Adisa Ao

Breast Cancer in Nigeria: Is Non‐Adherence to Chemotherapy Schedules a Major Factor in the Reported Poor Treatment Outcome?

To the Editor: Mortality from breast cancer has been declining steadily in many countries. This has been attributed to early detection, accurate diagnosis and prompt treatment (1,2). This is not the case in most developing countries. Breast cancer is now the leading female malignancy in Nigeria and the leading cause of cancer mortality among women seen in many centers across the country (3). The patients are young; they present late and have an overall poor survival. Various reports from Nigeria have shown a high incidence of tumors with unfavorable histopathological and molecular characteristics (4–6). Although a number of studies have attributed the poor treatment outcome to tumor biology, late presentation and poor knowledge of breast cancer (7), to the best of our knowledge, none has examined the phenomenon of non-adherence to therapeutic regimes and its possible effects on treatment outcome. This study examines the reasons for, and the frequency of occurrence of non-adherence to chemotherapeutic regimes among Nigerian women diagnosed with breast cancer. We also suggest ways to address the problem. A retrospective review of the case notes of patients who have been diagnosed with breast cancer and placed on cyclical chemotherapy regimes between January 1996 and December 2005 was carried out. We were specifically interested in the number of treatment cycles missed or delayed. We were also interested in the reasons why they were missed or delayed. The specific drug combinations were not analyzed, but the most commonly used regime in this centre is a course of six cycles of Cyclophosphamide, Methothrexate and 5-Fluorouracil (CMF). Modified radical mastectomy, axillary sampling and simple mastectomy are the commonest surgical procedures for confirmed breast cancer in the centre. A total of 188 cases were reviewed. Their ages ranged between 27 and 81 years with a mean of 49 (SD 10.3) years. One hundred and five (56%) of them were less than 50 years of age, and only 22 (11.7%) were aged above 65 years (elderly). One hundred and sixty-three (86%) of them presented with late stage (stages 3 & 4) disease. A total of 152 patients (80%) reported non-adherence to treatment at one stage or the other. There was no significant association between age or stage at presentation and non-adherence to treatment (v = 4.390, p = 0.624 and v = 5.465, p = 0.141, respectively). The reasons for non-adherence were available in only 110 patients. Among these patients, 21% received less than 75% while 55% received 50% or less of the expected cycles. About 52% of all patients who failed to take five or all of the six cycle of treatment did so because they could not afford the drugs. Paradoxically, 16% of all non-adherences to the regime was due to patients’ feeling well and did not think it important to continue the schedule. This was seen mostly commonly after the third cycle. Most of these patients however, returned and continued the cycle. About 13% of the patients opted out of treatment regime in order to attend faith ⁄ spiritual healing. About 10% experienced severe adverse effects of drug treatment like severe diarrhea, vomiting, and neutropenia. These patients either withdrew themselves from further treatment or their physician officially delayed their treatment. Other reasons for non-adherence to treatment include hospital staff strikes, unavailability of the drugs to buy, patients forgetting treatment cycle and lack of transportation to the treatment centre. These account for about 19% of non-adherence to treatment. Adequate adjuvant chemotherapy unequivocally improves outcome for breast cancer patients (8). This Address correspondence and reprint requests to: Isaac D. Gukas, BM; Bch, FMCS, MRCSEd, PhD, MA (Higher Education Practice), School of Medicine, Health Policy and Practice, Biomedical Research Centre (BMRC), University of East Anglia, Norwich NR4 7TJ, UK, or e-mail: i.gukas@uea. ac.uk.

Giant fibroadenoma presenting like fungating breast cancer in a Nigerian teenager

BACKGROUND Giant fibroadenoma of the breast is a rare benign breast tumour which seldom grows to a giant size, it is even rarer for this benign tumour to grow rapidly, ulcerate spontaneously and present like a fungating breast tumour in a way mimicking breast cancer. CASE PRESENTATION This is a presentation of a 14 year old premenarchal girl with a massive ulcerating and fungating left breast mass that was initially thought to be a fungating locally advanced breast carcinoma on clinical examination. Further examination of the morphology of the resected surgical specimen and histological examination confirmed it to be giant fibroadenoma of the breast. It was successfully managed by partial mastectomy and breast reconstruction with an excellent result and a high degree of patient satisfaction was achieved. CONCLUSION Though a rare clinical entity benign breast tumour can present like a fungating breast cancer and this must be bore in mind especially in young adolescent patients presenting with ulcerating breast tumour.

