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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 ; David M. Gershenson, MD, Professor and Chairman, Department of Gynecologic Oncology and Reproductive Medicine, 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

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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 for vaginal cancer include

  • Human papillomavirus infection

  • 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 as follows:

  • 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

  • Hematogenously

Symptoms and Signs

Most patients with vaginal cancer 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.

Vaginal cancers are staged clinically (see Table: FIGO 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.

FIGO 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.

Based on staging established by the International Federation of Gynecology and Obstetrics (FIGO) and American Joint Committee on Cancer (AJCC), AJCC Cancer Staging Manual, ed. 7. New York, Springer, 2010.

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, sometimes followed by radiation therapy.

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.

Key Points

  • Risk factors for vaginal cancer include human papillomavirus infection and cervical or vulvar cancer.

  • Most patients present with abnormal vaginal bleeding.

  • Usually diagnose with punch biopsy; sometimes wide local excision is necessary.

  • Treat tumors confined to the wall of the upper third of the vagina with hysterectomy plus vaginectomy and lymph node dissection, sometimes followed by radiation therapy, and treat most others with radiation therapy.

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* This is the Professional Version. *