia
B. Metaplasia
C. Inflammation and atrophy 1C 2A 3C 4C 5A 6D 7A 8A 9C 10A
D. Dysplasia END OF TRANS

TRANSCRIBER: Trans Group 9 (Mendoza, N- 09177111614) EDITOR: (Hana Sarmiento, 09154817560) Page 8 of 8