Ibrahim Yusuf

Validity of fine needle aspiration cytology of the palpable breast lesions: A teaching hospital experience

Background and Objective: Fine needle aspiration cytology has assumed a great importance in the pre-operative diagnosis of palpable breast lesions in several hospital and clinical settings worldwide. This study aims to audit its diagnostic utility and validity in a tertiary hospital, and to review some of the diagnostic pitfalls in interpretation of breast cytology. Materials and Methods: The study comprised of breast cytology reports and their subsequent tissue biopsy diagnoses recorded over a 5-year period from January 2008 to December 2012. Results: A total of 1162 breast cytology reports were made over the review period out of which 200 had histological confirmation. Out of the 200 cases, 109 (54.5%) were benign (C2), 20 (10.0%) cases were suspicious probably benign (C3), 27 (13.5%) cases were suspicious probably malignant (C4) and 44 (22.0%) were malignant (C5). The cytology reports were correlated with subsequent histological diagnoses. Of the 109 benign C2 reports, 99 were confirmed on tissue histology as truly benign (true negatives) and the remaining 10 cases were malignant (false negatives). Forty-three of the 44 malignant (C5) cytology reports initially made were confirmed as malignant on tissue histology (true positives). The remaining malignant (C5) cytology case was, however, revealed to be benign (false positive). The overall suspicious rate (C3 and C4) was 23.5%. The absolute sensitivity was 81.0%, specificity was 99.0%, positive predictive value (PPV) (C5) of 97.7%, negative predictive value (NPV) (C2) of 90.8%. The false positive rate (FPR), false negative rate (FNR) and suspicious rates (SR) were 1.2%, 12.0% and 23.5%, respectively. Conclusion: Fine needle aspiration cytology of the breast has recorded high absolute sensitivity and specificity in our centre with a marginally high false positive rate. It has thus continued to have relevance as an important pre-operative diagnostic tool in the management of palpable breast lesions in our hospital.

Role of Media in Portraying Ebola in and outside Africa

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Ebola and compliance with infection prevention measures in Nigeria

An outbreak of Ebola virus in Nigeria that began in July, 2014, after a Liberian man imported the virus to the country have raised the level of compliance to infection prevention and control measures in the nation. As researchers advocating for efficient infection control in both rural and urban health-care facilities and use of safe, environmentalfriendly methods to prevent infectious diseases in Nigeria, we read with interest a recent Editorial in The Lancet. The editorial emphasised the reasons why many people fear Ebola virus, and discussed the fact that if better infection control measures are in place—such as are available in medium-income or high-income countries—the long incubation period of 2–21 days of Ebola is suffi cient to treat those that become ill. Nigerians have never take infection prevention and control measures or environmental sanitation very seriously, despite the efforts of the government and advocates. However, amazingly with the Ebola outbreak, we have seen relatively improved compliance to WHO infection control practice guidelines of “clean care is safer care” (for which compliance was initially <5%) within a few weeks, because of fears about Ebola‘s mode of killing and the absence of a vaccine or cure for the disease. The fact that Ebola infection kills doctors and nurses treating victims of the disease, and the cases of the two American doctors who were infected despite their strict adherence to infection prevention and control measures, have forced many people to make a little eff ort and comply with guidelines. Raised anxieties among patients, health-care workers, and members of the community in fear of contracting the virus from each other have improved the use of handwashing techniques, not only in hospitals, but also in banks, markets, public places, and in communities, as advised by health-care workers through word of mouth, on print and social media, and in religious places. Use of ordinary soap, sanitisers, and even just ordinary water to wash hands after contact with other people has increased substantially, and more people are refusing to shake hands with strangers. Dissatisfaction with the world response to the Nigerian Ebola outbreak among many Nigerians; travel restrictions and stigmatisation of African communities abroad; an indefi nite strike initiated by medical doctors in the country at the start of the outbreak; the rate at which people are dying needlessly in neighbouring Liberia, Guinea, and Sierra Leone; and reports of doctors and nurses fl eeing when profusely bleeding accident victims are brought to hospitals have forced some Nigerians to go to extremes, such as following the advice of a mere rumour suggesting the use of concentrated salt solution for drinking and washing as a prevention or cure. Such misinformed control measures are not being used for a cholera outbreak that is occurring simultaneously in some areas of Nigeria. The outbreak, which has affected at least 352 people in two states within 3 months, has received less sympathy and fi nancial support from the community and government than Ebola, but has subsided as a result of improved infection prevention and control measures in the aff ected communities because of fears about Ebola. In a recent survey that we did in Nigeria of 56 health-care workers and 60 members of the community (23 rural and 37 urban dwellers) about measures taken by the government to curtail the spread of Ebola, many agreed that Ebola is real and that the preventative measures are acceptable, even though some religious and cultural rights need to be forfeited. Only seven of the 60 community members interviewed have never practiced handwashing and are never cautious about touching ill people even after the outbreak. They believe that Ebola does not really exist and is merely western propaganda. We have noted improvements in actions by all the stakeholders in Nigeria listed in a call to action for adoption of the Chennai declaration in combating spread of hospitalacquired infections and in strict adherence to the NICE quality standards of infection prevention and control and to WHO guidelines. Such improvements show that the outbreak of Ebola has successfully forced the Nigerian Government, non-governmental organisations, the media, and communities to take infection prevention and control issues seriously.

