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Vaginal Cancer

By

Pedro T. Ramirez

, MD, The University of Texas MD Anderson Cancer Center;


Gloria Salvo

, MD, MD Anderson Cancer Center

Last full review/revision Sep 2020| Content last modified Sep 2020
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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.

Primary vaginal cancer is rare; these cancers account for 1% of gynecologic cancers in the US. Metastases to the vagina or local extension from adjacent gynecologic structures is more common than primary tumors of the vagina. Average age at diagnosis is 60 to 65.

Risk factors for vaginal cancer include

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 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.

Table
icon

FIGO Vaginal Cancer by Stage

Stage

Description

5-Year Survival Rate*

I

Limited to the vaginal wall

75–95%

II

Invading paravaginal tissues

50–80%

III

Extending to the pelvic wall and/or the lower third of the vagina and/or causing hydronephrosis or nonfunctioning kidney

30–60%

IV

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

15−50%

* 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. 8. New York, Springer, 2017.

Treatment

  • Hysterectomy, vaginectomy, lymph node dissection and sometimes radiation therapy for stage I tumors confined to 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 HPV 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.

More Information

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

  • National Cancer Institute: Vaginal Cancer: This web site provides links to information about causes, prevention, and treatment of vaginal cancer, as well as links to information about screening and supportive and palliative care.

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