The prevalence of vulvar cancer in our study was determined to be 3.6%, consistent with numerous global reports that cite a prevalence range of 2 to 5%. Despite the common belief that vulvar cancer is infrequent in sub-Saharan Africa, our findings reveal an equivalent disease burden comparable to developed nations, largely attributed to the high rate of HPV infection in Africa [1]. A South African study reported a remarkably high HPV positivity rate of 62% [11]. In our study, the mean age of vulvar cancer patients was 42 years, significantly younger (20 to 30 years) than the average age reported in the US SEER data, which indicates a mean age of 68 years for vulvar cancer. This age difference aligns with findings from a similar Ethiopian study conducted at Black Lion Hospital, which reported a mean age of 36 years [4]. The notable increase in the incidence of vulvar cancer at a younger age is strongly associated with high rates of HPV and HIV infections. HIV-positive patients, constituting 67% of our study population, have contributed to the overall lower average age. It is imperative to underscore the importance of reinforcing HPV screening and awareness programs, particularly for individuals living with HIV. Additionally, given the psychosexual challenges associated with younger patients, there is a need to prioritize these aspects during treatment planning [1, 4, 10].
In our study, a common occurrence was a bulky tumor size, aligning with a report from Black Lion Hospital. This observation is attributed to a high prevalence of HPV infection, leading to bulkier and multifocal lesions. The size of the lesion, akin to disease stage and lymph node status, serves as a crucial prognostic factor influencing survival.one contributing factor to the larger lesion size is delayed presentation. Many women seek medical attention belatedly due to feelings of embarrassment and a lack of awareness. Additionally, some may not have consulted the appropriate healthcare professionals, particularly outside Addis Ababa, resulting in delayed referrals. The impact of large lesions extends beyond medical implications; it also affects the psychological well-being of patients due to postoperative disfigurement of the external genitalia and potential wound failure. [4, 5, 6].
Although the reported duration of symptoms by the patient was 12 months, the majority of patients (58%) presented at an early stage, specifically stage I and II. This is in contrast to findings from other African countries, where as much as 75% of cases are diagnosed in advanced stages [7, 8, 10].
There was significant time lapse (3.8 Months) between initial patient appearance to service delivery or referral. This time would be even much higher for those referred to radiotherapy. This is much higher than the report from Ghana of 58 days (9). These systemic bottlenecks could contribute for disappearance 7 cases from follow up.
Surgical intervention, specifically Modified Radical Vulvectomy and inguino-femoral lymph node dissection, stands as the optimal treatment for early-stage patients, offering the most favorable survival outcomes. In our hospital, 20 patients (39%) underwent surgical procedures. However, it's noteworthy that among early-stage patients eligible for surgery, eight were directed towards chemo-radiation. As per NCCN guidelines, palliative chemotherapy is advocated for stage IV patients and those deemed unfit for surgery. Localized advanced or stage III cases present multiple viable options, including surgery, neoadjuvant chemotherapy, and chemo-radiation. Notably, there is a paucity of evidence supporting the survival advantage of neoadjuvant chemotherapy preceding surgery in managing vulvar cancer. Within our hospital, six patients underwent surgery post-Neoadjuvant Chemotherapy (NACT). Post-operative pathology results revealed three cases with positive margins, and one patient experienced recurrence after one year. This prompts the necessity for further studies to ascertain the efficacy of this treatment modality. Groin dissection was performed on 15 patients, while cases classified as stage 1A, being at an early stage, do not derive benefits from groin dissection [ 7, 8,10].
The post-operative complication rate of 35% aligns with findings in other African studies. Only one case involving lymphocytes has been observed. Margin positivity was noted in six patients, with half undergoing re excision as supplementation. Enhancing tumor-free margin incisions during the initial surgery is recommended.
The suggested follow-up duration of 3 to 5 years needs reinforcement, especially for patients referred for radiotherapy at Black Lion Hospital. Unfortunately, many of them do not attend follow-up appointments, making it challenging to monitor their outcomes. However, all surgically managed patients received follow-up, revealing only one case of recurrent disease after a year. Apart from that, the remaining 19 cases remained disease-free at the last follow-up. Survival analysis was hindered by the absence of robust follow-up mechanisms, and utilizing telephones proved ineffective for most cases.
Strengths of this study include the ability to trace a good number of cases despite the rarity of the disease. The charts were evaluated rigorously, and strict criteria were applied for staging. All cases in the study originated from a single center, ensuring uniformity in management protocols and registration. This contributes valuable insights to the existing pool of knowledge on VC studies, particularly from developing countries. However, the study has some limitations. Its retrospective design poses a constraint, and the relatively small number of cases hinders the possibility of conducting advanced analyses. Unfortunately, the study couldn't perform survival analysis, and obtaining information on patients referred for radiotherapy to Black Lion Hospital proved unattainable.