Vaginal Cancer Treatment- Cancer/Oncology

Vaginal Cancer Treatment (PDQ®)–Patient Version was originally published by the National Cancer Institute.

KEY POINTS

• Vaginal cancer is a disease in which malignant (cancer) cells form in the vagina.
• Age and being exposed to the drug DES (diethylstilbestrol) before birth affect a woman’s risk of vaginal cancer.
• Signs and symptoms of vaginal cancer include pain or abnormal vaginal bleeding.
• Tests that examine the vagina and other organs in the pelvis are used to detect (find) and diagnose vaginal cancer.
• Certain factors affect prognosis (chance of recovery) and treatment options.

Vaginal cancer is a disease in which malignant (cancer) cells form in the vagina.

The vagina is the canal leading from the cervix (the opening of uterus) to the outside of the body. At birth, a baby passes out of the body through the vagina (also called the birth canal).

Vaginal cancer is not common. There are two main types of vaginal cancer:

• Squamous cell carcinoma: Cancer that forms in squamous cells, the thin, flat cells lining the vagina. Squamous cell vaginal cancer spreads slowly and usually stays near the vagina, but may spread to the lungs, liver, or bone. This is the most common type of vaginal cancer.
• Adenocarcinoma: Cancer that begins in glandular cells. Glandular cells in the lining of the vagina make and release fluids such as mucus. Adenocarcinoma is more likely than squamous cell cancer to spread to the lungs and lymph nodes. A rare type of adenocarcinoma is linked to being exposed to diethylstilbestrol(DES) before birth. Adenocarcinomas that are not linked with being exposed to DES are most common in women after menopause.

Age and being exposed to the drug DES (diethylstilbestrol) before birth affect a woman’s risk of vaginal cancer.

Anything that increases your risk of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Risk factors for vaginal cancer include the following:

• Being aged 60 or older.
• Being exposed to DES while in the mother's womb. In the 1950s, the drug DES was given to some pregnantwomen to prevent miscarriage (premature birth of a fetus that cannot survive). Women who were exposed to DES before birth have an increased risk of vaginal cancer. Some of these women develop a rare form of vaginal cancer called clear cell adenocarcinoma.
• Having human papilloma virus (HPV) infection.
• Having a history of abnormal cells in the cervix or cervical cancer.
• Having a history of abnormal cells in the uterus or cancer of the uterus.
• Having had a hysterectomy for health problems that affect the uterus.

Signs and symptoms of vaginal cancer include pain or abnormal vaginal bleeding.

Vaginal cancer often does not cause early signs or symptoms. It may be found during a routine pelvic examand Pap test. Signs and symptoms may be caused by vaginal cancer or by other conditions. Check with your doctor if you have any of the following:

• Bleeding or discharge not related to menstrual periods.
• Pain during sexual intercourse.
• Pain in the pelvic area.
• A lump in the vagina.
• Pain when urinating.
• Constipation.

Tests that examine the vagina and other organs in the pelvis are used to detect (find) and diagnose vaginal cancer.

The following tests and procedures may be used:

• Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
• Pelvic exam: An exam of the vagina, cervix, uterus, fallopian tubes, ovaries, and rectum. A speculum is inserted into the vagina and the doctor or nurse looks at the vagina and cervix for signs of disease. A Pap test of the cervix is usually done. The doctor or nurse also inserts one or two lubricated, gloved fingers of one hand into the vagina and places the other hand over the lower abdomen to feel the size, shape, and position of the uterus and ovaries. The doctor or nurse also inserts a lubricated, gloved finger into the rectum to feel for lumps or abnormal areas.
• Pap test: A procedure to collect cells from the surface of the cervix and vagina. A piece of cotton, a brush, or a small wooden stick is used to gently scrape cells from the cervix and vagina. The cells are viewed under a microscope to find out if they are abnormal. This procedure is also called a Pap smear.

