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Vaginal Cancer

by Pedro T. Ramirez, MD, David M. Gershenson, MD

Vaginal cancer is usually a squamous cell carcinoma, most often occurring in women > 60. The most common symptom is abnormal vaginal bleeding. Diagnosis is by biopsy. Treatment for many small localized cancers is hysterectomy plus vaginectomy and lymph node dissection; for most others, radiation therapy is used.

Vaginal cancer accounts for 1% of gynecologic cancers in the US. Average age at diagnosis is 60 to 65. Risk factors include human papillomavirus infection and cervical or vulvar cancer. Exposure to diethylstilbestrol in utero predisposes to clear cell adenocarcinoma of the vagina, which is rare; mean age at diagnosis is 19.

Most (95%) primary vaginal cancers are squamous cell carcinomas; others include primary and secondary adenocarcinomas, secondary squamous cell carcinomas (in older women), clear cell adenocarcinomas (in young women), and melanomas. The most common vaginal sarcoma is sarcoma botryoides (embryonal rhabdomyosarcoma); peak incidence is at age 3.

Most vaginal cancers occur in the upper third of the posterior vaginal wall. They may spread by direct extension (into the local paravaginal tissues, bladder, or rectum), through inguinal lymph nodes from lesions in the lower vagina, through pelvic lymph nodes from lesions in the upper vagina, or hematogenously.

Symptoms and Signs

Most patients present with abnormal vaginal bleeding: postmenopausal, postcoital, or intermenstrual. Some also present with a watery vaginal discharge or dyspareunia. A few patients are asymptomatic, and the lesion is discovered during routine pelvic examination or evaluation of an abnormal Papanicolaou (Pap) test.

Vesicovaginal or rectovaginal fistulas are manifestations of advanced disease.

Diagnosis

  • Biopsy

  • Clinical staging

Punch biopsy is usually diagnostic, but wide local excision is occasionally necessary. Cancers are staged clinically (see Vaginal Cancer by Stage), based primarily on physical examination, endoscopy (ie, cystoscopy, proctoscopy), chest x-ray (for pulmonary metastases), and usually CT (for abdominal or pelvic metastases). Survival rates depend on the stage.

Vaginal Cancer by Stage

Stage

Description

5-yr Survival Rate*

I

Limited to the vaginal wall

65−70%

II

Invading subvaginal tissues

47%

III

Extending to the pelvic wall

30%

IV

Extending beyond the true pelvis or involving the bladder or rectal mucosa

15−20%

*Prognosis is worse if the primary tumor is large or poorly differentiated.

Treatment

  • Hysterectomy plus vaginectomy and lymph node dissection for tumors confined to the wall of the upper third of the vagina

  • Radiation therapy for most others

Stage I tumors within the upper third of the vagina can be treated with radical hysterectomy, upper vaginectomy, and pelvic lymph node dissection. Most other primary tumors are treated with radiation therapy, usually a combination of external beam radiation therapy and brachytherapy. If radiation therapy is contraindicated because of vesicovaginal or rectovaginal fistulas, pelvic exenteration is done.

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