Vaginal cancer, or vaginal carcinoma, is one of the less common gynecological cancers. Secondary vaginal cancer (cancer that has spread from a different gynecological organ to the vagina) is more common than primary vaginal cancer (cancer that is first formed in the vagina). The symptoms of vaginal carcinoma often overlap with those of non-malignant gynecological conditions, and this makes early diagnosis challenging.
For early diagnosis, it is important for women to not ignore persistent gynecological symptoms and seek medical attention whenever necessary.
The vagina is a part of the female reproductive system. It is a muscular canal that connects the cervix and uterus with the vulva. Several types of cells are present in the vagina. These include parabasal cells, basal cells, intermediate cells, glandular cells, and superficial squamous flat cells. When one or more types of vaginal cells divide uncontrollably and form a tumor, it is referred to as vaginal cancer. Generally, vaginal carcinoma develops on the superficial vaginal lining. Women over 60 years of age or who are suffering from a human papillomavirus infection have a higher risk of developing this cancer.
Most cases of vaginal carcinoma are due to metastasis, i.e., cancer from another part of the body, especially from the reproductive organs, that spreads to the vagina. Primary vaginal cancer is rare. Vaginal carcinoma accounts for only 1% to 2% of all genital cancers found in women. The incidence rate of vaginal carcinoma in India is estimated to be 0.83/million population, while the mortality rate is estimated to be about 0.41/million population.
There are multiple vaginal cancer types depending on the type of cell and location from which they arise. The following are the different vaginal carcinoma types:
The following are more common vaginal cancer types are:
It is the most common vaginal cancer type, and 90% of the patients with primary vaginal carcinoma have squamous cell carcinoma. It begins in the flat, thin cells (the squamous cells) that are present in the lining of the vagina. Vaginal squamous cell carcinoma progresses slowly and is generally limited to the areas surrounding the vagina. However, in some cases, it may also spread to other organs, e.g., bones or lungs.
Glandular cells are present in the vagina that secrete mucus and lubricate the vagina. Adenocarcinoma of the vagina starts in these glandular cells. Vaginal adenocarcinoma is relatively more aggressive than squamous cell carcinoma and has a higher risk of spreading to lymph nodes and the lungs. It accounts for about 5–10% of vaginal cancers.
It is one of the vaginal cancer types, and it is often associated with prenatal exposure to diethylstilbestrol. However, certain studies have reported non-diethylstilbestrol clear cell carcinoma of the vagina as well. The most common site for occurrence is the anterior vaginal wall, although it may occur at any location in the vagina. Endometriosis of the peri-vaginal area and vagina may be considered a precursor for clear cell carcinoma in non-DES-exposed women.
Vaginal sarcoma occurs in the connective tissues and the muscles present in the vaginal wall. The most common vaginal sarcoma is rhabdomyosarcoma, which commonly occurs in children. Leiomyosarcoma generally occurs in women over the age of 50. In most cases, vaginal sarcoma is diagnosed in its advanced stages.
Melanoma of the vagina occurs in the melanocytes that give color to the skin. Patients with vaginal melanoma usually have a relatively poor prognosis. Symptoms of vaginal melanoma include abnormal vaginal bleeding, the presence of a palpable vaginal mass, and vaginal discharge. The average age for the diagnosis of vaginal melanoma is 55 years or older.
Some of the rare vaginal cancer types are:
It is extremely rare and has no established treatment. The treatment is often similar to small cell carcinoma of the lungs. It is a highly aggressive condition that has the potential to spread rapidly to other organs. Studies have reported that the survival rate for patients with small cell carcinoma is two years when the condition is treated in the early stages.
Undifferentiated carcinoma is usually diagnosed through biopsy. Undifferentiated carcinoma mostly comprises epithelial cells with scarce cytoplasm. Specific cellular differentiation is absent in the tumor cells. These tumors are rare but highly aggressive.
