Vain and Vaginal Cancer

Mary Rubin, RNC, Ph. D., CRNP

Coordinator Gyn Oncology Clinical Research
UCSF Comprehensive Cancer Center
San Francisco, CA

Fuente: Vain and Vaginal Cancer
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Incidence of Primary Vaginal Neoplasia
  • Vaginal Cancer very rare vs cervical cancer

+ 2 per 100,000 women

+ 1% - 2 % of all genital tract melignancies

  • Squamous cell most common (84%-90%)
    • + Mean age 60-65
      • Adenocarcinoma (includes DES clear cell) 4-9%
      • Sarcoma (young children) 2-3 %
      • Melanoma (postmenopausal) 1-2 %
  • Upper 1/3 of vagina 52%

+ Posterior wall 58%


Vaginal Intraepithelial Neoplasia (VAIN)
  • Intraepithelial neoplastic changes with malignant potential – grade like CIN
  • May be primary or exist adjacent to cervical or vulvar neoplasia

+ 1.5 % of women with CIN, 3% with HGSIL

+ VAIN same grade as CIN in 70%

- VAIN higher grade than CIN in 19%

  • VAIN present in 71 % of women with invasive cervical or vulvar cancer
  • Dxed after hysterectomy for CIN in 1-6%

Pathophysiology of VAIN
  • Etiology unknown

+ HPV implicated

  • Field effect: Increased risk of multiple lower genital tract squamous neoplasias
  • Multi-focal distribution common
  • May occur in original squamous epithelium

+ Pathophysiologic obscure


94 Cases of VAIN

Sillman et. Al. Am J Obstet Gynecol 1997:176:93-9

  • Dx

+ Routine pap leading to colpo 88%

+ Colposcopy for other anogenital lesions 11%

+ Leukoplakia 1%

  • Mean age: 51

+ VAIN 1 -39; VAIN 2 -43; VAIN 3 -57

  • All involved at least upper 1/3 of vagina
  • Multi-focal 51%
  • Existing or prior anogenital neoplasia 76%

VAIN post Hysterectomy for CIN 3

Kalogiuro et. Al. Eur J Gynaecol Oncol 1997:18:188-191

  • 41 cases of VAIN Dxed in 973 women followed cytologically for 10 yrs (5.2%)

+ Dx within 1 yr of Tx for CIN: 15 %, after 5 yrs: 7 %

+ Upper ½ of vagina: 65%; Cuff angles: 54%

+ Same grade as previous CIN: 51 %

+ Presenting Pap ASCUS 42%

  • ASCUS IN 20% of women without VAIN

Indications for Performing Vaginal Colposcopy
  • Abnormal Pap:

+ Normal cervix on colpo

+ Post treatment of CIN

+ Post hysterectomy

+ Immunosuppressed

  • Cervical or vulvar Carcinoma

+ High grade intraepithelial neoplasia

  • Workup of multi-centric HPV infection
  • Gross vaginal lesion
  • DES exposure in utero

Colposcopic examination of the Vagina
  • Careful insertion of speculum
  • Note grossly visible lesions/leukoplakia
  • Pap smear from vaginal vault if indicated
  • Examine entire vagina (+ cervix if present)

Difficulty With Colposcopic Examination of the Vagina
  • Area to be examined is large and tubular
  • Blades of speculum often cover lesion
  • Rotate speculum as needed

+ Attention to fornices and vaginal cuff angles if post-hysterectomy

+ Examine mucosa in rugal folds

+ Examine with Lugol´s solution after saline and acetic acid

  • Good Hand/eye coordination needed
  • Regional or general anesthesia may be needed
  • Grading for cervical lesions < accurate in the vagina

Treatment for VAIN
  • Dependent on pt's age, presence of cervix, location of lesion, availability of equipment, expertise of the practitioner
  • Observation: LG lesions often regress
  • Laser: Optimal for large lesions
  • Cryotherapy: only for small focal lesions; risk to surrounding tissue or bowel and bladder
  • TCA: for HPV
  • 5% fluorouracil: multi-focal LG lesions
  • Loop electrosurgical excision; risk to surrounding tissue or bowel and bladder
  • Surgical vaginal excision

VAIN and Vaginal Cancer
  • Mary M. Rubin RNC, Ph.D., CRNP

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Bibliography

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Anderson, M., Jordan, J., Morse, A., & Sharp, F. 1997. A text and atlas of integrated colposcopy. St. Louis, MO: Mosby

Burghardt E., Hellmut, P., and Girardi, F. 1998. Colposcopy cervical pathology textbook and atlas, 3rd ed. New York: Thieme.

Burke, L., Antioli, D.S., and Ducatman, B.S 1991. colposcopy text and atlas. Norwalk, CT: Appleton and Lange.

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Cheng, D., Ng, T.Y., Ngan, H.Y, and Wong, C. 1999. Wide local excision (WLE) for vaginal intraepithelial neoplasia (VAIN). Acta Obstetrica et Gynecologica Scandinavia 78(7):648-652

Diakomanolis, E., Rodokis, A., Sakellaropoulous, K., and Aravantinos, D. 1996. Conservative management of vaginal intraepithelial neoplasia (VAIN) by laser CO2 . European Journal of Gynecologic Oncologic Oncology 17(5) : 389-392.

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Krumholz, B.A. 2002. Vagina: Normal, premalignant.