Download A Clinicopathologic Review Of Oesophageal Carcinoma In Lagos

Nig. Of J. Hosp. /Wed. Vol. 18(2)April. -June, 2008
A Clinicopathologic Review Of Oesophageal
Carcinoma In Lagos
*F.B. Abdulkareem, *C.A. Onyekwere, **N.A Awolola, and *A.A.F Banjo
*Dept of Morbid Anatomy, College of Medicine University of Lagos,
Idi araba, P.M.B. 12003, Surulere, Lagos, Nigeria
**Dept of Morbid Anatomy, Lagos University Teaching Hospital,
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Id/araba, P.M.B.12003, Surulere, Lagos, Nigeria
v + Dept of Medicine, Lagos State University Teaching Hospital,
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Ikeja, Lagos, Nigeria.
Correspondence to:. F.B. Abdulkareem
ABSTRACT:
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growing malignancy in the United States2. Oesophageal
cancer has a widely variable geographic incidence in
Africa; while it is low in some parts such as Nigeria
representing 0.4-0.6% of all malignant tumours 3 4 , it
accounts for 13.8% in Addis Ababa and Kenya 56. It is an
endemic disease in Transkei, a region along the Indian
Ocean coast in South Africa, which is regarded as an
epicentre of the disease in Africa7. It is the most important
male cancer in some parts of Africa 68.
Epidemiological studies have identified tobacco,
consumption of maize contaminated by Fusarium
verticilloides and nitrosamine as well as HPV infection as risk
factors associated with the development of cancer of the
oesophagus9'11. Tobacco and HPV infection have been
associated with non-endemic Oesophageal cancer while the
endemic cancer has been associated with maize meal which
is used as staple food due to contamination by fungal
mycotoxins as well as nutritional deficiencies 1213
The peak age incidence is in the 6th decade in most
studies although adenocarcinoma appears to be
commoner in males under the age of 40years 14.There is a
racial variation in the histological types with a
predominance of squamous cell carcinoma SCC) in blacks
which represents over 90% of all Oesophageal cancers in
Africa 4'68. Adenocarcinoma is the predominant type in
Western countries 14. In fact adenocarcinoma of the
oesophagus is said to be the malignancy with the fastest
growing incidence in the US, having increased 6 times in 3
decades2.
The middle third of the oesophagus is the commonest
site for SCC while the tower third is the commonest site for
adenocarcinoma5'6'8'14. Most patients present with
dysphagia and weight loss with dysphagia being the most
important and the first symptom. As most patients present at
advanced stage, mortality is very high and even in operable
tumour, post operative mortality is about 50%15. The aim of
this study is to review the clinicopathological characteristics
of Oesophageal carcinoma in Lagos, South West Nigeria.
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Background: Oesophageal cancer is the 6th most common
cause of cancer death world wide. While the incidence is low
in some parts of Africa such as Nigeria accounting for 0.40.6% of all malignant tumours, it is endemic in Transkei, in
South Africa, which is regarded as an epicentre of the
disease in Africa.
Objective: To document the age and sex distribution,
clinical as well as histopathological characteristics of
Oesophageal carcinoma in Lagos, SW Nigeria, Methods:
The paraffin embedded blocks and slides as well as
pathology reports of Oesophageal carcinoma collected
between 1995 and 2007 from Morbid Anatomy Department of
the Lagos University Teaching Hospital and between 2002
and 2007 from two private histopathology laboratories in
Lagos State were reviewed. The clinical data such as the
age, sex, and clinical summary were extracted from
demographic information in patients' case file.
Results: Twenty cases representing 2.8% of all
gastrointestinal tumours were recorded. The mean age
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was 65.4years(SD-12.3) with M:F ratio of 1:1. Squamous
cell carcinoma predominated; 18 cases (90%); the
• remaining two cases (one of which showed evidence of
Barrett's oesophagus) were adenocarcinoma (10%). All
presented at advanced stage with dysphagia and weight
loss with or without vomiting, regurgitation, and/or
haematamesis. Two third had mid Oesophageal fungating
masses, the remaining were located in the lower third. Two
cases had surgery, the rest were not fit for any intervention.
Conclusion: Oesophageal cancer is not common in Lagos,
Nigeria, majority are squamous cell carcinoma. Late
presentation gives it a dismal outlook. Although the overall
survival is poor, efforts at improving quality of life by
palliative measures should be encouraged.
