Anatomy

Epidemiology, Presentation, and Management

• Rarity
  • 2% of adult and 4.5% of pediatric gynecologic malignancies.
    (~90%: metastasis from cervix/uterus)
• Histology
  • (Adults) 80-95% are Squamous Cell Carcinoma (SCC), mostly HPV-associated
  • (Pediatric) Embryonal Rhabdomyosarcoma (RMS) and Yolk Sac Tumour (YST).
• Survival
  • 5-years OS: 77%, 52%, 42%, 20% and 13% for stages I, II, III, IVA and IVB

1940-70년대에 임신 중 DES 복용 후 adenoca. 생기는게 사회적인 문제가 된 적이 있다.

Vaginal Intraepithelial neoplasia (VAIN)

Squamous Cell Carcinoma

Clinical Presentation

Patterns of Lymphatic Drainage

Staging

Diagnostic Workup

Risk Factors

Prognostic Factors

Treatment Options

• Stage I (T1N0)
  • Primary Surgery: if small (<2cm), R0 feasible, low morbidity
  • Primary (C)RT: combination of cisplatin-CCRT+brachy is recommended.
• Locally Advanced (T2-4 or N1)
  • Definitive platinum-based CCRT, consolidated by a brachytherapy boost

Melanoma

Treatment Options

genital melanoma는 상당한 난치병.. Carbon의 적응증에 해당된다.

Sarcoma

Prognostic Factors

Treatment Options

Outcomes

Malignant Mixed Mullerian Tumors

Clear Cell Adenocarcinoma

Epidemiology

Risk Factors

Histopathology

Clinical Presentation

Prognostic Factors

Treatment Options

Other Adenocarcinomas

Lymphoma

Small Cell Carcinoma of the Vagina and Other Rare Histologies

Pediatric vaginal tumors (RMS, YST) are highly chemosensitive. Primary goal is organ preservation, and initial radical surgery should be avoided.

Radiotherapy Techniques

EBRT

Dose: 45-46 Gy in 1.8-2.0 Gy/fx.
Chemo: Concurrent weekly Cisplatin (40 mg/m²).
Timing: Overall Treatment Time (OTT) < 7-8 weeks.
Technique: IMRT and IGRT are recommended.

<Target volume>

Standard: Primary tumor, entire vagina, paravaginal space,
parametria, pelvic LNs (iliacs, obturator, presacral).
Lower 1/3 Tumors: Must include inguino-femoral LNs.
N1 Disease: Boost nodes to 55-60 Gy EQD2 (SIB or
sequential); consider para-aortic field

3D Conformal Treatment

IMRT

Brachytherapy

IGABT (Image-Guided Adaptive Brachytherapy) is recommended, preferably MRI-based

Applicator

• Cylinder, mold, or combined intravaginal/interstitial.
• Vaginal cylinder로 치료하기에는 적절한 dose를 cover하기에 어려운 경우가 많다.
• Insertstitial (needles) is required residual tumors >7mm thick or with paravaginal disease.

Dose

• Total Dose (D90 for CTV-T_HR): ≥ 75-85 Gy EQD2 (Combined dose from EBRT + BT)
  

Intracavitary Brachytherapy: LDR

Intracavitary Brachytherapy: HDR

Interstitial Brachytherapy

Brachytherapy Versus External Beam Boost

Treatment Toxicity and Management

Patterns of Failure

General Management, Treatment Options, and Outcomes: Special Scenarios

The Post-hysterectomy Patient

History of Prior Pelvic Radiation

Carcinoma of the Neovagina

Salvage Therapy for Recurrent or Persistent Disease

Palliative Therapy

Follow-Up

70-80% of relapses occur within 2 years

Years 1-2: Every 3-4 months
Years 3-5: Every 6-12 months

Routine cytology is not recommended