Vulva and Vaginal Cancer

Diagnosis, Clinical Evaluation, and Staging

Carcinomas involving the vulva and vagina are classified according to FIGO guidelines. Cases are classified as vaginal carcinomas only when “the primary site of the growth is in the vagina.” Any tumor that has extended from the vulva to involve the vagina should be classified as a primary vulvar cancer, and any tumor that involves the area of the external cervical os should be classified as a cervical carcinoma.

Patients with invasive vulvar carcinoma usually present with pruritus or a mass; patients with VIN, however, may have no symptoms at diagnosis. Advanced vulvar lesions can be extremely painful. Patients with primary vaginal carcinoma usually present with abnormal vaginal bleeding but may also have pain (including dyspareunia), discharge, or a mass.

All patients with invasive disease should be evaluated with a careful physical examination including a detailed pelvic examination, chest radiography, a complete blood cell count, and a biochemical profile. In some cases, colposcopy may be needed to rule out a concurrent cervical cancer. Cystoscopy should be performed in patients with tumors near the bladder or urethra, and proctoscopy should be performed in patients with tumors near the anus or rectum. Computed tomography (CT) or magnetic resonance imaging (MRI) scans should be obtained to evaluate deep inguinal and pelvic lymph nodes, localize the kidneys, and rule out hydronephrosis. MRI also can be helpful in delineating the distribution of disease in patients with locally advanced vaginal cancer, although the results cannot be used to alter the clinical stage assigned to the lesion.

The FIGO staging system for carcinoma of the vulva was changed from a clinical to a surgical staging system in 1988 and depends on “thorough histopathologic evaluation of the operative specimen (vulva and lymph nodes).” The staging system was revised again in 1994 to create a separate stage IA for tumors that invade no more than 1 mm (Box 31-1). Many locally advanced vulvar lesions are being treated with initial radiation or chemoradiation therapy; consequently, the absence of a complete surgical specimen may interfere with accurate staging, particularly of the inguinal lymph nodes. FIGO has yet to address this problem.

The FIGO rules for clinical staging of carcinoma of the vagina (Table 31-1) are the same as those for clinical staging of cervical cancer. The categories are also similar, although distinguishing stage I from stage II disease tends to be quite subjective because it is often impossible to accurately assess the presence or absence of subvaginal involvement by clinical examination alone. Perez and colleagues recommend a modification of the FIGO system that distinguishes between tumors that infiltrate the parametrium (stage IIB) and tumors with paravaginal submucosal extension only (stage IIA). However, this system fails to clearly define what is meant by parametrium, particularly for women who have no uterus.

The American Joint Committee on Cancer (AJCC) suggests a tumor-node-metastasis (TNM) staging system that allows the stage assignment to be changed according to the presence of regional lymph node involvement. This system has not gained acceptance because patients rarely have surgical treatment for vaginal cancer, because the stage groupings are inconsistent with accepted FIGO staging criteria, and because no accepted guidelines are available for determination of regional involvement.