Key Words: Oesophageal cancer, squamous carcinoma,
dysphagia
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INTRODUCTION
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MATERIALS AND METHODS
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Oesophageal cancer is the 681 most common cause of
cancer death world wide'. A six fold increase in incidence
has been reported over the last decade in Americans and
Oesophageal adenocarcinoma is said to be the fastest
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The materials consisted of paraffin embedded blocks and
slides as well as pathology reports of oesophageal
carcinoma cases collected between 1995 and 2007 from the
archives of Morbid Anatomy Department of the Lagos
53
University Teaching Hospital (LUTH) and between 2002 and 2007 from two other private histopathology laboratories in
Lagos State.
The relevant haematoxylin and eosin stained slides were reviewed and (in poorly differentiated tumours), special
stains such as Periodic Acid Schiff stain, Alcian blue stain were utilized where necessary to demonstrate the presence
of neutral and acid mucin respectively. Presence or absence of columnar metaplasia with goblet cells was also
recorded to ascertain any associated Barrett's oesophagus. The clinical information such as the age, sex, and clinical
summary were extracted from the histopathology request forms and the patients' case files in their various clinics or
hospitals. Also noted was the presence or absence of features of reflux oesophagitis as well as the endoscopic
findings and forms of management. The tumours were classified using the standard histological characteristics and
graded according to the degree of histological differentiation. The data were then analyzed using Microsoft Excel
and presented as tables and figures
RESULTS
A total of 20 cases representing 2.8% of all gastrointestinal tumours were recorded during the period of study (11 cases
from the Morbid Anatomy dept, LUTH 1995-2007 and 9 cases from two private laboratories in Lagos from 2002-2007).
The age range was 43-84years age with a mean of 65.4years; SD-12.3(Figure 1). The male: female ratio is 1:1
Of all the cases, only two had oesophagectomy specimens in addition to biopsy; the remaining were endoscopic
biopsy samples. Histologically, squamous cell carcinoma (SCC) predominated; 18 cases (90%) with 2 cases (10%) of
adenocarcinoma. Six cases each (33%) of the SCC were well, moderately and poorly differentiated respectively. One of
the adenocarcinoma cases showed evidence of Barrett's oesophagus.
All the patients presented at advanced stage (stages III and IV) with dysphagia and weight loss (100%), 75% presented
with additional vomiting/regurgitation, while 10% presented with retrosternal pain and haematamesis (Figure 2).
Two third of the cases had mid oesophageal fungating and/or ulcerating masses causing varying degrees of
luminal obstruction, the remaining were located in the lower third. Only two cases whose tumour was located in the
lower third of oesophagus had surgical intervention, the rest were not fit for any intervention..
50-59
60-69
70-79
> 80
unspecified
Agegroupinyears
Om ale • fern a l e
Figure 1: Age & Sex distribution of cases of
oesophageal carcinoma
To
8 retrosternal pain
I
J
haematasis
vomiting + regurgriation
dysphagia+ weight loss
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i
0%
20%
40%
60%
80%
100%
:
120%
Percentage of pa« ente
:
Figure 2: Clinical features of oesophageal carcinoma
in Lagos, Nigeria
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DISCUSSION
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This study has shown that oesophageal carcinoma is uncommon in Lagos, South West Nigeria indicating a
frequency of 1.5 cases per annum. This is far low compared to the finding of Pindiga et al in Ibadan, also in South West
Nigeria who recorded 177 cases in SOyears (6cases per annum)4. Although oesophageal cancer has widely variable
geographic incidence, the difference between our study and that of Ibadan could partly be explained by the presence of
a virile cardiothoracic unit in the latter which has been absent in Lagos for over a decade. The presence of experts and
improved hospital facility for diagnosis in an area has often been associated with attendant increase in incidence6.
Until a few years ago, Morbid Anatomy department of LUTH was the only histopathological facility available to
government and private hospitals in Lagos State. Lagos which is a commercial city, situated in South Western part of
Nigeria has a population of about 9 million and the inhabitants are representatives from all the major cultural tribes in
Nigeria. Inadequate endoscopic facilities may also have contributed to non diagnosis of the disease. It is no wonder
then that the present series is the first histopathology report from Lagos.
In this study oesophageal cancer (EC) accounted for 2.8% of all malignant gastrointestinal tract(GIT) tumours; a
figure which is lower than 9.5-13.3% recorded in previous studies from Nigeria and 32.5% recorded from Addis
Ababa816'17. When compared with reports from other parts of Africa such as Kenya, Ethiopia and South Africa, the
incidence of oesophageal cancer in Nigeria appears to be relatively low5 8. Other parts of the world with high incidence of
this cancer include Northern Iran, Kazakhastan, and Northern China with incidence exceeding 200 per 100.00018.
In Kenya, it was found to be the commonest cancer in males representing 13.8% of all malignant tumours6. In
Transkei, South Africa, it was reported to be a major cause of death with age standardized rate of 357.2 per 100,000 for
age between 35-64years '9.