Vaginal cancer staging includes:
It refers to the earliest stage of vaginal carcinoma. It is also known as vaginal intraepithelial neoplasia, carcinoma-in-situ, or pre-cancer stage. In this stage, the cancerous lesions are present on the lining of the vagina and have not grown into the deeper vaginal tissues. Patients at this stage usually do not experience any symptoms.
In vaginal cancer stage 1, the tumor may spread to the deeper tissues of the vagina but has not spread outside the vagina.
In stage 2 vaginal cancer, the cancer spreads to the tissues surrounding the vagina but has not spread to the pelvic walls.
Stage 3 vaginal cancer is characterized by the spread of vaginal carcinoma to the nearby lymph nodes and/or walls of the pelvis.
Stage 4 vaginal cancer is divided into stages 4A and 4B. In stage 4A, the disease has spread to one or more locations among the bladder lining, rectal lining, and beyond the pelvic area, comprising the uterus, ovaries, bladder, and cervix.In stage 4B, the disease has spread to distant organs, such as bones or lungs.
Vaginal cancer symptoms may vary from one patient to another. The commonly observed symptoms include abnormal bleeding and discharge, pain and discomfort, rectal bleeding, problems related to urination, the presence of a lump, and unintended weight loss.
The exact cause of vaginal cancer is unknown. However, certain risk factors or possible vaginal cancer causes have been identified, and being associated with these factors can increase one’s vaginal cancer risk.
Vaginal cancer may occur in any woman. However, certain individuals have a higher chance of developing this cancer. Elderly women, women who smoke, or women who are prenatally exposed to diethylstilbestrol are more vulnerable to vaginal cancer. The risk of vaginal cancer is also high in women with a family or personal history of vaginal cancer, a history of human papillomavirus infection, a history of abnormal cervical cells, or a history of radiation exposure. Women with compromised immunity are also at risk for vaginal cancer.
Some of the common vaginal cancer symptoms are:
Patients with vaginal cancer experience abnormal vaginal bleeding, especially after sexual intercourse. The vaginal bleeding may occur in between the regular menstrual periods and after menopause.
One of the most common vaginal cancer symptoms is unusual vaginal discharge. The normal vaginal discharge is usually thin and milky white. However, the vaginal discharge in vaginal cancer patients is generally pale and thick and has a foul smell.
There is a feeling of pain or discomfort in patients with vaginal cancer. Pain may be consistent or intermittent and may also occur during sexual intercourse.
Patients with vaginal cancer have altered urination habits. These include painful urination, urinary urgency, and increased urination frequency.
Vaginal cancer symptoms also include altered bathroom habits, blood in urine or stools, and constipation.
Patients with vaginal cancer may also have a pelvic mass or lump, which is usually palpable. It is most commonly detected during the pelvic examination in patients suspected of vaginal cancer.
Pain in the lower back, legs, and pelvic region is also one of the vaginal cancer symptoms. The pain may progress to increased severity as the cancer progresses.
Weight loss and fatigue may also be caused by vaginal cancer. Patients with vaginal cancer may have a loss of appetite, leading to weight loss. Problems with the gastrointestinal system in advanced vaginal cancer may include reduced nutrient absorption, blocked bowel, difficulty swallowing, and a feeling of fullness.
Vaginal cancer types and their symptoms are:
Patients with vaginal squamous cell carcinoma experience abnormal vaginal bleeding, pelvic pain, a palpable lump in the vagina, thick or watery discharge, and lower back pain.
The symptoms of adenocarcinoma include abnormal vaginal bleeding, pelvic pain, pain during sexual intercourse, and fatigue.
Clear cell carcinoma symptoms include vaginal bleeding in postmenopausal women or in between the normal menstrual cycle, postcoital bleeding, and vaginal ulcer.
The symptoms of vaginal sarcoma include vaginal bleeding, the presence of vaginal mass, and difficulty in defecation.
Symptoms of vaginal melanoma include palpable vaginal mass, abnormal vaginal bleeding, vaginal discharge, and pain.
Symptoms of vaginal small cell carcinoma include a burning sensation during urination, vaginal mass, post-menopausal bleeding, and pain during sexual intercourse.