Prevalence and complications of gallstone disease among pregnant women in a Nigerian hospital

To determine the prevalence of gallstone disease and its complications among pregnant women in a semi‐urban Nigerian setting.

Incidental carcinoma of the prostate gland presenting with initial manifestation of disseminated intravascular coagulopathy (dic) in a middle aged man: a case report

BackgroundIncidental carcinoma of the prostate gland is a common clinical problem among elderly males but this malignancy presenting initially with features of Disseminated Intravascular Coagulopathy (DIC) in the African blacks is rare. Disseminateded intravascular coagulathy is the most frequent coagulation disorder in patients with prostate cancer, However DIC as a first manifestation of prostate cancer is unusual.Case reportThis paper reports a case of a 56 year old Nigerian civil servant who presented initially with clinical features of DIC characterised by bleeding from multilple orifices but was subsequently diagnosed at autopsy to be infiltrating adenocarcinoma of the prostate.ConclusionThis rare case of DIC should be considered especially in elderly men when no other cause can be found for coagulopathy.

A 5‑year Review of Darning Technique of Inguinal Hernia Repair

Context: The Darning technique of inguinal hernia repair is a tissue-based technique with documented low recurrence rate in some parts of the world. Though practiced in our setting, little is documented on its outcome. Aims: The aim was to review the outcome of Darning technique of inguinal hernia repair in our setting. Study Design: A descriptive retrospective study. Patients and Methods: Clinical records of all patients who had inguinal hernia repair using the Darning technique between January 2007 and December 2011 in our institution were obtained. Details of sociodemographic data, intraoperative findings and postoperative complications were reviewed. Statistical Analysis Used: simple frequencies, proportions and cross-tabulations. Results: A total of 132 patients whose ages ranged from 15 to 84 years (mean = 49.4 years) with a male: female ratio of 12:1 were studied. Majority of the hernias were right sided (68.9%), mostly indirect (81.8%). The procedures were for emergencies in 17 (12.9%) cases whereas the rest (87.1%) were done electively. Most procedures, 110 (83.3%) were performed under local anesthesia. Surgical site infection was the most common complication occurring in six patients (4.5%), while four patients (3%) had chronic groin pain. At a mean follow-up period of 15 months there were two recurrences (1.5%) both occurring in patients with bilateral hernias (P = 0.001). Conclusions: The Darning technique of inguinal hernia repair is a safe and effective method for inguinal hernia repair in our setting.

Traumatic urologic injuries in Ile-Ife, Nigeria

Background: In a developing country with limited healthcare resources, traumatic injuries and their management pose a significant challenge to healthcare delivery. Aim: To highlight the challenges in the management of traumatic urologic injuries in patients in our setting. Setting and Design: Patients presenting with traumatic injuries to the urinary tract, between January 1996 and December 2005, in a University Teaching Hospital in Southwestern Nigeria were the subjects of this study. Patients and Methods: Clinical records of patients who had such injuries were reviewed. Results: Ninety injuries occurred in 86 patients including 77 males and 9 females aged 14–68 years. Fourteen (15.5%) of the injuries involved the kidneys, urinary bladder was involved in 23 (25.6%) and the male urethra in 53 (58.9%) injuries. The mechanisms of injury were road traffic accidents in 52 (60.5%) patients, straddle injuries in 18 (20.9%), trauma to the back in 8 (9.3%), falls from a height in 6 (7.0%) and gunshot injuries in 2 (2.3%) patients. Associated injuries include pelvic fractures in 33 (38.4%) patients, limb bone fractures in 13 (14.1%), intestinal injuries in 12 (13.0%) and spinal injuries in 8 (8.7%) patients. In most patients, diagnosis was made based on clinical suspicion and minimal investigations such as abdominal ultrasound, urethrocystoscopy and/or urethrocystography. The outcome was good in most patients and mortality was recorded in only 2 (2.3%) patients who had concomitant spinal and burns injuries. Conclusion: Prompt management instituted on clinical suspicion of injuries presents a good outcome in patients in a limited resource setting.

Severe gastrointestinal haemorrhage due to primary intestinal Kaposi's sarcoma - a case report.

