Neoplasms of the vagina following cervical carcinoma

Neoplasm in the vagina which occurs following treatment of cervical carcinoma could represent a separate primary neoplasm, a “field” response to a common carcinogen, or be due to neoplastic transformation of tissue from previous radiation treatment. Fifty patients with a second neoplasm in the vagina were identified: 17 following total hysterectomy for carcinoma in situ of cervix; 4 following radical hysterectomy; and 29 following radiotherapy for invasive cervical carcinoma. Their clinical features, diagnosis, and treatment modalities are presented. Since vaginal neoplasm may occur long after treatment of the initial cervical carcinoma especially after previous radiotherapy, life-long follow-up of all patients with cervical carcinoma is mandatory.     

Microinvasive carcinoma of the vagina: a distinct clinical entity?

Six patients with superficially invasive squamous carcinoma of the vagina are described. All had less than 2.5 mm of invasion as measured from the surface, lacked involvement of the lymph-vascular spaces, and arose within a field of carcinoma in situ. Three of the six had previously been treated for carcinoma of the cervix. The patients with microinvasive carcinoma had a median age 10 years younger than that of patients with Stage I carcinoma of the vagina. Treatment of the six patients has been by partial or total vaginectomy. With follow-up of 51 to 172 months, there have been no recurrences. More experience is needed to define microinvasive squamous carcinoma of the vagina and to determine the optimal treatment for these lesions.     

Postirradiation vaginal occlusion: nonoperative management

The effects of irradiation therapy on the surrounding pelvic structures are well known. Most women develop some degree of vaginal stenosis following irradiation for cervical cancer. Although complete vaginal occlusion is less common, it seriously affects the patient's self-image. The author treated five patients who had complete vaginal occlusion following irradiation for stage II uterine cervical carcinoma. By means of a regimen of digital pressure and an estrogenic cream, for an average of six weeks, the function of the vagina was restored.     

Primary carcinoma of the vagina: a study of 29 cases

Twenty-nine cases of primary carcinoma of the vagina were reviewed. Vaginal carcinoma produced symptoms in 26 cases and postmenopausal bleeding was the most frequently observed symptom. Squamous carcinoma was the dominating histologic type (83%). Twelve patients had previously been treated for invasive or preinvasive cervical disease. Six patients had previously received pelvic irradiation. The median time from cervical carcinoma to vaginal carcinoma was 20 years, and from pelvic irradiation to vaginal carcinoma, 25 years. Two factors significantly influenced the results of treatment: the mode of delivery of radiation therapy and the total tumor dose. Clinical staging did not significantly influence the results of treatment although stage I patients did better than stage II-IV patients. Combination of external pelvic irradiation and brachytherapy, with a total tumor dose of 7000 R or more, was necessary to prevent local recurrence.     

Recurrent carcinoma of the vagina following Okabayashi's radical hysterectomy for cervical carcinoma

Between 1962 and 1976, 1847 cases of cervical cancer were treated by Okabayashi's radical hysterectomy. Of these, 42 cases developed vaginal invasive carcinoma and 5 developed vaginal intraepithelial carcinoma thereafter, giving a recurrence rate of 2.5%. The vaginal recurrence rate declined annually during the period 1962-1976, and was thought to be due to the efficacy of routinization of postoperative vaginal cuff irradiation. Of the 47 recurrent cases 33 were discovered within 2 years following the operation. Seventy-two percent of the recurrent cases were asymptomatic. The importance of close follow-up of the patients during the first 2 postoperative years was denoted. The incidence of developing a secondary vaginal cancer in the cases of cervical adenocarcinoma was 10.0%, higher than the 2.2% for squamous cell carcinoma. All the recurrent cases were treated with vaginal cuff irradiation, either alone or with external irradiation and/or chemotherapy. The 3-year survival rate of the patients who had vaginal recurrence alone was 40.0%, better than that of the cases accompanied with recurrence at the other sites.     

