Stage Information for Vaginal Cancer

Note: The American Joint Committee on Cancer has recently published a new edition of the AJCC Cancer Staging Manual, which includes revisions to the staging for this disease. The PDQ Adult Treatment Editorial Board, which is responsible for maintaining this summary, is currently reviewing the new staging to determine the changes that need to be made in the summary. In addition to updating this Stage Information section, additional changes may need to be made to other parts of this summary to ensure that it is up-to-date. The changes will be made as soon as possible.

Cervical biopsies are mandatory to rule out carcinoma of the cervix. Carcinoma of the vulva should also be ruled out.

Stages are defined by the Federation Internationale de Gynecologie et d’Obstetrique (FIGO) and the American Joint Committee on Cancer’s (AJCC) TNM classification.[1] The definitions of the T categories correspond to the stages accepted by the FIGO, and both systems are included for comparison.

TNM Categories/FIGO Stages

Primary tumor (T)

• TX: Primary tumor cannot be assessed
• T0: No evidence of primary tumor
• Tis/ 0: Carcinoma in situ
• T1/I: Tumor confined to vagina
• T2/II: Tumor invades paravaginal tissues but not to pelvic wall*
• T3/III: Tumor extends to pelvic wall*
• T4/IVA: Tumor invades mucosa of the bladder or rectum and/or extends beyond the true pelvis (Bullous edema is not sufficient evidence to classify a tumor as T4.)

* [Note: Pelvic wall is defined as muscle, facia, neurovascular structures, or skeletal portions of the bony pelvis.]

Regional lymph nodes (N)

• NX: Regional nodes cannot be assessed
• N0: No regional lymph node metastasis
• N1/IVB: Pelvic or inguinal lymph node metastasis

Distant metastasis (M)

• MX: Distant metastasis cannot be assessed
• M0: No distant metastasis
• M1/IVB: Distant metastasis

Stage 0

• Tis, N0, M0

Stage I

• T1, N0, M0

Stage II

• T2, N0, M0

Stage III

• T1, N1, M0
• T2, N1, M0
• T3, N0, M0
• T3, N1, M0

Stage IVA

• T4, any N, M0

Stage IVB

• Any T, any N, M1

References

1. Vagina. In: American Joint Committee on Cancer.: AJCC Cancer Staging Manual. 6th ed. New York, NY: Springer, 2002, pp 251-257. 
   
   

Treatment Option Overview

Factors to be considered in planning therapy for vaginal cancer are:

• Stage, size, and location of the lesion.
• Presence or absence of the uterus.
• Whether there has been prior pelvic radiation therapy.

In a large series of women studied retrospectively for 30 years, 50% had undergone hysterectomy prior to the diagnosis of vaginal cancer.[1] 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. The proximity of the vagina to the bladder or rectum limits treatment options and increases complications involving these organs. For patients with carcinoma of the vagina in its early stages, standard treatment applied by gynecologic oncologists or radiation oncologists is highly effective. For patients with stages III and IVA disease, radiation therapy alone is standard. For patients with stage IVB disease, current therapy is inadequate, and no established anticancer drugs can be considered standard treatment. Considering the rarity of such patients, they should be considered candidates for clinical trials using anticancer drugs and/or radiosensitizers to attempt to improve survival or local control.

Information about ongoing clinical trials is available from the NCI Web site.

References

1. 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]
   
   

Stage 0 Vaginal Cancer

This disease is usually multifocal and commonly occurs at the vaginal vault. Because vaginal intraepithelial neoplasia (VAIN) is associated with other genital neoplasias, the cervix (when present) and vulva should be carefully examined. The treatments listed below produce equivalent cure rates. The selection of treatment depends on patient factors and local expertise (e.g., anatomical distortion of the vaginal vault [related to wall closure at the time of hysterectomy] requires excision for technical reasons to exclude the possibility of invasion by buried disease). Lesions with hyperkeratosis respond better to excision or laser vaporization than to fluorouracil.[1]

