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Invasive Cancer of the Vagina and Urethra

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Invasive Cancer of the Vagina and Urethra UniversityUniversity ooff KentuckyKentucky MarkeyMarkey CancerCancer CenterCenter InvasiveInvasive CaCanncercer ofof thethe VVaaginagina andand UUrrethraethra FredFred UeUelland,and, MMDD “N“Noo mamattterter wwhhatat youyou acacccomplishomplish inin yyoourur lifelife,, tthhee sizesize ooff yyoourur ffuuneralneral willwill stistillll bebe determindetermineedd byby thethe wweeatheatherr”” VaginalVaginal CancerCancer 11--2%2% ofof allall gynecologicalgynecological cancanccersers IncidenceIncidence 0.6/100,0000.6/100,000 OccursOccurs llessess ccoommmmonlyonly thanthan mmeettastatastatiicc diseasedisease toto vaginavagina 60%60% havehave hadhad previousprevious hysterecthysterectoommyy EtiologyEtiology 33--10%10% associatedassociated withwith VAVAIINN HighHigh associationassociation wwithith HPVHPV – 30% with prior CIN ConsiderConsider – Residual disease from other primary – New primary – Association with radio-oncogenicity SSyymptomsmptoms PainlessPainless bleedingbleeding 5%5% withwith painpain frfromom advancedadvanced diseadiseassee 5%5% ccoompmplleteetellyy aasymsymptptoommaticatic …20%…20% mmissedissed onon speculspeculumum exexaamm RelationshiRelationshippss Uterus and cervix Pelvic lymph nodes Bladder and rectum – TD 5/5= 5500 cGy – TD 50/5= 8500 cGy VaginalVaginal CancerCancer LocatioLocationn UpperUpper ⅓⅓ 40%40% AnterioAnteriorr 40%40% MiddleMiddle ⅓⅓ 1313 PosteriorPosterior 30%30% LowerLower ⅓⅓ 31%31% LateLaterraall 30%30% EntirEntiree 30%30% DisseminatDisseminatiionon LocalLocal LLyymphatmphatiicc drainadrainaggee – Obturator, iliac, pelvic – Inguinal – Unpredictable HHemaematogenoustogenous – Less common LymLympphatichatic DrainageDrainage Upper vagina – Common or external iliac lymph nodes Middle vagina – Iliac or femoral triangle Lower vagina – Femoral triangle, inguinal nodes Unpredictable drainage. Any pelvic node can be involved by a vaginal cancer in any location IncidenceIncidence ofof VaginalVaginal CancerCancer AgeAge DependentDependent 300 250 200 150 No. Cancers 100 50 0 15-29 30-39 40-49 50-59 60-69 70-79 >80 HistologyHistology SquSquaamoumouss 85%85% AdenocarcinAdenocarcinomaoma 6%6% MelanMelanomomaa 3%3% SarcSarcomomaa 3%3% MisMisccellaneousellaneous 3%3% AdenocarcinomaAdenocarcinoma ofof VVaaginagina OnlyOnly 6%6% ofof allall vavagginalinal cancanccersers AriseArise frfromom – Mullerian adenosis – Endometriosis – Gartner’s ducts TreaTreattmmentent iiss ssaammee MMaayy bbee mmororee chchememoossensitiveensitive VaginalVaginal CancerCancer StagingStaging Stage I LLimimitedited toto vaginalvaginal mumucosacosa Stage II SubvaginalSubvaginal tissuetissue Stage III PelvicPelvic sidesidewwallall Stage IVa AdjacentAdjacent organsorgans oorr directdirect extensionextension beyondbeyond truetrue pelvispelvis Stage IVb DistantDistant sprspreeadad VaginalVaginal CancerCancer …TreatmentTreatment PicricPicric AcidAcid Used to manufacture explosives High explosive – < 30% water Flammable solid – >30% water Vagina + Cervix Surgery Radiation Stage I RH, lymphadenectomy 5000 cGy for (+) LNs Stage IIa …plus upper vaginectomy 5000 cGy for (+) LNs Stage IIb Exenteration if XRT failure 5000 cGy Stage IIIa,b Exenteration if XRT failure 6000 cGy Stage IV Individualize Vagina Only Surgery Radiation Stage I (upper) RH, upper vag, lymphad 5000 cGy for (+) LNs Stage I (lower) RH, total vag, lymphad 5000 cGy + brachy Stage II Exenteration if XRT failure 5000 cGy + brachy Stage III Exenteration if XRT failure 6000 cGy + brachy Stage IV Individualize VaginalVaginal BrachytherapyBrachytherapy VaginalVaginal BrachytherapyBrachytherapy LesionLesion depthdepth << 0.50.5cmcm – Cylinder implant LesionLesion depthdepth >> 0.50.5cmcm – Syed-Neblett interstitial applicator – Iridium (192I) – Consider laparoscopic visualization and omental J-flap VaginalVaginal BrachytherapyBrachytherapy TandemTandem andand OvoidsOvoids Locally advanced disease with uterus in-situ Cervical involvement Dosimetry like cervical cancer VaginalVaginal BrachytherapyBrachytherapy SSyedyed--NebletNeblet