Review ArticleCancer of the neovagina
Introduction
Cancer of the neovagina has been said to be rare. Creation of a neovagina is an infrequently performed procedure with no established follow-up pattern. The tissues used in neovaginal construction are varied and include bowel, skin graft, vulvar skin flaps, rectus abdominus (myocutaneous) flaps and inverted penile skin; traction and cleavage techniques are also used without tissue transplantation. The pathological criteria of abnormality are not well established partially because relocated tissue takes on some of the histological characteristics of vaginal tissue. The characteristics of dysplasia or carcinoma in this situation (a variety of tissue possibilities), have no singular appearance or screening option.
When exogenous tissue is used, tissue dysplasia may be expected because the tissue is suddenly subjected to new contacts or stresses. Epithelium transplanted to a vaginal location assumes some anatomic and physiologic characteristics of a normal vagina; one example is normal vaginal pH and normal vaginal flora. Skin grafted to form vagina loses hair follicles and sweat glands. A reduction in the number of elastic fibers and hyperplasia of epithelial cells occur. Grafts accumulate large amounts of glycogen [1], which is typical of vaginal mucosa but almost never occurs in normal skin. Such tissue is changed by cyclic estrogen environments. Specific to split-thickness skin grafts, cytologic specimens from vaginal smears showed enucleated squamous and keratinized squamous epithelial cells. Squamous cell maturation shows a shift to the right with a preponderance of superficial and intermediate squamous epithelial cells. Although the neovagina is modified cytologically in the direction of the normal vagina, it never loses certain characteristics of the original skin, such as keratinization.
Transplanted colon or bowel retains the basic properties of bowel including genetic factors such as oncogene activation for the development of cancer, chronic inflammatory bowel disease and any type of polyposis syndrome. The isolation of bowel as a segment for vaginal use excludes two factors for cancer development, exposure to bile acids and the direct carcinogenic influences of certain foods. Sexually transmitted influences to bowel from human papilloma type related DNA and c-myc oncogene alterations in colon cell lines have been reported.
Tumors associated with the exogenous tissue still have the potential to express the expected tumor or inflammatory change (as in the tissue's natural environment) [2]. An example of this is the appearance of ulcerative colitis in the neovagina [3], [4]. Typically, this is synchronous in the colon and colon vaginoplasy. Clinical symptoms of colicky diarrhea, rectal and vaginal bleeding, and weight loss are prominent.
Vaginal bleeding can also be a symptom of another but pathologically different inflammatory disorder. Diversion colitis is a non-specific inflammatory process that develops in segments of colorectum diverted from the fecal stream. This diversion causes the absence of short-chain fatty acids (from colonic contents) that are a nutritional requirement of the colonic epithelium. Short-chain fatty acids have a significant role in the regulation of cellular proliferation and differentiation, and their lack may alter the cellular environment in favor of the development of adenocarcinoma. Usually an asymptomatic disorder, the histologic changes of diversion colitis are seen in up to 70% of diverted colonic segments. The disorder may take up to 7 years to develop [5]. Glotzer et al. [6] have described clinical and pathologic findings including mucous discharge and bleeding, and surface changes on endoscopy notably of edema, erythema, petechial hemorrhages, easy friability of the tissue, nodularity and ulceration of the mucosa. Histologically, lymphoid follicular hyperplasia and apthoid ulceration are found. Treatment with short-chain fatty acid irrigation may result in remission when symptomatic [7].
There are many possibilities for neovaginal tissues to become subject to unexpected stresses. Examples include: recurrent dilatation to keep the vagina open, microabrasion and trauma from intercourse, reaction to semen and urine exposure, and reaction from stool if a fistula occurs. This may result in persistent granulation tissue, chronic infection and inflammation secondary to dampness, dysplastic surface change and pseudopolyps. Alteration of the donor surface by exogenous noxious agents may be the etiologic cause of disease. The potential for infection changes (human papillomavirus (HPV) infection of tissue that is sexually transmitted, colonization by bacteria that said tissues are usually not exposed to). The native vagina depends on free drainage of secretions, as those that do not drain and harden forming calcifications abrade the surface and cause inflammatory changes. Inflammation can be caused by stents left in place to prevent vaginal shrinkage.
Section snippets
Results
Although considered a rare malignancy, many cases of carcinoma of the neovagina have in fact been reported (Table 1) [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36]. Cancer type appears to be related to the type of transplanted tissue. All recorded cases of squamous cell carcinoma are related to split-thickness skin graft or McIndoe variations, and all adenocarcinomas to
Conclusion
Review of the literature documents many cases of cancer of the neovagina. This highlights the importance of careful follow up of patients who have undergone neovaginal construction.
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