Gynecological-cancers-Vaginal-cancer (ELearningPage)

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      <HtmlField Name="References"><![CDATA[Yutaka Ueda, et al. J Skin Cancer. 2011; 2011: 951250.
<br>
<br>
National Cancer Institute. SEER data: <a href="https://seer.cancer.gov/statfacts/html/vagina.html">Surveillance, epidemiology and end results</a>.<br>
<br>
Olsen J, et al. Incidence and cost of anal, penile, vaginal and vulvar cancer in Denmark. BMC Public Health 2012; 12:1082-9.
<br>
<br>
Madsen BS, et al. Risk factors for invasive squamous cell carcinoma of the vulva and vaginae population-based case-control study in Denmark. Int J Cancer 2008;122:2827e34
<br>]]></HtmlField>
      <HtmlField Name="Author"><![CDATA[Tine Henrichsen Schnack, Department of Gynecologic Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen Denmark]]></HtmlField>
      <HtmlField Name="TakeHomeMessage"><![CDATA[<ul>
    <li>Vaginal cancer is a very rare disorder affecting predominantly elderly women.</li>
    <li>Vaginal cancer is mainly caused by high risk HPV.</li>
    <li>Treatment is chemoradiation or chemotherapy in regional and distant disease, respectively.</li>
    <li>The one-year and five-year overall survival is 78% and 55%, respectively.
    </li>
</ul>]]></HtmlField>
      <HtmlField Name="PageContent"><![CDATA[<p>Gynecological cancers encompass malignancies in the female reproductive organs: </p>
<ul>
    <li><a href="~/link.aspx?_id=2913C25234B04C14B0457452A3DE9561&amp;_z=z">Ovarian cancer</a>, including cancer in the fallopian tubes and primary peritoneal cancer</li>
    <li><a href="~/link.aspx?_id=E116D8F166A9425D83E03A6403F30C45&amp;_z=z">Uterine cancer</a>, endometrial cancer and sarcoma (from the uterine myomatous wall)</li>
    <li><a href="~/link.aspx?_id=7578134A038949228AFEF818ECBEC7F9&amp;_z=z">Cervical cancer</a></li>
    <li>Vaginal cancer</li>
    <li><a href="~/link.aspx?_id=C2CEEEAA98EC43D9B4B399E4860A2798&amp;_z=z">Vulval cancer</a></li>
    <li><a href="~/link.aspx?_id=3C51AE6E129243F3B1228B840BA4031C&amp;_z=z">Trophoblast tumor</a>, originating from placental tissues </li>
</ul>
<h2>Introduction</h2>
<p>Gynecological cancers are classified according to FIGO (International Federation of Gynecology and Obstetrics, see Table 1), rather than the traditional TNM-classification. Localized/small tumors (FIGO stage I) have significantly better survival than tumors with distant spread (Typically FIGO stage IV). Cancers that generally are detected early (such as endometrial cancer after postmenopausal bleeding) have a mostly good prognosis, while ovarian cancer with few early signs are mostly diagnosed late and thus have a poorer overall survival rate. The only preventable gynecological cancer (HPV-vaccination, see Chapter Premalignant lesions of the uterine cervix) is also the only one with a good screening option (cervical smear/HPV-test, described in the Approach to the patient chapter, part Performing cervical cytology). Following mass vaccination the incidence of cervical cancer will likely decrease in the coming decades. Endometrial cancer on the other hand has displayed an increased incidence due to the general aging of the population in combination with obesity. </p>
<p>The different cancers and their treatment are described in the specific sub-chapters. The Nordic countries have guidelines that differ slightly. Links to specific Nordic/European guidelines are displayed in the FIGO table (Table 1).</p>
<table class="vandret-layout">
    <thead>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="col">Cancer type</th>
            <th class="vandret-layoutTableOddCol" scope="col">FIGO I</th>
            <th class="vandret-layoutTableEvenCol" scope="col">FIGO II</th>
            <th class="vandret-layoutTableOddCol" scope="col">FIGO III</th>
            <th class="vandret-layoutTableEvenCol" scope="col">FIGO IV</th>
        </tr>
    </thead>
    <caption>Table 1. FIGO (International Federation of Gynecology and Obstetrics) classification of gynecological cancer, simplified version.</caption>
    <tbody>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Ovarian </th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">one/both ovaries</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Pelvic tumor extension: </td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Metastasis above pelvic brim:</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Distant metastasis:</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Fallopian tube</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">one/both tubes</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Uterus/ovaries/tubes/bladder/rectum</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Retroperitoneal lymph nodes</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Pleura/thorax</td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Peritoneum</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">0/+ ascites</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Primary peritoneal cancer</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Peritoneal implants, capule spleen/liver</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Liver/Spleen/inguinal lymph nodes</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Uterine sarcoma</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Uterus only</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Pelvis: adnexa/extraadnexal</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Above pelvis, pelvic /paraortic l.n*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Endometrial </th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Endometrium/myometrium</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Cervical stroma</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Uterine serosa/tubes/ovaries/vagina/l.n*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row"><strong></strong>
            <p>Cervix</p>
            </th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Cervix only</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Upper 2/3 vagina, parametrium (not pelvic wall)</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Lower 1/3 vagina, pelvic wall, hydronephrosis, l.n*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Vagina</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Vagina only</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Paravaginal, not pelvic wall</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Pelvic wall, pelvic l.n.*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Bladder/rectum or distant metastasis</td>
        </tr>
        <tr class="vandret-layoutTableEvenRow">
            <th class="vandret-layoutTableEvenCol" scope="row"></th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;"></td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;"></td>
        </tr>
        <tr class="vandret-layoutTableOddRow">
            <th class="vandret-layoutTableEvenCol" scope="row">Vulva</th>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Vulva/peritoneum</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">Lower part urethra,vagina,anus</td>
            <td class="vandret-layoutTableOddCol" style="text-align: left;">Middle parts urethra,vagina,anus, groin l.n.*</td>
            <td class="vandret-layoutTableEvenCol" style="text-align: left;">
            <p>Higher parts urethra,vagina,anus, Distant metastasis</p>
            </td>
        </tr>
    </tbody>
</table>
<p><em>* l.n.= lymph nodes&nbsp;</em></p>
<p><em>Relevant guidelines regarding gynecological cancer:</em></p>
<p><em><strong>ESGO</strong>: <a href="https://www.esgo.org/explore/guidelines/">European Society of Gynecologic Oncology</a></em></p>
<p><em><strong>NSGO</strong>: <a href="https://nsgo.org/guidelines-2/">Nordic Society of Gynecologic Oncology</a></em></p>
<p><em><strong>National guidelines</strong></em></p>
<p><em><strong>DGCG</strong>: <a href="http://dgcg.dk/">Dansk Gynekologisk Cancer Gruppe</a></em></p>
<p><em><strong>Finland</strong>: <a href="https://gynekologiyhdistys.fi/wp-content/uploads/2019/12/HOITOSUOSITUKSET_FINGOG_12_2019_final.pdf">Finnish</a></em></p>
<p><em><strong>Iceland</strong>:</em></p>
<p><em><strong>NFGO</strong>: <a href="https://www.legeforeningen.no/foreningsledd/fagmed/norsk-gynekologisk-forening/veiledere/veileder-i-gynekologisk-onkologi-2015/">Norsk Forening Gynekologisk Onkologi</a></em></p>
<p><em><strong>Sweden</strong>: <a href="https://www.cancercentrum.se/samverkan/cancerdiagnoser/gynekologi/">Regionala Cancercentrum i Samverkan-Gynekologisk cancer</a></em></p>
<p>&nbsp;</p>
<p>
</p>
<p>The age standardized incidence rate is 0.4 per 100.000 women per year. Squamous cell carcinomas (90 %) are caused by high risk HPV infection.</p>
<p>
</p>
<h2>Symptoms</h2>
<ul>
    <li>
    Vaginal bleeding postmenopausal or postcoital</li>
    <li>Watery blood tinged, malodorous vaginal discharge</li>
    <li>Pain
    </li>
</ul>
<h2>Diagnostics</h2>
<p>
The main finding is an ulcerating mass, or an annular constricting lesion confined to the vagina. The diagnosis is made by a biopsy.
</p>
<h2>Risk Factors</h2>
<ul>
    <li>
    Smoking</li>
    <li>Sexual habits (number of partners, low age at first sexual intercourse)</li>
    <li>Immuno-suppression.</li>
    <li>HSIL: High grade squamous intraepithelial lesion (see cervical dysplasia chapter)</li>
</ul>
<h2>Treatment</h2>
<p>
The treatment of localized and advanced disease is radio-chemotherapy and chemotherapy, respectively.
</p>
<h2>Prognosis</h2>
<p>
The five-year overall survival rates are 75-95%, 50-80% and 15-60% in women diagnosed with localized, regional and distant disease, respectively.</p>
<p>&nbsp;</p>
<p><strong>Keywords: </strong>Vaginal cancer, human Papilloma virus, HSIL</p>
<h2>Multiple choice quiz</h2>
<p><a href="https://mcq.nfog.org/start/chapter/52">https://mcq.nfog.org/start/chapter/52</a></p>]]></HtmlField>
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