Squamous cell carcinomas of the vagina may appear grossly as either ulcerated or fungating tumors, or they may be exophytic and protrude through the vaginal canal. They are the most common vaginal malignancy and account for 90% of primary vaginal cancers. The disease occurs primarily in women over 50 years of age. Most squamous cell carcinomas occur in the upper third of the vagina. In examining the patient, it is important to visualize the entire vagina because lesions on the posterior wall can be concealed by the speculum.
Microscopically, these tumors have the classic findings of invasive squamous cell carcinoma. They have pleomorphic squamous cells with occasional keratin pearls.
Figure 100-7). The lymphatics of the middle and upper vagina communicate superiorly with the lymphatics of the cervix and drain into the pelvic nodes of the obturator, internal, and external iliac chains. The lymphatics of the distal third of the vagina drain to the inguinal and pelvic nodes, with a pattern of drainage similar to that of the vulva. The posterior wall lymphatics drain to the rectal lymphatic system.
Depending on the location, both radiation and surgery have been used effectively in treating these lesions (
Table 100-6). Treatment is often individualized, depending on the size, stage, and location of the tumor.
If the tumor is less than 2 cm thick, some investigators advocate using only local radiation. If the carcinoma is less than 0.5 cm thick, intracavitary irradiation with a vaginal cylinder to deliver 8,000 cGy to the mucosa will give over 90% tumor control. Spirtos and colleagues studied 23 stage I patients and noted only two local recurrences, and both of these had tumor doses of less than 7,500 cGy. For larger lesions, external radiation is used, with a concomitant reduction in the local vaginal component of primary tumor treatment. Implants, however, often cannot be used in patients with larger stage III or IV carcinomas. If such is the case, only external beam radiation is used, and a central boost is given after an initial whole-pelvis dose of 5,000 cGy radiation.
Small tumors located in the upper third of the vagina often can be excised. In patients with these, a radical hysterectomy, partial vaginectomy, or pelvic lymphadenectomy usually is effective. Surgery has been preferred in younger patients.
If distant metastasis occurs, effective chemotherapy for recurrent squamous cell carcinoma of the vagina has not been developed. For squamous cell carcinoma, a variety of regimens using multiagent chemotherapy similar to those for cervical carcinoma have been employed.
The overall survival rate for patients with primary carcinoma of the vagina has been reported as approximately 45% and is related to the stage of the disease (
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