Vaginal squamous cell carcinoma is the most common type of primary vaginal cancer, which is overall very rare. Symptomatic patients frequently report painless vaginal bleeding and dysuria. The diagnosis is based on the patient's history, physical exam, and the appropriate studies. To definitively achieve a diagnosis of primary vaginal cancer, other origins must be ruled out.
Primary vaginal carcinomas compose approximately 1 to 2% of all malignant gynecologic neoplasms  . Squamous cell carcinoma is the most common type of primary vaginal cancer. This malignancy mainly affects women above the age of 60  . Risk factors for primary vaginal cancer include HPV infection, of which subtypes 16 and 18 are common with the former being the most prevalent   . Other predisposing factors include high-risk sexual behaviors, smoking, the coexistence of other sexually transmitted infections (STIs), the presence of high-grade vaginal intraepithelial neoplasia (VaIN), history of cervical cancer, low socioeconomic status, and immunosuppression.
The clinical picture is most significant for painless vaginal bleeding , which may be found in up to 80% of patients. The bleeding is typically postmenopausal, which is reflective of the age group. However, the bleeding may be in the form of menorrhagia or postcoital bleeding. Other possible manifestations include dysuria, hematuria, vaginal discharge, and pelvic pain. Anterior lesions are consistent with urinary symptoms while posterior masses can cause constipation. A minority of patients will experience vaginal prolapse or report a vaginal mass. Asymptomatic patients with early stages of cancer could be discovered during routine gynecological exams.
The symptoms are averagely present for 6 to 12 months prior to diagnosis. Recognition is delayed since the cancer is rare. The definitive diagnosis, according to the International Federation of Gynecology and Obstetrics (FIGO), is based on confirming that vaginal cancer does not stem from other origins . Also, women with a prior gynecologic cancer should be cancer-free for 5 years to receive a diagnosis of vaginal cancer .
The components of the physical exam include visualization of the outside structures such as the labia, inspection of the cervix and particular inspection of the anterior and posterior wall of the vagina with the aid of a speculum, and palpation of the vagina. Masses appear as ulcerating, fungating, or annular.
The assessment for women who are symptomatic and those with incidental findings includes the patient's personal and detailed family history , a complete physical exam, and the appropriate studies.
Key components of the workup include studies that exclude more common malignancies such as cervical cancer. The Pap smear is a routine cervical cancer screening test that is obtained periodically or when indicated. Abnormal cervical or vaginal Pap test results warrant further investigation with colposcopy, which could rule out the cervical origin and allows visual inspection of the vagina and biopsies if needed. Note that any lesion should be biopsied.
Blood levels of tumor markers such as CA-125, CA-19-9, tumor antigen-4, and carcinoembryonic antigen should be obtained .
Staging of vaginal cancer according to FIGO is based on physical exam findings, chest radiography, cystoscopy, and proctoscopy. Magnetic resonance imaging (MRI) of the abdomen and pelvis, positron emission tomography-computed tomography (PET-CT), and chest computed tomography (CT) evaluate for metastatic disease . Specifically, CT and MRI reveal findings such as an involvement of lymph nodes, metastases to the liver and other organs, hydronephrosis, and ureteral compression. Skeletal X-rays are performed in patients reporting the bone pain.