Symptoms of undifferentiated carcinoma include vaginal bleeding, pain during sexual intercourse, and the presence of a vaginal mass.
Patients often wonder, “What causes vaginal cancer?”. The exact cause of vaginal cancer is unknown. However, we do know that certain individuals have a higher risk due to the presence of certain factors. These factors could be called risk factors or possible causes. The following are identified as possible vaginal cancer causes:
HPV infection is identified as one of the potential vaginal cancer causes. It has been reported that HPV infection accounts for almost 70% of vaginal cancer cases. A study reported an association between HPV-16 infection and the occurrence of vaginal squamous cell carcinoma and vaginal intraepithelial neoplasia.
The risk of vaginal cancer increases with age. The average age for the diagnosis of vaginal squamous cell carcinoma is 60 years.
Patients with a history of cervical cancer or the presence of abnormal cervical cells may develop vaginal cancer. Such women need to undergo routine examinations.
Women who are prenatally exposed to diethylstilbestrol may develop vaginal clear cell adenocarcinoma. Women with established in-utero exposure should undergo lifelong vaginal and cervical cancer screening.
Tobacco contains almost 500 harmful chemicals, of which several are carcinogens and tumor promoters. Therefore, smoking is also identified as one of the possible vaginal cancer causes.
A compromised immune system is also identified as one of the potential vaginal cancer causes. The immune system plays a major role in detecting and destroying abnormal cells. A compromised immune system fails to kill abnormal vaginal cells, causing their growth and multiplication.
Women with a history of vaginal cancer, especially those diagnosed with advanced-stage vaginal cancer, may have a vaginal cancer recurrence. Women with a family history of vaginal cancer may also develop this disease.
A history of radiation therapy for other genitourinary cancers, such as bladder cancer, endometrial cancer, and cervical cancer, is one of the causes of vaginal cancer. It is due to radiation-induced mutations in healthy vaginal cells.
Several symptoms of vaginal cancer overlap with those of other gynecological conditions. One must consult a gynecologist if they start experiencing abnormal vaginal bleeding, vaginal discharge, pelvic or low back pain, loss of appetite, unexplained weight loss, and pain during or after sexual intercourse.
Vaginal cancer diagnosis and treatment demand a comprehensive approach, wherein various tests are recommended to diagnose vaginal cancer accurately before recommending a personalized treatment plan. Managing vaginal cancers through personalized treatment plans positively impacts treatment results, survival rates, and the quality of life after the treatment.
Vaginal cancer causes various symptoms; it is important to see a specialist when these symptoms are persistent. The diagnosis begins with a physical examination, which is then followed by a battery of tests for a conclusive diagnosis. The following are the different tests recommended for vaginal cancer diagnosis:
If the patients experience gynecological symptoms that may indicate serious conditions, they should immediately consult with experienced gynecologists. The patients may expect a comprehensive physical examination to determine the cause of the symptoms. The doctor may inquire about the initiation, progression, frequency, and severity of the symptoms. The doctor may also perform a pelvic examination to detect any abnormal masses in the vagina, cervix, rectum, and bladder. The patients may also undergo a medical history assessment, as women who have a history of vaginal cancer or HPV infection are at increased risk of developing vaginal cancer.
Women, especially those with a high risk of developing vaginal cancer, may undergo Pap smear tests, a rarely recommended test for vaginal cancer diagnosis. The test determines the presence of abnormal cells that can potentially transform into cancerous cells. During the Pap smear test, the cervical and vaginal smears are collected and analyzed in the laboratory. The HPV test is usually performed along with the Pap smear test. The samples obtained during the Pap smear test may also be checked for the presence of human papillomavirus. However, a Pap smear does not serve as a confirmatory test for a vaginal cancer diagnosis. It is always performed with other tests to arrive at a conclusive diagnosis.
