Background
Retrospective single-institution series, MD Anderson. N=193, primary squamous cell carcinoma of the vagina treated with definitive RT, 1970-2000. Stages I-IVA. EBRT to pelvis (± para-aortic nodes) followed by brachytherapy (intracavitary or interstitial); subset received concurrent chemotherapy. One of the largest single-institution RT series in primary vaginal cancer.
Interventions and follow up
Treatment: Definitive EBRT ± para-aortic nodes + brachytherapy boost (intracavitary or interstitial), ± concurrent chemotherapy
Primary endpoint: Locoregional control, cause-specific survival, overall survival by stage
mFollow up: Median ~7 yr
Primary endpoint: Locoregional control, cause-specific survival, overall survival by stage
mFollow up: Median ~7 yr
Results
5yr locoregional control: ~78% overall; Stage I ~90%, Stage II ~75%, Stage III/IVA ~55%
5yr CSS: ~60% overall
5yr OS: ~52% overall
Brachytherapy type: interstitial associated with improved control for tumors >4 cm or involving middle/lower third of vagina
5yr CSS: ~60% overall
5yr OS: ~52% overall
Brachytherapy type: interstitial associated with improved control for tumors >4 cm or involving middle/lower third of vagina
Adverse events
Grade 3-4 late complications: ~10-15%
Fistula: rectovaginal ~4%, vesicovaginal ~3%
Other: bowel obstruction ~3%; vaginal stenosis common (usually grade 1-2)
Risk factors: higher total doses and prior pelvic surgery
Fistula: rectovaginal ~4%, vesicovaginal ~3%
Other: bowel obstruction ~3%; vaginal stenosis common (usually grade 1-2)
Risk factors: higher total doses and prior pelvic surgery
Conclusions
Definitive RT achieves durable locoregional control in primary vaginal cancer, with outcomes strongly stage-dependent. Brachytherapy is essential; interstitial is preferred for bulky or anatomically challenging tumors. Stage I lesions confined to the upper vagina have excellent outcomes comparable to early cervical cancer.
Key Limitations
Retrospective, single-institution over 30 years with marked treatment heterogeneity (LDR vs HDR, varying EBRT fields, variable chemotherapy); no standardized protocol; predates modern IMRT and image-guided brachytherapy; selection bias; no prospective randomized data in this rare disease.
Clinical Context
One of the most-cited series establishing RT as the primary curative modality in vaginal cancer (~1% of gynecologic cancers). No randomized trials are feasible. Standard of care per ASCO/ESMO practice is definitive EBRT (pelvic IMRT ~45-50.4 Gy) + brachytherapy boost, with concurrent weekly cisplatin for locally advanced disease (stage II-IVA) extrapolated from cervical cancer; surgery is reserved for early upper-third lesions or salvage.