0 Vaginal Cancer

DEFINITIONS
Vaginal cancer is a malignant tumor of the vagina.

The vagina is the canal along the 7.5 to 10 centimeters; the top edge associated with the cervix (neck of the womb / the lowest part of uterus), while the bottom end associated with the vulva.
Vaginal wall lined by epithelium that is formed from squamous cells. Under the epithelium there is connective tissue, involuntary muscles, lymph nodes, and innervation.
Vaginal walls have many folds that help to remain open during vaginal intercourse or childbirth took place.

There are several types of vaginal cancer:

1. Squamous cell carcinoma (85-90%)
Derived from the layer of vaginal epithelium. More prevalent in the upper vagina.
Squamous carcinoma is usually found in women aged 60-80 years.
Verukosa carcinoma is a type of squamous cell carcinoma is slow growing. Carcinoma was
growing toward the vaginal cavity and look like warts or cauliflower.
2. Adenocarcinoma (50-10%)
Adenocarcinoma is most common in women aged 12-30 years.
3. Malignant melanoma (2-3%)
Derived from pigment-producing cells, were more common in the lower vagina.
4. Sarcomas (2-3%)
This cancer to grow deep in the vaginal wall, rather than the epithelium.
There are several types of sarcomas, the most frequently found is leiomiosarkoma, who attacked the women aged 50 years and over.
Rhabdomyosarcoma is a cancer in childhood, usually occurs before the age of 3 years. Cells are similar to voluntary muscle cells, which is a network that under normal circumstances not found in the vaginal wall.


Squamous cell carcinomas do not grow all of a sudden, the cancer has grown over the years from a vaginal precancerous changes called vaginal intraepithelial neoplasi (Niva).

CAUSE
The cause is unknown.

Risk factor for vaginal cancer:

1. Age
Approximately 50% squamous carcinoma patients were women aged 60 years and older.
Most cases of vaginal cancer found in women aged 50-70 years.
2. Of DES (diethylstilbestrol)
DES is a hormonal drug that is widely used in the years 1940-1970 to prevent miscarriage in pregnant women.
As many as one in 1000 women whose mothers had taken DES consuming, suffered net cell adenocarcinoma of the vagina and cervix. The highest risk occurs if the mother consumes DES at 16 weeks gestation.
3. Adenosis vagina
Under normal circumstances the vagina is lined with flat cells called squamous cells.
In about 40% of women who have experienced menstruation, the vagina can be found in certain areas covered by cells similar to cells found in the bottom of the uterine glands and the lining of the uterus. This is called adenosis.
It occurs in almost all women who are exposed by DES during fetal development.
4. Infection with HPV (human papilloma virus)
HPV is the virus that causes genital warts that are transmitted through sexual intercourse.
5. First sexual intercourse at an early age
6. Multiple sexual partners
7. Sexual intercourse with someone who frequently have multiple sexual partners
8. Cervical Cancer
9. Iritsi vagina
10. Smoke.

SYMPTOMS
Vaginal cancer causes damage to the lining of the vagina and cause the formation of open sores that can bleed and become infected.

Patients may also experience vaginal bleeding (often after sexual intercourse) or watery fluid from vagina out.

If a large cancer can affect the function of the bladder and rectum so that patients have urgency to urinate and have pain when urinating.

Other symptoms are:
- Abnormal fluid out of the vagina
- Felt a bump
- Pain during sexual intercourse.

In advanced-stage cancer pain when urinating will timbuli, constipation and persistent pelvic pain.

DIAGNOSIS
Diagnosis based on symptoms and physical examination.
On pelvic examination will be felt the lump.

# Other checks are wont to do: Colposcopy (examination of the vaginal wall with the aid of a magnifying glass)
# Biopsy (microscopic examination of vaginal tissue samples).


Staging

Staging is the process of determining the spread of cancer, which is essential for determining the type of treatment and prognosis of disease.
Assessment of the spread of cancer involving the vagina following tests:
- A thorough physical examination
- Pielogram intravenous
- Barium enema
- Chest X-ray
- Cystoscopy
- Proctoscopy
- CT scan
- Skening bone.

