Cancer of the Vagina - Treatment

Contents

Treatment

Because vaginal cancer is rare, no uniform standard of treatment has been developed. Treatment recommendations are based on the results of small studies and of experience with other types of squamous cell carcinomas. The rate of positive lymph nodes in all stages varies between 30% and 40% and the incidence of positive lymph nodes in early stage vaginal carcinoma is not known. 

Surgery

The value of surgery is limited because it would require a very radical operation to achieve surgical margins clear of tumour. However, there might be a role for surgery in the following circumstances:

1. Patients with small lesions (especially in the upper one third of the vagina) might benefit from a radical hysterectomy (plus vaginal cuff) and a bilateral lymphadenectomy (for staging reasons). 
2. Patients with vaginal melanoma or vaginal sarcoma
3. Patients who are for radiotherapy may undergo an ovarian transposition or a lymph node dissection (staging or debulking) prior to commencement of radiotherapy
4. Patients presenting with a fistula (rectal involvement) may also require surgical intervention
5. Patients with central recurrence may be candidates for an exenteration

Radiotherapy

Vaginal cancer is generally considered radiosensitive. Radiotherapy usually comprises brachytherapy to the vagina with or without external beam radiation to the pelvis. Morbidity due to vaginal vault brachytherapy is usually very low and includes vaginal stenosis and dyspareunia. Radiotherapy given to the pelvis is associated with a risk of side effects to the bladder and the rectum (sterile cystitis, proctitis) and sometimes to the intestine (diarrhea, cramps). Severe side effects are rare and can be treated.

Chemotherapy

There is only very limited information on the impact of concurrent chemotherapy as an adjunct to radiotherapy. However, when we extrapolate the data from cervical cancer or from vulval cancer, concurrent chemoradiation with Cisplatin or 5-fluoruracil might be effective. There is no proven role for chemotherapy as a single modality treatment in vaginal cancer.

Adenocarcinoma

Adenocarcinomas comprise about 9% of all vaginal cancers. Clear cell adenocarcinoma was reported to be significantly associated with prenatal exposure to Diethylstilbestrol (DES). The risk of developing clear cell adenocarcinoma following DES exposure is estimated to be about 1:1000. DES was used in the 1950's and 1960's for maintaining high-risk pregnancies although the use in Australia was far less than in the United States of America.

Characteristically patients with DES-related vaginal carcinoma are very young with a mean age of 19 years (range 14 to 33 years). In addition to clear cell adenocarcinoma of the vagina, some more benign and structural abnormalities of the female genital tract can be detected in those women. 

Treatment: Even in small lesions, surgery should be followed by radiotherapy in order to minimise the risk for local recurrence. The risk of positive pelvic lymph nodes in patients with clinical stage I vaginal clear cell adenocarcinoma is 16%. This justifies a routine pelvic lymphadenectomy in these patients. 

Dr Andreas Obermair, MD
Associate Professor of Gynecology and Obstetrics,
University of Vienna
Clinical Fellow, Gynaecologic Oncology,Queensland Centre for Gynaecological Cancer.

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