Vaginal squamous carcinoma

Introduction to vaginal squamous cell carcinoma Vaginal squamous cell carcinoma is the most common vaginal malignancy. Because the vaginal mucosa is covered by squamous epithelium, 80% to 90% of primary vaginal cancer is squamous cell carcinoma (primarysquamouscellcarcinomaofvagina). It is generally believed that vaginal squamous cell carcinoma may be There are all processes from intraepithelial neoplasia (VAIN), microinvasive cancer to invasive cancer. Due to fewer cases, the natural progression of this cancer has not been fully understood. basic knowledge The proportion of disease: the common malignant tumor of this disease in women, the incidence rate is 0.01%. Susceptible people: women Mode of infection: non-infectious Complications: intestinal fistula, proctitis, cystitis, urethral stricture

Vaginal squamous cell carcinoma

Chronic stimulation (25%):

Primary vaginal squamous cell carcinoma often occurs in the posterior iliac crest, which may be related to the long-term use of pessary in patients with uterine prolapse. Long-term stimulation of pessary may lead to vaginal cancer, but there are not many cases of pessary use, and vaginal cancer occurs. The rate is not high, but rarely listed as a causative factor.

Pelvic radiation therapy (15%):

About 20% of patients with primary vaginal cancer have a history of pelvic radiation therapy. Bulk data show that after cervical cancer, 0.180% to 1.545% of primary vaginal cancer occurs after radiation therapy. It is generally considered that after cervical cancer radiotherapy 10~ 40 years of vaginal cell dysplasia or vaginal cancer can occur, and women with pelvic radiation therapy under 40 years of age have a higher incidence of vaginal cancer.

Viral infection (10%):

Because human papillomavirus (HPV) may play an important role in the etiology of cervical cancer, and 1% to 3% of cervical cancer patients can develop vaginal cancer at the same time or later, papillomavirus, especially Types 16 and 18 may be considered as promoters of these cancers.

Immunosuppression (12%):

In patients with congenital or acquired acquired and artificial immunosuppression, the incidence of cancer is higher, and vaginal cancer is no exception, and the incidence is higher in immunosuppressed patients.

Estrogen deficiency (10%):

Vaginal squamous cell carcinoma occurs in elderly women and may be associated with lower estrogen levels after menopause, leading to atrophy of the vaginal mucosal epithelium and creating favorable conditions for carcinogenic factors.

Pathogenesis

1. Primary vaginal squamous cell carcinoma can be divided into carcinoma in situ, early invasive carcinoma and invasive carcinoma with the development of lesions.

(1) carcinoma in situ: when the atypical hyperplasia of vaginal epithelial tumors develops severely, involving the entire epithelium, but does not penetrate the basement membrane, which is called carcinoma in situ, and its symptoms and signs are the same as those of intraepithelial neoplasia.

(2) vaginal microinvasive carcinoma: Because vaginal microinvasive carcinoma is clinically rare, most of them are found in the study of intraepithelial neoplasia, so the study of this type of cancer is superficial. However, it is generally believed that vaginal microinvasive carcinoma should be an epithelial carcinoma. Breaking through the basement membrane at the bottom, and infiltrating into the interstitial space below it, the infiltration depth is less than 3mm, and the interstitial blood vessels and lymphatic vessels are not invaded. The performance of the lesions observed by the naked eye is the same as that of the intraepithelial tumor.

(3) vaginal invasive squamous cell carcinoma:

1 Generally: Most tumors form exogenous masses, and half of the tumors form ulcers, which can be followed by papillary, cauliflower-like lesions, etc., which are located at 1/3 of the posterior wall of the vagina. Tumors often penetrate the vaginal wall and infiltrate the uterus. Tissue, rectum and bladder, 12% of lymph nodes were attacked in surgical cases.

2 Mirror: Vaginal squamous cell carcinoma is the same as other squamous cell tumors. Usually these tumors contain polymorphic squamous cells with tissue deficiency and lack of cohesiveness, nuclear staining and atypical mitosis. Keratinocytes with squamous cell beads and intercellular bridges.

2. There are three possible mechanisms for vaginal cancer after 5 years of treatment of cervical cancer:

(1) There are residual lesions in the vaginal epithelium after treatment of cervical tumors.

(2) The lower genital tract is prone to cancer due to HPV infection.

(3) Radiation therapy makes the lower genital tract susceptible to cancer.

3. Transfer method

The lymphatic vessels and blood vessels of the vaginal mucosa are extremely rich, and the connective tissue under the mucosa is loose. This structure leads to the metastasis of vaginal cancer mainly by lymphatic metastasis and direct infiltration of adjacent organs and tissues.

(1) Lymphatic metastasis: According to the anatomical site, 1/3 of the vaginal lymph nodes flow into the pelvic lymph nodes, and the lower 1/3 leads into the inguinal lymph nodes, and the middle third can be introduced into the pelvic lymph nodes, and can be introduced into the inguinal lymph nodes. Therefore, depending on the location of the vaginal cancer, the lymphatic metastasis is different. Since vaginal cancer located in various parts of the vagina may cause lymph node metastasis, it is important to emphasize the importance of regional treatment for most patients.