Standard treatment options:

1. Wide local excision with or without skin grafting.
2. Partial or total vaginectomy with skin grafting for multifocal or extensive disease.
3. Intravaginal chemotherapy with 5% fluorouracil cream. Instillation of 1.5 g weekly for 10 weeks has been found to be as effective as more frequent use.[2]
4. Laser therapy.[2]
5. Intracavitary radiation therapy delivering 60 Gy to 70 Gy to the mucosa.[3,4] The entire vaginal mucosa should be treated.[5]

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage 0 vaginal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References

1. Wright VC, Chapman W: Intraepithelial neoplasia of the lower female genital tract: etiology, investigation, and management. Semin Surg Oncol 8 (4): 180-90, 1992 Jul-Aug.  [PUBMED Abstract]
   
   
2. Krebs HB: Treatment of vaginal intraepithelial neoplasia with laser and topical 5-fluorouracil. Obstet Gynecol 73 (4): 657-60, 1989.  [PUBMED Abstract]
   
   
3. Perez CA, Camel HM, Galakatos AE, et al.: Definitive irradiation in carcinoma of the vagina: long-term evaluation of results. Int J Radiat Oncol Biol Phys 15 (6): 1283-90, 1988.  [PUBMED Abstract]
   
   
4. Woodman CB, Mould JJ, Jordan JA: Radiotherapy in the management of vaginal intraepithelial neoplasia after hysterectomy. Br J Obstet Gynaecol 95 (10): 976-9, 1988.  [PUBMED Abstract]
   
   
5. Perez CA, Garipagaoglu M: Vagina. In: Perez CA, Brady LW, eds.: Principles and Practice of Radiation Oncology. 3rd ed. Philadelphia, Pa: Lippincott-Raven Publishers, 1998, pp 1891-1914. 
   
   

Stage I Vaginal Cancer

The treatments listed below produce equivalent cure rates. The selection of treatment depends on patient factors and local expertise.

Standard treatment options for superficial lesions less than 0.5 cm thick:

1. Intracavitary radiation therapy. In most instances, 60 Gy to 70 Gy prescribed to 0.5 cm is delivered to the tumor for 5 to 7 days (external-beam radiation therapy [EBRT] is required for bulky lesions).[1] For lesions of the lower third of the vagina, elective radiation therapy of 45 Gy to 50 Gy is given to pelvic and/or inguinal lymph nodes.[1]
2. Surgery. Wide local excision or total vaginectomy with vaginal reconstruction, especially in lesions of the upper vagina. In cases with close or positive surgical margins, adjuvant radiation therapy should be considered.[2]

Standard treatment options for lesions greater than 0.5 cm thick:

1. Surgery. In lesions of the upper third of the vagina, radical vaginectomy and pelvic lymphadenectomy should be performed. Construction of a neovagina may be performed if feasible and if desired by the patient.[2,3] In lesions of the lower third, inguinal lymphadenectomy should be performed. In cases with close or positive surgical margins, adjuvant radiation therapy should be considered.[2]
2. Radiation therapy. Combination of interstitial (single-plane implant) and intracavitary therapy to a dose of at least 75 Gy to the primary tumor. In addition to brachytherapy, EBRT is advocated for poorly differentiated or infiltrating tumors that may have a higher probability of lymph node metastasis.[1,4] For lesions of the lower third of the vagina, elective radiation therapy of 45 Gy to 50 Gy is given to the pelvic and/or inguinal lymph nodes.[1]

Standard treatment options:

1. Surgery. Because the tumor spreads subepithelially, total radical vaginectomy and hysterectomy with lymph node dissection are indicated. The deep pelvic nodes are dissected if the lesion invades the upper vagina, and the inguinal nodes are removed if the lesion originates in the lower vagina. Construction of a neovagina may be performed if feasible and if desired by the patient.[2] In cases with close or positive surgical margins, adjuvant radiation therapy should be considered.[2,3]
2. Intracavitary and interstitial radiation as previously described for squamous cell cancer.[1] For lesions of the lower third of the vagina, elective radiation therapy of 45 Gy to 50 Gy is given to the pelvic and/or inguinal lymph nodes.[1]
3. Combined local therapy in selected cases, which may include wide local excision, lymph node sampling, and interstitial therapy.[5]

