Vaginal cancer

Nodal drainage
Proximal 1/3 drains to internal iliac via cervical lymphatics
Distal 1/3 drains to inguinal nodes and external iliac
Posterior to the presacral, perirectal nodes
Extensive communication along the entire vaginal nodal network

Epidemiology
2400 cases per year, 800 deaths

Risk factors
Age
HPV
Prior cervical cancer
Vaginal intraepithelial neoplasia
DES exposure associated with clear cell vaginal carcinoma
Vaginal adenosis
Chronic irritation leads to squamous cell ca

Pathology
80-90% are SCC with VAIN as precursor lesion and HPV association
To diagnose a vaginal SCC, no cervical or vulvar involvement may be present and patient cannot have a diagnosis of cervical cancer within the past 5 years (otherwise considered recurrent cervix ca)
Clear cell cancer: associated with DES, vaginal adenosis; usually in proximal 1/3 of vagina
Melanoma: second most common histology (3-5%); most commonly lower 1/3, anterior wall

Clinical
Goes to nodes early; node risk correlates with clinical stage
Stage I: 5-15% risk; Stage II: 30%
Nodal stage is the most important prognostic factor
Others include tumor grade, non-squamous histology

Treatment
VAIN/Carcinoma in situ: Surgery or brachytherapy alone (50-60Gy to whole vagina, 70-80Gy to tumor)
Stage I (Limited to vaginal wall): Brachy alone (60Gy to whole vagina, 20-30Gy tumor boost)
Stage II and up: requires WPRT because of high risk of nodal involvement; interstitial brachy often preferred; total dose to tumor 75-80Gy