|ORIGINAL RESEARCH REPORT
|Year : 2017 | Volume
| Issue : 3 | Page : 113-118
Head and neck cancers: An histopathologic review of cases seen in three Tertiary Hospitals in Northwestern Nigeria
Abdul-Warith Olaitan Akinshipo1, Abdulrazak O Taiwo2, Kabiru Abdullahi3, Abdulqadir Yalaraba Fatimah4, Saddiku Malami Sahabi3, Mayun Audu Ahmed5
1 Department of Oral and Maxillofacial Pathology/Biology, Lagos College of Medicine University of Idi-Araba, Lagos, Nigeria
2 Dental and Maxillofacial Surgery, College of Health Sciences Surgery Usmanu Danfodiyo University, Sokoto, Sokoto State, Nigeria
3 Department of Pathology, Usmanu Danfodiyo Universty Teaching Hospital, Sokoto, Sokoto State, Nigeria
4 Department of Laboratories Gusau, Federal Medical Center Gusau, Maiduguri, Borno, Nigeria
5 Department of Histopathology, University of Maiduguri Medical College, Maiduguri, Borno, Nigeria
|Date of Web Publication||17-Aug-2017|
Abdul-Warith Olaitan Akinshipo
Department of Oral and Maxillofacial Pathology/Biology, Faculty of Dental Sciences, College of Medicine, University of Lagos, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Context: Head and neck cancers (HNCs) display variable biological and geographical variations even within the same country. Aims: This study aims to determine the histopathologic pattern of HNCs in three Northwestern states of Kebbi, Sokoto, and Zamfara in Nigeria. Settings and Design: This was an hospital-based descriptive retrospective study carried out at Federal Medical Centre, Birnin Kebbi; Federal Medical Centre, Gusau; and Usmanu Danfodio Teaching Hospital, Sokoto. Subjects and Methods: Medical and histopathologic records of all HNCs seen at these centers between January 2006 and December 2013, were reviewed, and data on time of presentation, sociodemographic, anatomic site, and histology were collected and analyzed using the Statistical Package for the Social Sciences (version 20) (SPSS Inc., Chicago, IL, USA) statistical software. Quantitative data were summarized using simple descriptive statistics of means and standard deviation (SD). Chi-square tests were used to analyze the nonparametric variables. Statistical significance was inferred at P ≤ 0.05. Results: Three hundred and eighty-one malignant HNCs were seen over a period of 8 years with an annual frequency of 47 cases. There was a male to female ratio of 1.2:1, and the mean age was 39.5 ± 19.2 (±SD). About 70.3% of cases were carcinomas, 15.0% were sarcomas, and 8.7% were lymphomas. Squamous cell carcinoma (34.9%) was the highest carcinomas while non-Hodgkin's lymphomas (6.6%) and rhabdomyosarcoma (4.2%) were the most common lymphomas and sarcomas observed, respectively. The most common sites were those of the lips, oral cavity, and pharynx International Statistical Classification of Diseases-10 (C00–C14). Conclusions: This present study demonstrates the rising trend of HNCs in these regions and highlights the urgent need for adoption of grass root policies that would incorporate public participation especially those under 40 years, in the awareness on the harmful use of carcinogenic substances such as tobacco and alcohol and dangerous sexual habits. There should also be concerted promotion of targeted preventive strategies, early screening, treatment, support, and lifelong rehabilitation.
