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Vaginal cancer is usually a squamous cell carcinoma involving the posterior wall of the upper third of the vagina. It may directly invade the bladder or rectum. Lesions may be ulcerative or exophytic.
Those in the upper vagina metastasise in a similar way to cervical carcinoma - eg, regional lymph nodes and para-aortic nodes. Those in the middle can invade in either direction. Tumours in the lower third metastasise mainly to inguinal nodes.
The distinction between squamous cell carcinoma and adenocarcinoma is important because the two types represent distinct diseases, each with a different pathogenesis and natural history:
- Approximately 85% of cases of primary vaginal cancer are squamous cell vaginal cancer. This initially spreads superficially within the vaginal wall and later invades the paravaginal tissues and the parametria. Distant metastases occur most commonly in the lungs and liver.
- Approximately 10% of cases of primary vaginal cancer are adenocarcinoma. This has a peak incidence between 17 and 21 years of age and differs from squamous cell carcinoma by an increase in pulmonary metastases and supraclavicular and pelvic node involvement.
- 80% of vaginal carcinoma is metastatic spread, such as from the urethra, bladder, Bartholin's gland, rectum, endometrium, kidney, ovary or endocervix.
Rarely, melanoma and sarcoma are described as primary vaginal cancers.
Adenosquamous carcinoma is a rare and aggressive mixed epithelial tumour comprising approximately 1-2% of cases. Clear cell adenocarcinomas plus vaginal adenosis are most often associated with in utero exposure to diethylstilbestrol.
Primary vaginal cancer can only be diagnosed if the cervix is uninvolved or only minimally involved by tumour obviously of vaginal origin. Where malignancy involves both the cervix and vagina and histology indicates either origin, then it is conventionally denoted as a cervical carcinoma.
Vaginal cancer is a rare cancer in the UK, accounting for around 1% of all gynaecological cancers.
HIV-positive women have more vaginal intraepithelial lesions compared with negative controls. In a recent study, the incidence of vulval, vaginal or anal intraepithelial neoplasia was 1.96 per 100 person-years for the HIV-infected women and 0.26 per 100 person-years for the control women.
- Vaginal bleeding or bloody discharge may be seen.
- Advanced tumours may affect the rectum or bladder, or extend to the pelvic wall, causing pain or leg oedema.
- Colposcopy; because vaginal intraepithelial neoplasia (VAIN) is associated with other genital neoplasias, the cervix (when present) and vulva should be examined carefully.
- Biopsy, cervical cytology, endometrial biopsy.
- CT scan.
- Fluorodeoxyglucose-positron emission tomography (FDG-PET) - may be more sensitive than CT scanning.
- Cystoscopy, sigmoidoscopy.
- Stage 0 - squamous cell carcinoma in situ; this disease is usually multifocal and commonly occurs at the vaginal vault.
- Stage I - the disease is limited to the vaginal wall mucosa.
- Stage II - the disease involves the subvaginal tissue, but not the pelvic wall.
- Stage III - the disease extends to pelvic wall.
- Stage IV - the disease either extends beyond the true pelvis or involves the bladder or rectal mucosa:
- Stage IVA - the disease has spread to adjacent organs.
- Stage IVB - the disease has spread to distant organs.
Treatment options depend on tumour stage; surgery and radiotherapy are very effective in early-stage disease, whereas radiation therapy is the primary treatment for more advanced stages. Chemotherapy has not been shown to be curative for advanced vaginal cancer; there are no standard drug regimens.
Carbon dioxide laser is a safe and effective tool in premalignant disease. Sexual function is not compromised.
Stage I and some stage II patients may undergo radical hysterectomy with removal of the upper vagina.
There is limited evidence on the feasibility of conservative surgery in women aged under 40 years, wishing to preserve sexual and reproductive function. In one report, four women are disease-free at 51 months' follow-up after tumour removal and pelvic lymphadenopathy with subsequent radiotherapy.
Prognosis depends primarily on the stage of disease, but survival is reduced in patients who:
- Are older than 60 years of age.
- Are symptomatic at the time of diagnosis.
- Have lesions of the middle and lower third of the vagina.
- Have adenocarcinoma rather than squamous cell carcinoma.
- Have poorly differentiated tumours.
The length of vaginal wall involvement and stage of disease have been found to be significantly correlated to survival in squamous cell carcinoma patients.
Further reading and references
Gynaecological cancer - suspected; NICE CKS, July 2005 (UK access only)
Vaginal cancer statistics; Cancer Research UK
Jamieson DJ, Paramsothy P, Cu-Uvin S, et al; Vulvar, vaginal, and perianal intraepithelial neoplasia in women with or at risk for human immunodeficiency virus. Obstet Gynecol. 2006 May
Lamoreaux WT, Grigsby PW, Dehdashti F, et al; FDG-PET evaluation of vaginal carcinoma. Int J Radiat Oncol Biol Phys. 2005 Jul 162(3):733-7.
General Information About Vaginal Cancer; (US) National Cancer Institute
Cutillo G, Cignini P, Pizzi G, et al; Conservative treatment of reproductive and sexual function in young woman with squamous carcinoma of the vagina. Gynecol Oncol. 2006 Apr 2
Otton GR, Nicklin JL, Dickie GJ, et al; Early-stage vaginal carcinoma--an analysis of 70 patients. Int J Gynecol Cancer. 2004 Mar-Apr14(2):304-10.