A biopsy is the only method available for confirming a vaginal cancer diagnosis. The symptoms of vaginal cancer are similar to those of various other gynecological conditions, such as endometriosis. Thus, it is important to rule out the presence of serious and malignant conditions at an early stage. During a biopsy, a tissue sample from the vagina is obtained and evaluated under the microscope for the presence of cancerous cells. .
Vaginal ultrasound uses sound waves to obtain images of the vagina and surrounding organs. The doctors recommend transvaginal ultrasound, which involves inserting a probe into the vagina to obtain the images. Ultrasound may help to detect the abnormal mass present in the vaginal tissues. However, ultrasound cannot detect if the mass is benign or malignant. Thus, if the mass is detected on transvaginal ultrasound, the patients are advised to undergo additional tests, such as a biopsy.
An MRI scan may serve as an important tool in vaginal cancer diagnosis. It assists in diagnosing vaginal cancer, staging the disease, planning for treatment, and monitoring the treatment response. MRI is a commonly recommended imaging method for diagnosing various gynecological malignancies because of its high resolution for soft tissues. It also helps in determining the extent of the spread of vaginal cancer.
A CT scan also assists in vaginal cancer diagnosis. Not only does it help in determining the position and size of the tumor in the vagina, but it also helps in comprehensively evaluating the nearby tissues, including lymph nodes. To obtain clearer images, a contrast agent is injected before the CT. In some cases, CT is also used to guide the needle to obtain a sample of the abnormal tissues from the vagina or other parts (CT-guided biopsy).
A PET scan uses radioactive substances to diagnose vaginal cancer. When the radioactive sugar substance is injected into the patient's blood, it is preferentially taken up by the cancer cells due to their rapid metabolism. A special tracer device then detects the accumulation of the radioactive sugar substance. In some cases, a PET scan is combined with a CT scan to improve the quality of the images. As one of the most effective vaginal cancer tests, a PET scan plays an important role in staging the disease, detecting cancer metastasis, optimizing treatment strategy, and assessing treatment response.
Specialists recommend colposcopy in patients with abnormal Pap test or HPV test results. Colposcopy is done with the assistance of a colposcope that magnifies the superficial tissues of the vagina and the cervix. This is a painless procedure as there is no insertion of the instrument involved.
Personalized vaginal cancer treatment is planned once the diagnosis and stage of vaginal cancer are confirmed. Specialists also consider parameters like the patient’s age, overall health status, underlying medical conditions, and preferences while devising a treatment plan. The following are the different vaginal cancer treatment options available:
Surgery is one of the most common vaginal cancer treatments. In the early stages, especially when the disease is in a precancerous state, surgery is often recommended as a cure for vaginal cancer. Depending on the stage, vaginal cancer treatment may be unimodal (one treatment) or multimodal (a combination of different treatments). Surgery is often combined with chemotherapy, radiotherapy, and other treatments for better outcomes.
Surgery for vaginal cancer involves the removal of the abnormal tissues of the vagina, the vagina itself, and surrounding tissues of the vagina, depending on the stage of the disease.
Laser surgery is usually a non-invasive vaginal cancer treatment. It involves the use of high-energy radiation to vaporize and kill the abnormal cells. It is particularly effective in treating precancerous vaginal lesions; however, it is also used to treat large lesions. Laser surgery can be repeated if required and usually has mild side effects. It is not indicated for the treatment of invasive cancer.
Wide local excision involves removing the cancerous tissues and a small portion of surrounding healthy tissues, called the margin. It is a relatively less invasive procedure compared to traditional vaginal cancer surgery. However, this procedure is associated with a higher risk of recurrence. The border tissues are tested for cancer. If the border tissues are free from malignant cells, it is known as a clear margin. Obtaining a clear margin is important as it lowers the chances of vaginal cancer recurrence.
Vaginectomy is removing part of the vagina (partial vaginectomy) or the complete vagina (complete vaginectomy). The type of vaginectomy performed, partial or complete, depends upon the extent of cancer spread in the vagina. After the removal of the vagina, the doctor may recommend vaginal reconstruction surgery. During this surgery, the doctor takes muscles and skin from another part of the body to reconstruct the vagina. In cases of advanced-stage vaginal cancer, the doctor may also advise the removal of surrounding organs in addition to the vagina.
