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Vaginal Cancer symptoms and treatment

This page presents information on the symptoms and treatment of vaginal cancer.

Table 6.1 shows the FIGO staging guidelines for vaginal cancer.

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The majority of women diagnosed with vaginal cancer present with discharge or bleeding, but asymptomatic women often present with other gynaecological problems.

Up to 20% of vaginal cancer patients have no symptoms and may be diagnosed during routine examination or smear.1 In more advanced disease there may be pelvic or suprapubic pain. Lesions involving the anterior vaginal wall may cause urinary symptoms or urethral obstruction and retention of urine. Other symptoms include pain during intercourse, a palpable lump or persistent vaginal itching.

Fluorodeoxyglucose-positron emission tomography (FDG-PET) scanning may have a useful role in staging vaginal malignancy and may be more sensitive than CT scanning.2

Women with adenocarcinomas are most likely to present either at a very early or very advanced stage (35% at stage I and 30% at stage IV), while the greatest proportion of women with squamous cell carcinoma (SCC) present with stage II tumours (31%). Six per cent of SCC and 9% of adenocarcinomas are diagnosed as in situ.3

Patients with HPV only or grade 1 VAIN (vaginal intraepithelial neoplasia) often regress spontaneously and so usually receive no treatment.

Most VAIN patients are treated with ablative therapies such as laser or loop diathermy.4,5 However grade 3 VAIN is more likely to include invasive lesions, so in these cases wide local excision, or even total vaginectomy may be given.1 There should be regular follow-up after treatment, as recurrences are relatively common.6,7

Survival from vaginal cancer is similar whether radical surgery or chemoradiotherapy is used and therefore organ-sparing treatment is preferred in the majority of cases.

Radiotherapy is delivered using a combination of external beam radiotherapy and either interstitial or intracavity brachytherapy.8 Local control depends on the volume of the tumour and the dose of radiation delivered.9,10

With small localised tumours it is sometimes possible to deliver high doses of radiation with brachytherapy and obtain a high probability of local control.11 When treating more advanced disease, the radiotherapy treatment volume includes the pelvic nodes (in upper vaginal tumours) or the inguino-femoral nodes (lower vaginal tumours).12 If patients are fit enough for systemic chemotherapy, cisplatin may be given with radiotherapy.13

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Surgery may be preferred in small tumours of the upper third of the vagina involving the posterior wall where hysterectomy and partial vaginectomy give good results. Similarly some localised tumours of the lower third of the vagina can be satisfactorily excised with a partial vulvectomy and inguinal lymphadenectomy.

Adjuvant radiotherapy may be used after surgery for vaginal cancer to reduce the likelihood of recurrence. Where radical radiotherapy has failed exenterative (an operation in which all the contents of a body cavity are removed) surgery may result in cure for a small number of patients.14 Where total vaginectomy is given reconstructive surgery is possible.

Vaginal Cancer screening and prevention

The International Society for the Study of Vulvovaginal Disease recommends monthly self-examination for all women.15 The pap smear test can detect VAIN, but the rarity of vaginal cancer means population screening programmes for vaginal cancer are an inefficient use of resources, even in increased risk groups such as women with a previous cervical cancer.16

Preliminary trials of immunotherapies have been promising for VAIN, although numbers of trial participants have been small and larger-scale trials are needed to confirm results.17

The recent European Union approval of Gardasil, an HPV vaccine would help to reduce the numbers of women affected by vaginal cancer.

References for vaginal cancer symptoms and treatment

1. De Vita, V., S. Hellman, and S.A. Rosenberg, Cancer: principles and practice of oncology. 6th Edition ed. 2001: Lippincott, Williams and Wilkins.
2. Lamoreaux, W.T., et al., FDG-PET evaluation of vaginal carcinoma. Int J Radiat Oncol Biol Phys, 2005. 62(3): p. 733-7.
3. Beller, U., et al., Carcinoma of the vagina. Int J Gynaecol Obstet, 2003. 83 Suppl 1: p. 27-39.
4. Yalcin, O.T., et al., Vaginal intraepithelial neoplasia: treatment by carbon dioxide laser and risk factors for failure. Eur J Obstet Gynecol Reprod Biol, 2003. 106(1): p. 64-8.
5. Diakomanolis, E., et al., Conservative management of vaginal intraepithelial neoplasia (VAIN) by laser CO2. Eur J Gynaecol Oncol, 1996. 17(5): p. 389-92.
6. Jones, R.W., Vulval intraepithelial neoplasia: current perspectives. Eur J Gynaecol Oncol, 2001. 22(6): p. 393-402.
7. Dodge, J.A., et al., Clinical features and risk of recurrence among patients with vaginal intraepithelial neoplasia. Gynecol Oncol, 2001. 83(2): p. 363-9.
8. Frank, S.J., et al.,Definitive radiation therapy for squamous cell carcinoma of the vagina. Int J Radiat Oncol Biol Phys, 2005. 62(1): p. 138-47.
9. Samant, R., et al., Radiotherapy for the treatment of primary vaginal cancer. Radiother Oncol, 2005. 77(2): p. 133-6.
10. Perez, C.A., et al., Factors affecting long-term outcome of irradiation in carcinoma of the vagina. Int J Radiat Oncol Biol Phys, 1999. 44(1): p. 37-45.
11. Chyle, V., et al., Definitive radiotherapy for carcinoma of the vagina: outcome and prognostic factors. Int J Radiat Oncol Biol Phys, 1996. 35(5): p. 891-905.
12. Mock, U., et al., High-dose-rate (HDR) brachytherapy with or without external beam radiotherapy in the treatment of primary vaginal carcinoma: long-term result s and side effects. Int J Radiat Oncol Biol Phys, 2003. 56(4): p. 950-7.
13. Dalrymple, J.L., et al., Chemoradiation for primary invasive squamous carcinoma of the vagina. Int J Gynecol Cancer, 2004. 14(1): p. 110-7.
14. Tjalma, W.A., et al., The role of surgery in invasive squamous carcinoma of the vagina. Gynecol Oncol, 2001. 81(3): p. 360-5.
15. International Society for the Study of Vulvovaginal Disease. Vulvar cancer FAQs. Accessed 2006
16. Cooper, A.L., et al., Is cytologic screening an effective surveillance method for detection of vaginal recurrence of uterine cancer? Obstet Gynecol, 2006. 107(1): p. 71-6.
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17. Baldwin, P.J., et al., Vaccinia-expressed human papillomavirus 16 and 18 e6 and e7 as a therapeutic vaccination for vulval and vaginal intraepithelial neoplasia. Clin Cancer Res, 2003. 9(14): p. 5205-13.

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