Treatment Option Overview
Roles of Radiation, Surgery, and Chemotherapy
Given the rarity of vaginal carcinoma, studies are limited to retrospective case series that may span a number of years, usually from single-referral institutions.[Level of evidence 3iiiD] Comparison of different treatment approaches is further complicated by the frequent failure of investigators to provide precise staging criteria (particularly for stage I vs. stage II disease) or criteria for the choice of treatment modality. This has led to a broad range of reported disease control and survival rates for any given stage and treatment modality. In addition, given the long time span covered by these case series, there are often changes within a given case series in the available staging tests and radiation techniques, including the shift to high-energy accelerators and conformal- and intensity-modulated radiation.[2,3]
Factors to be considered in planning therapy for vaginal cancer include:
- Stage and size of the lesion.
- Proximity to radiosensitive organs or organs that preclude radical resection without unacceptable functional deficits (e.g., bladder, rectum, urethra).
- Ability to retain a functional vagina.
- Presence or absence of the uterus.
- Whether there has been prior pelvic radiation therapy.
In a series of 100 women studied retrospectively over 30 years, 50% had undergone hysterectomy prior to the diagnosis of vaginal cancer. In this posthysterectomy group, 31 of 50 (62%) women developed cancers limited to the upper third of the vagina. In women who had not previously undergone hysterectomy, upper vaginal lesions were found in only 17 of 50 (34%) women.
The lymphatics may drain to pelvic or inguinal nodes or both, depending on tumor location, and consideration should be given to these areas in treatment planning.
- Rectovaginal fistulas.
- Vesicovaginal fistulas.
- Rectal or vaginal strictures.
- Premature menopause from ovarian damage.
- Soft tissue or bone necrosis.
The proximity of the vagina to the bladder or rectum also limits surgical treatment options and increases short- and long-term surgical complications and functional deficits involving these organs.
For patients with carcinoma of the vagina in its early stages, radiation or surgery or a combination of these treatments are standard treatment. Data from randomized trials are lacking and the choice of therapy is generally determined by institutional experience and the factors listed above. For patients with stages III and IVA disease, radiation therapy is standard and includes external-beam radiation, alone or with brachytherapy. Regional lymph nodes are included in the radiation portal. When used alone, external-beam radiation involves a 60 Gy to 70 Gy tumor dose, using shrinking fields, delivered within 6 to 7 weeks. Intracavitary brachytherapy provides insufficient dose penetration for locally advanced tumors, so interstitial brachytherapy (75 Gy–85 Gy) is used if brachytherapy is employed.[1,5]
Local control is a problem with bulky tumors. In recent years, some investigators have also used concurrent chemotherapy with agents such as cisplatin, bleomycin, mitomycin-C, floxuridine, and vincristine; but this practice has not been proven to improve outcomes. It is an extrapolation from treatment approaches used in cervical cancer, based on shared etiologic and risk factors.
For patients with stage IVB or recurrent disease that cannot be managed with local treatments, current therapy is inadequate. No established anticancer drugs can be considered of proven clinical benefit, although patients are often treated with regimens used to treat cervical cancer. (Refer to the PDQ summary on Cervical Cancer Treatment for more information.)
Concurrent chemotherapy, using 5-fluorouracil or cisplatin-based therapy, and radiation are sometimes advocated, again based solely on extrapolation from cervical cancer management strategies.[6-8] Experience is limited to small case series and the incremental impact on survival and local control is not well defined.[Level of evidence 3iiiDiv] Because of the rarity of these patients, they should be considered candidates for clinical trials of anticancer drugs and/or radiosensitizers to attempt to improve survival or local control.
Management of the extremely rare vaginal clear cell carcinoma is generally similar to the management of squamous cell carcinoma, though techniques that preserve vaginal and ovarian function are given strong consideration in treatment planning, given the young average age at diagnosis.
In light of the many uncertainties about the relative efficacy of treatment approaches, ongoing clinical trials should be discussed with patients if they are eligible. Information about ongoing clinical trials is available from the NCI Web site.Post-therapy Surveillance
As is the case with other gynecologic malignancies, the evidence base for surveillance after initial management of vaginal cancer is weak because of a lack of randomized, or even prospective, clinical studies. There is no reliable evidence that routine cytologic or imaging procedures in patients improve health outcomes beyond what is achieved by careful physical examination and assessment of new symptoms. Therefore, outside the investigational setting, imaging procedures may be reserved for patients in whom physical examination or symptoms raise clinical suspicion of a recurrence or progression.References
- Eifel PJ, Berek JS, Markman MA: Cancer of the cervix, vagina, and vulva. In: DeVita VT Jr, Lawrence TS, Rosenberg SA: Cancer: Principles and Practice of Oncology. 9th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2011, pp 1311-44.
- Frank SJ, Jhingran A, Levenback C, et al.: Definitive radiation therapy for squamous cell carcinoma of the vagina. Int J Radiat Oncol Biol Phys 62 (1): 138-47, 2005. [PUBMED Abstract]
- Tran PT, Su Z, Lee P, et al.: Prognostic factors for outcomes and complications for primary squamous cell carcinoma of the vagina treated with radiation. Gynecol Oncol 105 (3): 641-9, 2007. [PUBMED Abstract]
- Stock RG, Chen AS, Seski J: A 30-year experience in the management of primary carcinoma of the vagina: analysis of prognostic factors and treatment modalities. Gynecol Oncol 56 (1): 45-52, 1995. [PUBMED Abstract]
- Chyle V, Zagars GK, Wheeler JA, et al.: Definitive radiotherapy for carcinoma of the vagina: outcome and prognostic factors. Int J Radiat Oncol Biol Phys 35 (5): 891-905, 1996. [PUBMED Abstract]
- Grigsby PW: Vaginal cancer. Curr Treat Options Oncol 3 (2): 125-30, 2002. [PUBMED Abstract]
- Dalrymple JL, Russell AH, Lee SW, et al.: Chemoradiation for primary invasive squamous carcinoma of the vagina. Int J Gynecol Cancer 14 (1): 110-7, 2004 Jan-Feb. [PUBMED Abstract]
- Samant R, Lau B, E C, et al.: Primary vaginal cancer treated with concurrent chemoradiation using Cis-platinum. Int J Radiat Oncol Biol Phys 69 (3): 746-50, 2007. [PUBMED Abstract]
- Senekjian EK, Frey KW, Anderson D, et al.: Local therapy in stage I clear cell adenocarcinoma of the vagina. Cancer 60 (6): 1319-24, 1987. [PUBMED Abstract]
- Salani R, Backes FJ, Fung MF, et al.: Posttreatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncologists recommendations. Am J Obstet Gynecol 204 (6): 466-78, 2011. [PUBMED Abstract]