Vaginal cancer stage based on FIGO system:
# Stage 0 (carcinoma in situ, Niva 3): cancer cells are confined to the vaginal epithelium and has not spread to other vaginal lining.
At this stage cancer could not spread to other body parts.
# Stage I: Cancer has spread to the epithelium but is still confined to the vaginal mucosa (mucosa consists of two layers, ie epithelium and lamina propria or stroma subepithelial).
# Stage IA: tumor size less than 2 cm and has grown into the wall less than 1 millimeter deep.
# Stage IB: tumors larger than 2 cm and has penetrated deep into the wall more than 1 millimeter.
# Stage II: cancer has spread to the connective tissue of the vagina but has not spread to other organs or pelvic wall.
# Stage III: cancer has spread to the pelvic wall and / or have spread to lymph nodes on the same side with the tumor.
# Stage IVA: Cancer has spread to organs near the vagina (eg, bladder) and / or taelah spread beyond the pelvis and / or has spread to the lymph nodes on both sides of the pelvis.
# Stage IVB: cancer has spread to distant organs (eg lungs).

TREATMENT
Treatment for precancerous conditions (Niva)

To determine the exact location of Niva, colposcopy examination.
To confirm the diagnosis a biopsy done.

Treatment options for Niva:

1. Surgical laser to vaporize the abnormal tissue.
2. LEEP (loop electroexcision procedure): kauter heat used to remove lesions in the vagina. Effective for small lesions.
3. Topical chemotherapy: use of chemotherapy (5FU/fluorouracil) are applied directly to the vagina every night for 1-2 weeks or every week for 10 weeks.
These drugs can cause irritation of the vagina and vulva.


Niva low levels often disappears by itself, so treatment is usually only done at medium or high level Niva.


Treatment for vaginal cancer

There are three kinds of treatment for vaginal cancer:

1. Surgery
- Laser Surgery
- Wide local excision: removal of the cancer and made some surrounding tissue. To fix the vagina may dilkukan skin grafting taken from other body parts.
- Vaginektomi (removal of vagina).
If the cancer has spread beyond the vagina, performed vaginektomi and radical hysterectomy (removal of uterus, ovary / ovaries and fallopian tubes / ovaries channel). Dissection may be accompanied by removal of lymph nodes.
- Eksenterasi done if the cancer has spread beyond the vagina and other female organs. In this surgery done under the engangkatan colon, rectum or bladder (depending on the location of the spread of tumor) accompanied by the appointment of cervical / cervix, uterus and vagina.
After this surgery may be necessary to transplant skin and plastic surgery to make an artificial vagina.

2. Radiation therapy
In radiation therapy used high doses of X rays or high energy rays to kill other cancer cells and reduce tumor size.
Radiation originating from a machine called external radiation, whereas radiation originating from a capsule / tube containing a radioactive substance is inserted into the vagina and internal radiation.
Radiation can be used separately or after surgery.

3. Chemotherapy
In the chemotherapy drugs used to kill cancer cells.
Chemotherapy is available in pill form or intravenous injection (through a blood vessel).
Chemotherapy is a systemic treatments because the drugs enter the bloodstream and move throughout the body and kill cancer cells that are outside the vagina.
In intravagina chemotherapy, chemotherapy drugs directly inserted into the vagina.


Treatment based on staging
Vaginal cancer treatment depends on the stage and type of disease, and the patient's age and general condition.

1. Stage 0 vaginal cancer
- Vaginektomi. After vaginektomi skin grafting may be done to repair damage to the vagina.
- Internal radiation therapy
- Laser Surgery
- Chemotherapy intravagina.

2. Stage I vaginal cancer
Squamous Cancer
- Internal radiation with or without external radiation
- Wide local excision, can be followed by vaginal repair. In some cases, could be followed by radiation therapy.
- Vaginektomi and lymph node dissection
Adenocarcinoma
- Vaginektomi and removal of the uterus, ovaries and fallopian tubes, along with pelvic lymph node dissection. This procedure was followed by vaginal repair.
In some cases could be followed by radiation therapy.
- Internal radiation with or without external radiation.
- In certain cases, wide local excision performed and dissection multiple pelvic lymph nodes, followed by internal radiation.

3. Stage II vaginal cancer
- The combination of internal and external radiation
- Surgery, which can be followed by radiation therapy

4. Stage III vaginal cancer
- The combination of internal and external radiation
- Surgery, sometimes combined with radiation therapy
5. Stage IVA vaginal cancer
- The combination of the internal and external radiation
- Surgery is sometimes combined with radiation therapy
6. Stage IVB vaginal cancer
- Irradiation to alleviate the symptoms of pain, nausea, vomiting and gastrointestinal dysfunction
- Chemotherapy.


If the recurrent cancer (recurrence) and spread to organs other woman, then carried eksenterasi, depending on the location of the spread of cancer.
Can also be radiation and chemotherapy treatments.

AVOIDANCE
The best way to reduce the risk of vaginal cancer is to avoid the risk factors.