Vaginal Carcinoma



Vaginal Carcinoma


Akram M. Shaaban, MBBCh




























































(T) Primary Tumor


Adapted from 7th edition AJCC Staging Forms.


TNM


FIGO


Definitions


TX


Primary tumor cannot be assessed


T0


No evidence of primary tumor


Tis2


Carcinoma in situ (preinvasive carcinoma)


T1


I


Tumor confined to vagina


T2


II


Tumor invades paravaginal tissues but not to pelvic wall


T3


III


Tumor extends to pelvic wall2


T4


IVA


Tumor invades mucosa of the bladder or rectum &/or extends beyond true pelvis (bullous edema is not sufficient evidence to classify a tumor as T4)


(N) Regional Lymph Nodes


NX


Regional lymph nodes cannot be assessed


N0


No regional lymph node metastasis


N1


III


Pelvic or inguinal lymph node metastasis


(M) Distant Metastasis


M0


No distant metastasis


M1


IVB


Distant metastasis


1 FIGO no longer includes stage 0 (Tis).

2 Pelvic wall is defined as muscle, fascia, neurovascular structures, or skeletal portions of the bony pelvis. On rectal examination, there is no cancer-free space between the tumor and pelvic wall.















































AJCC Stages/Prognostic Groups


Adapted from 7th edition AJCC Staging Forms.


Stage


T


N


M


0


Tis


N0


M0


I


T1


N0


M0


II


T2


N0


M0


III


T1-T3


N1


M0



T3


N0


M0


IVA


T4


Any N


M0


IVB


Any T


Any N


M1








H&E stain shows dysplastic cells with enlarged and pleomorphic nuclei and high nuclear-to-cytoplasmic ratio involving the full thickness of the mucosa. Numerous dysplastic cells extend all the way to the surface image. Mitotic figures are evident image. (Original magnification 400x.)






Low-power magnification of H&E stain shows nonstratified squamous epithelium of vaginal mucosa with invasive squamous cell carcinoma. Both the mucosal surface image and irregular basement membrane image are highlighted. Few nests are noted deeper in the submucosa image. (Original magnification 20x.)






Higher magnification of the lower aspect of the mucosa shows irregular basement membrane with projections of cords image and nests image of cells indicating an invasive component to the submucosa. (Original magnification 100x.)






Tumor extends to the pelvic wall (T3). H&E stain from pelvic wall nodule shows vaginal squamous carcinoma. Note the nests and sheets of neoplastic squamous cells image invading into the fibroconnective tissue and fascia image of the pelvic wall. (Original magnification 400x.)







Graphic illustrates T1 tumor. Tumor is confined to the vagina without invasion of the paravaginal tissues.






Graphic illustrates T2 tumor. Tumor invades paravaginal tissues but does not reach to the pelvic wall.






Graphic illustrates T3 tumor. Tumor invades paravaginal tissues and extends to the pelvic wall. Pelvic wall is defined as muscle, fascia, neurovascular structures, or bony pelvis.






Graphic illustrates T4 tumor. Tumor invades mucosa of bladder (to the left of the divider) or rectum (to the right of the divider) &/or extends beyond the true pelvis.







Graphic illustrates nodal drainage of tumors arising in the lower 1/3 of the vagina. Those tumors spread to inguinal and femoral lymph nodes.






Graphic illustrates nodal drainage of tumors arising in the upper 2/3 of the vagina. Those tumors spread to pelvic lymph nodes, including obturator and internal and external iliac nodes.


















image


METASTASES, ORGAN FREQUENCY


Lungs


Liver


Bones


Skin



Because vaginal carcinoma is a rare tumor, there are no data present in the literature describing the incidence of distant metastases. Metastatic sites described in the literature include lungs, liver, bones, and skin.