(2) direct infiltration: vaginal anterior wall cancer can involve the urethra and bladder; posterior wall lesions can involve rectal or rectal tissue; sidewall lesions often invade the vagina, upper 1/3 and lower 1/3 lesions can be involved Cervical and vulva.

(3) Hematogenous metastasis: often occurs in advanced cases, distant metastasis through the blood, such as metastasis to the lungs, liver and bones, etc., blood-borne metastasis usually occurs later, the most common blood metastasis is the lungs.

Vaginal squamous cell carcinoma prevention

1. Actively treat diseases such as vaginal leukoplakia, chronic inflammation and ulcers.

2. Anyone with irregular vaginal bleeding, abnormal leucorrhea, early diagnosis and active treatment.

Vaginal squamous cell carcinoma complications Complications, intestinal fistula, cystitis, urethral stricture

Late complicated bladder and intestinal fistula, radioactive cyst and proctitis, cystitis, urethral stricture, rectal stenosis or ulcer, radiation vaginal necrosis, ulcer or stenosis, vaginal fibrosis.

Treatment complications: the main complication rate is 10% to 15%, regardless of surgery or radiation therapy. Because vaginal cancer is close to the urethra, bladder and rectum, the incidence of complications is higher than that of cervical cancer. The main complications Is the bladder and intestinal fistula, radioactive cysts and proctitis, cystitis, urethral stricture, rectal stenosis or ulceration, radiation vaginal necrosis, ulcer or stenosis, vaginal fibrosis, after treatment should expand the vagina and encourage the patient to restore regularity Living and vaginal topical administration of estrogen maintains a good function of the vagina.

Vaginal squamous cell carcinoma Symptoms Common symptoms Urinary urinary urinary frequency defecation difficult scaly epithelium vaginal secretions increased vaginal bleeding after acute vesicular edema hematuria squamous cell carcinoma

Symptom

10% to 20% of vaginal intraepithelial neoplasia or early invasive cancer may have no obvious symptoms, or only vaginal secretions and contact bleeding and irregular bleeding or access to mass, this mass can be expressed as External growth or ulcer formation, invasive growth, with the development of the disease course, the enlargement of vaginal cancer, necrosis, vaginal discharge of odor, painless vaginal bleeding, when the tumor expands to surrounding organs and tissues, The corresponding symptoms, urinary tract or bladder may occur, frequent urination, urgency, hematuria and dysuria; involving the rectum may cause difficulty in defecation or urgency; vaginal, main ligament, uterine ligament infringement, lumbosacral pain may occur Wait.

2. Signs

Vaginal squamous cell carcinoma occurs in the posterior wall of the upper third of the vagina and the anterior wall of the lower third. Vaginal intraepithelial neoplasia or early invasive cancer lesions may only be erosive, and most invasive cancer lesions are exogenous. Papillary or cauliflower type is common, and it can also be ulcerated, flat submucosal or invaginated form of vagina. Early vaginal lesions are more limited, and late vagina, vagina, main ligament and uterine genus may appear later. Infiltration of ligaments, vaginal fistula or recto-vaginal fistula of the bladder or urethra, and metastasis of the groin, pelvis, supraclavicular lymph nodes, and even distant metastases.

3. Clinical staging

The staging of vaginal cancer is based on the FIGO staging system. This clinical staging system is based on clinical physical examination, chest radiograph, cystoscopy, colonoscopy and bone radiography, lymphangiography, CT, MRI or surgical staging. To change the clinical stage, AJCC recommended a TNM staging system, which is rarely used. The FIGO staging of vaginal cancer is as follows:

Stage 0: carcinoma in situ, intraepithelial neoplasia.

Stage I: The cancer is confined to the vaginal wall.

Stage II: The cancer has invaded the subvaginal tissue, but it has not reached the pelvic wall.

Stage III: The cancer has reached the pelvic wall.

Stage IV: The cancer has exceeded the true pelvis or the clinical involvement of the bladder and rectal mucosa, but the vesicular edema should not belong to stage IV.

Stage IVa: The tumor invades adjacent organs or directly expands the true pelvis.

Stage IVb: The tumor spreads to distant organs.

Examination of vaginal squamous cell carcinoma

1. Diagnostic curettage: understanding the presence of a tumor in the endometrium of the cervix.

2. Tissue biopsy and vaginal cytology examination: All suspicious tissues on the vaginal wall require biopsy to be qualitative. For patients without obvious lesions, vaginal cytology is feasible, and the positive rate can be from 10% to 42%.

3. Serum immunological examination: preoperative CEA, AT-4 and CA125 examinations are conducive to the evaluation of prognosis and follow-up monitoring after treatment.