Keywords: Head and neck cancers, histopathologic, Northwestern Nigeria
|How to cite this article:|
Akinshipo AWO, Taiwo AO, Abdullahi K, Fatimah AY, Sahabi SM, Ahmed MA. Head and neck cancers: An histopathologic review of cases seen in three Tertiary Hospitals in Northwestern Nigeria. J Clin Sci 2017;14:113-8
|How to cite this URL:|
Akinshipo AWO, Taiwo AO, Abdullahi K, Fatimah AY, Sahabi SM, Ahmed MA. Head and neck cancers: An histopathologic review of cases seen in three Tertiary Hospitals in Northwestern Nigeria. J Clin Sci [serial online] 2017 [cited 2018 Mar 20];14:113-8. Available from: http://www.jcsjournal.org/text.asp?2017/14/3/113/213082
| Introduction|| |
The head and neck are randomly defined as the area from the clavicles to the sella turcica. It is an intricate anatomic site due to the range of tissues found in the region. Biopsies from the region are often small, frequently distorted, and difficult to orient for paraffin embedding, all of which impact on evaluation and diagnosis. Conventionally, head and neck cancers (HNCs) refer to a heterogeneous group of primary cancers originating from the upper aerodigestive of which 90% are squamous cell carcinomas (SCCs). Eighteen different cancer sites may be categorized as HNCs and as such several studies have either included or excluded malignancies of the eyes, skin, thyroid, salivary glands.,, This is because the various organs are a few inches apart with the same tissue types, and pathologist finds it difficult to focus on one organ and neglect the nearby organs. Epidemiologically, HNC is the sixth most common cancers worldwide with approximately 560,000 new cases and 300,000 deaths with increasing incidence in developing countries. Accounting for 5%–50% of all cancer globally, South Asia and parts of central and southern Europe have the highest incidences  with approximately 30% of all cancers in India, 3.3% of all cancers in the United States, 4.2% in Europe, and about 1.2% in Nigeria.,
The etiology of HNCs like most cancers is not clear. However, several risk factors are associated with them, of which, tobacco use and alcohol consumption independently or in combination are associated with increased incidence. Other observed risk factors are human papillomavirus infection in tongue, tonsil, and oropharyngeal HNCs particularly in nonsmoking cases of HNC. The use of bidis is strongly associated with cancer of the hypopharynx and larynx and betel quid with oral cancer. Clinically, HNCs are associated with significant loss of vital functions such as breathing, speech, and swallowing. Definitive diagnosis is through histology while imaging is used for staging and treatment. Patients in this environment usually present late, and treatment is financially and psychologically demanding.
The gold standard for HNC treatment is multimodal with the use of surgery, radiotherapy, and chemotherapy and often involves the maxillofacial surgeons, otolaryngologists, histopathologist, dentists, nurses, psychiatrists, therapists, social workers, and others. In most centers in low- and middle-income countries, surgery is principally the mainstay of treatment as few places possessed the facilities for chemotherapy and radiotherapy. Ironically, reconstructive surgery is also financially out of reach for most patients even when suitable technical expertise is available, as more than 60% of Nigerian pay out of pocket for their health care compared to 16.8% in the United Kingdom. In spite of several decades of progress and improvements in treatment and supportive care, the prognosis has remained unacceptably low for this group of patients stagnating at about 50% 5 years survival rate.
The World Health Organization International Statistical Classification of Diseases-10 (ICD-10) classification system used for this study helps to standardize and serves as useful reference for assessment and monitoring of mortality, morbidity, and other relevant parameters related to HNC tumors and other health issues.
Sokoto, Kebbi, and Zamfara are three states in Northwestern Nigeria. Before 1991, Sokoto state included Zamfara and Kebbi states. Currently, each of these three states has a referral hospital catering for a combined population of 10.2 million people with the largest center in Sokoto. Since these states share health care personnel and other resources, it was deemed necessary to review the pattern of HNCs in these three centers together as the spectrum of HNCs varies from place to place even in the same country. Furthermore, provision of accurate data on prevalence, common anatomic sites, and histologic types will serve as a baseline for further studies. In addition, it will serve as an important strategy for developing policies and planning resources to manage this group of pathologies in any population. We studied pathology and clinical charts in three tertiary health institutions in Kebbi, Zamfara, and Sokoto state to determine the demographic and histopathologic pattern of primary head and neck malignant tumors and to compare the demographic and histopathologic patterns of HNC with other Nigerian centers and some developing countries.
| Subjects and Methods|| |
The present histopathologic retrospective study of HNCs was performed at the Federal Medical Centre, Birnin Kebbi, Federal Medical Centre, Gusau, and Usmanu Danfodio Teaching Hospital, Sokoto, together with a 2150 capacity bed space. A review of records of all patients with HNCs between January 2006 and December 2013, was obtained from the histopathology department of these hospitals. The total numbers of malignancies were also obtained from the records. The cases were identified and classified based on anatomy and invasiveness using ICD-10 3rd edition, categories C00–C97. Medical records of identified cases were reviewed, and information on the date of diagnosis, primary site, histology, and demographic data were retrieved. Duplicate cases were eliminated by cross-checking name, address, age, sex, and hospital number of each patient. In situ carcinoma and precancerous lesions were excluded from the study. Data were entered and analyzed using Statistical Package for the Social Sciences version 21 (SPSS Inc., Chicago, IL, USA). Quantitative data were summarized using simple descriptive statistics of means and standard deviation (SD). Chi-square tests were used to analyze the nonparametric variables. Statistical significance was inferred at P ≤ 0.05.
