Babatunde M. Duduyemi

Characteristics, management, and outcomes of patients with hepatocellular carcinoma in Africa: a multicountry observational study from the Africa Liver Cancer Consortium

BACKGROUND Hepatocellular carcinoma is a leading cause of cancer-related death in Africa, but there is still no comprehensive description of the current status of its epidemiology in Africa. We therefore initiated an African hepatocellular carcinoma consortium aiming to describe the clinical presentation, management, and outcomes of patients with hepatocellular carcinoma in Africa. METHODS We did a multicentre, multicountry, retrospective observational cohort study, inviting investigators from the African Network for Gastrointestinal and Liver Diseases to participate in the consortium to develop hepatocellular carcinoma research databases and biospecimen repositories. Participating institutions were from Cameroon, Egypt, Ethiopia, Ghana, Ivory Coast, Nigeria, Sudan, Tanzania, and Uganda. Clinical information-demographic characteristics, cause of disease, liver-related blood tests, tumour characteristics, treatments, last follow-up date, and survival status-for patients diagnosed with hepatocellular carcinoma between Aug 1, 2006, and April 1, 2016, were extracted from medical records by participating investigators. Because patients from Egypt showed differences in characteristics compared with patients from the other countries, we divided patients into two groups for analysis; Egypt versus other African countries. We undertook a multifactorial analysis using the Cox proportional hazards model to identify factors affecting survival (assessed from the time of diagnosis to last known follow-up or death). FINDINGS We obtained information for 2566 patients at 21 tertiary referral centres (two in Egypt, nine in Nigeria, four in Ghana, and one each in the Ivory Coast, Cameroon, Sudan, Ethiopia, Tanzania, and Uganda). 1251 patients were from Egypt and 1315 were from the other African countries (491 from Ghana, 363 from Nigeria, 277 from Ivory Coast, 59 from Cameroon, 51 from Sudan, 33 from Ethiopia, 21 from Tanzania, and 20 from Uganda). The median age at which hepatocellular carcinoma was diagnosed significantly later in Egypt than the other African countries (58 years [IQR 53-63] vs 46 years [36-58]; p<0·0001). Hepatitis C virus was the leading cause of hepatocellular carcinoma in Egypt (1054 [84%] of 1251 patients), and hepatitis B virus was the leading cause in the other African countries (597 [55%] of 1082 patients). Substantially fewer patients received treatment specifically for hepatocellular carcinoma in the other African countries than in Egypt (43 [3%] of 1315 vs 956 [76%] of 1251; p<0·0001). Among patients with survival information (605 [48%] of 1251 in Egypt and 583 [44%] of 1315 in other African countries), median survival was shorter in the other African countries than in Egypt (2·5 months [95% CI 2·0-3·1] vs 10·9 months [9·6-12·0]; p<0·0001). Factors independently associated with poor survival were: being from an African countries other than Egypt (hazard ratio [HR] 1·59 [95% CI 1·13-2·20]; p=0·01), hepatic encephalopathy (2·81 [1·72-4·42]; p=0·0004), diameter of the largest tumour (1·07 per cm increase [1·04-1·11]; p<0·0001), log α-fetoprotein (1·10 per unit increase [1·02-1·20]; p=0·0188), Eastern Cooperative Oncology Group performance status 3-4 (2·92 [2·13-3·93]; p<0·0001) and no treatment (1·79 [1·44-2·22]; p<0·0001). INTERPRETATION Characteristics of hepatocellular carcinoma differ between Egypt and other African countries. The proportion of patients receiving specific treatment in other African countries was low and their outcomes were extremely poor. Urgent efforts are needed to develop health policy strategies to decrease the burden of hepatocellular carcinoma in Africa. FUNDING None.

Hepatocellular carcinoma occurs at an earlier age in Africans, particularly in association with chronic Hepatitis B

Hepatocellular Carcinoma Occurs at an Earlier Age in Africans, Particularly in Association With Chronic Hepatitis B

Clinicopathological review of surgically removed appendix in Central Nigeria

Abstract Background Acute appendicitis is a disease of the young presenting in children and early adolescents although no age group is exempt. It is the most common cause of acute surgical abdomen worldwide. This clinicopathological study aims to determine the various lesions of the surgically removed appendix in our centre and if any, changing trend in this lesion in our environment. Method A retrospective study was undertaken to review the histopathology reports of all appendicectomy specimens submitted to the Department of Pathology of the Asokoro District Hospital, Abuja; Nigeria from November 2009 to October 2012 Patient’s biodata, clinical signs and symptoms were extracted from the request form. Result A total of 293 appendices were received during the 3-year study period constituting about 10% of total specimens. The male to female ratio was 1:1.3 with a mean age of 26.33 ± 11.39 years. Acute appendicitis was found in 81.2% of our cases while other lesions constitute 14.7% and negative appendectomy occurred in 4.1% of the cases. No mortality was recorded. Conclusion The findings in this study compared favourably with those of our environment and in the developed world although acute appendicitis in this study showed slight female preponderance.

Nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline

In order to address the status of gastrointestinal (GI) endoscopy in Africa, a European Society of Gastrointestinal Endoscopy (ESGE) International Affairs Working Group (IAWG) was established with participation from the World Endoscopy Organization (WEO) 1 . A previous survey conducted by the IAWG on the main indications of GI endoscopy in African countries showed nonvariceal upper GI hemorrhage (NVUGIH) to be among the top three indications 1 . This indication may reflect the very high prevalence of Helicobacter pylori infection, which is well known to be associated with gastroduodenal peptic ulcers and their complications, such as bleeding. In addition, the increased use of aspirin as prevention and treatment of cardiovascular disease, and the increase in life expectancy, may also, at least in part, account for the NVUGIH indication 2 3 4 . The management of NVUGIH requires a multi-step approach, involving endoscopic factors such as emergency endoscopy with different hemostatic devices, and clinical factors such as hospitalization, blood transfusion, and drugs. Such an approach is clearly sensitive to organizational, medical, pharmaceutical, and technological resources. However, the lack of structural endoscopic and clinical health resources in some underserved African areas is likely to affect the clinical outcome of patients with NVUGIH. In this regard, the previous IAWG survey revealed several critical needs in training, education, and technology that may represent a barrier to adequate NVUGIH management 1 . Most of the respondents from the African countries participating in the IAWG survey reported a lack of national guidelines for GI endoscopy; however, there was interest in the international guidelines, pending adaptation to reflect the endoscopic resources available in their regions. For this reason, the IAWG decided to apply the cascade methodology to adapt ESGE guidelines to resource-sensitive settings in partnership with African experts 1 . Cascade guidelines are resource oriented and provide hierarchical recommendations based on the resources available to the medical care provider 5 6 . In detail, four levels of resource availability – basic, limited, enhanced, and maximal levels – are identified, with most of the interest being in the basic and limited levels. We aimed to standardize the management of NVUGIH in low-resources setting. Here, we report the cascade adaptation of the ESGE guideline on the diagnosis and management of NVUGIH 7 .

Cytopathology practice in Kumasi: A 2-year retrospective audit

Aim: Surgical pathology service is generally unavailable in most developing countries and comes with challenges. Cytopathology is a reliable, inexpensive adjunct to surgical histopathology. We present a retrospective review of the various cytopathology cases received at the department. Materials and Methods: A retrospective review of 836 cytopathology cases from January 2010 to December 2011 at the Department of Pathology of our hospital was conducted. All cytopathology reports and records from the department were retrieved and analyzed using the Statistical Package for the Social Sciences version 16 for windows. Results: A total of 836 (mean age 38.18 ± 22.18) cases were reviewed, at an average of approximately 418 cases performed a year (5.7% of the total workload). More than half (58.0%) of the cases received had no clinical diagnosis indicated on request forms. Seventy-seven percent (77%) of the cases were diagnosed as either definite or nondefinite. The breast was the most aspirated specimen site (20.2%). Benign cases formed 45.0% of all the cases and 29.0% were malignant. There were more benign than malignant cases with respect to all sites aspirated except the breast (18.3%), lymph nodes (35.0%), and soft tissues (11.7%) where the reverse occurred. Conclusion: Patronage of cytopathology in Kumasi is increasing and serves as a quick, cheap, and effective alternate means for diagnosis. Improving and expanding on the current practice will ensure that pathologists in practice sustain and improve diagnostic cytopathology and provide material for training young pathologists.

Synchronous rhabdomyosarcoma of the testis and kidney: A case report and review of the literature

Abstract Rhabdomyosarcoma is the commonest soft tissue sarcoma in both children and adolescents representing 40% of such tumours in North America and more than 50% in Africa. The involvement of the paratesticular tissue, testis and the kidney are generally rare and more so when it is occurring synchronously. We present a case of 22 year old male with inguinoscrotal swelling, fever and abdominal distention who was diagnosed as having obstructed left inguinoscrotal hernia and a right renal mass. The patient had surgery, and a diagnosis of synchronous rhabdomyosarcoma of the left testis, paratesticular tissue and right kidney was made by histology and immunohistochemistry.