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

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+ 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%

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+ Posterior wall 58%

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Vaginal Intraepithelial Neoplasia (VAIN)

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

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+ 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%

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Pathophysiology of VAIN

• Etiology unknown

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+ 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

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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%

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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

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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

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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)

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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

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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

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VAIN and Vaginal Cancer

• Mary M. Rubin RNC, Ph.D., CRNP

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