Increased susceptibility to carcinogenesis caused by radiation therapy be considered at risk. Therefore, in addition to screening cytology, careful bimanual examination of the entire vagina and vulva is recommended for women at high risk.
Symptoms Painless vaginal bleeding and discharge are the most common symptoms of vaginal cancer. With more advanced tumors, urinary retention, bladder spasm, hematuria, and frequency of urination may occur. In a large series, 14% were asymptomatic and diagnosis was made by routine examination or abnormal cytology (206). Tumors developing on the posterior vaginal wall may produce rectal symptoms, such as tenesmus, constipation, or blood in the stool.
Diagnosis The diagnostic workup includes a complete history and physical examination, careful speculum examination and palpation of the vagina, and bimanual pelvic and rectal examinations. It is important to rotate the speculum to obtain a careful view of the entire vagina because posterior wall lesions frequently occur and may be overlooked.
In early squamous cell lesions, the diagnosis is often suggested by an abnormal Pap test result; however, this is not true for clear cell adenocarcinomas, which are characterized by submucosal growth. In these cases, the diagnosis is suggested by cytologic findings in only 33% of cases. Visually suspicious areas in the vagina should be evaluated with a targeted biopsy using the same instruments as those used for cervical biopsies. Careful palpation of the vagina may be helpful in detecting submucosal irregularities. The most common site of vaginal cancer is in the upper one-third of the vagina on the posterior wall. The developing tumor may be missed during initial inspection because of obscured visualization caused by the blades of the speculum (214). Colposcopy is valuable in evaluating patients with abnormal Pap test results, unexplained vaginal bleeding, or ulcerated erythematous patches in the upper vagina. A colposcopically targeted biopsy may not allow a definitive diagnosis, and a partial vaginectomy may be necessary to determine invasion. Occult invasive carcinoma may be detected by such an excision, particularly in patients who have a history of prior hysterectomy in whom the vaginal vault closure may bury some of the vaginal epithelium at risk for cancer (215).
Pathology Cancer of the vagina spreads most often by direct extension into the pelvic soft tissues and adjacent organs. Metastases to the pelvic and para-aortic lymph nodes may occur in advanced disease. Lesions in the lower one-third of the vagina may spread directly to the inguinal femoral lymph nodes and the pelvic nodes (216). Hematogenous dissemination to the lungs, liver, or bone may occur as a late phenomenon.
Squamous cell carcinomas are the most common form of vaginal cancer, occurring in 80% to 90% of cases. These tumors most commonly occur in the upper one-third, posterior wall of the vagina. The mean age of patients with squamous cell cancer is 60 years (217,218). Malignant melanoma is the second most common cancer of the vagina, accounting for 2.8% to 5% of all vaginal neoplasms (219–221). Other histologic subtypes include adenocarcinoma and sarcoma.