I CANCER OF THE VULVA

II CANCER OF THE VAGINA

Virgilio R. Oblepias M.D.

CANCER OF THE VULVA

I. PRE-MALIGNANT LESION
( INTRA-EPITHELIAL DISEASE)

II. MALIGNANT LESION

(CANCER)

I. PRE-MALIGNANT LESION
Frequently occurs & co-exist with cervical &
vaginal lesions
causes & epidemeologic bases are common in all
three locations
treatment typically is ablative and conservative
early diagnosis and management are essential for
the prevention of disease progression to invasive
cancer

Classification of Diseases of the Vulva

(Vulva Dystrophies)
1. Non-neoplastic epithelial disorders of skin and mucosa
-Lichen Sclerosus
-Squamous Hyperplasia
-Other Dermatoses
2. Mixed Non-neoplastic & neoplastic epithelial disorders
3. Intra-epithelial Neoplasia
-Squamous intra-epithelial Neoplasia
VIN 1
VIN 2
VIN 3 (severe displasia or Ca-in-situ)
-non-squamous intra-epithelial neoplasia
Pagets disease
Tumors of the melanocytes, non-invasive
4. Invasive Tumors

Vulvar Intra-epithelial Neoplasia (VIN)

VIN 1 (Mild Dysplasia)
-immature cells
-cellular disorganization
-mitotic activities, lower third
VIN 2 (Moderate dysplasia)
-immature cells
-cellular disorganization

VIRAL (HPV) INFECTION EVIDENT-perinuclear halos

-displacement of nuclei
-thickened cell borders
-binucleation
-multinucleation

Treatment of VIN
1. Simple Excision
2. Laser Ablation
3. Superficial vulvectomy

Other intra-epithelial lesion

Pagets Disease, adenocarcinoma-in-situ, extramamary

predominant among post-menopausal woman, Caucasian
associated pruritus & vulvar sorenes
eczematoid appearance
may be associated with cancer of the cervix, colon,
bladder, gall bladder and breast
treat accordingly

II. Malignant Neoplasia of the

Vulva

Incidence
- 3% - 5% of all malignancies of the
female reproductive organs.
- PGH from 1961-1990 (30 years)
177
cases of vulvar cancer out
of 7,203 gynecologic cancers
(2.5%)
- 4th among Gyne cancers.

Age Incidence
- disease of older women
- peak age range 51-70 years
- 80% to 84.8% above 50 years

Social Status
- high among women in the low socioeconomic, class (3x those of
women in the higher class.)
- more frequent among caucasians
and relatively less among Negroes
and Semitic race.
- relatively lower among Spanish
Americans.

Etiology
- not established
- chronic inflammation and vulvar
dystrophys
- luekplakia + VIN
- condyloma acuminata (HPV)
- cigarette smoking

Associated Diseases with the Vulvar

Cancer
1. Hypertension
- 24%
2. Diabetes Mellitus
- 12.5%
3. Tuberculosis
- 9.3%
4. Bronchial Asthma
- 7.1%
5. Cardiovascular disease - 5.5%
6. Others
- 2.8%

Associated Malignant Tumors

1. Cervix
2. Vagina

Histologic Types
1. Squamous Ca
2. AdenoCa
3. Malignant Melanoma
4. Paget
5. Others
- Basal cell
- ChorioCa
- Sarcoma

78.%
7.5%
6.8%
3.1%
3.7%

Signs and Symptoms

1. Mass or ulcer
2. Pruritis
3. Bleeding/Discharge4. Pain
5. Others
-

37%
24%
24%
7%
7%

Site of the Lesions

1. Labia majora 2. Labia minora 3. Clitoris
4. Periurethral 5. Perineum
6. Mons
-

44.2%
44.1%
19.2%
19.2%
13.7%
11.2%

Recommended Screning Tools

1. No routine screening is recommended
2. Inspection of vulva when Pap Smear is performed

STAGE

PRIMARY TREATMENT

ADJUVANT

Stage O

Wide local excision with at least 2None

3mm surgical margin with removal of
the full thickness of the skin and
mucosa.
OPTIONS:
1.Wide local excision using LEEP
2.CO2 Laser
3.Skinning vulvectomy with or without
grafting for wide/extensive lesions
4. 5% Fluorouracil cream (50%-60%
response rate)1

