The pathologic behavior of primary vaginal carcinoma and its relationship to cervical cancer

Prognostic Significance of P16 Expression and P53 Expression in Primary Vaginal Cancer

To evaluate the correlation between p16 expression and clinical outcomes in patients with primary vaginal cancer treated with definitive radiotherapy. P16 immunohistochemical was performed on 25 patient samples and recorded from pathology reports in 7 patients. P53 immunohistochemical was performed on 3 p16-negative samples. Baseline characteristics were compared using the Fisher exact test. Outcomes were compared using log-rank tests, and cox proportional hazards models. Survival and recurrence analysis was performed with the Kaplan-Meier method and cumulative incidence estimates. P16 expression was positive in 29 patients and negative in 3 patients. Two of the p16-negative tumors showed positive expression of p53. The median overall survival, progression-free survival and 2-yr cumulative incidence of recurrence were 66 mo [95% confidence interval (CI), 31-96], 34 mo (95% CI, 21-86), and 19% (95% CI, 7%-34%), respectively. P16-positive tumors had higher median overall survival and progression-free survival compared with p16-negative tumors (82 vs. 31 mo, P=0.02 and 35 vs 16 mo, P=0.04, respectively). The 2-yr cumulative incidence of recurrence was 14% for p16-positive tumors compared with 67% for p16-negative tumors (P=0.07). On univariable analysis, p16-negative status, age older than 65, and advanced stage were associated with inferior overall survival. P16 negativity is an independent predictor of inferior overall survival. P16-positive vaginal cancers have a better prognosis and decreased incidence of recurrence compared with p16-negative tumors. These prognostic findings associated with p16-negative vaginal cancers will need to be confirmed in larger patient cohorts.

Human papillomavirus as a favorable prognostic biomarker in squamous cell carcinomas of the vagina

OBJECTIVE

Recent evidence has confirmed two independent pathways in the development of vaginal squamous cell carcinoma (VaSCC): one related to and the other independent of human papillomavirus (HPV). The aim of our study was to evaluate whether HPV status has prognostic significance in this neoplasm.

METHODS

All confirmed primary VaSCCs diagnosed and treated from 1995 to 2009 in two institutions were retrospectively evaluated (n=57). HPV infection was detected by PCR using SPF-10 primers and typed with the INNO-LIPA HPV assay and p16(INK4a) expression by immunohistochemistry. Disease-free and overall survival (DFS and OS) were analyzed by Kaplan-Meier analysis with the log-rank test and a multivariate Cox proportional hazard's model.

RESULTS

HR-HPV DNA was detected in 70.2% patients. HPV16 was the most prevalent genotype (67.5% of cases). p16(INK4a) was positive in 97.5% HPV-positive and 17.6% HPV-negative tumors (p<.001). FIGO stage was associated with DFS (p=.042) and OS (p=.008). HPV-positive tumors showed better DFS (p=.042) and OS (p=.035) than HPV-negative tumors. Multivariate analysis confirmed better DFS and OS of HPV-positive patients independent of age and stage. This reduced risk of progression and mortality in HPV-positive patients was limited to women with FIGO stages I and II tumors (HR=0.26; 95% CI 0.10-0.69; p=0.006).

CONCLUSIONS

HPV-positive early stage (FIGO I and II) VaSCCs have a better prognosis than early HPV-negative tumors. HPV detection and/or p16(INK4a) immunostaining can be easily implemented in routine pathology and should be considered as valuable prognostic biomarkers in the study of patients with VaSCC.

Primary squamous cell carcinoma of the vagina: human papillomavirus detection, p16(INK4A) overexpression and clinicopathological correlations

AIM

To determine the role of human papillomavirus (HPV) in the pathogenesis of primary squamous cell carcinoma of the vagina (SCCVa), and to evaluate its clinicopathological significance.

METHODS AND RESULTS

All cases of SCCVa diagnosed over a 15-year period from two hospitals in Barcelona, Spain (n=32) were retrieved. Patients with a history of carcinoma of the cervix diagnosed <5 years before were excluded. HPV was detected and typed by polymerase chain reaction (PCR) using SPF10 primers. Immunohistochemistry was performed for p16 and p53. HPV was detected in 25 cases (78.1%). HPV16 was the most prevalent type. Patients with HPV-positive tumours were associated frequently with a history of carcinoma or intraepithelial neoplasia of the cervix or vulva diagnosed more than 5 years before (56% versus 0%; P=0.01). HPV-positive tumours were more frequently of non-keratinizing, basaloid or warty type than HPV-negative neoplasms (84% versus 14.3%; P<0.001), and showed diffuse positive immunoreactivity for p16(INK4a) (96%, versus 14.3%; P<0.001). The sensitivity and specificity of p16 to identify HPV-positive tumours were 96% and 85.7%, respectively.