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I vaginal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References

1. Perez CA, Camel HM, Galakatos AE, et al.: Definitive irradiation in carcinoma of the vagina: long-term evaluation of results. Int J Radiat Oncol Biol Phys 15 (6): 1283-90, 1988.  [PUBMED Abstract]
   
   
2. 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]
   
   
3. Rubin SC, Young J, Mikuta JJ: Squamous carcinoma of the vagina: treatment, complications, and long-term follow-up. Gynecol Oncol 20 (3): 346-53, 1985.  [PUBMED Abstract]
   
   
4. Andersen ES: Primary carcinoma of the vagina: a study of 29 cases. Gynecol Oncol 33 (3): 317-20, 1989.  [PUBMED Abstract]
   
   
5. 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]
   
   

Stage II Vaginal Cancer

Radiation therapy is the standard treatment for patients with stage II vaginal carcinoma.

Standard treatment options:

1. Combination of brachytherapy and external-beam radiation therapy (EBRT) to deliver a combined dose of 70 Gy to 80 Gy to the primary tumor volume.[1] For lesions of the lower third of the vagina, elective radiation therapy of 45 Gy to 50 Gy is given to the pelvic and/or inguinal lymph nodes.[1,2]
2. Radical surgery (radical vaginectomy or pelvic exenteration) with or without radiation therapy.[3,4]

Standard treatment options:

1. Combination of brachytherapy and EBRT to deliver a combined dose of 70 Gy to 80 Gy to the primary tumor.[1] For lesions of the lower third of the vagina, elective radiation therapy of 45 Gy to 50 Gy is given to the pelvic and/or inguinal lymph nodes.[1,2]
2. Radical surgery (radical vaginectomy or pelvic exenteration) with or without radiation therapy.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage II vaginal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References

1. Perez CA, Camel HM, Galakatos AE, et al.: Definitive irradiation in carcinoma of the vagina: long-term evaluation of results. Int J Radiat Oncol Biol Phys 15 (6): 1283-90, 1988.  [PUBMED Abstract]
   
   
2. Andersen ES: Primary carcinoma of the vagina: a study of 29 cases. Gynecol Oncol 33 (3): 317-20, 1989.  [PUBMED Abstract]
   
   
3. Rubin SC, Young J, Mikuta JJ: Squamous carcinoma of the vagina: treatment, complications, and long-term follow-up. Gynecol Oncol 20 (3): 346-53, 1985.  [PUBMED Abstract]
   
   
4. 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]
   
   

Stage III Vaginal Cancer

Standard treatment options:

1. Combination of interstitial, intracavitary, and external-beam radiation therapy (EBRT). EBRT for a period of 5 to 6 weeks (including pelvic nodes) followed by an interstitial and/or intracavitary implant for a total tumor dose of 75 Gy to 80 Gy and a dose to the lateral pelvic wall of 55 Gy to 60 Gy.[1]
2. Rarely, surgery may be combined with the above.[2]

Standard treatment options:

1. Combination of interstitial, intracavitary, and EBRT as described for squamous cell cancer.[1]
2. Rarely, surgery may be combined with the above.[2]

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage III vaginal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References

1. Perez CA, Camel HM, Galakatos AE, et al.: Definitive irradiation in carcinoma of the vagina: long-term evaluation of results. Int J Radiat Oncol Biol Phys 15 (6): 1283-90, 1988.  [PUBMED Abstract]
   
   
2. Boronow RC, Hickman BT, Reagan MT, et al.: Combined therapy as an alternative to exenteration for locally advanced vulvovaginal cancer. II. Results, complications, and dosimetric and surgical considerations. Am J Clin Oncol 10 (2): 171-81, 1987.  [PUBMED Abstract]
   
