Is it the red dot? Yep. We're good. Okay. All right. So we're going to talk about vaginal cancers today. So in general, vaginal cancers represent 2% of all gynecological malignancies. So it's about 2,980 cases a year with 840 deaths in the U.S. 30% of the patients have a history of in situ or invasive cervical cancer in the past five years. Most of the time it occurs in postmenopausal women. Most common histology is squamous cell carcinoma, but adenocarcinomas make about 14 to 18% of the cases. So this just shows you the percentages of the different histologies. And as you can see, majority of them are squamous cell carcinomas and a minority, only like 13% of them are adenocarcinomas. But you also can see the HPV prevalence. So you can see patients who are HPV positive have a high likelihood of getting squamous cell carcinomas, while if you're HPV negative, it's most likely going to be an adenocarcinoma or an undifferentiated carcinoma. HPV 16 is the most common. So what are the most important prognostic factors for vaginal cancers? FIGO staging, and it is clinical still, PET CT, and MRI. So staging, as I said, staging is still clinical and this has not changed. So this just goes over the different staging. Stage one is where it's just in the vagina and hasn't gone through the wall of the vagina. Stage two, it goes through the wall of the vagina, but it's not fixed. Stage three is going into the pelvic wall. So then the vaginal lesion is actually fixed and you can't move it. And then stage four would be to bladder or rectum. So as I mentioned, vaginal cancers are very rare. They do have a very complex regional spread pattern. They're very close to critical organs, so the treatment is really technically challenging. So the most common site for vaginal cancers is at the vaginal apex, but other sites as we all can know are lateral walls, distal anterior, which is the suburethral area, posterior mid-vagina, or posterior distal vagina. So this is the type of treatment if you were going to do surgery for a vaginal cancer. So let's say you had a stage one disease that involved the posterior upper vagina. If the uterus is in place, then you do a radical hysterectomy and upper vaginectomy with at least one CM clearance and a pelvic node dissection. If they've had a previous hysterectomy, then you do a radical upper vaginectomy with pelvic lymph node dissection. Stage four with the retrovaginal or vesicovaginal fistula, you do a pelvic exempt. The other times that you can do surgery is if there's a central recurrence after radiation therapy, and that's usually a pelvic exempt. Or there is a small paper that looked at neoadjuvant chemotherapy followed by surgery, 11 patients. Most of them were stage two. They got three cycles of pachytaxel and cisplatinum followed by surgery. 27% had complete response, 64% had a partial response, and 91% were alive at 75 months. 73 were free of disease. So surgery has a very limited role in patients with vaginal cancers, and these are really the key times that you can do surgery. Stage one, where you do an upper vaginectomy, or stage four, where you would do an exempt recurrence after radiation therapy, or you could try neoadjuvant chemotherapy followed by surgery, but there's very limited data with a very small series. So key is, radiation therapy is the mainstay treatment for vaginal cancer. So surgery, as I showed you, has a very limited role in vaginal cancers, unless radiation therapy is not available. If radiation therapy is available, it really is the mainstay treatment. And it is, just like cervical cancer, a combination of external beam treatment and brachytherapy. It's really important, and I'm going to show you this data a little bit later, how important brachytherapy is, just like it is for cervical cancer. So the brachytherapy can be either intercavitary or interstitial, and that depends on the thickness of the lesion after the external beam. If the thickness is less than five millimeters, an intercavitary is enough. If it's greater than five millimeters, you've got to put needles in. So the standard field, so this is a standard field for a distal vaginal lesion. So the lymph nodes, which I didn't talk to you about, but let's talk about the lymph node drainage. If it's an apical lesion, the lymph node drainage is the same as the cervix. So it's going to be obturator, external iliacs, and internal iliacs. Mid-vagina, also a lot like the cervix, so it's going to go superiorly. It's also going to the obturator nose, external iliacs, and internal iliacs. Distal vagina goes like the vulva to the inguinal nodes. So if you have a distal vaginal lesion or a vaginal lesion that goes all the way and involves the distal vagina, you have to include the inguinal nodes. So this is just a case of a patient with a distal vaginal lesion, comparing the standard old way of doing it, which is a 3D conformal where you treated anterior and posterior versus IMRT. And this is really the way we're treating now so that we can spare tissue, like you can see where this tissue is being spared, the necks are being spared, and a lot of things are being spared. So now we really tend to treat vaginal lesions with IMRT, VMAT versus standard 3D conformal, but you can still do it with 3D conformal, you just are going to be treating more of the tissue in between. So key, as I said, radiation therapy is the mainstay treatment for vaginal cancers, and it includes external beam, and usually with the external beam, you're going to treat the nodes at risk as well as the vaginal cancer. So you treat that to 45 gray, and then you come back and you're going to boost the vaginal disease. So how do you boost the vaginal disease? And we talked about that. You can do intercavitary or needles, depending on how thick the lesion is after the external beam. So intercavitary is just a cylinder, or if it's an upper vaginal lesion and you still have the uterus, you can do tandem and ovoids, where the ovoids actually treat the vaginal lesion, and you give a little bit of margin above that with the tandem. Or you can do interstitial, either template or freehand. You could also boost with external beam if you cannot do interstitial, but really, brachytherapy is so important in this, just like it is for cervix cancer. So just going to show you some really nice pictures of how you can treat these vaginal cancers. So this lesion, you can see here, is a very small, flat lesion, right? So it's less than five millimeters. So this lesion can actually be treated with a cylinder alone, and you can see, sorry, so with a cylinder alone, because a cylinder gives you just surface dose. So you can see, if it's a surface lesion, the cylinder is enough. And you can see, with a cylinder, the dose really decreases the further away you go. So