CONCLUSIONS

A high number of SCCVs are related to HPV infection and may be identified by immunohistochemistry for p16. HPV-positive tumours tend to affect women with history of cervical neoplasia.

Clinical and histopathologic factors related to prognosis in primary squamous cell carcinoma of the vagina

The goal of this retrospective study concerning primary carcinoma of the vagina (PCV) was to analyze clinical and histopathologic prognostic factors in one of the largest known material, which comprised 314 patients. PCV is a rare disease, and the majority of published studies are based on small materials; therefore, the established knowledge concerning prognostic factors is insufficient. Routine treatment is based on irradiation with risk for undertreatment or overtreatment, which leads to unnecessary complications in the absence of prognostic factors. The overall 5-year disease-specific survival rate in this study was 45% and in stage I 75%. In the univariate statistical analysis, several factors correlated significantly with disease-specific survival. However, in the multivariate analysis, there were only three factors that independently could predict poor survival-high age at diagnosis, large tumors (> or =4 cm), and advanced stage. Common background factors with no prognostic significance were prior hysterectomy, other gynecological malignancies, and pelvic irradiation. In conclusion, this study has elucidated three strong prognostic factors that might be considered in the choice of therapy and also for modification of the FIGO guidelines. Increased knowledge concerning complementary biologic markers to discriminate between low- and high malignant tumors is however of great importance.

Therapeutic Effect of Topical Applications of Trichloroacetic Acid for Vaginal Intraepithelial Neoplasia after Hysterectomy

OBJECTIVE

We attempted to evaluate the therapeutic effect of trichloroacetic acid (TCA) for vaginal intraepithelial neoplasia (VaIN) after hysterectomy and to identify factors affecting persistence/recurrence.

METHODS

Twenty-eight post-hysterectomy patients with various grades of VaIN were enrolled in this study between January 2001 and December 2003. They were managed with intravaginal 50% TCA once weekly for 1-4 weeks, and all patients were followed up every 3 months for at least 1 year. Assessments by Papanicolaou smear and colposcopy were performed, as was biopsy when indicated during the follow-up period. Cox regression analysis was used to identify independent factors predicting persistence/recurrence.

RESULTS

In 20 of 28 patients (71.4%) VaIN went into remission. Treatment success was observed in all 11 patients with VaIN I, whereas only 9 out of 17 patients (53%) with VaIN II/III went into remission (P = 0.009). Severity of VaIN was the only significant independent predictor of persistence/recurrence (odds ratio = 3.5; 95% confidence interval = 1.1, 11.6; P = 0.038). The treatment was well tolerated with no major side effects.

CONCLUSIONS

Based on our findings, 50% TCA was a potential agent with minimal side effects for low-grade VaIN. Further prospective controlled study is warranted to verify our statements. However, as for high-grade lesions, further investigation with different TCA concentration is compelling.

Primary carcinoma of the vagina: factors influencing the age at diagnosis. The Radiumhemmet series 1956-96

The objective to this retrospective study of 341 cases of primary carcinoma of vagina (PCV) diagnosed between 1956 and 1996 was to find whether epidemiological, clinical, and histopathological variables were related to the age at diagnosis of patients with PCV. The univariate statistical analysis showed that younger age at diagnosis significantly correlated with a history of cervical dysplasia, hysterectomy, gynecological infections, and tumors located in the upper part of the vagina, whereas older age at diagnosis significantly correlated with late menarche and exophytically growing tumors. In the multivariate regression analysis, the remaining independent predictors were a history of cervical dysplasia and age at menarche. Further, parity >/=4 as well as nulliparity, smoking, and unstable marital status were more common among patients with PCV than among those in the general Swedish female population. This study indicates that the etiology of vaginal carcinoma may be age related. In young patients, the disease seems to be etiologically related to cervical neoplasia and thus human papillomavirus (HPV) dependent. However, in the most common age group, the older patients, there might be another (probably non-HPV-related) etiology associated with hormonal factors and trauma to the vagina.