Several risk factors have been implicated in the geographic variation in incidence of EC. In endemic high
incidence areas, the histological type is SCC which is the one that has been associated with the presence of certain
carcinogens in the environment including tobacco, HPV infection, fungal mycotoxins, nitrosamines, solanum
nigrum710"13. Fungal mycotoxins, fumonisin B1 produced
by fusarium verticilloides is found in commercial corn world wide but much more common in high incidence areas 12 20. Both the
fungus and the toxins are known to be carcinogenic. Tobacco has strong association with non-endemic EC worldwide;
higher with increased consumption 2 '. In Zimbabwe, the relative risk f o r oesophageal cancer was 5.7 among male
smokers of 15 sticks or more per day". Nitrosamines in non-endemic areas has been proven to be carcinogenic and its effect is
dose and time related acting as co-carcinogen with other agents and is found in tobacco and some foods (dried spices, fried
bacon and beer) with high urinary excretion having been reported in China21. HPV has been identified in 67-71% of SCC of EC in
endemic areas, particularly types 11, 16, 18 which cause neoplastic transformation through their oncoproteins E6 and E72223.
Human papilloma virus (HPV) appears not to play significant role in pathogenesis of SCC of EC in the UK 24.
Although no definite exposure to any of these predisposing agents was established in any of our patients, it will be
worthwhile to explore these risk factors particularly in Nigeria where HPV prevalence of 26.3-42.2% has been reported in
cytological samples of Nigerian women 2526. Maize diet in various forms is consumed by inhabitants of this country and due to
increasing urbanization; many more individuals are being exposed to tobacco and alcohol.
The male: female ratio of 1:1 in this study concurs with previous studies from Ibadan, SW Nigeria 4, and Kenya6 but contrasts
with 3.4:1 recorded in the US". The difference could be explained by the higher incidence of adenocarcinoma (81%) in the
US study which also noted that adenocarcinoma had greater male predominance with ratio of 4.9:1 than 1.2:1 for SCC 14. The
mean age of 64.5years in this study also concurs with previous studies from within and outside Nigeria4'6'14'27.
SCC is the predominant histological type of EC in this study accounting for 90% of cases. This is similar to reports from other
parts of Africa and India in which over 90% are SCC46827. This contrast with studies from the USA in which adenocarcinoma
accounted for 81% and SCC accounted for 17%14. In another study among Asian/Pacific Islanders in the US, the rate of
oesophageal SCC was 81% higher than in whites28. The high prevalence of adenocarcinoma in Western countries reflects the
pathophysiology of the tumour which has been associated with gastro-oesophageal reflux disease (GERD). Only two of our
cases, (10%) were adenocarcinoma, with one case showing histological features of Barrett's oesophagus. Although data from
Africa is scanty, a review of GERD in African literature by several workers have confirmed that overall, there is higher
prevalence of GERD and adenocarcinoma in western countries than in all regions of sub-saharan Africa and that although
urbanisation has increased the risk factors associated with GERD, the impact of this is yet to be seen
29,30
The location of the tumour within the length of the oesophagus varies with the histological type. SCC is commonly found
in the middle and distal third of the oesophagus while adenocarcinoma is more commonly located in the distal third. In this
study, over 60% of our cases were located in the middle third, the remaining in the lower third which is consistent with previous
studies68.
The two most common symptoms present in all our patients were dysphagia and weight loss which is similar
to previous studies from within and outside Africa 4 6 ' 8 1 4 31 Dysphagia and weight loss are so commonly associated that some
authors regard them as being pathognomonic 6. Dysphagia is usually associated with bulky tumours that obstruct the
oesophageal lumen, impairing its function and causing pain14; the reason why most patients also have associated vomiting and
regurgitation as well odynophagia and or retrosternal pain. Only two of our patients presented with haematemasis, a symptom
which is less common.
EC in Nigeria has a dismal prognosis because of the advanced stage at presentation. Majority of our patients presented with
late stage disease; (stages III and IV) making them inoperable. In operable cases, resection even when successful only offers
palliation for severe dysphagia not cure. Several workers have reported high post-operative mortality of over 50%, following
oesophagectomy for oesophageal carcinoma15 33'35.
Oesophageal cancer is therefore not common in Lagos, Nigeria, majority are squamous cell carcinoma. Late presentation
gives it a dismal outlook. Although the overall survival is poor, efforts at improving quality of life by palliative measures should
be encouraged. •;
ACKNOWLEDGEMENT
We are grateful to the management of The Specialist laboratory and Histolab diagnostics limited for allowing us access to
their records.
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