External Radiation Therapy
Vaginal Cancer Treatment
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After the diagnostic tests have been carried out (see vaginal cancer diagnosis), your healthcare team will recommend a plan of treatment. At this point it is important not to feel rushed into making a decision. Cancer of the vagina is rarely a medical emergency so taking a few weeks to consider your options should not be an issue. Like all cancer treatments, the type of therapies recommended will depend on the stage of cancer, its location and size. Other factors will include whether or not the woman has already had a hysterectomy operation or radiation to the pelvis region. Your doctor will also take into account if you want more children, your overall health and age. Every treatment option will have potential side effects so this is why it is worth seeking a second medical opinion before starting anything. If nothing else, it will help make you feel more comfortable about your choice. Additionally some insurance companies will insist on a second opinion before covering the costs.
The following is an overview of the treatment options for different vaginal cancer stages. It covers the two main types of cancer: squamous cell carcinoma (85 percent of cases) which tends to effect women over 60 and adenocarcinoma (most of the remaining cases) which occurs more commonly in women under 30. If possible the goal of treatment is to completely destroy malignant cells. If a cure is not possible then the next option is to reduce the size of the tumor to prevent it from spreading. This may mean intermittent therapy over a number of years. If cancer has spread throughout the body the main focus is palliative care. That is, to make the woman as comfortable as possible because no cure is possible.
Stage 0: Vaginal Intraepithelial Neoplasia (VAIN)
• Total or partial vaginectomy.
Stage 1: Squamous Cell Cancer
• Vaginectomy or wide local excision with vaginal reconstruction. Radiation therapy may be applied after surgery.
Stage 1: Vaginal Adenocarcinoma
• Hysterectomy, vaginectomy and lymph node dissection. This may be combined with radiation therapy and vaginal reconstruction.
Stage 2: Squamous Cell Cancer and Adenocarcinoma
Stage 4A: Squamous Cell Cancer and Adenocarcinoma
Stage 4B: Squamous Cell Cancer and Adenocarcinoma
Recurrent Vaginal Cancer
• Radiation therapy combined with radiosensitizers.
Laser involves the use of a high energy beam or light to destroy cancerous or abnormal cells. It is a very effective treatment for the precancerous condition VAIN and large lesions. It is not an option for invasive cancer and if it is to be used the surgeon will want to ensure the worst lesions have been removed by biopsy.
This is another alternative for treating VAIN, but it is never used for invasive cancer. It involves rubbing the cream directly to the suspicious area. One option is the chemotherapy drug fluorouracil (5-FU) which is rubbed directly to the vaginal lining once a week for 10 weeks or nightly for up to 14 days. However, it can cause irritation to the vulva and vagina and it may not work as well as laser combined with biopsy. Another option is the drug Imiquimod cream (not a chemo drug) which acts by boosting the body's immune response to abnormal cells. It has had excellent results in completely curing some women of VAIN.
The benefits of Chemo (see Chemotherapy Guide) as a systemic therapy (where chemotherapy drugs are taken orally to work throughout the body) for vaginal cancer are not clear. For this reason it is rarely used on its own as a treatment. It may be used alongside radiation therapy to enhance the benefits of radiation.
Very often both types of radiation therapies are combined in treating vaginal cancer - typically external radiation followed by brachytherapy. Small doses of chemotherapy may also be given. Radiosensitizers are drugs that are still in clinical trials. They are sometimes combined with radiation therapy in later stages of the disease to boost the amount of malignant cells killed.
Surgery is only usually given for stage 1 tumors or for cancers which are not cured by radiation. It is not generally the choice for treating squamous cell vaginal cancer (the most common type). It is however used for rarer types: malignant melanoma and sarcoma cancers.
Wide Local Excision
This removes the cancer and some of the healthy surrounding tissue (to create a safe margin). Skin grafts may be needed to repair the vagina. For VAIN a small local excision may be all that is required. A radical wide local excision can be used for small stage 1 cancers. Some lymph nodes may also be extracted for biopsy. This is also an option for vulva cancer treatment.
If sections of the vagina are removed by surgery then skin grafts may be necessary to repair the area. This involves taking skin from another part of the body such as the thigh or buttocks and attaching it to the damaged area.
This surgery removes the entire vagina (total vaginectomy). If only part of the vagina is removed it is called a partial vaginectomy. If surrounding supporting tissues are also removed it is known as a radical vaginectomy. It is sometimes combined with a radical hysterectomy. Lymph nodes in the pelvis are also usually extracted (lymphadenectomy). A vaginal reconstruction will be necessary.
Sometimes called lymph node dissection, a lymphadenectomy involves surgically removing lymph nodes. For vaginal cancer, sometimes the lymph nodes in the groin area or in the pelvis need to be removed to check for signs of cancer. This can cause poor fluid drainage in the legs leading to swelling, a condition known as lymphedema. After the operation women are usually advised to wear special support stockings or compression devices to reduce the chance of swelling.
As most vaginal cancers are located in the upper section of the vagina near the cervix, it may be necessary to remove the cervix. The procedure which removes the cervix but leaves the rest of the uterus behind is called a trachelectomy. This operation is rarely performed for vaginal cancer.
Pelvic exenteration is an extensive operation that includes vaginectomy and removing the pelvic lymph nodes, as well as of one or more of the following structures: the lower colon, rectum, bladder, uterus, and cervix. How much has to be removed depends on how far the cancer has spread. If part of the colon is removed the woman will need to wear a colostomy bag in the front of the abdomen to remove stool waste. A urostomy or small plastic bag worn in front of the abdomen is necessary to collect urine if the bladder is removed. Given the severity of the procedure, it is rarely performed. Generally it is viewed as a treatment of last resort when all else has failed.
This is a follow-up treatment for women who have had all or part of their vagina removed. It involves taking sections of skin and muscles (usually cut from the inner thigh) to create a new vagina. A tube is created in the pelvic cavity to replace the original vagina. After surgery the area will be packed with sterile gauze. The woman may also wear a stent or vaginal mold for several weeks to aid the healing process. Once the tissue has healed she will be encouraged to use a vaginal dilator, probably for the rest of her life. She may also need to apply estrogen creams to encourage blood vessel formation. Douching daily with vinegar may also be recommended. Generally the woman can start having sexual intercourse again after about 2 months. The new vagina will not be able to naturally lubricate so a water soluble lubricant will be necessary. When the vagina is touched the woman may initially have the sensation that her thigh is being stroked. This is because the thigh muscle transferred to the vagina is still attached to its original nerve supply.
What Follow Up Is Needed?
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