A recurrent gain of chromosome arm 3q in primary squamous carcinoma of the vagina

Primary carcinomas of the vagina are rare tumors, accounting for 2%-3% of all gynecologic malignancies. Only a few karyotypes based on chromosome banding techniques have been reported. We have, therefore, used comparative genomic hybridization to establish a pattern of genomic imbalances in vaginal squamous cell carcinomas. Analysis of 16 formalin-fixed and paraffin-embedded tumors revealed that 70% of vaginal carcinomas carry relative copy number increases that map to chromosome arm 3q. Other recurring gains were observed on chromosome arms 5p and 19p. Chromosomal losses were infrequent. Most tumors were aneuploid, as measured by image cytometry on Feulgen-stained tissue sections. The cytogenetic data were related to the presence of human papillomavirus genomes, expression of laminin-5 as a marker for invasiveness, and expression levels of markers for proliferative activity and mutated TP53. All relevant clinical data were recorded. The results suggest that vaginal carcinomas are defined by a specific distribution of chromosomal aneuploidies and that the pattern of genomic imbalances is strikingly similar to that observed in squamous cell carcinomas of the uterine cervix. Age at diagnosis (P=0.031), tumor size (P=0.025), and increased laminin-5 expression (P=0.006) have a significant influence on the survival time.

Radiotherapy for centrally recurrent cervical cancer of the vaginal stump following hysterectomy

PURPOSE

This study was performed to establish the classification and the treatment modality for recurrent cervical cancer of the vaginal stump after hysterectomy.

PATIENTS AND METHODS

Ninety patients with centrally recurrent cervical cancer of the vaginal stump following hysterectomy were treated with high-dose-rate intracavitary brachytherapy with or without external irradiation. The intervals between primary surgery and vaginal recurrences varied from 3 months to 36 years. Tumor size of the vaginal stump was determined by bimanual rectovaginal examination at the time of recurrence and was classified into three groups, i.e., small (no palpable tumor), medium (less than 3 cm), and large (3 cm or more).

RESULTS

The 10-year survival rates for all patients were 52%. Survival was greatly influenced by the tumor sizes of the vaginal stump. The 10-year survival rates of patients with small, medium, and large size tumors were 72, 48, and 0%, respectively. All patients with large size tumors died within 5 years. Of 90 patients, 75 (83%) were determined by physical examination to be free of tumor on at least one visit within 2 months of the completion of treatment (CR). The remaining 15 patients (17%) had physical findings suggestive of residual tumor (Residual). The overall 10-year survival rate for all patients with CR was 63%, compared with 10% for the patients with Residual (P < 0.0001). The incidences of distant metastases of the patients with or without local failure were 55 and 13%, respectively (P < 0.0001). The patients with local failure had significantly higher incidence of metastases. Most patients with small size tumor were treated with brachytherapy alone, and the survival rates of these patients were not improved by combination with external irradiation.

CONCLUSION

These results suggest that tumor size was a significant prognostic factor for recurrent cervical cancer of the vaginal stump. Patients with small size tumors were recommended to be treated with brachytherapy alone.

Vaginal cancer: the role of infectious and environmental factors

Primary cancers of the vagina are rare. They comprise 1% to 2% of all gynecologic malignancies and occur predominantly in older women. The diagnosis of primary carcinoma of the vagina requires that the cervix and vulva be intact and that no clinical evidence of other primary tumors exist. Approximately 90% of all vaginal tumors are squamous cell in type on histologic examination. Adenocarcinoma, which is much less common (2% to 4%), is seen primarily in younger women with in utero exposure to diethylstilbestrol. In addition to exposure to diethylstilbestrol, other environmental factors have been associated with the development of vaginal tumors, including chronic irritation from pessaries, previous hysterectomy for benign disease, immunosuppression therapy, cervical irradiation, and endometriosis. Infectious causes seem to play an even more pernicious role in vaginal cancer. The two agents most often implicated are herpes simplex virus and human papillomavirus. These viruses appear to serve as cofactors in the inducement of various genital cancers, working together or with environmental agents such as diethylstilbestrol and host-related genetic abnormalities. The prognosis of vaginal cancer depends on the stage of the disease, with an overall 5-year survival rate of 80% to 90% for early stages.

High dose rate intracavitary brachytherapy for recurrent cervical cancer of the vaginal stump following hysterectomy

Forty-eight patients with recurrent cervical cancer of the vaginal stump following hysterectomy for cervical cancer, were treated with high dose rate intracavitary brachytherapy with or without external irradiation. The intervals between primary surgery and vaginal recurrences varied widely from 3 months to 36 years. Patients were classified into two groups, either with or without palpable tumor of the vaginal stump. Tumor size was determined by bimanual rectovaginal examination at the time of recurrence. Survival rates were 8% for the group with palpable tumors and 80% for those without, respectively. The survival rate of patients who did not have palpable masses and were treated with brachytherapy alone was not improved by combination with external irradiation. The time interval from the primary hysterectomy to the recurrence did not influence survival. These results suggest that the only significant prognostic factor for recurrent cervical cancer after hysterectomy is tumor size. The relationship between recurrent cervical cancer of the vaginal stump and second primary vaginal cancer is also discussed.

