Around 90% of tumours are squamous cell carcinomas and 5-10% are adenocarcinomas. Other tumour types are rare and include clear cell carcinoma, small cell carcinoma, melanoma and sarcomas.
Most vaginal carcinomas arise in the upper vagina. Direct involvement of the cervix is common. This may lead to problems with classification as the FIGO classification system states that vaginal tumours that extend to the external cervical os should be considered cervical carcinomas.
Tumours breaching the vaginal wall commonly infiltrate around the urethra anteriorly and the rectovaginal fascia posteriorly. Larger tumours may directly involve the bladder or rectum. Laterally tumours extend into the paracolpol tissues and may extend to the pelvic side-wall. Lower vaginal tumours may extend onto the perineum and involve the vulva, urethra and anus.
The vagina has a rich lymphatic drainage. The lower vaginal lymphatics drain with those of the vulva to the inguinal nodes. Those of the mid and upper vagina drain predominantly to the obturator nodes, although the posterior wall may drain first to the perirectal nodes. Tumour spread is then usually contiguous, through the internal, external and common iliac chains and eventually to the upper retroperitoneum.
Haematogenous spread may occur and is most commonly to the lungs.
The following factors affect prognosis:
• Tumour stage. Stage is the most important prognostic factor; in one large series, 10 year disease free survival was 80% for stage I, 38% for stage III and 0% for stage IV.
• Tumour size. Tumours>4.0cm in diameter have a worse prognosis, but this variable is not independent of tumour stage.
• Tumour position. In one series tumours of the lower of the vagina or involving the posterior wall had a worse prognosis.
• Tumour morphology. Stage I tumours with a superficially ulcerated exophytic morphology have a better prognosis than infiltrative or necrotic tumours of the same stage.
• Histological type. One series suggested that adenocarcinomas had a worse prognosis, but this has not been confirmed by other studies.
• Histological grade. Poorly differentiated tumours have a worse prognosis.
Table 7.1. Clinical staging of vaginal cancer: correlation of TNM (2002) and FIGO (1994) classifications
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