Kaposi’s Sarcoma (KS) was previously a relatively rare disease. With the advent of HIV/AIDS pandemic however, AIDS-related KS has been on the increase and so has interest in the disease. Ninety percent of patients with KS present with skin lesions. While the gastrointestinal tract is a fairly common site of metastatic KS, primary gastrointestinal KS is uncommon. The presentation of gastrointestinal KS with severe gastrointestinal bleeding is rarer still. In this report, we present a 56-year-old HIV-negative patient who presented with severe gastrointestinal bleeding without any skin lesions. Multiple hemorrhagic polypoidal lesions were found on the walls of the jejunum and ileum as well as the liver at exploratory laparotomy and these were found to be KS on histopathologic examination. We also discuss the diagnostic and therapeutic challenges we had with this rare cause of severe GI bleeding.

Safety and feasibility of early postmastectomy discharge and home drain care in a low resource setting: OLASEHINDE et al.

Early postmastectomy discharge with a drain in place is standard practice in most developed countries. Its feasibility has not been evaluated in low resource settings like Nigeria.

Early Experience with Stapled Gastrointestinal Anastomoses in a Nigerian Hospital.

Background: Hand-sewn gastrointestinal anastomoses has been the traditional approach to gastrointestinal anastomosis in Nigeria while stapled anastomoses are infrequently performed in few centers. Objectives: To describe the outcome of our initial experience with stapled gastrointestinal anastomoses in a semi-urban patient population. Patients and Methods: Consecutive patients who had stapled gastrointestinal anastomoses between January 2011 and June 2014 in a Nigerian tertiary hospital were prospectively evaluated. Indications for operation, procedures performed and anastomoses constructed and postoperative outcome of each patient were documented. Results: Nineteen patients including seven males and 12 females had stapled anastomoses within the period. Their ages ranged between 41 and 68 (mean 52.5) years. Six (31.6%) Roux-en-Y gastrojejunostomies, 6 (31.6%) ileo-colic, 3 (15.8%) ileo-ileal, 2 (10.5%) colo-colic, and 2 (10.5%) colo-anal anastomoses were performed. Indications include antral gastric cancer in 4 (21.1%), right colon cancer 4 (21.1%), ileal perforations in 3 (15.8%) while 2 (10.5%) each had left colon cancer, common bile duct obstruction, rectal cancer and ruptured appendix. Mean duration of operation was 108 ± 46 min and mean duration of postoperative stay was 5 ± 2.6 days. No intraoperative complications were recorded and no anastomotic leakage occurred. At a median follow-up of 5 months no staple related stricture had occurred. Conclusions: Stapled gastrointestinal anastomoses are associated with a good outcome in our center. We propose a prospective, large-population randomized comparison of the technique with hand-sewn anastomoses.

Early experience with laparoscopic surgery in children in Ile-Ife, Nigeria

Background: Laparoscopy is not yet routinely employed in many Paediatric Surgical Units in Nigeria despite the advantages it offers. This study describes the preliminary experience with laparoscopic procedures in a single centre. Patients and Methods: A retrospective analysis of all children who had laparoscopic surgery between January 2009 and December 2013 at the Paediatric Surgical Unit of Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife was carried out. Their sociodemographic, preoperative and intraoperative data along with postoperative records were subjected to descriptive analysis. Results: Eleven (44%) diagnostic and 14 (56%) therapeutic procedures were performed on 25 children whose age ranged from 5 months to 15 years (Median: 84 months, Mean: 103 ± 64.1 months), including eight (32%) females and 17 (68%) males. Indications included acute appendicitis in 12 (48%), intra-abdominal masses in six (24%), three (12%) disorders of sexual differentiation, two (8%) ventriculoperitoneal shunt malfunctions and impalpable undescended testes in two (8%) children. The procedures lasted 15-90 minutes (Mean = 54 (±21.6) minutes). Conversion rate was 17% for two patients who had ruptured retrocaecal appendices. No intra operative complications were recorded while three (12%) patients had superficial port site infections post-operatively. All diagnostic (11) and two therapeutic procedures were done as day case surgery. The mean duration of hospital stay was 3.1 (±3.3) days for those who had appendectomies. Conclusion: Laparoscopic surgery in children is safe and feasible in our hospital. We advocate increased use of laparoscopy in paediatric surgical practice in Nigeria and similar developing settings.