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Vaginal Cancer

By Pedro T. Ramirez, MD, Professor, Department of Gynecologic Oncology and Reproductive Medicine, David M. Gershenson Distinguished Professor in Ovarian Cancer Research, and Director of Minimally Invasive Surgical Research and Education, The University of Texas MD Anderson Cancer Center ; Gloria Salvo, MD, Rotating Research Resident, Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson Cancer Center

Cancer of the vagina, an uncommon cancer, usually develops in the cells lining the vagina, typically in women over 60.

  • Vaginal cancer may cause abnormal vaginal bleeding, particularly after sexual intercourse.

  • If doctors suspect cancer, they remove and examine samples of tissue from the vagina (biopsy).

  • The cancer is surgically removed, or radiation therapy is used.

In the United States, vaginal cancer accounts for only about 1% of gynecologic cancers. The average age at diagnosis is 60 to 65.

Locating the Internal Female Reproductive Organs

Vaginal cancer may be caused by human papillomavirus (HPV), the same virus that causes genital warts and cervical cancer. Having HPV infection, cervical cancer, or vulvar cancer increases the risk of developing vaginal cancer.

More than 95% of vaginal cancers are squamous cell cancers (carcinomas), which develop in the flat, skinlike cells that form the surface of vaginal lining. Most other vaginal cancers are adenocarcinomas, which develop from gland cells. One rare type, clear cell carcinoma, occurs almost exclusively in women whose mothers took the drug diethylstilbestrol (DES), prescribed to prevent miscarriage during pregnancy. (In 1971, the drug was banned in the United States.)

If untreated, vaginal cancer continues to grow and invades surrounding tissue. Eventually, it may enter blood and lymphatic vessels, then spread to the bladder, rectum, nearby lymph nodes, and other parts of the body.

Symptoms

The most common symptom of vaginal cancer is abnormal bleeding from the vagina, which may occur during or after sexual intercourse, between menstrual periods, or after menopause. Sores may form on the lining of the vagina. They may bleed and become infected. Other symptoms include a watery discharge and pain during sexual intercourse. A few women have no symptoms.

Large cancers can also affect the bladder, causing a frequent urge to urinate and pain during urination. In advanced cancer, abnormal connections (fistulas) may form between the vagina and the bladder or rectum.

Diagnosis

  • Biopsy

Doctors may suspect vaginal cancer based on symptoms, abnormal areas seen during a routine pelvic examination, or an abnormal Papanicolaou (Pap) test result. Doctors may use an instrument with a binocular magnifying lens (colposcope) to examine the vagina.

To confirm the diagnosis, doctors remove tissues from the vaginal wall to examine under a microscope (biopsy). They make sure to get tissue samples from any growth, sore, or other abnormal area seen during the examination.

Other tests, such as use of a viewing tube (endoscopy) to examine the bladder or rectum, a chest x-ray, and computed tomography (CT), may be done to determine whether the cancer has spread.

Staging of vaginal cancer

Doctors stage the cancer based on how far it has spread. Stages range from I (the earliest) to IV (advanced):

  • Stage I: The cancer is confined to the wall of the vagina.

  • Stage II: The cancer has spread through the wall of the vagina to nearby tissues but is still within the pelvis (which contains the internal reproductive organs, bladder, and rectum).

  • Stage III: The cancer has spread throughout the pelvis (but not the bladder or rectum).

  • Stage IV: The cancer has spread to the bladder or rectum or outside the pelvis (for example, to the lungs or bone).

Prognosis

The prognosis for women with vaginal cancer depends on the stage of the cancer.

The percentages of women who are alive 5 years after diagnosis and treatment (5-year survival rate) are

  • Stage 1: About 65 to 70%

  • Stage 2: 47%

  • Stage 3: 30%

  • Stage 4: Only about 15 to 20%

Treatment

  • For early-stage vaginal cancers, surgery to remove the vagina, uterus, and nearby lymph nodes

  • For most other vaginal cancers, radiation therapy

Treatment of vaginal cancer also depends on the stage.

For early-stage vaginal cancers, surgery to remove the vagina, uterus, and lymph nodes in the pelvis and the upper part of the vagina is the treatment of choice.

Radiation therapy is used for most other cancers. It is usually a combination of internal radiation therapy (using radioactive implants placed inside the vagina, called brachytherapy) and external radiation therapy (directed at the pelvis from outside the body).

Radiation therapy cannot be used if fistulas have developed. In such cases, some or all of the organs in the pelvis are removed (called pelvic exenteration). These organs include the reproductive organs (vagina, uterus, fallopian tubes, and ovaries), bladder, urethra, rectum, and anus. Which organs are removed and whether all are removed depends on many factors, such as the cancer's location, the woman's anatomy, and her goals after surgery. Permanent openings—for urine (urostomy) and for stool (colostomy—see Figure: Understanding Colostomy)—are made in the abdomen so that these waste products can leave the body and be collected in bags. After the procedure, women usually have some bleeding, a discharge, and considerable tenderness and pain for a few days. Typically, the hospital stay is 3 to 5 days. Complications, such as infection or opening of the surgical incision, blockages in the intestine, and formation of abnormal connections between organs (fistulas), can occur.

Sexual intercourse may be difficult or impossible after treatment for vaginal cancer.

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