Vaginal radiation brachytherapy to reduce central recurrence after radical hysterectomy for cervical carcinoma

Seventeen (17%) of one hundred and two patients were treated with radiation brachytherapy (without external-beam therapy) to the proximal vagina to reduce the possibility of central pelvic recurrence following radical hysterectomy for cervical carcinoma. The 17 were considered to be at greater risk of developing recurrent cancer in the central pelvis because the cancer invaded halfway through the cervix; however, no lesions extended beyond the cervix, nor were metastases to lymph nodes present or surgical margins involved. The brachytherapy treatment was evaluated for prevention of central pelvis recurrence and for related complications. The 17 women treated with radiation brachytherapy were also compared with 74 patients who did not receive brachytherapy after radical hysterectomy because their cancers were smaller and did not invade halfway through the cervix. Both groups were similar with respect to age (41 and 40 years, respectively), weight (69.5 and 65.9 kg), operative characteristics, and the proportions of squamous cell carcinoma and adenocarcinoma. Recurrences have not been observed among the patients treated with brachytherapy during a mean follow-up of 39 months (range, 9-92 months). No complications were attributed to the brachytherapy. However, two patients with large tumors refused adjuvant brachytherapy and suffered central pelvic recurrences. Brachytherapy in selected patients following radical hysterectomy was safely administered and appeared to reduce the risk of central pelvic recurrence.     

阴道上皮内瘤变20例临床分析

目的 探讨阴道上皮内瘤变(VAIN)的临床特征、治疗方法及预后.方法 收集中国医学科学院肿瘤医院1999年1月-2007年12月收治的20例VAIN患者的临床资料,对其进行回顾性分析.结果 20例患者均无明显临床症状和体征,多数患者(17例,85%)因阴道液基细胞学检查异常或诊断为宫颈癌后而行进一步检查(妇科检查、阴道镜检查及阴道镜下活检组织病理检查)时发现,少数患者(3例,15%)为宫颈癌术后随访时发现.85%(17例)的患者合并宫颈癌(12例)或宫颈上皮内瘤变(CIN,5例).90%的患者为VAIN Ⅲ.主要发生于阴道上段(17例,85%),且多呈多灶性分布(13例,65%).VAIN的治疗主要采用手术治疗(13例)和放疗(7例),治疗后的局部控制率达100%.3例(15%)复发患者均为VAIN Ⅲ,其中1例为放疗后复发,2例为手术后复发,分别经手术或放疗后病变仍可得到有效控制.结论 单纯性VAIN诊断阑难.常合并宫颈癌或CIN,病变多位于阴道上段且呈多灶性分布,手术和放疗均可有效控制VAIN,但治疗后应密切随访,以及早发现、诊断和治疗复发病变.     

Stage IIIA carcinoma of the uterine cervix

Carcinoma of the uterine cervix presenting with extension to the lower third of the vagina but without hydronephrosis or fixation to the pelvic sidewall is uncommon. It is classified as stage IIIA by the criteria of the International Federation of Gynecology and Obstetrics (FIGO) and accounts for less than 2% of all cervical cancer cases seen in our institution. Because of the paucity of such cases, the results of treatment of FIGO stage IIIA cervical cancer are generally not reported separately. The radiation therapy treatment program at Yale--New Haven Hospital for stage IIIA patients includes intracavitary and vaginal brachytherapy plus external beam radiation therapy, with a strong emphasis on individualization of treatment. The results of treatment in 17 stage IIIA patients were reviewed. Local--regional tumor control was achieved in 12 of the 17 patients (71%) treated. The actuarial 5-year disease-free survival rate was 58%. Our results suggest that FIGO stage IIIA carcinoma of the cervix has a much better prognosis than FIGO stage IIIB cervical cancer, and we recommend that the results of treatment for FIGO stage IIIA be reported separately.     

The clinical outcome of patients with stage Ia1 and Ia2 squamous cell carcinoma of the uterine cervix: a Cooperation Task Force (CTF) study

PURPOSE OF INVESTIGATION: The objective of this retrospective multicenter study was to assess the clinical outcome of patients with microinvasive squamous cell carcinoma of the uterine cervix. METHODS: The hospital records of 166 patients with microinvasive squamous cell carcinoma of the uterine cervix were reviewed. All cases were retrospectively staged according the 1994 International Federation of Gynecology and Obstetrics (FIGO) nomenclature. One hundred and forty-three cases were in Stage Ia1 and 23 in Stage Ia2 disease. Surgery consisted of conization alone in 30 (18.1%) patients, total hysterectomy in 82 (49.4%), and radical hysterectomy in 54 (32.5%). All patients in whom conization was the definite treatment had Stage Ia1 disease and had cone margins negative for intraepithelial or invasive lesions. RESULTS: None of the 67 patients submitted to pelvic lymphadenectomy had histologically proven metastatic lymph nodes. Of the 166 patients, eight (4.8%) had an intraepithelial recurrence and four (2.4%) had an invasive recurrence. With regard to FIGO substage, disease recurred in nine (6.3%) out of 143 patients with Stage Ia1 and three (13.0%) out of 23 with Stage Ia2 cervical cancer. With regard to type of surgery, disease recurred in three (10.0%) out of the patients treated with conization alone, four (4.9%) out those who underwent total hysterectomy, and five (9.3%) out of those who underwent radical hysterectomy. It is worth noting that none of the 30 patients treated with conization alone had recurrent invasive cancer after a median follow-up of 45 months. However three (10%) of these patients developed a cervical intraepithelial neoplasia (CIN) III after 16, 33, and 94 months, respectively, from conization. CONCLUSIONS: Conization can represent the definite treatment for patients with Stage Ia1 squamous cell cervical cancer, if cone margins and apex are disease-free. For patients with Stage Ia2 cervical cancer extrafascial hysterectomy with pelvic lymphadenectomy might be an adequate standard therapy, although the need for lymph node dissection is questionable.     