• Colposcopy : A procedure in which a colposcope (a lighted, magnifying instrument) is used to check the vagina and cervix for abnormal areas. Tissue samples may be taken using a curette (spoon-shaped instrument) or a brush and checked under a microscope for signs of disease.
• Biopsy : The removal of cells or tissues from the vagina and cervix so they can be viewed under a microscope by a pathologist to check for signs of cancer. If a Pap test shows abnormal cells in the vagina, a biopsy may be done during a colposcopy.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) depends on the following:

• The stage of the cancer (whether it is in the vagina only or has spread to other areas).
• The size of the tumor.
• The grade of tumor cells (how different they look from normal cells under a microscope).
• Where the cancer is within the vagina.
• Whether there are signs or symptoms at diagnosis.
• The patient's age and general health.
• Whether the cancer has just been diagnosed or has recurred (come back).

When found in early stages, vaginal cancer can often be cured.

Treatment options depend on the following:

• The stage and size of the cancer.
• Whether the cancer is close to other organs that may be damaged by treatment.
• Whether the tumor is made up of squamous cells or is an adenocarcinoma.
• Whether the patient has a uterus or has had a hysterectomy.
• Whether the patient has had past radiation treatment to the pelvis.

Stages of Vaginal Cancer

KEY POINTS

• After vaginal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the vagina or to other parts of the body.
• There are three ways that cancer spreads in the body.
• Cancer may spread from where it began to other parts of the body.
• In vaginal intraepithelial neoplasia (VAIN), abnormal cells are found in tissue lining the inside of the vagina.
• The following stages are used for vaginal cancer:
  • Stage I
  • Stage II
  • Stage III
  • Stage IV

After vaginal cancer has been diagnosed, tests are done to find out if cancer cells have spread within the vagina or to other parts of the body.

The process used to find out if cancer has spread within the vagina or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following procedures may be used in the staging process:

• Chest x-ray : An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body.
• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging (NMRI).
• PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radioactive glucose (sugar) is injected into a vein. The PET scanner rotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells do.
• Cystoscopy : A procedure to look inside the bladder and urethra to check for abnormal areas. A cystoscopeis inserted through the urethra into the bladder. A cystoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue samples, which are checked under a microscope for signs of cancer.
• Ureteroscopy : A procedure to look inside the ureters to check for abnormal areas. A ureteroscope is inserted through the bladder and into the ureters. A ureteroscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue to be checked under a microscope for signs of disease. A ureteroscopy and cystoscopy may be done during the same procedure.

• Proctoscopy : A procedure to look inside the rectum to check for abnormal areas. A proctoscope is inserted through the rectum. A proctoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue to be checked under a microscope for signs of disease.
• Biopsy : A biopsy may be done to find out if cancer has spread to the cervix. A sample of tissue is removed from the cervix and viewed under a microscope. A biopsy that removes only a small amount of tissue is usually done in the doctor’s office. A cone biopsy (removal of a larger, cone-shaped piece of tissue from the cervix and cervical canal) is usually done in the hospital. A biopsy of the vulva may also be done to see if cancer has spread there.

There are three ways that cancer spreads in the body.

Cancer can spread through tissue, the lymph system, and the blood:

• Tissue. The cancer spreads from where it began by growing into nearby areas.
• Lymph system. The cancer spreads from where it began by getting into the lymph system. The cancer travels through the lymph vessels to other parts of the body.
• Blood. The cancer spreads from where it began by getting into the blood. The cancer travels through the blood vessels to other parts of the body.

Cancer may spread from where it began to other parts of the body.

When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.

• Lymph system. The cancer gets into the lymph system, travels through the lymph vessels, and forms a tumor (metastatic tumor) in another part of the body.
• Blood. The cancer gets into the blood, travels through the blood vessels, and forms a tumor (metastatic tumor) in another part of the body.