Stage 1A

Wide local excision with at least 1 cm None

surgical margin and dissection carried
down to the urogenital diaphragm2

STAGE

PRIMARY TREATMENT

Stage 1B Wide local excision with at least 1 cm surgical

margin and dissection carried down to the
urogenital diaphragm 2

1.For lateral lesions (more than 2 cm from

the midline): radical local excision /
hemivulvectomy with ipsilateral groin node
dissection2,3,4
2. For central lesions (within 2cm from
clitoris or perineal body) radical local
excision or radical vulvectomy with
bilateral groin node dissection (morbidity
can be reduced by using separate groin
incisions)5
3. For those patients unable to tolerate
radical vulvectomy or deemed unsuitable
for surgery because of site or extent of
disease, radiation therapy is an option6,7,8,9

ADJUVANT
None

STAGE
Stage II

PRIMARY TREATMENT
RVBGND
OPTIONS:
1.For lateral lesions (more than 2 cm from
the midline)
a. Radical local excision with at least 2 cm
surgical margin with ipsilateral groin
node dissection
b. Radical hemivulvectomy with ipsilateral
groin node dissection2,3,4
2. For those patients unable to tolerate
radical vulvectomy or deemed
unsuitable for surgery because of
site or extent of disease, radical
radiation therapy (Complete RT with
vulvar and groin irradiation) may
result in long term survival6,7,8,9

ADJUVANT
None

STAGE

PRIMARY TREATMENT

ADJUVANT

Stage III

RVBGND with excision of involved urethra,

vagina and/or anus:
OPTIONS:
1. For lesions involving the lower urethra
and/or clitoris and for lesions technically
difficult to debulk: neoadjuvant
chemoradiation followed by RV +/BGND10,13,14
2. RVBGND with clitoral sparing for lesions in
the posterior half of vagina
3. For those patients unable to tolerate
radical vulvectomy or deemed unsuitable
for surgery because of site or extent of
disease, primary radiation with
chemotherapy7,8

Localized
radiotherapy
with
chemotherapy if
(+) lines of
resection,
surgical
margins <8mm,
capillary
lymphatic space
invasion
thickness
>5mm

(4 PHASE II trials of concurrent 5FU with or

without Cisplatin with radiation resulted in
complete response rates of 53% to 89% for
primary unresectable disease)15,16,17

STAGE

PRIMARY TREATMENT

Stage IV RVBGND

ADJUVANT

>3
microscopically
OPTIONS:
positive nodes;
1. Preoperative chemoradiation to
macroscopically
improve operability followed by
involved nodes
13,14
radical sugery.
(>10mm);
extracapsular
spread :
2. RV and pelvic exenteration
bilateral pelvic
3. For those patients unable to tolerate
and inguinal RT
radical vulvectomy or deemed unsuitable (4,500 to 5,000
for surgery because of site or extent of
cGy) 4,5,10,11,12
disease, primary radiation with
chemotherapy7,8

STAGE

PRIMARY TREATMENT

Recurrent Individualize
OPTIONS:
1. Wide local excision with or without
radiation in patients with local
recurrence
2. Radical vulvectomy and pelvic
exenteration
3. Synchronous radiation and cytotoxic
chemotherapy with or without surgery15

ADJUVANT

LEVEL

TREATMENT

I
II

Radical local excision with at least 2 cm surgical margin

III

Radical local excision with at least a 2 cm surgical margin.

Inguinofemoral lymphadenectomy is done primarily for
prognostication
*Radiotherapy may be useful in enhancing local and
regional control.
*Chemotherapy is generally ineffective.
*INterferon

TREATMENT
Wide local excision with removal of underlying dermis, in the
absence of clinical or histologic evidence of invasive carcinoma.
Frozen section of surgical margins is recommended to ensure
complete removal of tumor.
Options:
a. Take representative samples around the specimen and send
for frozen section.
b. Extend surgical margins beyond the usual margins of the
gross lesion
c. No frozen section, wait for final histopath report of specimen
and do re-excision if necessary
d. Wait for recurrence to develop then re-excise, (the disease is
slow-growing and is amenable to excision).