OVERVIEW


General Comments



  • Vaginal involvement with malignant disease occurs more commonly from metastatic spread



    • Most commonly due to direct local invasion from female urogenital tract


  • Vaginal carcinoma should be diagnosed only if other gynecologic malignancies have been excluded



    • Tumor involving cervix, including external os, should always be assigned to carcinoma of cervix


    • Tumor involving vulva and extending to vagina should always be assigned to carcinoma of vulva


    • Different clinical approaches in treatment of cervical and vulvar carcinoma


Classification



  • Tumors involving vagina can be



    • Squamous cell carcinoma



      • Approximately 85-90% of cases


    • Adenocarcinoma



      • Approximately 10% of cases


    • Adenosquamous carcinoma



      • Approximately 1-2% of cases


    • Melanoma


    • Sarcoma


PATHOLOGY


Routes of Spread



  • Local spread



    • Tumor spreads locally into paravaginal soft tissues and eventually to pelvic side wall, mucosa of bladder, or rectum


  • Lymphatic spread



    • Early spread to regional lymph nodes



      • 1/3 of patients have pelvic or groin lymph node involvement at diagnosis


    • Nodal spread usually depends on site of primary tumor



      • Expected nodal disease



        • Upper and middle 1/3 → pelvic obturator nodes, internal and external iliac nodes, and paraaortic nodes


        • Lower 1/3 → inguinal and femoral nodes


        • Disease progression or tumor involving whole length of vagina may → inguinal and iliac nodes


    • Lymphatic drainage does not always follow expected lymphatic channels predicted anatomically based on tumor location


  • Hematogenous spread



    • Most common sites of distant metastases are lung, liver, and bone


General Features



  • Etiology



    • Squamous cell carcinoma



      • Squamous carcinoma of vagina is associated with human papilloma virus (HPV)



        • HPV viral particles can be identified in approximately 60% of invasive squamous cancers of vagina


        • Up to 30% of patients have history of intraepithelial or invasive carcinoma of cervix or vulva


    • Adenocarcinoma



      • Thought to arise from



        • Areas of vaginal adenosis


        • Foci of endometriosis


        • Wolffian rest remnants


        • Periurethral glands


      • Develop in up to 2% of women exposed in utero to diethylstilbestrol (DES)



        • 2/3 have history of in utero exposure to DES


        • Associated with congenital T-shaped uterus


  • Epidemiology & cancer incidence



    • Uncommon tumor comprising 1-2% of gynecologic malignancies



      • 5th in frequency behind carcinoma of ovary, uterus, cervix, and vulva


    • 2,160 estimated new cases in USA in 2009



      • Highest incidence among African-American women (1.24 per 100,000 person-years)


    • 770 estimated deaths in USA in 2009


    • Age of presentation depends on histological type



      • Squamous cell carcinoma



        • Predominantly in postmenopausal women


        • Mean age ± standard deviation at diagnosis was 65.7 ± 14.3 years


      • Adenocarcinoma



        • Typically occurs in younger women ages 14-21 years (peak age: 19 years)


        • Majority are clear cell histology


  • Associated diseases, abnormalities



    • Vaginal carcinoma frequently found in association with vaginal intraepithelial neoplasia


Gross Pathology & Surgical Features



  • Most common patterns of presentation of vaginal squamous cell carcinoma are



    • Ulcerating lesion (50%)


    • Fungating mass (30%)


    • Annular constricting mass (20%)


  • Tumor location in vagina depends on tumor histologic type



    • Squamous cell carcinoma



      • Occurs mainly in upper 1/3 on posterior wall


    • Adenocarcinoma



      • Occurs mainly in upper 1/3 on anterior wall


Microscopic Pathology



  • Squamous cell carcinoma



    • Tumor composed of malignant squamous cells


    • Tumors can be graded as



      • Well differentiated


      • Moderately differentiated


      • Poorly differentiated


      • Undifferentiated


    • Squamous cell carcinoma can be



      • Keratinizing


      • Nonkeratinizing


    • Subtypes of squamous cell carcinoma include



      • Verrucous


      • Warty


      • Spindle


  • Adenocarcinoma



    • Clear cell adenocarcinoma




      • Tumor cells have clear or eosinophilic cytoplasm


      • Type of vaginal adenocarcinoma related to DES exposure


      • May be seen next to areas of adenosis in older women


    • Endometrioid adenocarcinoma



      • Closely resemble morphology of uterine endometrial carcinoma


      • May be seen in association with adenosis or endometriosis


    • Mucinous adenocarcinoma



      • Rare in vagina


      • Can be of endocervical or enteric (contain goblet cells) types


    • Mesonephric adenocarcinoma


IMAGING FINDINGS


Detection

Sep 18, 2016 | Posted by in OBSTETRICS & GYNAECOLOGY IMAGING | Comments Off on Vaginal Carcinoma
Premium Wordpress Themes by UFO Themes