The metastatic tumor is the same type of cancer as the primary tumor. For example, if vaginal cancer spreads to the lung, the cancer cells in the lung are actually vaginal cancer cells. The disease is metastatic vaginal cancer, not lung cancer.

In vaginal intraepithelial neoplasia (VAIN), abnormal cells are found in tissue lining the inside of the vagina.

These abnormal cells are not cancer. Vaginal intraepithelial neoplasia (VAIN) is grouped based on how deep the abnormal cells are in the tissue lining the vagina:

• VAIN 1: Abnormal cells are found in the outermost one third of the tissue lining the vagina.
• VAIN 2: Abnormal cells are found in the outermost two-thirds of the tissue lining the vagina.
• VAIN 3: Abnormal cells are found in more than two-thirds of the tissue lining the vagina. When abnormal cells are found throughout the tissue lining, it is called carcinoma in situ.

VAIN may become cancer and spread into the vaginal wall. VAIN is sometimes called stage 0.

The following stages are used for vaginal cancer:

Stage I

In stage I, cancer is found in the vaginal wall only.

Stage II

In stage II, cancer has spread through the wall of the vagina to the tissue around the vagina. Cancer has not spread to the wall of the pelvis.

Stage III

In stage III, cancer has spread to the wall of the pelvis.

Stage IV

Stage IV is divided into stage IVA and stage IVB:

• Stage IVA: Cancer may have spread to one or more of the following areas:
  • The lining of the bladder.
  • The lining of the rectum.
  • Beyond the area of the pelvis that has the bladder, uterus, ovaries, and cervix.
• Stage IVB: Cancer has spread to parts of the body that are not near the vagina, such as the lung or bone.

Recurrent Vaginal Cancer

Recurrent vaginal cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the vagina or in other parts of the body.

Treatment Option Overview

KEY POINTS

• There are different types of treatment for patients with vaginal cancer.
• Three types of standard treatment are used:
  • Surgery
  • Radiation therapy
  • Chemotherapy
• New types of treatment are being tested in clinical trials.
  • Radiosensitizers
• Treatment for vaginal cancer may cause side effects.
• Patients may want to think about taking part in a clinical trial.
• Patients can enter clinical trials before, during, or after starting their cancer treatment.
• Follow-up tests may be needed.

There are different types of treatment for patients with vaginal cancer.

Different types of treatments are available for patients with vaginal cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.

Three types of standard treatment are used:

Surgery

Surgery is the most common treatment of vaginal cancer. The following surgical procedures may be used:

• Laser surgery: A surgical procedure that uses a laser beam (a narrow beam of intense light) as a knife to make bloodless cuts in tissue or to remove a surface lesion such as a tumor.
• Wide local excision: A surgical procedure that takes out the cancer and some of the healthy tissue around it.
• Vaginectomy: Surgery to remove all or part of the vagina.
• Total hysterectomy: Surgery to remove the uterus, including the cervix. If the uterus and cervix are taken out through the vagina, the operation is called a vaginal hysterectomy. If the uterus and cervix are taken out through a large incision (cut) in the abdomen, the operation is called a total abdominal hysterectomy. If the uterus and cervix are taken out through a small incision in the abdomen using a laparoscope, the operation is called a total laparoscopic hysterectomy.

Lymph node dissection: A surgical procedure in which lymph nodes are removed and a sample of tissue is checked under a microscope for signs of cancer. This procedure is also called lymphadenectomy. If the cancer is in the upper vagina, the pelvic lymph nodes may be removed. If the cancer is in the lower vagina, lymph nodes in the groin may be removed.

• Pelvic exenteration: Surgery to remove the lower colon, rectum, bladder, cervix, vagina, and ovaries. Nearby lymph nodes are also removed. Artificial openings (stoma) are made for urine and stool to flow from the body into a collection bag.

Skin grafting may follow surgery, to repair or reconstruct the vagina. Skin grafting is a surgical procedure in which skin is moved from one part of the body to another. A piece of healthy skin is taken from a part of the body that is usually hidden, such as the buttock or thigh, and used to repair or rebuild the area treated with surgery.