   

Stage IVA Vaginal Cancer

Standard treatment options:

1. Combination of interstitial, intracavitary, and external-beam radiation therapy (EBRT).[1]
2. Rarely, surgery may be combined with the above.[2]

Standard treatment options:

1. Combination of interstitial, intracavitary, and EBRT.[1]
2. Rarely, surgery may be combined with the above.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IVA vaginal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References

1. Perez CA, Camel HM, Galakatos AE, et al.: Definitive irradiation in carcinoma of the vagina: long-term evaluation of results. Int J Radiat Oncol Biol Phys 15 (6): 1283-90, 1988.  [PUBMED Abstract]
   
   
2. Boronow RC, Hickman BT, Reagan MT, et al.: Combined therapy as an alternative to exenteration for locally advanced vulvovaginal cancer. II. Results, complications, and dosimetric and surgical considerations. Am J Clin Oncol 10 (2): 171-81, 1987.  [PUBMED Abstract]
   
   

Stage IVB Vaginal Cancer

Patients should be considered candidates for one of the ongoing clinical trials to improve therapeutic results. Standard treatment is inadequate.

Standard treatment options:

• Radiation (for palliation of symptoms) with or without chemotherapy.

Patients should be considered candidates for one of the ongoing clinical trials to improve therapeutic results.

Standard treatment options:

• Radiation (for palliation of symptoms) with or without chemotherapy.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IVB vaginal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

Recurrent Vaginal Cancer

Recurrence carries a grave prognosis. In a large series only five of fifty patients with recurrence were salvaged by surgery or radiation therapy. All five of these salvaged patients originally presented with stage I or II disease and failed in the central pelvis.[1] Most recurrences are in the first 2 years after treatment. In centrally recurrent vaginal cancers, some patients may be candidates for pelvic exenteration or radiation therapy. Neither cisplatin nor mitoxantrone has significant activity in recurrent or advanced squamous cell cancer. There is no standard chemotherapy.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent vaginal cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References

1. 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]
   
   

Changes to This Summary (07/28/2011)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

General Information About Vaginal Cancer

Updated statistics with estimated new cancer cases and deaths for 2011 (cited American Cancer Society as reference 1).

About This PDQ Summary

This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of vaginal cancer. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.

This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).

Board members review recently published articles each month to determine whether an article should:

• be discussed at a meeting,
• be cited with text, or
• replace or update an existing article that is already cited.

Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.

The lead reviewers for Vaginal Cancer Treatment are:

• Leslie R. Boyd, MD (New York University Medical Center)
• Franco M. Muggia, MD (New York University Medical Center)

Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.

Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.

PDQ is a registered trademark. Although the content of PDQ documents can be used freely as text, it cannot be identified as an NCI PDQ cancer information summary unless it is presented in its entirety and is regularly updated. However, an author would be permitted to write a sentence such as “NCI’s PDQ cancer information summary about breast cancer prevention states the risks succinctly: [include excerpt from the summary].”

The preferred citation for this PDQ summary is:

National Cancer Institute: PDQ® Vaginal Cancer Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/treatment/vaginal/HealthProfessional. Accessed <MM/DD/YYYY>.

Images in this summary are used with permission of the author(s), artist, and/or publisher for use within the PDQ summaries only. Permission to use images outside the context of PDQ information must be obtained from the owner(s) and cannot be granted by the National Cancer Institute. Information about using the illustrations in this summary, along with many other cancer-related images, is available in Visuals Online, a collection of over 2,000 scientific images.

Based on the strength of the available evidence, treatment options may be described as either “standard” or “under clinical evaluation.” These classifications should not be used as a basis for insurance reimbursement determinations. More information on insurance coverage is available on Cancer.gov on the Coping with Cancer: Financial, Insurance, and Legal Information page.

More information about contacting us or receiving help with the Cancer.gov Web site can be found on our Contact Us for Help page. Questions can also be submitted to Cancer.gov through the Web site’s Contact Form.