http://www.cs.nsw.gov.au/cancer/sgog/Vagina_Guide.htm
General Considerations

Invasive carcinoma of the vagina is an uncommon tumour constituting less
than 2% of all gynecological malignancies. The incidence is only 1/30th of
that of cervical cancer. The age incidence is higher than cervical cancer
(reports of mean age vary from 51-65) but the symptoms bear close
resemblance. Squamous carcinoma is the predominant histological type.
Adenocarcinoma (including those in young females exposed to DES in utero)
melanoma, sarcoma and embryonal rhabdomyosarcoma in children are rare. The
majority of malignant vaginal tumors result from metastases or extension
from nearby organs. There is increasing evidence that vaginal cancer is
associated with infection with high risk HPV types. However the
progression from the preinvasive form (VAIN III) to invasive cancer is
much less common (<5%) and the time course for such progression is
unknown. It is sometimes found in association with multifocal preinvasive
disease of the lower genital tract in young women, particularly in
smokers(150).

Squamous vaginal cancers are usually located in the upper one-third of the
vagina on the posterior wall. Lesions may be exophytic or endophytic with
surface ulceration occurring late in the course of the disease (151).
Vaginal cancers are staged clinically (Appendix A). Spread usually occurs
by direct extension to pelvic soft tissues, pelvic bones, bladder and
rectum. The upper third of the vagina is thought to drain in a way similar
to that of the cervix, i.e. to the pelvic nodes, whereas the lower third
simulates that of the vulva, i.e. to the inguinal nodes. The middle third
may drain either way. Despite the theoretical existence of such a simple
stratification, the true picture would appear to be more complicated.
There is little information on the incidence of lymph node metastases in
vaginal cancer as most patients are not surgically staged. Haematogenous
dissemination to distant organs including lungs liver and bone is a late
phenomenon.

Survival is stage dependent with stage I patients having a 75%, stage IIA
55%, stage IIB 43% and stage III 32% and stage IV 0% survival(152).
Treatment

Due to the relative rarity of this condition, most centres tend to
individualize therapy. The close proximity of the bladder and rectum
present special problems in management. The predominant mode of therapy is
a combination of interstitial, intracavitary and external high voltage
pelvic irradiation with surgery being reserved for early stage disease and
the treatment of recurrences (153, 154).
Surgery

Surgery has a limited role in the management of patients with vaginal
cancer. Small lesions involving the upper vagina may be treated by radical
hysterectomy and vaginectomy and pelvic lymphadenectomy. In young patients
requiring radiation therapy ovarian transposition and possible surgical
staging with node dissection may be appropriate. Consideration may be
given to construction of a neovagina in younger patients managed
surgically.

Patients with stage IVa disease particularly if a rectovaginal or
vesicovaginal fistula is present or with central recurrence after
radiation therapy, may if suitable be managed by primary pelvic
exenteration.
Chemotherapy

To date there have been few reports on the role of chemotherapy in the
management of vaginal tumours. In squamous tumours, chemotherapy regimens
similar to those used for cervical squamous carcinoma seem plausible. In
tumours with rare histology, treatment should be individualized. Some of
these rare tumours in young patients that are chemosensitive may be
managed primarily with chemotherapy allowing preservation of fertility.
Radiation Therapy

Generally due to advanced aged and poor performance status of patients
with vaginal carcinoma, radiation therapy comprising an integration of
teletherapy and intracavitary/interstitial therapy remains the treatment
of choice.  If the lower third of vagina is involved then groin nodes
should also be treated or dissected. If the uterus is intact and the
lesion involves the upper vagina, an intrauterine tandem and ovoids can be
used. Complications of irradiation include radiation cystitis,
vesicovaginal and rectovaginal fistulae and stenosis of vagina, urethra
and rectum  (152-154).

Other Cancers of the Vagina...