41. Endoscopy: All patients with a late stage of the disease need to undergo urethra-cytoplasmoscopy, rectal-sigmoidoscopy to exclude cancerous organs from invading these organs.

5. Imaging examination: All patients need to perform this examination before treatment, including B-ultrasound, CT, magnetic resonance (MRI), intravenous pyelography and chest X-ray examination.

Diagnosis and diagnosis of squamous squamous cell carcinoma

diagnosis

The diagnosis of primary vaginal squamous cell carcinoma was established according to the International Federation of Obstetrics and Gynecology: 1 no cancer in the cervix and vulva; 2 5 years after surgical treatment of invasive cervical cancer, 2 years after surgery for cervical carcinoma in situ Cervical cancer receiving radiation therapy should be 10 years.

Vaginal cancer is often misdiagnosed at the first examination, especially when the lesion is small and located 2/3 of the vagina, because the leaves of the speculum cover the diseased tissue, Frick et al reported at least 10 of 52 cases of vaginal cancer. Misdiagnosed in the first examination, the speculum should be rotated to withdraw the lesions of the anterior and posterior wall of the vagina, and the local biopsy of the lesion visible to the naked eye can be clearly diagnosed. For the vaginal Pap smear positive, the unexplained vaginal discharge: blood and Patients with ulcerative erythema on the upper end of the vagina should undergo careful colposcopy and iodine coating of the entire vaginal wall. When the colposcopy biopsy cannot be clearly diagnosed, it is necessary to perform partial vaginal resection to determine whether there is occultity: invasive cancer, especially A patient who had undergone hysterectomy, and some vaginal epithelial cells were embedded in the vaginal vault when surgery was closed, which is a risk factor for canceration. Tjalma reported from 1974 to 1999: 55 primary squama hospitalized in NGOC The average age of patients with squamous cell carcinoma is 58 years (range, 34-90 years), and the average follow-up time is 45 months (0.6 to 268 months). 62% of patients have increased vaginal secretions. 16% due to positive vaginal cytology; 13% due to vaginal masses; 4% due to pelvic pain; 2% due to dysuria; 3% due to other concomitant symptoms Most patients were misdiagnosed. The average misdiagnosis time was 4 months (range, 3 to 12 months). The tumor size during gynecological examination was 4 to 115 mm, and the average diameter was 39 mm. 53% of patients had lesions in the upper third of the vagina. 16% in the lower third of the vagina, 7% in the middle third of the vagina, 13% covered the entire vagina, 24% of the lesions in the anterior wall of the vagina, 47% in the posterior wall of the vagina, the anterior and posterior wall of the vagina All accounted for 29%.

For invasive vaginal cancer diagnosed by pathology, blood routine, biochemical complete, chest X-ray, cystoscopy and proctoscopy should be examined. For some patients, barium enema or bone radiography is also required. CT and MRI can determine whether or not to metastasize.

Differential diagnosis

1. Vaginal epithelial atrophy: ovarian epithelial atrophy caused by estrogen deficiency in elderly women, vaginal epithelial cytology can be suspected of vaginal cancer, vaginal epithelial histological examination due to the entire epithelium composed of basal cells or subbasal cells and epithelial top cells lack glycogen, The iodine test was positive, similar to the vaginal epithelial tumor, the whole epithelium was thin, the cell-to-cell junction and its structure were normal, and the nucleus was mononuclear and had no nuclear fission.

2. Vaginal HPV infection: vaginal condyloma acuminata caused by HPV infection is difficult to distinguish from vaginal squamous cell carcinoma under the naked eye. Pathological findings of condyloma acuminata may have mild to moderate dysplasia, and they have hyperkeratosis, rod-like echinoderma The foot is separated from the tubular matrix nipple. The vacuolar degeneration in the cytoplasm is accompanied by thickening of the membrane, and the nucleus is deeply stained. HPV particles may be seen under electron microscope.

3. Vaginal tuberculosis ulcers: can be expressed as vaginal bleeding secretions, but tuberculous ulcers are rare, the lesions develop slowly, initially limited small nodules, formed superficial ulcers after ulceration, irregular shape, local lymph node enlargement Large, secretion smear may find tuberculosis, other parts of the body may have tuberculosis symptoms or signs, vaginal ulcer biopsy can confirm the diagnosis.

4. Endometriosis: The formation of nodular lesions in the posterior vaginal fornix, with dark red small protrusions, hard, often accompanied by dysmenorrhea symptoms, biopsy can confirm.

5. Vaginal metastatic choriocarcinoma: The characteristics of this disease are metastasized from uterine choriocarcinoma. The vaginal nodules are purple-blue, brittle, easy to hemorrhage, have a history of hydatidiform mole, abortion, childbirth, positive pregnancy test, pathological examination. Confirmed diagnosis.

6. Cervical cancer: more common in middle-aged women, irregular vaginal bleeding, vaginal discharge with stench symptoms, difficult to distinguish from vaginal cancer, gynecological examination found lesions in the cervix, can be ulcers, erosion and hypertrophy.

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