Tamoxifen-induced endometrial cancer

OBJECTIVE: Tamoxifen-induced endometrial changes in postmenopausal women with breast carcinoma are well-known. Due to the popularity of postoperative chemotherapy for breast cancer, chemotherapy-induced early menopause in women with breast cancer on tamoxifen treatment needs more attention, because these women have higher risk for endometrial cancers than premenopausal women. SUBJECT: From May 1995 to May 1997, three premenopausal women aged 46, 43, and 39 with breast cancer were treated in our center. All patients received standard surgery for their breast cancers followed by six courses of adjuvant chemotherapy and 5-year tamoxifen treatment. All patients were regularly followed-up at the Breast Cancer Center and evaluated annually at the gynecological clinics including pelvic examination, Pap smear and transvaginal sonography. RESULTS: All patients became menopausal after six courses of chemotherapy ranging from three months to 14 months. The endometrial cancers occurred at 36 months, 28 months, and 33 months, respectively, after initial treatment for the breast cancers. Their last gynecologic examinations performed at six months, eight months and five months before the diagnosis of endometrial cancer showed nothing remarkable. Only one patient complained of vaginal spotting before diagnosis and the other two patients only complained of increasing purulent vaginal discharge. All patients received standard treatment for endometrial cancer and none of them died of their disease but one patient died of recurrent breast cancer 52 months later. CONCLUSION: Women with breast cancer on tamoxifen treatment need more attention and frequent evaluation of their reproductive organs, especially postmenopausal (either spontaneous or chemotherapy induced) women, although the American College of Obstetricians and Gynecologists (ACOG) comments that no more than annual pelvic exams with Pap smears are needed in asymptomatic women.     

Clear-cell adenocarcinoma of the lower genital tract: Memorial Hospital 1974-1984

Seventeen previously unreported cases of clear-cell adenocarcinoma originating in the vagina (13) and cervix (four) are presented. The mean age of the patients was 23.6 years. Four patients with cervical tumors and four patients with vaginal tumors underwent radical hysterectomy, bilateral pelvic lymphadenectomy, and partial vaginectomy. A total vaginectomy, with replacement of the excised vagina with a split-thickness skin graft or a segment of sigmoid colon, was added to the above procedure in five patients with vaginal cancer. In four patients, definitive treatment was radiation. All of the patients in the present series are without evidence of disease, with follow-up ranging from 21 months to more than ten years.     

Lower genital tract rhabdomyosarcoma: case series and literature review

OBJECTIVE: Rhabdomyosarcoma (RMS) of the lower genital tract is a rare tumor. It tends to occur in childhood in the vagina and in rare cases, RMS can originate in the uterine cervix, with a peak incidence in the 2nd decade. METHODS: A hospital-based tumor registry was searched to find all patients with female genital tract RMS, which were treated between 1999 and 2004. The medical records of all patients were reviewed. A single pathologist reviewed all pathologic specimens. RESULTS: Among the 1,528 patients with genital tract malignancies, six RMS were found: three vaginas, three cervixes. All patients presented with vaginal bleeding. Mean age of patients was 16(13-30). The lesions in vagina were clinically staged as stage I (2), stage II (1) and in cervix were stage I (2) and stage III(1). All of the patients were treated with surgery and adjuvant chemotherapy. One patient with cervical RMS was treated with adjuvant chemo radiation. Two patients with cervical RMS died from the large size and extent of the disease 9 and 11 months after diagnosis, but all patients with vaginal RMS remain alive after a mean follow-up of 38 months. CONCLUSION: Most patients present with vaginal bleeding and a palpable cervical or vaginal mass. While the optimal management of these tumors is uncertain, primary therapy with wide local excision and chemotherapy can result in prolonged survival and cure in patients with early stage RMS. Vaginal lesions have a better prognosis than cervical lesions. In patients with un-embrional RMS, large size of lesion, cervical origin and extent of disease, survival rates was decreased.     

