This article will help you read and understand your pathology report for squamous cell carcinoma of the vagina.
by Emily Goebel MD FRCPC, updated January 6, 2021
The vagina is part of the female genital tract. It forms a canal that starts at the cervix and ends at the vulva on the outside of the body. The vagina is lined by special cells called squamous cells that form a barrier on the inner lining of the vagina called the epithelium. The tissue beneath the epithelium is called the lamina propria and contains blood vessels and connective tissue. Together, the epithelium and lamina propria are called mucosa.
Squamous cell carcinoma is a type of cancer that develops in the vagina from the squamous cells in the epithelium. Most of the time squamous cell carcinoma develops from a pre-cancerous disease called high grade squamous intraepithelial lesion (HSIL).
In HSIL the abnormal cells are seen only in the epithelium of the vagina. Squamous cell carcinoma develops when the abnormal cells spread from the epithelium into the lamina propria below. The spread of cancer cells into the lamina propria is called invasion.
Almost all cases of squamous cell carcinoma and HSIL in the vagina are a result of the normal squamous cells in the vagina becoming infected with a high risk type of virus called human papillomavirus (HPV). The most common types of high risk HPV that cause HSIL are HPV-16 and HPV-18.
The diagnosis of squamous cell carcinoma is usually made after a small tissue sample is removed in a procedure called a biopsy. The entire tumour is usually then removed in a procedure called an excision or resection.
Grade is a word pathologists use to describe the difference between the cancer cells and the normal squamous cells in the epithelium. The grade can only be determined after tissue has been examined under the microscope.
The grade is usually divided into three levels of differentiation:
Grade is important because poorly differentiated tumours tend to behave more aggressively than well differentiated tumours.
After the entire tumour is removed, your pathologist will measure it in three dimensions but only the largest dimension is usually described in your report. The size of the tumour and depth of invasion are important because they are used to determine the tumour stage (see Pathologic stage below).
Tumour extension describes how far the cancer cells have traveled from their starting point in the vagina. All tumours start in the vagina, however larger tumours can grow to involve the bladder, rectum, or surrounding soft tissue.
Your pathologist can only look for tumour extension out of the vagina after the entire tumour has been removed. For this reason, tumour extension is usually not described in the pathology report after a small tissue sample such as a biopsy is removed.
Blood moves around the body through long thin tubes called blood vessels. Another type of fluid called lymph which contains waste and immune cells moves around the body through lymphatic channels.
Cancer cells can use blood vessels and lymphatics to travel away from the tumour to other parts of the body. The movement of cancer cells from the tumour to another part of the body is called metastasis. Before cancer cells can metastasize, they need to enter a blood vessel or lymphatic. This is called lymphovascular invasion.
Lymphovascular invasion increases the risk that cancer cells will be found in a lymph node or a distant part of the body such as the lungs.
A margin is any tissue that has to be cut by the surgeon in order to remove the tumour from your body. A negative margin means that no cancer cells were seen at the cut edge of the tissue. In contrast, a positive margin means that cancer cells were seen at the cut edge of the tissue. If HSIL is seen at the margin that will also be described in your report. A positive margin increases the risk that the tumour will grow back in that location.
Lymph nodes are small immune organs located throughout the body. Cancer cells can travel from the tumour to a lymph node through lymphatic channels located in and around the tumour (see Lymphovascular invasion above). The movement of cancer cells from the tumour to a lymph node is called a metastasis.
Most reports include the total number of lymph nodes examined and the number, if any, that contain cancer cells.
Your pathologist will carefully examine all lymph nodes for cancer cells. Lymph nodes that contain cancer cells are often called positive while those that do not contain any cancer cells are called negative.
Isolated tumour cells are a group of a cancer cells found in a lymph node that measure less than 0.2 millimeter in size.
Finding cancer cells in a lymph node is associated with a higher risk that the cancer cells will be found in other lymph nodes or in a distant organ such as the lungs. The risk is less if only isolated tumour cells were found.
The pathologic stage for squamous cell carcinoma of the vagina is based on the TNM staging system, an internationally recognized system originally created by the American Joint Committee on Cancer.
This system uses information about the primary tumour (T), lymph nodes (N), and distant metastatic disease (M) to determine the complete pathologic stage (pTNM). Your pathologist will examine the tissue submitted and give each part a number. In general, a higher number means more advanced disease and worse prognosis.
Squamous cell carcinoma is given a tumour stage between 1 and 4. Your pathologist will look for two features to determine the tumour stage:
Squamous cell carcinoma is given an nodal stage of 0 or 1 based on the presence or absence of cancer cells in a lymph node.
If no cancer cells are seen in any of the lymph nodes examined, the nodal stage is N0. Lymph nodes with isolated tumour cells are also given an nodal stage of N0.
If no lymph nodes are submitted for pathological examination, the nodal stage cannot be determined and the nodal stage is listed as NX.
Squamous cell carcinoma is given an metastatic stage of 0 or 1 based on the presence of cancer cells at a distant site in the body (for example the lungs). The metastatic stage can only be assigned if tissue from a distant site is submitted for pathological examination. Because this tissue is rarely present, the metastatic stage cannot be determined and is listed as MX.