Treatment
1. Surgery
2. Radiotherapy
3. Chemotherapy

CHANGING TRENDS IN THE SURGICAL

MANAGEMENT OF VULVAR CANCER

in the early part of the

20th century,
the treatment of
vulvar cancer
was by excision
or simple vulvectomy

Five - year survival

rate was only
20 25 %

BASSET OPERATION :
Radical En-bloc removal of the
vulva and groin lymph nodes

In the middle of the 20th century

TAUSSIG (1940)
WAY (1948)
Gave favorable reports on the
management of vulvar cancer
based on the Basset operation

Five year survival rate gained

an increase to
60 70 %

RADICAL VULVECTOMY AND

BILATERAL GROIN NODE DISSECTION
EN BLOC

became the standard treatment

of vulvar cancer

The operation invloves

radical removal of the entire
vulva including the mons
pubis, and inguino-femoral
lymph nodes and, often, pelvic
lymph nodes

POST OPERATIVE PROBLEMS

1) Wound dehiscence
2) Urinary incontinence (cystocele)
3) Fecal incontinence (rectocele)
4) Vaginal relaxation (prolapse
uterus)

POST OPERATIVE COMPLICATIONS

(1961-1990, PGH)
1) Wound dehiscence over 2 cms.
2) Lymph edema
3) Cystorectocele
4) Prolapse of uterus
5) Prolapse of vaginal vault

-21.9%
- 9.7%
- 7.3%
- 6.1%
- 1.2%

Benitez 1994

To correct some of these problems,

may need another operation :
1) Release of scar contracture
2) anterior vaginal repair (cystocele)
3) posterior vaginal repair (rectocele)
4) v. hysterectomy (prolapse uterus)
5) Colpocleisis (vault prolapse)

Other discouraging complications are

1) Lymphedema of the lower extremities
2) Genital disfigurement

MORBIDITIES
- Physical
- Psychological

In the latter part of the century

(1970), several attempts were
made to modify the Standard
Treatment Plan for vulvar
cancer

Factors considered :
1) disease occurring in younger
women with early lesion
2) post-operative morbidity &
associated long term
hospitalization
3) psychosexual consequences

The Recent Trends in the

Management of
Vulvar Cancer

Individualization of treatment
for all patients with invasive
vulvar cancer

There should be no standard

operation applicable to every
patient
And
Emphasis is on performing the
most conservative operation
consistent with cure rate

Changes are :
I) Modifications in the Management
of Vulvar lesion
II) Modifications in the Regional
Nodal Management
III) Separate incisions for the
vulvectomy & groin dissection
IV) Management of locally advanced
disease
V) Management of Recurrent Disease

I Modifications in the
Management of Vulvar Lesion

Traditionally, invasive squamous

cell carcinoma was considered
as a diffuse disease involving
the entire vulva

Recently, it has been shown that

squamous cell carcinoma of the
vulva spread by lymphatic
embolization rather than
permeation

Currently, authorities agree that

an aggressive but effective local
resection of T1 vulvar cancer is
safe and effective treatment

Various Terms :
-

Radical local excision

Radical wide excision
Wide deep excision
Modified vulvectomy
Radical hemivulvectomy
Modified Radical vulvectomy

Wide and deep excision of primary

tumor with the surgical margin at
least 1-2 cm with the dissection
carries down to the fascia of the
urogenital diaphragm

Incidence of local invasive recurrence

after Radical excision & Radical
vulvectomy for T1 section of vulva
No
Radical local
Excision
Radical
Vulvectomy

165
365

Recurrence Deal of
Disease
12 (7.2%)
1 (0.6%)
23 (6.3%)

2 (0.5%)

Hacher and Van der Velden

II Modifications in the Regional

Nodal Management

1) Omission of groin dissection for

patients with stage IA vulvar
cancer

Nodal Status in T1 Squamous Carcinoma of

the vulva vs depth of Stomal Invassive
Depth of
invasion in
mm.

No

Positive
nodes

% Positive
nodes

< 1.0

163

1.1-2

145

11

7.6

2.1-3

131

11

8.4

3.1-5

101

27

26.7

> 5.0

38

13

34.2

Total

578

62

10.7
Hacher

2) Elimination of Routine Pelvic

Lymphadenectomy

Pelvic Lymphadenectomy should

be reserved for patients with
positive and suspicious groin
nodes

Pelvic Node Metastases may occur

in patients with :
1) Clinically suspicious nodes (N2)
in the groin
2) Three or more positive unilateral
groin nodes
(Hacher, UCLA)

3) Omission of contralateral groin

node dissection in lateral T1,
& negative ipsilateral groin
nodes

Except in involvement of the

1) anterior labia minora
2) clitoris
3) perineal body
4) within 2 cms. from midline

Incidence of positive contralateral nodes in patients with

lateral T1 SCCA vulva is 0.4%
(Hacher)

4) Omission of full groin

dissection for patients with
grossly positive nodes to
reduce morbidity from
subsequent radiotherapy