This procedure involves the removal of several organs in the pelvic region. Pelvic exenteration is recommended for advanced-stage vaginal cancers. It is also recommended if the cancer recurs or the patient does not respond to conservative therapy. During this procedure, the surgeon removes the ovaries, uterus, bladder, rectum, vagina, and fallopian tubes. If necessary, alternate pathways may be created for expelling urine and fecal matter out of the body after the procedure.
Radiation therapy for vaginal cancer uses high-energy, ionizing radiation to kill cancer cells. It is usually combined with surgery or chemotherapy for better treatment results. There are two types of radiation therapy, i.e., external beam radiation therapy and brachytherapy. Usually, a combination of both types is used. Brachytherapy may be administered at a low dose rate or a high dose rate, depending on the extent of the cancer.
Chemotherapy for vaginal cancer involves the administration of anti-cancer drugs to kill the cancer cells by interfering with vital steps of their cell cycle. It is a commonly recommended treatment for metastatic vaginal cancer and is generally combined with surgery and radiation therapy. The drugs are administered orally, topically, or through injection. When used before surgery, it shrinks the tumor. It may also be used after the surgery to kill the residual cancer cells.
There are several vital proteins and enzymes present in cancer cells that assist them in growth and proliferation. As one of the latest vaginal cancer treatments, targeted therapy interferes with the functioning of these substances and prevents the division, growth, and proliferation of cancer cells.
The immune system is the main protective barrier to cancer, as it identifies and kills abnormal cells in the body. However, cancer cells have certain molecular mechanisms that help them hide from the immune system. Immunotherapy drugs interfere with these mechanisms and make cancer cells more vulnerable to the attacks launched by the immune system. Further, immunotherapy drugs also strengthen the immune system.
Palliative care is recommended for patients with terminal vaginal cancer. The goal of palliative care is to manage the symptoms and discomfort caused by the disease and improve the quality of life. Palliative care may involve the administration of surgery, chemotherapy, and radiation therapy. The palliative care team comprises oncologists, physicians, nurses, and other experienced and trained professionals.
As a leading cancer treatment hospital in India, HCG Cancer Hospital has a dedicated department for the screening, diagnosis, treatment, and management of vaginal cancer. The hospital is equipped with all the testing facilities under a single roof for the timely diagnosis of vaginal cancer. The operation theater is equipped with advanced facilities to perform complex surgeries to treat vaginal cancer. The multidisciplinary team at HCG comprises medical oncologists, oncology surgeons, gynecologists, radiation therapists, experienced nurses, and paramedical staff, and these specialists carefully go through each case before recommending a treatment plan.
Certain women are more susceptible to vaginal cancer than others. This is because they carry a higher risk due to their association with certain factors. It is possible to modify one’s vaginal cancer risk by adopting certain lifestyle changes. While these measures can help bring down one’s risk of developing vaginal cancer, they do not prevent it.
Various factors contribute to the increased risk of vaginal cancer. Some factors are lifestyle-related and are modifiable, while others are not related to the lifestyle and therefore are not modifiable. The following are the important vaginal cancer risk factors:
HPV infection is one of the biggest vaginal cancer risk factors. Reports suggest that HPV infection is the cause of almost 70% of primary vaginal cancer cases. HPV has the potential to induce genetic changes in the vaginal cells. If these abnormal changes are not detected and removed in the early stages, they have the potential to progress to cancer.
Increasing age is another important vaginal cancer risk factor. Although vaginal cancer may occur in women of any age, it is most commonly found in elderly women. It has been estimated that almost 50% of the vaginal cancer cases are diagnosed in women over the age of 70 years.
A history of cervical cancer also increases vaginal cancer risk. A study reported that a history of cervical precancer was present in 23.5% of vaginal cancer patients, and a history of cervical cancer was present in about 71% of the patients with vaginal cancer. It is possibly because the underlying risk factors for cervical and vaginal cancer are similar. Similarly, the history of vulvar cancer also enhances the vaginal cancer risk.
