The Farber Center: For Radiation Oncology

Vaginal cancer is a disease in which malignant (cancer) cells form in the vagina.The vagina is the canal leading from the cervix (the opening of uterus) to the outside of the body. Vaginal cancer is uncommon. When found in early stages, it can often be cured. There are two main types of vaginal cancer:

• Squamous cell carcinoma: Cancer that forms in squamous cells, the thin, flat cells lining the vagina. Squamous cell vaginal cancer spreads slowly and usually stays near the vagina, but may spread to the lungs and liver. This is the most common type of vaginal cancer. It is found most often in women aged 60 or older.
• Adenocarcinoma: Cancer that begins in glandular (secretory) cells. Glandular cells in the lining of the vagina make and release fluids such as mucus. Adenocarcinoma is more likely than squamous cell cancer to spread to the lungs and lymph nodes. It is found most often in women aged 30 or younger.

Vaginal cancer often does not cause early symptoms and may be found during a routine Pap test.
When symptoms occur they may be caused by vaginal cancer or by other conditions.

Symptoms could include:

• Bleeding or discharge not related to menstrual periods.
• Pain during sexual intercourse.
• Pain in the pelvic area.
• A lump in the vagina.

Age and exposure to the drug DES (diethylstilbestrol) before birth affect a woman's risk of developing vaginal cancer.

Risk factors:

• Age: most vaginal cancers occur in older women
  
• Exposed to DES while in the mother's womb. In the 1950s, the drug DES was given to some pregnant women to prevent miscarriage (premature birth of a fetus that cannot survive). Women who were exposed to DES before birth have an increased risk of developing vaginal cancer. Some of these women develop a rare form of cancer called clear cell adenocarcinoma.
• Having HPV human papilloma virus infection.
• History of abnormal cells in the cervix or cervical cancer.

Physical Examination
The doctor will conduct a pelvic and rectal examination where organs such as the uterus, ovaries, cervix, vagina, bladder, and rectum will be checked for their health state. During the physical examination, the doctor will also perform a PAP smear.

Imaging Tests

Coloposcopy: This is a medical procedure where the vagina and cervix are closely examined with an electric microscope magnifying lens instrument. In most of the cases, during this procedure the doctor might remove a tissue sample for microscopic examination.

Proctosigmoidoscopy: This is a medical procedure highly recommended for patients with a large tumor or with the tumor located close to the rectum or colon. It is also used in patients that might suffer from metastasis (when the cancer has spread to the colon or rectum). This procedure uses a thin instrument having a tube-like shape with a camera device attached at one end which allows the doctor to see parts of the body that cannot be investigated during a normal physical examination.

Computed Tomography (CT scan): This imaging test is similar with an x-ray test, and creates a detailed cross-sectional image of the body. A CT scan is usually performed in two steps for a better diagnosis outcome:

1. First, the targeted area is scanned without a contrast agent.
2. Second, the targeted area is scanned after a contrast agent was administrated In general, this technique is useful in providing information regarding the size and the exact location of the tumor, and can show if the cancer has spread to other organs or areas in the body.

Magnetic Resonance Imaging (MRI): An MRI is an advanced, painless, noninvasive technique that uses radio waves and strong magnets to reveal a complete image of a targeted area of the body. The energy from the radio waves is absorbed by the tissues and then released into a pattern that allows the cancer to be detected and diagnosed.

Chest X-ray: An x-ray test uses high energy electromagnetic radiation to penetrate the body and creates its image on a film. This is a test not commonly performed in vaginal cancer patients. It is used if the cancer has spread within the body and the doctor suspects that cancer has invaded the lungs.

Cystoscopy: This is a medical procedure where the doctor examines the bladder and urethra for abnormal tissue with the help of a cytoscope (a thin tube with a camera attached at the one end). This is not a common procedure for vaginal cancer patients, but is performed when the cancer may have spread to the bladder. During this procedure, the doctor might remove a sample of tissue. This procedure is highly recommended when the tumor is large or is located in the front walls of the vagina near the bladder.