5) The use of post-operative

irradiation to decrease the
incidence of groin recurrences
in patients with multiple groin
positive nodes

1977 GOG
2 year survival rate
. Radiation group
-68%
. Pelvic lymphadenectomy group -54%
Groin recurrences
. Radiation group
-5.1%
. Pelvic lymphadenectomy group -23.6%

6) Sentinel node mapping

- Technetium 99m sulfur colloid

injected in the vulvar lesion
- Isosuflan blue dye

The sentinel node is the first node

in the lymphatic chain that
receives primary lymphatic flow
from the lesion

III Separate incisions for

the vulvectomy & groin
dissection

In 98 cases there were

14 major and 30 minor wound
breakdowns
HACHER, UCLA

Over all survival rate

Stage I
Stage II
Stage III

86%
97.1%
86%
49%
HACHER, UCLA

Contraindications
1) Clinically positive groin nodes
2) Clitoral lesion
3) Lesion in the mons pubis
4) Suspicious lymph nodes

Therefore, the geographic

distributions and the size of the
carcinoma must be the deciding
factors in designing the resection

IV Management of locally
advanced lesion

1) Use of pre-operative radiation

therapy to obviate the need
for exenteration in patient with
advanced disease

Radiation therapy
- Orthovoltage
- Megavoltage

Boronow was the first to suggest

that a combined radiosurgical
approach as alternative to pelvic
exenteration

Treatment is
. Intracavitary radium with or
without external irradiation
then RV and BGND

1984, Hacher
. Pre-operative Teletherapy
. Brachytherapy for persistent
disease that would otherwise
necessitate exenteration

1987, Boronow
. Pre-operative Radiation for advanced,
vulvo vaginal cancer
36 primary cases
- 75.6% 5-year
Survival
11 recurrent cases
- 62.6% rate

. No residual disease
local recurrence
fistula

- 42.5%
- 16.7%
- 10.4%

Final suggestions . External beam therapy for all

cases with more selective use
of brachy therapy

2) Introduction of chemotherapy
concomitant with radiotherapy
in the pre-operative treatment
with advanced disease

Thomas, GM

(1989)

Berek, JS

(1991)

Russel, AH

(1993)

V The Management of
recurrent squamous cell
carcinoma of the vulva

Approximately 15% to 40% of

patients with squamous cell of
the vulva will develop
recurrence following treatment

Incidence of recurrence is
influenced by several factors,
including
1) original stage
2) depth of invasion
3) regional lymph nodes
status

Approximately 70% of
recurrences have a local
component with 55% to 90% of
these being isolated local
recurrences

Salvage rate is 40 to 80%

Other factors predisposing the

patient to develop vulvar
recurrence
1) close resection, margin less
than 1 cm.
2) deep invasion
3) large tumor

Treatment
1) Radical resection if feasible
2) Radiotherapy followed by
resection
3) Radiotherapy with chemotherapy
followed by resection

The prognosis for a patient with

regional or systemic recurrences
is poor

All modalities of treatment may

not be effective

VULVAR CANCER
GENERAL GUIDELINES
1) Vulvar cancer is diagnosed by wedge biopsy (include normal
surrounding skin, underlying dermis and connective tissue
to determine depth of stromal invasion)
2) An associated lesion in the vagina and the cervix must be ruled
out by careful elvic examination with pap smear and/or
colposcopy.
3) If clinically indicated, proctosigmoidoscopy and cytoscopy
should be done to rule out bladder and bowel involvement
4) A CT Scan (with contrast) of the pelvis and groins is often
helpful to detect any enlarged lymph nodes in the groin
and pelvis.
5) Radical vulvectomy with bilateral inguinofemoral lymphanedectomy (RVBGND) is the mainstay of treatment.

Stage 0 Wide local excision with at least 2-3

None
mm surgical margin with removal of
the full thickness of the skin and
mucosa
OPTIONS:
1) Wide local excision using LEEP
2) CO2 Laser
3) Skinning vulvectomy with or without
grafting for wide/extensive lesions
4) 5% Fluorouracil cream (50-60%
response rate)

Stage 1A Wide local excision with at least 1 cm None

surgical margin and dissection carried
down to the urogenital diaphragm

Stage Wide local excision with at least 1 cm surgical

1B
margin and dissection carried down to the
urogenital diaphragm
1) For lateral lesions (more than 2 cm from the
midline) : radical local
excision/hemivulvectomy with ipsilateral
groin node dissection
2) For central lesions (within 2cm from clitoris
or perineal body) radical local excision or
radical vulvectomy with bilateral groin
node dissection (morbidity can be reduced
by using separate groin incisions)
3) For those patients unable to tolerate radical
vulvectomy or deemed unsuitable for
surgery because of site or extent of
disease, radiation therapy is an option

