Vaginal Cancer - Causes, Types, and Treatment Options

Introduction

Cancer is considered one of the most dangerous diseases of modern times because of its tremendous mortality rate. Around 10 million people all over the world lose their lives every year due to cancer diseases. Every year around 19.3 million people are affected by various types of cancers. The prevalence of vaginal cancer among all cancer diseases is little. Only one to two percent of all cancer cases belong to vaginal cancer. But recently, a rise in the incidence of vaginal cancer cases has been observed. Early diagnosis and proper treatment can save and increase the affected person's life expectancy.

What Is Vaginal Cancer?

The vagina is a muscular canal-like portion of the female reproductive tract that can connect the outer genital parts to the womb. Malignant transformation of the cells of the vagina is known as vaginal cancer. Malignant transformation is characterized by cellular atypia, which has several unusual features. Some of the features are abnormal cell growth, the presence of multiple nuclei, and abnormal shaped cells. The growth of such cells is known as carcinomatous growth. In advanced cases, such cells spread to other organs and form cancerous growth. This property is known as metastasis.

What Are the Types of Vaginal Cancer?

Vaginal cancer can be of different types. They are:

1. Squamous Cell Carcinoma: This is the most commonly seen vaginal cancer. Around 85 percent of cases of vaginal cancer belong to this type. This occurs more commonly in the proximal third of the vagina. It is developed from a precancerous condition called vaginal intraepithelial neoplasia or VaIN.

2. Adenocarcinoma: This type of carcinoma is seen in the upper third of the vagina. Around 10 percent of vaginal cancer belong to this group. Sometimes adenocarcinoma occurs in young women with Diethylstilbestrol (DES) exposure in utero. This variant of adenocarcinoma is a clear cell type variant.

3. Melanoma: This is a rare form of carcinoma that mainly affects postmenopausal women. The incidence of such carcinoma is less than three percent.

4. Sarcoma: This type of carcinoma arises from connective tissues and from muscles. Rhabdomyosarcoma mainly affects children.

The most common cause of carcinoma of the vagina is infection from human papillomavirus (HPV). Other than this, genetic factors also play a very crucial role. The clinical manifestations of vaginal cancer are:

1. Pain and discomfort during intercourse.

2. Pain during intercourse.

3. Vaginal discharge, mainly watery in consistency.

4. Unusual vaginal bleeding.

5. Pain in the pelvic area.

6. Growth of tissue in the vagina.

How to Determine the Extent of the Cancer?

Determination of the extent and severity of vaginal cancer is important to determine the treatment protocol for vaginal cancer. For this purpose, a proper examination of vaginal cancer is done. The examination of vaginal cancer is done in the following ways:

1. Pelvic examination is the most common diagnostic procedure. At first, the outer genitalia is examined. Then two fingers are inserted into the vagina, and pressure is applied to the abdomen through the other hand to feel the uterus and ovaries.

2. Colonoscopy is done to obtain a magnifying view of the vagina and internal structures.

3. A Pap test is a quick diagnostic procedure to determine cellular abnormalities.

4. Imaging modalities are essential to determine the extent of the spread of vaginal carcinoma. Computerized tomography (CT) scans, magnetic resonance imaging (MRI), or positron emission tomography (PET) are used to observe the spread of the carcinoma.

The federation of gynecology and obstetrics (FIGO) proposed a staging system for vaginal carcinoma. This is as follows:

1. Stage I: In this condition, carcinoma is limited to the vaginal wall.

2. Stage II: In this case, the carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall.

3. Stage III: The carcinomatous growth has extended the pelvic wall.

4.Stage IV: The cancerous growth has extended beyond the true pelvis. It involves the mucosa of the bladder or rectum.

• Stage IVA: The carcinoma is extended beyond the true pelvis. Bladder and/ or rectal mucosa is already invaded.
• Stage IVB: The carcinoma has invaded distant organs.

Other stages used for cancer assessment are TNM staging and the American Joint Committee on Cancer (AJCC) staging. In these stages, the involvement of the lymph nodes and metastasis (involvement of the distant organs by cancerous cells) have also been evaluated.

What Is the Treatment Protocol?

Different treatment modalities are used for the treatment of vaginal cancer. These include procedures like surgical resection, radiotherapy, and chemotherapy. The surgical procedures are:

1. Laser Surgery: In this procedure, relatively small lesions are removed. Laser-assisted procedures are bloodless and non-invasive. This is also called laser ablation. The high-energy beam is used to vaporize abnormal tissue.

2. Wide Local Excision: In this case, wide areas around the lesions are removed along with some healthy tissues.

3. Vaginectomy: Removal of all or parts of the vagina. This is done in cases where the extension of squamous cell carcinoma has not breached the basement membrane. Tissue approximately 2 centimeters below the abnormal area is removed in this process. Reconstruction of the vagina is done through skin grafts.

4. Total Hysterectomy: In this procedure uterus and cervix is taken out. If the vaginal approach is used, it is called a vaginal hysterectomy. In an abdominal hysterectomy, the incision is made on the abdomen to take out the uterus and cervix.

In the lymphadenectomy procedure, lymph nodes are removed pelvic lymph nodes are removed in upper vaginal lesions. Lymph nodes of the groin area are removed in lower vaginal carcinoma. In cases of extensive extension of the carcinoma, pelvic extension surgeries are done. The application of radiation therapy is necessary to kill potentially malignant cells and cancerous cells. This also prevents the further growth of cancer cells. Based on the radiation source, it can be divided into internal or external types. Brachytherapy is an internal radiation therapy used to deliver radiation to the affected site via seeds, ribbons, or capsules. Chemotherapy is also used to kill cancer cells. Chemotherapeutic drugs can be taken orally or injected through blood vessels. Local application of the chemotherapeutic agents can be seen in squamous cell carcinoma of vaginal cancer. The treatment protocol for vaginal cancer is entirely based on cancer staging.

• Stage I and stage II belong to the early stage of vaginal cancer. The treatment protocol for this these stages is surgical resection or definitive radiotherapy. For well-circumscribed lesions in the upper vagina, vaginectomy, radical hysterectomy, and removal of lymph nodes on both sides are done. Total vaginectomy, or vulvovaginectomy, and removal of inguinofemoral lymph nodes are done in cases of distal vaginal cancer. For superficial stage-I lesion,brachytherapy is done.

• Combination of both external and internal radiation is applied in advanced cases of vaginal cancer (stage I and stage IV cases). Along with this, chemotherapy and pelvic extension surgeries are done.

Conclusion

Vaginal cancer is a rare cancer that may cause the patient's death. Early diagnosis of this carcinoma can help in curing the affected persons. Surgical removal, radiotherapy, and chemotherapy can help increase the patient's life expectancy. Modern applications of immunotherapeutic drugs and radiosensitizers have also shown promising results in treating vaginal cancer.