Needle applicator Iridium-192 – Alluvial deposits, rare – Half-life of 73.83 days – 192I beta decays into platinum-192 Laparoscopy and omental J-flap may be required RecurrenceRecurrence SSimimilailarr toto vulvarvulvar aandnd cervicalcervical cancanccererss – Epidermoid 80%80% ffooundund clinicallyclinically 80%80% inin pelvispelvis andand withinwithin 22 yeyeaarsrs ExenterativeExenterative surgsurgeeryry forfor pelvicpelvic rrecurecurrrenceence – 40% success ChCheemothmotheeraprapyy oftenoften ineffectiveineffective VaginalVaginal CancerCancer …SurvivalSurvival VaginalVaginal CancerCancer FiveFive--YearYear SurvivalSurvival Author Patients I II III IV All Stages Eddy ’91 84 70 45 35 28 50 Stock ‘95 100 67 53 0 15 46 Creasman 792 73 58 58 58 NA ‘98 VaginalVaginal CancerCancer Stock et al Gyn Onc 56:45, 1995 80 70 60 50 40 Local % 30 5 year 20 10 0 Stage I Stage II Stage III Stage IV VaginalVaginal CancerCancer …UnusualUnusual CellCell TTyypespes UnusualUnusual VaginalVaginal CancersCancers Adenocarcinoma – Clear cell CA Verrucous – Locally invasive, rarely metastatic Melanoma – Problematic Sarcoma – Sarcoma botryoides – Leiomyosarcoma Endodermal sinus tumor ClearClear CellCell AdenocarcinAdenocarcinoomama HerbstHerbst andand SculScullly,y, AprilApril 19701970 AgeAge 1515--2222 oofffsprifsprinngg ofof DESDES exposedexposed mmothotheersrs PolypoidPolypoid ttuumormor – 60% upper vagina – 40% involve cervix also DESDES exposureexposure beforebefore 1818 weekweekss inin uteroutero TeratogenicTeratogenic ((adeadennosisosis)) notnot carcinogcarcinogeenicnic ClearClear CellCell AdenocarcinAdenocarcinoomama TreatmentTreatment RadicalRadical surgesurgerryy – Ovarian preservation AdjuvantAdjuvant therapytherapy – VAC – Pelvic radiotherapy ClearClear CellCell CancerCancer SurvivalSurvival 100 90 80 70 60 50 5 yr 40 10 yr 30 20 10 0 I 2a 2b 2 va 3 4 Stage MelanomaMelanoma ooff VaginaVagina SurgicalSurgical theratherappyy iiss mmainstainstaayy LocationLocation – Distal 1/3 55% – Anterior 45% OverallOverall survivalsurvival << 20%20% NoNo provenproven adjuvaadjuvanntt therapytherapy SarcomaSarcoma BBootryoidestryoides Embryonal rhabdomyosarcoma – Undifferentiated mesenchyme of vaginal lamina propria – Grape-like masses Vaginal cancer in children – Age 3-5 years – Peak incidence age 3 years Cervical origin in teens Treatment – Surgery + VAC + XRT Survival – 85-90% EndodermaEndodermall SinusSinus TuTummoror Rare – 50 case reports Peak age 10 months (usually under 1 year) αFP – Non-dysgerminomatous germ cell tumor Treatment – Chemotherapy and partial vaginectomy Survival – 85-90% ConclusionConclusionss 1. ClinicalClinical stagingstaging ssyyststemem 2. RadiotherapyRadiotherapy 3. ModestModest cucurree rratesates 4. PreventionPrevention UrethralUrethral CCaancerncer …RareRare UrethralUrethral CCaancerncer RareRare – < 1% (600 reported cases) PoorPoor prognosiprognosiss RadicalRadical cystouretcystourethhrectrectomyomy inin earearllyy ddiiseasesease RadiotherapyRadiotherapy ConsiderConsider inguinalinguinal llymymphadenectphadenectoomymy oror pelvicpelvic imimagingaging (fusion(fusion PET/CT)PET/CT) – If (+), pelvic XRT UrethralUrethral CCaancerncer RiskRisk FactorFactorss AgeAge >> 6060 WhiteWhite ffeemmaleale ChronicChronic inflinflaammmmaattion:ion: UTI,UTI, SSTTDD HPVHPV SignsSigns andand SSymptymptoomsms HHemaematuriaturia,, vaginalvaginal spottingspotting PainPain oror voidingvoiding dysfunctidysfunctioonn DyspaDysparreuniaeunia PalpablePalpable mamassss inin uurethrarethra oorr vaginavagina InguinalInguinal adenopaadenopatthyhy RecurrentRecurrent UTIUTI UrinaUrinarryy fistulafistula HistologyHistology Squamous- distal ⅔ – 60% Transitional- proximal ⅓ – 20% Adenocarcinoma – 10% – Submucosa of periurethral (Skene) glands Other – Sarcoma 8% – Melanoma 2% LymLympphatichatic DrainageDrainage DistalDistal urethurethrraa ⅓⅓ – Superficial and deep inguinal lymph nodes ProxProximimalal urethrurethraa ⅔⅔ – Pelvic lymph nodes TreatmentTreatment Surgery – Local excision – Radical cystourethrectomy and lymphadenectomy Radiation – Preop ChemoRT – Postoperative RT Chemotherapy – Mtx, Vinblastine, Adriamycin, Cisplatin – Protocol.
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