Ureteroscopy: This is a medical procedure used to examine whether or not the cancer has spread to the ureters. The instrument used is called ureteroscope which is a thin tube with a camera device attached to one end.

Lymphangiogram: This is a procedure similar with the x-ray, but it focuses on the lymph system. A lymphagiogram uses a dye agent injected into the lymph vessels in the feet, which travels through out the entire lymph system of the body. The x-ray will show if there is any blockage caused by a cancer invasion. This test is performed in patients with advanced stages of vaginal cancer.

Biopsy: Biopsy is a medical procedure where a tissue sample is removed from the tumor or abnormal looking surface of an organ for a microscopic examination. The biopsy is the most conclusive test, because it clearly establishes where the abnormal tissue is cancer or not, and if cancer, what type of cancer is. There are two types of biopsies performed in vaginal cancer patients:

• Excisional biopsy: This is a type of biopsy where the entire lesion/tumor is removed. The excisional biopsy can be performed with local or general anesthesia, depending on the tumor size and location.
• Punch biopsy: During this type of biopsy only a small amount of abnormal tissue/tumor is removed with a instrument that looks like a tiny apple corer. This biopsy is usually performed under local anesthesia.

Stage 0 (Carcinoma in Situ)
abnormal cells are found in tissue lining the inside of the vagina. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

Stage I
cancer has formed and is found in the vagina only.

Stage II
cancer has spread from the vagina to the tissue around the vagina.

Stage III
cancer has spread from the vagina to the lymph nodes in the pelvis or groin, or to the pelvis, or both.

Stage IV

• Stage IVA: Cancer may have spread to lymph nodes in the pelvis or groin and has spread to one or both of the following areas:
• The lining of the bladder or rectum.
• Beyond the pelvis.
• Stage IVB: Cancer has spread to parts of the body that are not near the vagina, such as the lungs. Cancer may also have spread to the lymph nodes.

SURGERY
depending on the stage of the cancer, several options exist:

• Laser surgery: A surgical procedure that uses a laser beam as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
• Wide local excision: A surgical procedure that takes out the cancer and some of the healthy tissue around it. Vaginectomy: Surgery to remove all or part of the vagina.
• Hysterectomy. The uterus is surgically removed with or without other organs or tissues.

In a total hysterectomy, the uterus and cervix are removed. In a total hysterectomy with salpingo-oophorectomy, (a) the uterus plus one (unilateral) ovary and fallopian tube are removed; or (b) the uterus plus both (bilateral) ovaries and fallopian tubes are removed.
In a radical hysterectomy, the uterus, cervix, both ovaries, both fallopian tubes, and nearby tissue are removed.


• Lymphadenectomy: A surgical procedure in which lymph nodes are removed and checked under a microscope for signs of cancer. This procedure is also called lymph node dissection. If the cancer is in the upper vagina, the pelvic lymph nodes may be removed. If the cancer is in the lower vagina, lymph nodes in the groin may be removed.
• Pelvic exenteration: Surgery to remove the lower colon, rectum, and bladder. In women, the cervix, vagina, ovaries, and nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body into a collection bag.

RADIATION THERAPY
is the use of high-dose X-rays to destroy cancer cells and shrink tumors.
Radiation may come from a machine outside the body (external radiation therapy).
Radiation may come from the placement a radiation source inside the body (internal radiation therapy, or brachytherapy).

CHEMOTHERAPY
is the use of medicine to destroy cancer cells. Chemotherapy is called a systemic treatment because the medicines enter the bloodstream, travel through the body, and can destroy cancer cells that may have escaped the vagina. Chemotherapy is often used in combination with radiation after surgery or as primary treatment.

Possible Treatment Side Effects
Dr. Farber, Dr. Spierer, and their staff at The Farber Center for Radiation Oncology will discuss potential side effects with you before, during, and after treatment, and ensure that your experience is personalized.