Carcinoma of the cervix, FIGO Stage IB: treatment failures

All patients with carcinoma of the cervix, FIGO Stage IB, treated at the University of Minnesota Hospitals during a 10-year period were reviewed. Of the 220 patients 31 (14.0%) developed recurrent disease and did not survive. Thirteen patients had pelvic wall recurrences, with concurrent cervical involvement. No patient had a resectable pelvic recurrence. Hysterectomy was subsequently performed on 10 of the 172 patients who received radiation therapy. Carcinoma was not present in any of the operative specimens although two patients with adenocarcinoma later died of metastatic cancer. Median time of recurrence was 9 months, with median survival following recurrence of 6 months. Cervical cytology was not of value in the early diagnosis of recurrent disease. The 5-year adjusted actuarial survival rate for patients with adenosquamous carcinoma was significantly lower than that for patients with squamous cell carcinoma. The median age of patients not surviving with adenosquamous carcinoma was significantly lower than that for patients not surviving with squamous cell carcinoma. Patients with invasive carcinoma presumably confined to the cervix may have disseminated disease. It is essential such selected patients receive primary treatment that includes systemic therapy.     

Stage IA1 cervical adenocarcinoma: definition and treatment

Objective: To propose a definition for stage IA₁ cervical adenocarcinoma, based on the International Federation of Gynecology and Obstetrics (FIGO) staging system, and to determine if patients meeting criteria might be candidates for conservative surgery.Methods: Two hundred women were diagnosed with early-stage cervical adenocarcinoma from 1982 to 1996. Histopathologic sections were reviewed by a gynecologic pathologist. Medical records were reviewed, and patients included in this study had microscopically identifiable lesions, up to 3 mm invasive depth, up to 7 mm tumor width, and negative margins if cone biopsy was performed.Results: Twenty-one patients with microinvasive adenocarcinoma met criteria for FIGO stage IA₁ carcinoma of the cervix. The median (range) follow-up was 76 (30–172) months and median (range) patient age was 38 (24–75) years. Definitive treatment included type II or III radical hysterectomy in 16 cases, simple abdominal or vaginal hysterectomy in four cases, and loop electrosurgical excision procedure in one case; one patient received adjuvant pelvic radiation. The histologic subtypes were endocervical adenocarcinoma in 18 cases, adenosquamous carcinoma in two cases, and clear-cell adenocarcinoma in one case. There was no evidence of parametrial invasion or lymph node metastases in any patient who had radical surgery, and there were no disease recurrences.Conclusion: Patients with microinvasive adenocarcinoma who met criteria for FIGO stage IA₁ cervical carcinoma had disease limited to the cervix, and conservative surgery, such as cone biopsy or simple hysterectomy, might offer them definitive treatment.     

The barrel-shaped cervical carcinoma.

Twelve patients had barrel-shaped cervical carcinoma among 493 new patients with primary invasive cervical carcinoma, at the Downstate Medical Center, New York from January, 1964 to December, 1972. The incidence of barrel-shaped lesions among invasive carcinoma of the cervix was 2.43%. All 12 patients were treated with external radiation to the whole pelvis followed by two radium applications. In six patients an extrafascial hysterectomy was performed 6 to 12 weeks after radiation. Six patients died and six survived (50%). Six patients survived for over 2 years after therapy with no evidence of recurrence. Of these, four are alive and well for over 5 years. All six patients died within 20 months after therapy. The barrel-shaped cervical carcinoma fared poorly (six deaths among 12 patients or 50%) when compared with the over-all Stage I and Stage II cervical carcinoma (87 deaths among 339 patients or 25.5%).     