| Results|| |
During the 8-year study period, a total of 1481 patients with head and neck lesions were seen; of which, 381 were malignant, constituting 25.7% prevalence. The highest number of cases presented in 1 year was in 2013 with 83 cases (21.8%) [Table 1]. There were 211 males (55.4%) and 170 females (44.6%) with a male to female ratio of 1.2:1. Their age ranged from 2 to 82 years with mean age of 39.50 years (SD = 19.2). The mean age for males was 41.00 years (SD = 19.45) and for females was 37.65 years (SD = 18.84). The most common age group was 45–64 years group with 145 (38.1%) cases [Figure 1]. Two hundred and sixty-eight patients (70.30%) had carcinomas followed by 57 (15.0%) cases of sarcomas [Table 2], [Figure 2]. According to ICD-10 classification system used in this study, the most common head and neck malignancy were C00-C14 consisting of cancers of the lips, oral cavity, and pharynx (n = 145, 38.1%) [Table 3].
|Table 2: Broad histologic classification of head and neck malignancies according to gender ratio and mean age|
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|Table 3: Frequency, mean age, and gender distribution of head and neck cancers according to International Statistical Classification of Diseases-10 classification|
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(The majority of the carcinomas were SCC (133;34.9%) followed by adenoid cystic carcinoma (23; 6.0%) while non-Hodgkin's lymphoma (25; 6.6%) and rhabdomyosarcoma (16; 12.0%) were predominant among the lymphomas and sarcomas, respectively [Table 4] and [Table 5].). Comparative analysis among males and females revealed a gender difference in the anatomic distribution of HNCs according to ICD-10 classification (P = 0.007) [Table 3]. There was also a statistical difference between gender and broad histologic types [Table 4].
|Table 4: Distribution of broad histological types of head and neck cancer according to International Statistical Classification of Diseases-10 classification|
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|Table 5: Frequency distribution, mean age, and gender ratio of the ten most common histologic types of head and neck malignancies|
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| Discussion|| |
The epidemiology of HNCs in Nigeria is difficult to ascertain since most of the studies rely on data from clinical and histopathological records of hospitals. Nonexistence or nonfunctional centralized tumor registry is the main reason for the lack of precise statistical data about prevalence and incidence of cancer. Regional and institution-based registry systems from different centers including these centers are providing scattered but useful information regarding the prevalence of cancer. However, regional multicenter study utilized in this study is a better alternative to determine the true picture of HNCs than the latter.
The male to female ratio of 1.2:1 in this study is within the range of 1:1–2.3:1 in a review of Nigerian studies by da Lilly-Tariah et al. Our result is also comparable to other African studies.,,,, However, studies from Brazil,, Korea  and India  showed a much higher male to female gender ration of 3.9:1, 3.6:1, 5:1, and 2.9:1 respectively, when compared to findings in our study. These discrepancies revealed the importance of looking into the role of etiological factors, as these regions might have more men exposed to high-risk etiologic factors of smoking, alcohol consumption, human papillomavirus, and other risk factors associated with cancer incidence. A study from Ilorin, North Central Nigeria, had more females affected than males. The reason for this was not stated by the investigators.
The overall mean age of 39.5 years (SD = 19.2) seen in this study is lower than those seen in most Nigerian ,, and African studies.,,, The reason for this low average is unknown; but, worldwide, there is an increasing incidence of HNC in younger age groups which is thought to be associated with changing sexual habits and exposure to unknown carcinogen in addition to the strong etiologic factors of smoking and alcohol consumption. Furthermore, a peak incidence of 50–59 years which was observed in this study is similar only to the study of Onotai and Nwogbo  but higher than other studies from Nigeria ,,,, However, this present study is in agreement with the general observation that HNCs tend to occur at a younger age group in sub-Sahara Africa compared to Caucasians with evidence suggesting increasing incidence among young people worldwide., Widespread poverty, unemployment among young people also creates some concern as HNCs affect those with the lowest income and least education.
