Vaginal cancer and vaginal intraepithelial neoplasia (VaIN): FIGO staging, the HPV association, radiotherapy-dominant management and survival by stage

Also known as Vaginal cancer · Vaginal carcinoma · Primary vaginal squamous cell carcinoma · Vaginal intraepithelial neoplasia · VaIN · Vaginal SIL · Clear cell adenocarcinoma of the vagina · Diethylstilbestrol-related vaginal cancer

Exam-exhaustive FRANZCOG fellowship topic on primary vaginal cancer and vaginal intraepithelial neoplasia (VaIN): the FIGO staging system for vaginal cancer reproduced verbatim (framework retained through the 2018 FIGO revision), the HPV association in around four in five squamous cell carcinomas mirroring the cervix, the radiotherapy-dominant management with brachytherapy and concurrent cisplatin, the narrow surgical role, the SEER survival-by-stage data (stage I about 76 per cent down to stage IV about 22 per cent), and the ESGO/ISSVD 2023 VaIN management ladder with the distinction from VIN. Anchored to the FIGO staging framework, the Nogueira-Rodrigues 2025 CA Cancer J Clin comprehensive review, the Jhingran 2022 treatment update, the Kesic 2023 ESGO/ISSVD VaIN consensus, and SEER survival analyses. Cross-links the cervical cancer, vulvar cancer and cervical screening topics.

high11 referencesUpdated 27 July 202615 min readVerification in progress

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8 MCQs

One-line fellowship answer

Primary vaginal cancer is rare (under 1 per cent of female cancers) and around four in five squamous cell carcinomas are HPV-associated (mainly 16 and 18), mirroring the cervix through a VaIN-to-cancer sequence. Stage it with the FIGO system reproduced verbatim (I limited to the vagina; II paravaginal tissues not the pelvic sidewall; III pelvic wall and/or lower third vagina and/or hydronephrosis with inguinal nodes; IV beyond the true pelvis and/or bladder or rectal mucosa and/or distant metastases) — a framework retained through the 2018 FIGO revision that revised cervix, corpus and ovary. Treat most tumours with radiotherapy (external beam plus brachytherapy) with concurrent cisplatin, because the vagina lies against bladder, urethra and rectum and surgery rarely achieves clear margins; reserve surgery for small stage I proximal tumours in women without prior pelvic radiotherapy. VaIN 1 is observed, VaIN 2 to 3 is treated with excision as the mainstay (CO2 laser, imiquimod, total vaginectomy for extensive disease). SEER five-year survival falls from about 76 per cent in stage I to about 22 per cent in stage IV.^[1]^[2]^[3]^[4]

A 58-year-old woman presents with three months of postcoital bleeding and a small ulcerated plaque on the upper posterior vaginal wall; her cervix is normal and her last cervical screen was normal six months ago. This is not "atrophic vaginitis" — it is primary vaginal squamous cell carcinoma until a punch biopsy proves otherwise. Your job is to confirm it is primary (not a cervical or vulvar recurrence), stage it with FIGO, route her to radiotherapy rather than a surgery that cannot achieve a clear margin, and explain why HPV drives both the lesion and her surveillance. The FIGO staging, the HPV field effect, and the radiotherapy-dominant management are the three things a fellowship candidate must defend.^[1]^[2]^[3]

Overview and definition

Primary vaginal cancer is a malignant epithelial tumour arising in the vagina. It is rare — fewer than 1 per cent of all female cancers, with an estimated 17,500 new cases globally in 2020 — and the five-year survival across all stages ranges from 50 to 70 per cent.^[2]^[9] The FIGO definition of a primary vaginal cancer is strict: a tumour involving the cervix or vulva, or a cervical or vulvar cancer within the previous five years, is classified as that cancer, not as vaginal. This rule exists because the lower genital tract shares an HPV field, and a lesion at the cervicovaginal junction is far more likely to be a cervical primary with vaginal extension than a true vaginal primary.^[1]^[2]

Squamous cell carcinoma comprises about 80 per cent of primary vaginal cancers, adenocarcinoma 5 to 10 per cent (including the diethylstilbestrol-related clear cell adenocarcinoma), with melanoma, sarcoma and embryonal rhabdomyosarcoma (sarcoma botryoides, in children) as rarer subtypes.^[2]^[5]

Vaginal cancer — the numbers a candidate must know

under 1%Share of all female cancersrare tumour; ~17,500 cases globally in 2020

~80%SCC share of vaginal cancersremainder adenocarcinoma, melanoma, sarcoma

~75 to 85%HPV-associated SCCmainly HPV 16 and 18, mirroring the cervix

~76%Stage I 5-year survival (SEER)falls to ~22% in stage IV

58%All-stage 5-year survivalSEER 2004-2014 overall CSS

^[2] ^[6] ^[9]

References11Show

[1]FIGO Committee on Gynecologic Oncology Current FIGO staging for cancer of the vagina, fallopian tube, ovary, and gestational trophoblastic neoplasia. Int J Gynaecol Obstet, 2009.PMID 19322933
[2]Nogueira-Rodrigues A, Oonk MHM, Lorusso D, Slomovitz B, Leitão MM Jr, Baiocchi G Comprehensive management of vulvovaginal cancers. CA Cancer J Clin, 2025.PMID 40377134
[3]Jhingran A Updates in the treatment of vaginal cancer. Int J Gynecol Cancer, 2022.PMID 35256422
[4]Kesic V, Carcopino X, Preti M, Vieira-Baptista P, Bevilacqua F, Bornstein J, et al. The European Society of Gynaecological Oncology (ESGO), the International Society for the Study of Vulvovaginal Disease (ISSVD), the European College for the Study of Vulval Disease (ECSVD), and the European Federation for Colposcopy (EFC) consensus statement on the management of vaginal intraepithelial neoplasia. Int J Gynecol Cancer, 2023.PMID 36958755
[5]Di Donato V, Bellati F, Fischetti M, Plotti F, Perniola G, Panici PB Vaginal cancer. Crit Rev Oncol Hematol, 2012.PMID 21571543
[6]Huang J, Cai M, Zhu Z Survival and prognostic factors in primary vaginal cancer: an analysis of 2004-2014 SEER data. Transl Cancer Res, 2020.PMID 35117314
[7]Wolfson AH, Reis IM, Portelance L, Diaz DA, Zhao W, Gibb RK Prognostic impact of clinical tumor size on overall survival for subclassifying stages I and II vaginal cancer: A SEER analysis. Gynecol Oncol, 2016.PMID 26970567
[8]Shah CA, Goff BA, Lowe K, Peters WA 3rd, Li CI Factors affecting risk of mortality in women with vaginal cancer. Obstet Gynecol, 2009.PMID 19384118
[9]Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Bray F Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin, 2021.PMID 33538338
[10]Drolet M, Bénard É, Pérez N, Brisson M Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis. Lancet, 2019.PMID 31255301
[11]Joura EA, Giuliano AR, Iversen OE, Bouchard C, Mao C, Mehlsen J, Moreira ED Jr, Ngan Y, Petersen LK, Lazcano-Ponce E, Pitisuttithum P, Restrepo JA, Stuart G, Woelber L, Yang YC, Cuzick J, Garland SM, Huh W, Kjaer SK, Bautista OM, Chan IS, Chen J, Gesser R, Moeller E, Ritter M, Vuocolo S, Luxembourg A A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med, 2015.PMID 25693011