Carcinoma of the cervix and pregnancy

All patients with cervical cancer diagnosed during pregnancy at Jackson Memorial Hospital, the University of Miami School of Medicine, from 1960–1970 have been reviewed. There are 122 patients in this group; 99 had carcinoma in situ and 23 had invasive cancer. The prevalence rate for carcinoma in situ during pregnancy, was 0.192% and for invasive carcinoma, 0.046%. Of the patients, 95% had a Class III or higher Papanicolaou smear which led to the diagnosis. This is a young population in that the mean age was 29.6 years.Therapy for Stage 0 carcinoma and Stage IA (microinvasive) carcinoma was total hysterectomy, whereas radical hysterectomy with pelvic lymphadenectomy was recommended for Stage IB/IIAcarcinoma of the cervix. Radiotherapy was utilized for more advanced disease or in patients with contraindications to surgery.The importance of adequate follow-up is emphasized in that six patients with carcinoma in situ during pregnancy were found to have invasive carcinoma at a later date and two patients with invasive carcinoma had progression of their disease when treatment was delayed. The survival rate with radical operation during pregnancy for Stage IB and IIA carcinoma has been 90% in 10 patients followed nearly 3 years or longer. An additional four patients had radical operation in the follow-up period and all four are clinically free of recurrent cancer at the present time. Major complications were high in those patients treated with primary radiotherapy, and of the five patients who were so treated, four have died, one with recurrent carcinoma and the other three from complications of radiotherapy. An additional three patients were treated with primary radiotherapy during the intrapartum period. In this group two have died of recurrent cancer while one remains clinically free of cancer.     

Glassy cell carcinoma arising in the vagina

Glassy cell carcinoma is a rare neoplasm that occurs most frequently in the uterine cervix. We describe the first reported case of glassy cell carcinoma arising in the vagina. A 77-year-old Japanese woman was admitted to our hospital for atypical genital bleeding. Gynecological examination revealed a macroscopic vaginal cancer of 1.5 cm in diameter located in the upper 1/3 of the vagina. The pathological diagnosis of the biopsied specimen was glassy cell carcinoma. She was successfully treated by conventional radiation therapy and chemotherapy under the diagnosis of stage I vaginal cancer (International Federation of Gynecologists and Obstetricians classification, 1986). The patient is alive, without evidence of recurrence, 21 months following the radiation therapy. Glassy cell carcinoma is classified as the most poorly differentiated form of adenosquamous carcinoma. The present case illustrates the potential for glassy cell carcinoma to arise in the Mullerian epithelium throughout the female genital tract.     

The management of the patient with abnormal vaginal cytology following hysterectomy

Thirty-two patients presenting with abnormal vaginal cytology following hysterectomy were studied. Seven (21.8%) had had hysterectomy for benign conditions whilst 25 (78.1%) had cervical intraepithelial neoplasia (CIN) or invasive cervical carcinoma. Twenty-five patients had partial or total vaginectomy (15 as the primary procedure), and one required laser treatment following vaginectomy. Of 11 (34.3%) patients treated primarily by laser, five subsequently required vaginectomy because of persistent or recurrent cytological abnormality. All four patients treated with topical 5-fluorouracil or dinitrochlorobenzene subsequently required surgery. Nine of the 32 patients (28.1%) proved to have invasive carcinoma of the vagina on histological examination of the vaginectomy specimen. At the time of writing all patients in the study are well with no evidence of disease.     

The management of the patient with abnormal vaginal cytology following hysterectomy

Summary. Thirty-two patients presenting with abnormal vaginal cytology following hysterectomy were studied. Seven (21·8%) had had hysterectomy for benign conditions whilst 25 (78·1%) had cervical intraepithelial neoplasia (CIN) or invasive cervical carcinoma. Twenty-five patients had partial or total vaginectomy (15 as the primary procedure), and one required laser treatment following vaginectomy. Of 11 (34·3%) patients treated primarily by laser, five subsequently required vaginectomy because of persistent or recurrent cytological abnormality. All four patients treated with topical 5-fluorouracil or dinitrochlorobenzene subsequently required surgery. Nine of the 32 patients (28·1%) proved to have invasive carcinoma of the vagina on histological examination of the vaginectomy specimen. At the time of writing all patients in the study are well with no evidence of disease.     

Neoplasia in vaginal cuff epithelial inclusion cysts after hysterectomy

Between Jan 1, 1985, and Dec 31, 1987, 26 women were treated for vaginal intraepithelial neoplasia (VAIN). Twenty-two of them had undergone hysterectomy, 15 for a cervical intraepithelial neoplasia or cancer. Five patients were identified whose management was complicated by the presence of the neoplastic process within vaginal cuff inclusion cysts (or sinuses). All five patients ultimately underwent upper vaginectomy as part of their treatment, and two of them were found to have an invasive squamous cell carcinoma of the vagina. Women who are found to have an abnormal Papanicolaou smear or VAIN in the upper vagina following hysterectomy should be examined carefully for vaginal cuff abnormalities. Those with nodularity or distortion of the cuff are best managed with surgical excision for both treatment of VAIN and discovery of an occult invasive cancer.