If
(+) lines of
resection,
surgical margins
<8mm capillary
lumphatic space
invasion,
thickness >5mm
2 options
1) Re-operative
2) Radiotherapy
with or w/out
chemotherapy

Stage II

RVBGND
OPTIONS:
1) For lateral lesions (more than 2 cm from the
midline):
a) Radical local excision with at least 2 cm
surgical margin with ipsilateral groin node
dissection
b) Radical hemivulvectomy with ipsilateral
groin node dissection
2) For those patients unable to tolerate radical
vulvectomy or deemed unsuitable for
surgery because of site or extent disease,
radical radiation therapy (complete RT with
vulvar and groin irradiation)may result in
long term survival

Stage III

RVBGND with excision of involved urethra, vagina and/or anus:

OPTIONS:
1) For lesions involving the lower urethra and/or clitoris and for
lesions technically difficult to debulk: neoadjuvant
chemoradiation followed by RV+/-BGND
2) RVBGND with clitoral spring for lesions in the posterior half of the
vagina
3) For those patients unable to tolerate radical vulvectomy or deemed
unsuitable for surgery because of site or extent of disease,
primary radiation with chemotherapy
(4 PHASE II trials of concurrent 5FU with or without Cisplatin with
radiation resulted in complete response rates of 53% to 89%
for primary unresectable disease)

Stage IV

RVBGND
OPTIONS:
1) Pre-operative chemoradiation to improve operability followed by
radical surgery
2) RV and pelvic exenteration
3) For those patients unable to tolerate radical vulvectomy or deemed
unsuitable for surgery because of site or extent of disease,
primary radiation with chemotherapy

Localized
radiotherapy with
chemotherapy
If (+) lines of resection,
surgical margins
<8mm, capillary
lymphatic space
invasion thickness
>5mm Lymph node
status: If with one to
two Microscopically
positive node:
Observe
3 microscopically
postive nodes;
macroscopically
involved nodes
(>10mm);extracapsular
spread : bilateral pelvic
and inguinal RT (4,500
to 5,000 cGy)

Recurrent Individualize
OPTIONS:
1) Wide local excision with or without
radiation in patients with local
recurrence
2) Radical vulvectomy and pelvic
exenteration
3) Synchronous radiation and
cytotoxic chemotherapy with or
without surgery

CANCER OF THE
VAGINA

I. Premalignant Lesion
II.Malignant Lesion

I Pre-Malignant Lesion
Vaginal Intra-epithelial Neoplasia (VAIN)
-often accompanies (CIN or Cervical
Intra- epithelial neoplasia)
-may be an extension from the cervix or
satellite lesion

Usually asymptomatic

RECOMMENDED SCREENING TOOLS

-No routine screening test is recommended
-Careful inspection of the vagina when Pap smear
is performed
(frequency of Pap smear as recommended
in cervical cancer screening guidelines)

Colposcopy
VAIN 1
Lesions are located along the vaginal ridges
ovoid shape & slightly raised
surface spicules
koilocytosis indicating HPV infection
VAIN 2
Thicker acetowhite epithelium

II. Cancer of the Vagina

Primary Cancer of the Vagina is

uncommon, representing about
2% of all Gynecologic cancers.

Age Incidence: 50 years and above.

(PGH) 85% of cases were over 50.
> youngest is 28 and
> oldest is 80.
> peak age incidence (35.6%) is in the 7th
decade of life.

Histology
Squamous 85%
Adenocarcinoma
Sarcoma 15%
Melanoma

Primary vaginal cancer

- cervix is uninvolved
- bulk is obviously arising from the
vagina
- vulva involved should be considered
as vulvar cancer.
- Adenocarcinoma has to rule out
adenocarcinoma of endocervix
and
endometrium

Etiology
- not known
- maybe same as cervical
cancers.
- HPV

Frequent site of involvement if

the upper vagina, particularly
the posterior wall

Spread or Metastasis of the tumor is by the

lymphatics.
1. Lesions is the upper vagina pelvic lymph
node.
2. Lesions in the lower vagina inguinal
lymph node
3. Lesions in the middle third either
inguinal or pelvic lymph node