Primary vaginal squamous cell carcinoma in the young patient

This report, prompted by the recent observation of three cases of primary squamous cell carcinoma in relatively young patients, reviews the English-language literature in search of information on age-related incidence for this tumor in the below-40 age group. From those series providing data, it was found that only 10% of these tumors occur in patients less than 40 years old. No authentic squamous cell vaginal cancer could be found in patients less than 10 years of age, and only five such well-documented cases were found in the age group 11-20. The incidence of this tumor then rises abruptly to 60 patients in the age group 21-30 and to 160 patients in the age group 31-40. The rarity of the tumor, particularly with regard to the anatomical location, is impressive as well as enigmatic.

Survival and recurrence patterns in the radiation treatment of carcinoma of the vagina

Fifty-three patients with invasive cancer of the vagina were treated with a curative course of radiation at Tufts New England Medical Center between September 1958 and December 1979. There were 37 patients with "primary" carcinoma of the vagina and 16 with metastatic disease to this site. The treatment comprised an integration of teletherapy and intracavitary/interstitial therapy. The 5-year relapse-free survival for primary vaginal carcinoma was 88% for Stage I, 44% for Stage II, 35% for Stage III, and 0% for Stage IV. Patients with metastatic disease had an overall 5-year survival of 63%. There was local recurrence in 35% of the patients with primary and 19% with metastatic vaginal carcinomas. The incidence of local recurrence appeared to be increased with higher grade pathology, lesions other than vault carcinomas, and lesions involving the entire length of the vagina. Due to immediacy of adjacent structures in the high dose volume, complications excluding those patients with persistent recurrent disease were somewhat high (11%).

Subsequent malignancies associated with carcinoma of the uterine cervix: including an analysis of the effect of patient and treatment parameters on incidence and sites of metachronous malignancies

The incidence and sites of metachronous malignancies were retrospectively determined from the records of 763 patients seen at Yale University medical Center and affiliated hospitals with previously untreated, invasive carcinoma of the uterine cervix from 1953-1972. These patients were treated predominantly with radiation therapy; follow-up status was known for periods of 5-25 years or until time of death in over 96% of the patients. Forty-four patients had second malignancies noted at least 6 months after the initial cervical cancer was diagnosed. The expected incidence of second malignancies was determined from the Connecticut State Tumor Registry data controlling for year of diagnosis of the cervical cancer, patient age, sex, and time at risk (person-years exposure). To correct for any error in estimation of second malignancies introduced by the existence of a latency period for the development of a second cancer, the expected incidence of malignancies was also computed for 5-year time intervals following the cervical cancer. No significant increase in second malignancies was found (observed/expected-44/36) for the entire follow-up period nor for any individual 5-year interval. However, a statistically significant increase in lung cancer and vulva-vaginal cancer was noted and a significant decrease in breast cancer was observed. Cox regression analyses were performed to study the effect of total radium exposure and total external beam treatment, adjusting for other factors. No statistically significant increased risks were found.

Squamous cell carcinoma of the vagina following hysterectomy

A retrospective analysis of 29 cases of squamous cell neoplasia of the vagina following hysterectomy is presented. Two groups of patients were identified; the first presented following hysterectomy for cervical dysplasia or neoplasia on an average of 5.7 years later, and the second presented following hysterectomy for benign or unrelated disease 13.1 years after initial surgery. All 17 patients in the first group had Stage I disease whereas two thirds of the second group had Stage II or greater disease at the time of diagnosis. Surgery was the primary mode of therapy in 82.4% of the first group and radiotherapy was used in 83.3% of the second group. In all patients 20.7% had received previous radiotherapy to the pelvis. Carcinoma of the vagina following hysterectomy for benign disease tends to be more advanced at the time of diagnosis and subsequently has a poorer ultimate prognosis. Disease following previous cervical neoplasia is often asymptomatic and only detected on routine cytologic testing.

Carcinoma of vagina 10 or more years following pelvic irradiation therapy

Gynecologic cancer records of 4,238 patients treated between 1956 and 1974 were reviewed. Sixteen patients developed noeplasia in the cervix or vagina 10 or more years following pelvic irradiation. Three patients had squamous carcinoma in situ; the other 13 patients had invasive squamous cancer involving the upper vagina. Only 1.26 per cent of invasive carcinoma of the cervix treated by radiation therapy from 1956 to 1966 presented with a late or recurrent or new primary tumor involving the vagina or cervix 10 or more years after primary treatment. The authors conclude that the risk of developing radiation-induced carcinoma in the upper vagina or cervix following pelvic irradiation is low. Follow-up Pap smears are indicated for all patients treated for cervical or vaginal malignancies by radiation therapy in order to detect vaginal neoplasia as well as recurrent carcinoma of the cervix.