Radiation therapy is another vaginal cancer risk factor. Radiation therapy is a treatment modality for various types of cancers, including pelvic cancers, such as cancers of the bladder, ovaries, uterus, fallopian tube, and cervix. While treating one or more of these cancers, the healthy vaginal cells are also exposed to high-energy radiation. Radiation may cause genetic changes in the vaginal cells, which may lead to their uncontrolled growth and proliferation.
Women who smoke are twice at increased risk of vaginal cancer than women who do not smoke. Several substances present in cigarette smoke have the potential to cause cancer through DNA damage.
Alcohol also increases the vaginal cancer risk. Studies suggest that women who consume alcohol are at a higher risk of developing vaginal cancer than those who do not.
The immune system plays a vital role in protecting the body against cancers. A healthy immune system detects abnormal cells and kills them through an immune response. However, a compromised immune system is unable to kill these abnormal cells resulting in an increased risk of developing cancer.
DES was used between 1940 and 1971 for prevention of miscarriage. Women who were prenatally exposed to DES (DES daughters) are at increased risk for developing vaginal cancer than women who are not exposed. DES daughters have a relatively higher risk of developing clear cell adenocarcinoma of the vagina than that of the cervix. Further, the risk of vaginal cancer is highest in those DES daughters who were exposed to the drug during the initial 16 weeks of pregnancy.
100% vaginal cancer prevention is not possible. This is because we do not know the exact cause of this cancer type. That said, it is possible to reduce the risk of vaginal cancer with certain lifestyle modifications. The following are some of the important vaginal cancer prevention measures:
As HPV infection is one of the most common vaginal cancer risk factors, getting vaccinated with the HPV vaccine is considered one of the most effective vaginal cancer prevention methods.
Vaginal cancer begins with the formation of precancerous lesions. It means that the abnormal cells occur at the initial stage, and when they are not detected and treated appropriately, they lead to cancer formation. Thus, it is important for women, especially those at high risk for vaginal cancer, to undergo regular Pap smear tests to look for the presence of precancerous cells in the vaginal lining. Pap smear is an effective method for vaginal cancer prevention. Those with precancerous lesions in their cervix are at a higher risk for vaginal cancer. Therefore, it is important to opt for Pap tests regularly or as recommended by the gynecologist.
Avoiding smoking reduces the risk of vaginal cancer by lowering the body’s exposure to harmful carcinogens. It not only lowers vaginal cancer risk but significantly reduces the risk of other cancers, including lung and bladder cancer.
It is important to practice safe sex to lower the vaginal cancer risk. Practicing safer sex lowers the risk of HPV infection, as this infection may also spread through sexual activity, such as anal, vaginal, and oral sex. To increase the chances of vaginal cancer prevention, it is thus advisable to use condoms while engaging in sexual activity.
Following a healthy lifestyle and a standard immunization schedule is also an effective vaginal cancer prevention measure. Limiting the consumption of alcohol and daily exercise improves the overall health status. Further, a healthy diet has a direct effect on strengthening the immune system.
Women, especially those who are at increased risk for gynecological cancers, should be aware of various symptoms. If persistent symptoms are experienced, it is important to see a gynecologist to determine the cause of the symptoms.
Regular health check-ups, especially for the elderly, are also important, as certain chronic conditions also reduce the body's ability to fight against abnormal cells. A regular health check-up also helps determine one’s vaginal cancer risk.
Vaginal carcinoma is a cancer that occurs in the vagina. Primary vaginal carcinoma is rare, and most vaginal carcinomas are due to metastasis (spread from other organs). Vaginal cancer types include squamous cell carcinoma, adenocarcinoma, sarcoma, vaginal melanoma, vaginal small cell carcinoma, and undifferentiated carcinoma. Stages of vaginal cancer range from 0 to 4. Stage 0 is considered precancerous, while stage 4 is the most advanced stage of vaginal carcinoma.