The frequency of malignant head and neck neoplasm in this study was about 47 cases/year with an increasing trend. This figure is greater than those published from Jos, Ife, and Gombe. This is considerably low for the three centers combined, and reasons for this may include harvesting phenomenon from late presentation due to barriers such as preference for traditional medicine, financial, structural, and institutional impediments. Recent expansion in specialist services preventing referrals of cancer cases outside the region might have contributed to the rising trend in number of cases presenting in these facilities.
Carcinomas were the most common HNC type in this present study, which is in agreement with various studies worldwide. However, a study from Ile-Ife Nigeria  reported lymphoma as the most frequently diagnosed HNC. In this study, carcinoma accounts for 70.3% of cancers reported which was below the reported range from Nigeria, of between 73.5% and 91%.,,, SCC was the most frequently seen of the carcinomas types in most series.,,,,,,,,,,,,,,,, SCC constituted 34.9% of all carcinomas in this study which is comparable with findings from studies in Sokoto, Gombe, and Ilorin, incidentally all in Northern Nigeria ,, but lower than published figures across Southern Nigeria,,, Sub-Saharan Africa,,,,, Brazil, India,, and some western countries., These variations in geographic prevalence need further investigation as it could reflect differences in exposure to HNC carcinogens.
Sarcomas were the second most common histologic type in this study similar to research from Port Harcourt. It, however, refutes data from many centers across Nigeria, Ghana, and Western countries that found lymphomas to be the second most common histologic type.,,,, Rhabdomyosarcoma was the primary sarcoma in this current study in consonance with the study from Ibadan. Rhabdomyosarcoma is considered the most common soft tissue sarcoma in children. However, most studies of childhood malignancies in Nigeria observed lymphomas to be the most common childhood malignancy in their studies.
Retinoblastoma constituting 5.2% of HNC was the most common neuroendocrine tumors in this study. A range of 2.6% to 13% has previously been reported in Nigeria.,,
This study showed categories C00–C14, consisting of malignant neoplasm of the lips, oral cavity, and pharynx (38.1%) to be the most common group of malignant lesions in the head and neck, followed by lesions of the respiratory system consisting of the nasal cavity, sinuses, and larynx (C30–C39), with 21.0% of cases. A study in Ghana which used the ICD-10 also observed categories C00–C06 and C10 to be the most common group of lesion seen in their study. However, a previous study from Sokoto  which used the ICD-9 classification and another one from Jos  which used ICD-10 observed the eyes (C69–C72) to be the most common site of malignant tumors.
Lesions of the eyes were not included in some studies from Nigeria. In contrast to Nigerian studies, oral cavity cancers followed by laryngeal carcinoma were the most common HNCs in the western world. Oral cavity cancers were also the most common HNCs from studies in Ghana  and Brazil.,
Despite this clear and present danger in limitations of personnel, equipment, and poor control of risk factors associated with HNC, the government has not shown enough political will to tackle these problems. Government and private agencies including health maintenance organization. (HMOs) are being urged to properly equip treatment centres and subsidize the diagnosis, treatment and rehabilitation of HNCs.
Our study was limited by the fact that it was an interpretation of data from hospitals, which reflects our specific patient population reporting to the hospital and not the community as a whole. Furthermore, being a retrospective study, the specific histological subtype could not be correlated with risk factors and prognostic factors. A prospective study of risk factors, clinical parameters, and prognostic factors is important in understanding the prevalence and pattern of HNC in our environment which will aid in allocating necessary resources.
| Conclusion|| |
This study showed that HNCs in three states of Northwestern Nigeria commonly involve the eyes, oral cavity, nasal and paranasal structures, the younger age group when compared to the western world and are majorly carcinomas. It highlights the need for structured data collection of HNC epidemiology in Nigeria to get the true demographic pattern of cancer problem in Nigeria and to investigate further on the specific risk factors that accounted for the younger age occurrence including the role of human papillomavirus.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]