Vaginal cancer

Vaginal cancer: Excerpt from Professional Guide to Diseases (Eighth Edition)

Vaginal cancer accounts for approximately 2% of all gynecologic cancers. It usually appears as squamous cell cancer, but occasionally as melanoma, sarcoma, or adenocarcinoma.

Causes and incidence

The exact cause of vaginal cancer remains unknown. This cancer generally occurs in women in their early to mid-50s, but some of the rarer types occur in younger women, and rhabdomyosarcoma appears in children. (Clear cell adenocarcinoma has an increased incidence in young women whose mothers took diethylstilbestrol).

Vaginal cancer varies in severity according to its location and effect on lymphatic drainage. (The vagina is a thin-walled structure with a rich lymphatic drainage.) Vaginal cancer is similar to cervical cancer in that it may progress from an intraepithelial tumor to an invasive cancer. However, it spreads more slowly than cervical cancer.

A lesion in the upper third of the vagina (the most common site) usually metastasizes to the groin nodes; a lesion in the lower third (the second most common site) usually metastasizes to the hypogastric and iliac nodes; but a lesion in the middle third metastasizes erratically. A posterior lesion displaces and distends the vaginal posterior wall before spreading to deep layers. By contrast, an anterior lesion spreads more rapidly into other structures and deep layers because, unlike the posterior wall, the anterior vaginal wall isn't flexible.

Signs and symptoms

Commonly, the patient with vaginal cancer has experienced abnormal bleeding and discharge. Also, she may have a small or large, in many cases firm, ulcerated lesion in any part of the vagina. As the cancer progresses, it commonly spreads to the bladder (producing frequent voiding and bladder pain), the rectum (bleeding), vulva (lesion), pubic bone (pain), or other surrounding tissues.

Diagnosis

The diagnosis of vaginal cancer is based on the presence of abnormal cells on a vaginal Papanicolaou smear. Careful examination and a biopsy rule out the cervix and vulva as the primary sites of the lesion. In many cases, however, the cervix contains the primary lesion that has metastasized to the vagina. Then, any visible lesion is biopsied and evaluated histologically. It's sometimes difficult to visualize the entire vagina because the speculum blades may hide a lesion, or the patient may be uncooperative because of discomfort. When lesions aren't visible, colposcopy is used to search out abnormalities. Painting the suspected vaginal area with Lugol's solution also helps identify malignant areas by staining glycogen-containing normal tissue, while leaving abnormal tissue unstained. (See Staging vaginal cancer.)

Treatment

In early stages, treatment aims to preserve the normal parts of the vagina. Topical chemotherapy with 5-fluorouracil and laser surgery can be used for stages 0 and I. Radiation or surgery varies with the size, depth, and location of the lesion and the patient's desire to maintain a functional vagina. Preservation of a functional vagina is generally possible only in the early stages. Survival rates are the same for patients treated with radiation as for those with surgery.

Surgery is usually recommended only when the tumor is so extensive that exenteration is needed because close proximity to the bladder and rectum permits only minimal tissue margins around resected vaginal tissue.

Radiation therapy is the preferred treatment of advanced vaginal cancer. Most patients need preliminary external radiation treatment to shrink the tumor before internal radiation can begin. Then, if the tumor is localized to the vault and the cervix is present, radiation (using radium or cesium) can be given with an intrauterine tandem or ovoids; if the cervix is absent, a specially designed vaginal applicator is used instead.

To minimize complications, radioactive sources and filters are carefully placed away from radiosensitive tissues, such as the bladder and rectum. Internal radiation lasts 48 to 72 hours, depending on the dosage. (See Safe time for radiation implant.)

Special considerations

For internal radiation:

❑Explain the internal radiation procedure, answer the patient's questions, and encourage her to express her fears and concerns.

❑Because the effects of radiation are cumulative, wear a radiosensitive badge and a lead shield (if available) when you enter the patient's room, and adhere to internal radiation safety precautions.

❑Check with the radiation therapist concerning the maximum recommended time that you can safely spend with the patient when giving direct care.

❑While the radiation source is in place, the patient must lie flat on her back. Insert an indwelling urinary catheter (usually done in the operating room), and don't change the patient's linens unless they're soiled. Give only partial bed baths, and make sure the patient has a call bell, phone, water, or anything else she needs within easy reach. The physician will order a clear liquid or low-residue diet and an antidiarrheal drug to prevent bowel movements.

❑To compensate for immobility, encourage the patient to do active range-of-motion exercises with both arms.

❑Before radiation treatment, explain the necessity of immobilization, and tell the patient what it entails (such as no linen changes and the use of an indwelling urinary catheter). Throughout therapy, encourage her to express her anxieties.

❑Instruct the patient to use a stent or do prescribed exercises to prevent vaginal stenosis. Coitus is also helpful in preventing stenosis.

Pictures

Book Source Details

• Book Title: Professional Guide to Diseases (Eighth Edition)
• Author(s): Springhouse
• Year of Publication: 2005
• Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Professional Guide to Diseases (Eighth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2005 ISBN: 1-58255-370-X

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