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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.[1] 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]

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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.[4] 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.

Radiation-induced damage to nearby organs may include:[2,3]

  • Rectovaginal fistulas.
  • Vesicovaginal fistulas.
  • Rectal or vaginal strictures.
  • Cystitis.
  • Proctitis.
  • 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]

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