Vaginal cancer medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Therapeutic alternatives depend on stage; surgery or radiation therapy is highly effective in early stages, while radiation therapy is the primary treatment of more advanced stages. Chemotherapy has not been shown to be curative for advanced vaginal cancer, and there are no standard drug regimens.

Therapies based on stage

Stage 0 Vaginal Cancer

Squamous Cell Carcinoma In Situ

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.

Standard treatment options:

• Wide local excision with or without skin grafting.
• Partial or total vaginectomy with skin grafting for multifocal or extensive disease.
• 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.
• Laser therapy.
• Intracavitary radiation therapy delivering 60 Gy to 70 Gy to the mucosa. The entire vaginal mucosa should be treated.

Stage I Vaginal Cancer

Squamous Cell Carcinoma

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:

• 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). 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.
• 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.

Standard treatment options for lesions greater than 0.5 cm thick:

• 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. 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.
• 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. 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.

Adenocarcinoma

Standard treatment options:

• 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. In cases with close or positive surgical margins, adjuvant radiation therapy should be considered.
• Intracavitary and interstitial radiation as previously described for squamous cell cancer. 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.
• Combined local therapy in selected cases, which may include wide local excision, lymph node sampling, and interstitial therapy.

Stage II Vaginal Cancer

Squamous Cell Carcinoma

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

Standard treatment options:

• 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. 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.
• Radical surgery (radical vaginectomy or pelvic exenteration) with or without radiation therapy.

Adenocarcinoma

Standard treatment options:

• Combination of brachytherapy and EBRT to deliver a combined dose of 70 Gy to 80 Gy to the primary tumor. 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.
• Radical surgery (radical vaginectomy or pelvic exenteration) with or without radiation therapy.

Stage III Vaginal Cancer

Squamous Cell Carcinoma

Standard treatment options:

• 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.
• Rarely, surgery may be combined with the above.

Adenocarcinoma

Standard treatment options:

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

Stage IVA Vaginal Cancer

Squamous Cell Carcinoma

Standard treatment options:

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

Adenocarcinoma

Standard treatment options:

• Combination of interstitial, intracavitary, and EBRT.
• Rarely, surgery may be combined with the above.

Stage IVB Vaginal Cancer

Squamous Cell Carcinoma

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.

Adenocarcinoma

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.

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. 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.