Histopathological study of soft tissue sarcomas seen in a teaching hospital in Kano, Nigeria

Background and Objective: Malignant soft tissue tumours account for less than 1% of overall human burden of malignant tumours. Increasing incidences of these tumours have been noted worldwide. This study aims to determine the pattern of soft tissue sarcomas seen in a teaching hospital. Materials and Methods: The study comprised of all cases of soft tissue sarcoma diagnosed over a 10-year review from 1 January 1999-31 December 2008. Results: A total of 264 cases of soft tissue sarcomas were reviewed; 162 males and 102 females with a male to female ratio of 1.6:1. The age range was between 3 months and 89 years with a mean age of 39.0 years. Kaposi sarcoma was the predominant histological type with 56 cases (21.2%). This was followed by rhabdomyosarcoma with 54 (20.5%) cases, dermatofibrosarcoma with 52 (19.7%) cases and liposarcoma with 32 (12.0%) cases. The most common site of affectation was the lower limb with 73 (27.7%) cases, followed by the trunk with 66 (25.0%) cases, head and neck with 45 (17.0%) cases and upper limb with 35 (13.3%) cases. Two hundred and eight cases satisfied the criteria for grading, out of which 34.1% were classified in grade I, 32.2% in grade II and 33.7% in grade III. Conclusion: Soft tissue sarcomas accounted for 8.8% of malignant tumours seen over the review period and Kaposi sarcoma was the predominant histological subtype commonly affecting young adults in our centre.

Bilateral synchronous mature ovarian teratoma and mucinous cystadenoma

Published reports of different synchronous tumours in both ovaries are scanty, and the few reported cases are mostly malignant. This report of synchronous benign tumors in both ovaries occurred in a 26 year old female who presented with one year history of painless abdominal swelling and two large multicystic masses on ultrasound scan. She had bilateral oophorectomy and histology revealed right sided benign cystic teratoma and left sided mucinous cystadenoma. Conclusion: Both tumours were benign and therefore potends no adverse consequences for the patient. Nonetheless, given the unusual presentation, she is being followed up.

Audit of nottingham system grades assigned to breast cancer cases in a Teaching Hospital