at five millimeters, if you're prescribing 50 gray at the surface, at five millimeters, that 50 gray is already down to 28, and at a CN, it's already down to 18 gray. So that's why, if you have a lesion that's less than five millimeters after external beam, you can do this cylinder that will give a dose right to the surface. But if you have a thicker lesion, so here's your thicker lesion, right? So here's your 50 gray. The thicker lesion, only 28 gray is going to just this part. And you can see, further out, it's only getting 18 gray, and parts of it's not even being treated. So a thicker lesion than five millimeters, a cylinder is not enough. And that's so, so important to know. So this thicker lesion, you treat with a SCIA template. So here's your SCIA template, and you put the needles in, and this is good. So here's the SCIA obturator, and here's the needles that go into the lesion, like that. Now, at MD Anderson, we actually still do it with laparoscopic guidance, so that you can actually see the needles, and we're making sure that the needles don't go into the bladder or into the rectum. You can do this under CT guidance as well, making sure it doesn't go into the bladder or the rectum. But you can see right here, here's the bladder, here's the needles. So the needles are not going right into the rectum, but they're right into the lesion. If it's a lateral wall lesion, you can also use a SCIA template, but you also can do freehand needles. So here's my freehand needles, and the needles are going directly right into the lesion. When we feel the lesions going in, the needles are one cm apart. Distal vaginal lesion, here's the distal vaginal lesions. You can see very thick. So here, we actually have a cylinder with needles, as well as needles into that distal vaginal lesion, so that we have a two-plane. But the key is, and what's important, and what I want you guys to get out of this, is vaginal cancers can be treated, but they need to be treated with both external beam and brachytherapy. And the type of brachytherapy is important, depending on how thick that lesion is. And this just shows you the plan of that cancer, and again, show you how the needles actually will bring that dose out, giving a good dose to that lesion. Now big tumors like this, you can't even treat with needles. So those patients will have to get external beam radiation therapy all the way, and we use IMRT, and we usually take it to 66. The bigger, really big lesions, even needles will not cover it. So what's the goal? The goal is to give about 75 to 85 gray to the lesion in the vagina. If it can't be safely treated with brachytherapy, then use external beam, but it's really important to try to use brachytherapy whenever possible. And so we're just going to talk about some experiences, and there's really small, very little in the literature on treatment of vaginal cancer because it's rare. So this is just our experience of 235 patients who were treated for vaginal cancer. As you can see, all of them got 40 to 50 gray, and then they got radiation therapy, then they got intercavitary. And you can see the bigger lesions did get external beam boost, but majority of them got brachytherapy. And what we found was that in 195 patients, stage 1 to 4a, vaginal control rate was 89%. Pelvic control rate at 10 years was 80%. So we did really well. Disease-specific survival was correlated with stage, but it was not correlated with size, site, or treatment modality. But I'm going to show you that this is different from other sites. So actually, treatment modality is really important. And you can see that most of the patients did recur in the pelvis or distantly, and even in the vagina. So it's really important that you get the right dose and you treat the right area. We did look at squamous cell versus adenocarcinomas, and adenocarcinomas actually did worse than squamous cell carcinomas. 74% disease-specific survival versus 47% for adenocarcinomas. Adenocarcinomas had a higher distal metastasis rate and a decreased pelvic control rate, as well as a vaginal control rate. Complications, we actually did well. Overall, grade 3 to 4 was 11%. GI was 9%, and GU was 2%. And remember, this was when we were doing 3D conformal. So our complications rates have even gone lower now that we're doing VMAT. Another study also looked at patients with vaginal cancers, and they found that overall survival was correlated with stage, size of disease. So if it was greater than 4CM, the patients did worse than if they had less than 4CM. But total dose and prior hysterectomy made no difference at all. So unfavorable factors are advanced age, tumor size, especially tumor size bigger than 4CM, location, patients who have apical lesions do better than the rest of the patients, older age. Favorable factors are high-risk HPV DNA and low MIB1 index. So let's just talk about brachytherapy and how important this is. So this is actually a study that looked at vaginal cancers and looked at what type of boost they were getting. And as you can see, in the United States, brachytherapy boosts are decreasing in patients with vaginal cancers, and IMRT boosts are actually going up. And what we found was that in this study base, the patients who said that there was a decline in brachytherapy, but there was actually a decrease in overall survival with the decline in brachytherapy. So the patients who got IMRT boost did worse than the patients who got brachytherapy boost. And this also shows you the same thing for vaginal cancers. Patients who got brachytherapy did better than patients who got external beam alone. So brachytherapy, just like in cervical cancer, is key, key, key in trying to cure these patients. So what about chemotherapy? So we have seen that there is an increase in the use of concurrent chemotherapy with vaginal cancers. And even though there's not a survival benefit in stage one, there does seem to be a trend in survival benefit in stage two, three, and four with concurrent cisplatinum and radiation therapy over just radiation therapy alone. So in conclusion, surgery has very limited role in vaginal cancer. And I just went over that, which is really, really early stage, stage one, stage four A's, recurrent disease, really that's it. Otherwise, radiation therapy really is the mainstay treatment for vaginal cancers. We actually do well, but you have to use both external beam and brachytherapy together. Concurrent chemotherapy does seem to improve survival, but we do need other studies. But unfortunately, because vaginal cancers are so rare, we're not going to have randomized studies, but we do know what works and really radiation therapy is the best option for most cases. Thank you.

vaginal cancers

squamous cell carcinoma

adenocarcinomas

radiation therapy

brachytherapy