Tumor of the vagina

1- Swellings of the vagina 2- Vaginal cyst 3-Benign Neoplasms 4- Malignant Neoplasms

SWELLING OF THE VAGINA A complaint of swelling or fullness in the vagina May be caused by the following : -Retained fluid – heamatocolpos , pyocolpos -prolapse of the vaginal wall or uterus -A congenitally short vagina with a relatively low cervix . -Varicose veins which are usually low on the anterior wall and are mostly seen during pregnancy

-Tumor of the urethra Enlargement of the cervix Any tumor which impacted within the pelvis Vaginal cysts Benign neoplasms Malignant neoplasms

VAGINAL CYSTS Since the vaginal epithelium is normally devoid of glands, most cysts arise from included or adjacent structures . Their nature and origin are therefore determined clinically by their position

A- cysts of vestigial structures --- Mullerian : a- single b- multiple Lined by tissue similar to that of the cervical epithelium and containing mucinous material, sometimes occur near the cervix . They are from displaced cervical glands or from mullerian duct diverticula and their remnants.

-- Wolffian Their lining is a single layer of flattenend columnar or cuboidal epithlium, but can be transitional, their fluid content is free from mucine. The majority arise from Gartner s duct

---- Cysts of Skene s Tubules (Parauretheral ) Maybe infected to cause a paraurethral abscess ----- Diverticulum of the urethra ,it is either . Congental . abscess or periurethral glands which burst into the urethra . Obstetrical or surgical injuries

--- Epidermoid Cyst; Implantaton Dermoid Endometrotic cyst

BENINGN NEOPLASMS Papilloma: True papillomas (including multiple warts) Most tumor of this type are skin tags remaining from obstetrical injuries or operations. Angioma: is a congenital malformation of the blood vessels usually seen under the lateral walls. Fibroma and Lipoma: These arise from the outer coats of the vagina or from the paracolpos. .

Adenoma: this is a rare tumor arises in association with Gartner s duct and has therefor anterolateral sites. Adenosis: it is result from faulty diffrerentoation or distribution of mullerian duct tissue during the development of the vagina.One of the caus is exposure to diethylstillbesterol 1-it very unusual condition in which columner epithlium, sometimes multi- layered replaces the squmous lining.

2- patchy distribution 3- the area dull red granulomatous appearance and failing to stain with Lugosl solutionor Schiller s iodine 4- the epithelial cells secretes mucus Diagnosis usually in adolescence or early maturity, it is sometimes associated with minor degree of vaginal stricture formation, just below the level of the cervix . There is a chance to run to a clear cell adenocacinoma ,

Vaginal cancer Primary vaginal CA represent 2% to3% of malignant neoplasms of the female genital tract And squamous cell CA REPRESENT 80% OF cases. 84% of Vaginal CA were secondary 32% from the cervix 18%fom the endometrium 9% from colon and rectum 6% from the ovary 6%from the vulva

Squamous cell ca Women who have been treated for a prior anogential cancer , particularly of the cervix, have a high relative risk of developing vaginal cancer, and 30% of patients with primary vaginal carcinoma have a history of in situ or invasive cervical cancer treated at least 5 years earlier

There are three possible mechanisms for the occurrence of vaginal cancer after cervical neoplasia: 1- occult residual disease 2-new primary disease arising in an “at risk “ lower genital tract 3- radiation carcinogcity

There is controversy regarding the distinction between a new primary vaginal cancer and recurrent cervical cancer . Many authorities use a 5 years cut-off because 95%CA of cervix will recur within this period , but other prefer a 10-year interval. The true malignant potential of vaginal intraepithelial neoplasia is unclear because once diagnose , the condition is treated Chronic local irritation from long – term use of apessary may also be of significance . Most lesion are situated in the upper one- third of the vagina , usually at the apex or on the posteror wall

Diagnosis: The diagnosis of carcinoma of the vagina is often missed on first examination, particularly if the lesion is small and situated in the lower two-thirds of the vagina,where it may be covered by the blades of the speculum. In patients with an abnormal Pap smear and no gross abnormality , careful vaginal colposcopy and the liberal use of Lugol s iodine to stain the vagina are necessary. For definitive diagnosis of early vaginal carcinoma, it may be necessary to resect the entire vaginal vault and submit it for carful histologic evaluation because the lesion may be partially buried by closure of the vaginal at the time of hysterectomy

Symptoms and Sign: 1- painless vaginal bleeding and discharge is usually postmenopausal but may be postcoital 2- bladder pain and frequancy of micturition

Staging Stage I: The carcinoma is limited to the vaginal wall Stage II: The carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall. Stage III : The carcinoma has extended to the pelvic wall. Stage IV :The carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum IVA: Tumor invades bladder and/or rectal mucosa and/or direct extension beyond the true pelvis IVB: Spread to distant organs

Surgical staging for vaginal cancer has been used less commonly than for cervical cancer, but in selected premenopausal patients , a pretreatment laparotomy may allow better definition of the extent of disease, excision of any grossly enlarged lymph nodes , and placement of an ovary up into the paracolic gutter beyond the radiation field

Patterns of spread 1- Direct extension 2- lymphatic dissemination 3-heamatogenous dissemination

Treatment Therapy must be individualized and varies depending on the stage of the disease and the site of vaginal involvement , further limiting individual experience. For most patients, maintenance of functional vagina is an important factor in the planning of therapy

1-Surgery It has limited role in the management of patients with vaginal cancer a – in patient with stage I disease involving the upper posterior vagina. If the uterus still in situ, these patients require radical hysterectomy , partial vaginectomy ,and bilateral lymphadenectomy

If the patient has hysterectomy , radical upper vaginectomy and pelvic lymphadenectomy . b- In young patient who require radiation therapy. Pretreatment laparotomy in such patient may allow ovarian transposition, surgical staging , and resection of any enlarge lymph node . c- In patient with stage IVA disease ,particularly if a rectovaginal or vesicovaginal fistula is present , pelvic exenteration is a suitable treatment

2- Radiation Therapy It is the treatment of choice for all patients except those listed previously . If the lower 1/3 of the vagina is involved, the groin nodes should be treated or dissected