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 to 2% of gynecologic cancers in the United States. 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 years.
Risk factors for vaginal cancer include
Vaginal intraepithelial neoplasia (VAIN)
Cervical, vulvar, or anal intraepithelial neoplasia or cancer
In-utero exposure to diethylstilbestrol
Most vaginal cancers are caused by persistent human papillomavirus (HPV) infection. Exposure to diethylstilbestrol in utero predisposes to clear cell adenocarcinoma of the vagina, which is a rare histologic type of vaginal cancer; mean age at diagnosis is 19 years.
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 years.
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 of Vaginal Cancer
Most patients with vaginal cancer present with abnormal intermenstrual vaginal bleeding, often postmenopausal or postcoital. Some also present with a watery vaginal discharge or dyspareunia. 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 of Vaginal Cancer
Biopsy
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.
FIGO Vaginal Cancer by Stage
Stage | Description | 5-Year Survival Rate* |
|---|---|---|
I | Limited to the vagina | 75–95% |
II | Invading paravaginal tissues, but not to pelvic sidewall | 50–80% |
III | Extending to the pelvic wall and/or the lower third of the vagina and/or causing hydronephrosis or nonfunctioning kidney; with or without metastases to inguinal lymph nodes | 30–60% |
IV | Extending beyond the true pelvis and/or involving the bladder or rectal mucosa and/or distant metastases (lung or bones); with or without metastases to nearby lymph nodes | 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): Adams TS, Rogers LJ, Cuello MA: Cancer of the vagina: 2021 update. Int J Gynaecol Obstet 155 Suppl 1:19–27, 2021. doi: 10.1002/ijgo.13867 | ||
Treatment of Vaginal Cancer
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
Vaginal cancer is caused by HPV infection or in utero exposure to diethylstilbestrol.
Risk factors include cervical or vulvar precancer or cancer.
Most patients present with abnormal vaginal bleeding.
Usually diagnose with 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 other tumors with radiation therapy.
More Information
The following English-language resource 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.