After the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given radiation therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.

Radiation therapy

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy:

• External radiation therapy uses a machine outside the body to send radiation toward the cancer.
• Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer.

The way the radiation therapy is given depends on the type and stage of the cancer being treated. External and internal radiation therapy are used to treat vaginal cancer and may also be used as palliative therapy to relieve symptoms and improve quality of life.

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can affect cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Topical chemotherapy for squamous cell vaginal cancer may be applied to the vagina in a cream or lotion.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI website.

Radiosensitizers

Radiosensitizers are drugs that make tumor cells more sensitive to radiation therapy. Combining radiation therapy with radiosensitizers may kill more tumor cells.

Treatment Options by Stage

Vaginal Intraepithelial Neoplasia (VAIN)

Treatment of vaginal intraepithelial neoplasia (VAIN) 1 is usually watchful waiting.

Treatment of VAIN 2 and 3 may include the following:

• Watchful waiting.
• Laser surgery.
• Wide local excision, with or without a skin graft.
• Partial or total vaginectomy, with or without a skin graft.
• Topical chemotherapy.
• Internal radiation therapy.
• A clinical trial of a new topical chemotherapy drug.

Stage I Vaginal Cancer

Treatment of stage I squamous cell vaginal cancer may include the following:

• Internal radiation therapy.
• External radiation therapy, especially for large tumors or the lymph nodes near tumors in the lower part of the vagina.
• Wide local excision or vaginectomy with vaginal reconstruction. Radiation therapy may be given after the surgery.
• Vaginectomy and lymph node dissection, with or without vaginal reconstruction. Radiation therapy may be given after the surgery.

Treatment of stage I vaginal adenocarcinoma may include the following:

• Vaginectomy, hysterectomy, and lymph node dissection. This may be followed by vaginal reconstruction and/or radiation therapy.
• Internal radiation therapy. External radiation therapy may also be given to the lymph nodes near tumors in the lower part of the vagina.
• A combination of therapies that may include wide local excision with or without lymph node dissection and internal radiation therapy.

Stage II Vaginal Cancer

Treatment of stage II vaginal cancer is the same for squamous cell cancer and adenocarcinoma. Treatment may include the following:

• Both internal and external radiation therapy to the vagina. External radiation therapy may also be given to the lymph nodes near tumors in the lower part of the vagina.
• Vaginectomy or pelvic exenteration. Internal and/or external radiation therapy may also be given.

Stage III Vaginal Cancer

Treatment of stage III vaginal cancer is the same for squamous cell cancer and adenocarcinoma. Treatment may include the following:

• External radiation therapy. Internal radiation therapy may also be given.
• Surgery (rare) followed by external radiation therapy. Internal radiation therapy may also be given.

Stage IVA Vaginal Cancer

Treatment of stage IVA vaginal cancer is the same for squamous cell cancer and adenocarcinoma. Treatment may include the following:

• External radiation therapy and/or internal radiation therapy.
• Surgery (rare) followed by external radiation therapy and/or internal radiation therapy.

Stage IVB Vaginal Cancer

Treatment of stage IVB vaginal cancer is the same for squamous cell cancer and adenocarcinoma. Treatment may include the following:

• Radiation therapy as palliative therapy, to relieve symptoms and improve the quality of life. Chemotherapy may also be given.
• A clinical trial of anticancer drugs and/or radiosensitizers.

Although no anticancer drugs have been shown to help patients with stage IVB vaginal cancer live longer, they are often treated with regimens used for cervical cancer. (See the PDQ summary on Cervical Cancer Treatment.)

Treatment Options for Recurrent Vaginal Cancer

Treatment of recurrent vaginal cancer may include the following:

• Pelvic exenteration.
• Radiation therapy.
• A clinical trial of anticancer drugs and/or radiosensitizers.

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