Clinical investigations
Vagina
Definitive radiation therapy for squamous cell carcinoma of the vagina

Presented at the 45th Annual Meeting of the American Society of Therapeutic Radiology and Oncology, Salt Lake City, UT, October 18–23, 2003.
https://doi.org/10.1016/j.ijrobp.2004.09.032Get rights and content

Purpose: To evaluate outcome and describe clinical treatment guidelines for patients with primary squamous cell carcinoma of the vagina treated with definitive radiation therapy.

Methods and Materials: Between 1970 and 2000, a total of 193 patients were treated with definitive radiation therapy for squamous cell carcinoma of the vagina at The University of Texas M. D. Anderson Cancer Center. The patients’ medical records were reviewed to obtain information about patient, tumor, and treatment characteristics, as well as outcome and patterns of recurrence. Surviving patients were followed for a median of 137 months. Survival rates were calculated using the Kaplan-Meier method, with differences assessed using log-rank tests.

Results: Disease-specific survival (DSS) and pelvic disease control rates correlated with International Federation of Gynecology and Obstetrics (FIGO) stage and tumor size. At 5 years, DSS rates were 85% for the 50 patients with Stage I, 78% for the 97 patients with Stage II, and 58% for the 46 patients with Stage III–IVA disease (p = 0.0013). Five-year DSS rates were 82% and 60% for patients with tumors ≤4 cm or >4 cm, respectively (p = 0.0001). At 5 years, pelvic disease control rates were 86% for Stage I, 84% for Stage II, and 71% for Stage III–IVA (p = 0.027). The predominant mode of relapse after definitive radiation therapy was local-regional (68% and 83%, respectively, for patients with stages I–II or III–IVA disease). The incidence of major complications was correlated with FIGO stage; at 5 years, the rates of major complications were 4% for Stage I, 9% for Stage II, and 21% for Stage III–IVA (p < 0.01).

Conclusions: Excellent outcomes can be achieved with definitive radiation therapy for invasive squamous cell carcinoma of the vagina. However, to achieve these results, treatment must be individualized according to the site and size of the tumor at presentation and the response to initial external-beam radiation therapy. Brachytherapy plays an important role in the treatment of many vaginal cancers but should be carefully selected and applied to obtain optimal coverage of the target volume.

Introduction

Vaginal carcinomas are rare, comprising only 2% of gynecologic malignancies. Treatment of vaginal carcinomas poses special challenges to the multidisciplinary team, because the techniques used to treat them are highly specialized and because the distribution of disease in the vagina and paravaginal tissues has an important influence on the type of treatment needed to obtain the best results. Because of the vagina’s close proximity to critical structures, cancers arising in this area are rarely amenable to curative organ-sparing surgery; fortunately, radiation therapy is an effective treatment and is currently used to treat most patients with invasive vaginal cancers.

The rarity of vaginal cancer makes it a difficult subject for study. To our knowledge, there have been no prospective randomized trials of vaginal cancer treatment. Most retrospective studies have been small or have included patients who had rare, nonsquamous cancers or a previous history of treatment for cervical or other gynecologic malignancies. During the last 50 years, there have been several retrospective reviews of the experience with vaginal cancer at The University of Texas M. D. Anderson Cancer Center (1, 2, 3, 4, 5). Most recently, Chyle et al. (3) reported results of radical radiation therapy in patients treated between 1953 and 1991. Although that series was relatively large, it included patients treated before high-energy accelerators were available and patients who had in situ disease or adenocarcinoma or presented with a previous history of invasive cervical cancer. The purpose of this report is to update our institutional experience, focusing on patients with primary invasive squamous cell carcinoma of the vagina who had not previously been treated for gynecologic malignancies, and to suggest guidelines for treatment of these rare cancers.

Section snippets

Patients

The medical records, including clinical notes and tumor diagrams, of all patients treated with definitive radiation therapy for primary invasive squamous cell carcinoma of the vagina at M. D. Anderson Cancer Center between January 1970 and December 2000 were reviewed retrospectively. Patients whose tumors involved the vulva or extended to the external os of the cervix were excluded (6). Patients who had noninvasive carcinoma of the vagina (i.e., in situ disease) or nonsquamous histologic

Patient and tumor characteristics

The pretreatment characteristics of the 193 patients included in this analysis are summarized in Table 3. The median age was 61 years (range, 31–92 years). The most common presenting symptom was vaginal bleeding, which was present in 104 patients (54%); 39 patients (20%) presented with vaginal discharge, and 30 patients (16%) presented with vaginal pain or dyspareunia. One hundred twenty-one patients (63%) had had a previous hysterectomy for benign or preinvasive disease (20%); the most common

Discussion

This report describes the largest single-institution study of definitive radiation therapy for patients with invasive squamous cell carcinoma of the vagina without a prior history of an invasive gynecologic malignancy. Although other authors (1, 2, 3, 4, 5) have described results of radiation therapy in patients treated with radiation for vaginal cancer, the small size and heterogeneity of their study populations have often made it difficult to generalize their conclusions to current practice.

References (26)

  • R.G. Stock et al.

    A 30-year experience in the management of primary carcinoma of the vaginaAnalysis of prognostic factors and treatment modalities

    Gynecol Oncol

    (1995)
  • G.R. Brown et al.

    Irradiation of ‘in-situ’ and invasive squamous cell carcinoma of the vagina

    Cancer

    (1971)
  • P.M. Chau

    Radiotherapeutic management of malignant tumors of the vagina

    AJR Am J Roentgenol

    (1963)
  • Cited by (161)

    • Role of radiotherapy in the treatment of primary vaginal cancer: Recommendations of the French society for radiation oncology

      2022, Cancer/Radiotherapie
      Citation Excerpt :

      In addition, the probability of complications is also greater due to vaginal fragility and patients often suffer comorbidities (elderly age). In older retrospective cohorts that did not include three-dimensional brachytherapy, the probability of specific survival rates were around 75 to 85% at five years for early stage tumours [stages I and II according to the International federation of gynaecology and obstetrics (FIGO) classification] and 50 to 60% for stages III-IV [6–8]. The FIGO classification of vaginal cancers, 2018 version, is shown in Table I [9].

    • Role of adjuvant and post-surgical treatment in gynaecological cancer

      2022, Best Practice and Research: Clinical Obstetrics and Gynaecology
    View all citing articles on Scopus
    View full text