Symptoms / signs
1. Mostly asymptomatic
2. Post-coital bleeding
3. Vaginal discharge
4. UTI
5. Rectal Problems
6. Groin discomfort or palpable lymph
nodes

- no recommended screening tools

- good vaginal inspection

Prognosis
- depends largely on Clinical Stage

TREATMENT OF VAGINAL CANCER

PRE-TREATMENT WORK-UP
Complete History and Physical Examination
Pap Smear
Colposcopy of cervix, vagina and vulva
CBC with platelet count
Urinalysis
Liver and Renal Profile
Chest X-Ray
ECG, IVP, Cystoscopy, Proctoscopy, CT Scan,
Barium enema, Ultrasonography

FIGO Clinical Staging

Stage 0 Carcinoma-in-situ
(Intra-epithelial carcinoma)
VAIN
Stage I Carcinoma is limited to the vaginal wall
Stage II Carcinoma has involved the sub-vaginal tissue, but
has not extended to the pelvic wall.
Stage III Carcinoma has extended to pelvic wall
Stage IV Carcinoma has extended beyond the true pelvis or has
involved the mucosa of the u. bladder or the rectum;
however, bullous edema as such does not permit one
to classify a case as Stage IV.
IV- a spread to adjacent organ.
IV- b spread to distant organ.

Stage
Treatment
O 1. Wide local excision with a least 2-3 cm
margin with or without skin grafting
2. For multifocal/extensive disease, partial
or total vaginectomy with or without
skin grafting
3. Laser therapy, 5-FY (1.5 grams weekly
for 10 weeks)1
Brachytherapy (6000-7000cGy) to the
entire vaginal mucosa2,3,4

Stage
I

Status

Intervention

< 2cm Brachytherapy (6000-7000

cGy)
Lesions of the lower third of
the vagina: irradiation of
pelvic +/- inguinal lymph
nodes (4500-5000) cGy)2
Note: for early stage lesions
radiotherapy is the preferred
option
Wide local excision or total
vaginectomy with vaginal
reconstruction5

Adjuvant Treatment

Close or positive
surgical margins:
adjuvant radiation
therapy5

STAGE

TREATMENT

II

Radiotherapy (external pelvic beam, interstitial and/or intracavity combined

dose of 7,000 to 8,000 cGy2 for lesions in the lower third of the vagina 4,500
to 5,000 inguinal lymph node)2,7
Radical surgery (radical vaginectomy or pelvic exenteration with or without
radiotherapy)5,6

III

Radiotherapy (external pelvic beam, interstitial and/or intracavity plus

additional dose to the lateral pelvic wall)
Rarely, surgery may be combined with RT)8

IVA

Radiotherapy (external pelvic beam, interstitial and/or intracavity plus

additional dose to the lateral pelvic wall)
Rarely, surgery may be combined with RT)9

IVB

Radiotherapy (external pelvic beam, interstitial and/or intracavity plus

additional dose to the lateral pelvic wall) with or without chemotherapy
Rarely, surgery may be combined with RT)8

Recurrent

Individualize; Surgery, Radiation therapy

Follow-up
a) Weekly while on cobalt therapy
b) Two weeks post-brachytherapy
c) After completion of treatment, follow-up is as
follows:
a) Monthly for the 1st year, every 2 months for the second year,
every 3 months for the 3rd year, every 4 months for the 4th year,
every 6 months for the 5th year, then yearly thereafter.
b) Pap smear every 3 months for the 1st year, followed by pap
smear every 6 months for the 2nd year, then annual pap smear
thereafter.
NOTE: Perform colposcopy with colpo-guided biopsy, if
indicated, for abnormal cytology results.
c) Ideally, an annual computed tomography for the first three
years post-treatment should be requested.
d) Annual chest x-ray

DES and Clear Cell Adenocarcinoma

- daughters of mothers with a history of
ingestion of diethylstelhestrol (DES)
- presenting as abnormal bleedings
- treatment - surgery and irradiation

SARCOMA
- primary sarcoma of the vagina is very rare.
- usually occurs in extremes of age.
- young: sarcoma botryoides
- other types - fibrosarcoma and
leiomyosarcoma
- treatment - surgical removal.
- resistant to irradiation.
- chemotherapy is useful in sarcoma
botryoides

Melanoma
- extremely rare
- rapidly growing
- very poor prognostic
- treatment is surgery
- resistant to radiation
- chemotherapy - DTIC or Dacarbazine
(25-30 response)