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Vaginal Cancer Vaginal cancer is usually a squamous cell carcinoma, most often occurring in women > 60. The most common symptom is abnormal vaginal bleeding. Diagnosis is by biopsy. Treatment for many small localized cancers is hysterectomy plus vaginectomy and lymph node dissection; radiation therapy is used for most others. Vaginal cancer accounts for 1% of gynecologic cancers in the US. Average age at diagnosis is 60 to 65. Risk factors include human papillomavirus infection and cervical or vulvar cancer. Exposure to diethylstilbestrol in utero predisposes to clear cell adenocarcinoma of the vagina, which is rare; mean age at diagnosis is 19. Most (95%) primary vaginal cancers are squamous cell carcinomas; others include primary and secondary adenocarcinomas, secondary squamous cell carcinomas (in older women), clear cell adenocarcinomas (in young women), and melanomas. The most common vaginal sarcoma, sarcoma botryoides (embryonal rhabdomyosarcoma), has a peak incidence at age 3. Most vaginal cancers occur in the upper 1⁄3 of the posterior vaginal wall. They may spread by direct extension (into the local paravaginal tissues, bladder, or rectum), through inguinal lymph nodes from lesions in the lower vagina, through pelvic lymph nodes from lesions in the upper vagina, or hematogenously. Symptoms and Signs Most patients present with abnormal vaginal bleeding: postmenopausal, postcoital, or intermenstrual. Some also present with a watery vaginal discharge or dyspareunia. A few patients are asymptomatic, and the lesion is discovered during routine pelvic examination or evaluation of an abnormal Pap test. Vesicovaginal or rectovaginal fistulas are manifestations of advanced disease. Diagnosis Punch biopsy is usually diagnostic, but wide local excision is occasionally necessary. Cancers are staged clinically, based primarily on physical examination, endoscopy (ie, cystoscopy, proctoscopy), chest x-ray (for pulmonary metastases), and usually CT (for abdominal or pelvic metastases). Stage 0 is carcinoma in situ. Stage I tumors are limited to the vaginal wall. Stage II tumors involve subvaginal tissue. Stage III tumors extend to the pelvic wall. Stage IV tumors extend beyond the true pelvis or involve the bladder or rectal mucosa. Prognosis and Treatment The 5-yr survival rates are 65 to 70% with stage I, 47% with stage II, 30% with stage III, and 15 to 20% with stage IV. Prognosis is worse if the primary tumor is large or poorly differentiated. Stage 0 tumors are treated with wide local excision only. Stage I tumors within the upper 1⁄3 of the vagina can be treated with radical hysterectomy, upper vaginectomy, and pelvic lymph node dissection. Most other primary tumors are treated with radiation therapy, usually a combination of external beam and brachytherapy. If radiation therapy is contraindicated because of vesicovaginal or rectovaginal fistulas, pelvic exenteration is done.
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