Background: Histologic grade of breast cancer is a Category I prognostic factor. Thus, accurate and reproducible grading must be ensured by periodic auditing and training. Objective: The objective of this study is to audit interobserver agreement in grading and evaluate agreement of grading on core needle biopsies with surgical pathology. Materials and Methods: Slides of 73 cases of invasive carcinomas of the breast were retrieved from archives. These were grouped into 43 cases on which consensus grades assigned by 3 pathologists were compared with initial grades assigned to the cases. The next 24 cases were graded independently by 4 pathologists and compared. In the last 6 cases, consensus grades were assigned to both the initial core needle biopsy (CNB) and the excisional biopsy. Kappa values were then calculated. Results: Kappa value (κ) for the first 43 cases was 0.50 (moderate agreement; P < 0.05). There was only fair agreement (κ = 0.25) between CNB grade and final surgical pathology grade, with 50% being upgraded from Grades 2–3. There was moderate agreement (κ = 0.53, P < 0.05) in the 24 cases on which inter-rater agreement was tested. Specific rating of both mitotic count and nuclear pleomorphism showed fair agreement (κ = 0.25 and 0.34, respectively) while rating of tubule formation showed moderate agreement (κ = 0.57; P < 0.05). Pairwise kappa agreement ranged from fair to good (0.31–0.63). Conclusion: To ensure reproducibility, greater attention should be paid to accurately assessing nuclear pleomorphism and mitotic activity in particular. Re-grading of excisional breast biopsies after initial CNB is also essential to prevent undergrading.

Benign tumors of the breast in Kano, Northern Nigeria: A 10-year experience and review of literature

Background: Benign breast tumors are common worldwide and various reports suggest an increasing incidence in Nigeria which necessitates an urgent need to differentiate it from malignant tumors. The study was carried out to classify and determine the pattern, frequency, age, and sex distribution of benign breast tumors seen in a tertiary hospital. Materials and Methods: This was a 10-year retrospective study of all benign breast tumors diagnosed at the Pathology Department of a teaching hospital from January 1 2001 to December 31 2010. Results: A total of 1566 breast tumors were diagnosed during the study period, 1035 cases of benign breast tumors constituting 66.3% of all breast tumors were seen. The female to male ratio was 72.9:1. The overall mean age for benign breast tumor was 29 years with a peak age occurrence in the third decade. Fibroadenoma (FA) was the most common benign breast tumor followed by fibrocystic change and they accounted for 47.1% and 25.4% of benign breast tumors with mean age of 24.7 years and 33.4 years, respectively. FA has a peak occurrence in the third decade while fibrocystic change has a peak occurrence in the fourth decade. Other major tumors encountered were tubular adenoma (6.0%), lactating adenoma (5.6%), benign phyllodes (4.8%), sclerosing adenoma (3.3%), and blunt duct adenoma (2.5%). Gynecomastia (1.4%) was the only benign breast tumor seen in males.Conclusions: Benign breast tumors are quite common, presenting mostly as FA and fibrocystic change. The tumors are seen in both sexes with a striking female preponderance and occurred predominantly in young females with a peak in the third decade. The findings are generally similar to the most previous studies from Nigeria, Africa, and the Western world with minimal variations.

Skin adnexal tumours in Kano, Northern Nigeria

Background and Objective: Tumours of skin adnexae are an uncommon group of neoplasms that have not been formally studied in our locality. We undertook this review to document and evaluate the pattern in Kano, northern Nigeria. Materials and Methods: This is a 10-year (2004-13) retrospective study of all skin adnexal tumours diagnosed at the pathology department of Aminu Kano Teaching Hospital (AKTH), Kano. Results: Ninety-two skin adnexal tumours were diagnosed during the study period, and there was no significant gender predilection - males (49%), females (51%). The overwhelming majority were benign (86%), while malignancies comprised just 14%. Patients ranged from 4 to 90 years of age, peaking in the third and fifth decades. The most common histological types were nodular hidradenoma (17.4%), eccrine poroma (9.8%) and pilomatrixoma (9.8%), with sebaceous carcinoma (5.4%) as the most frequent adnexal malignancy. The tumours were most commonly located in the head and neck region (52%), followed by the trunk (25%) and extremities (23%). Conclusion: Skin adnexal tumours are relatively uncommon in Kano affecting predominantly people in the third and fifth decade without a definitive sex predilection. Most of the tumours showed sweat gland differentiation with nodular hidradenoma and sebaceous gland carcinoma being the most common benign and malignant tumours, respectively.

Giant malignant phyllodes tumor with liposarcomatous differentiation

Malignant phyllodes tumor may occur with heterelogous differentiation. Sarcomatous stromal elements that may be seen in these tumors include angiosarcoma, chondrosarcoma, leiomyosarcoma, osteosarcoma, rhabdomyosarcoma, and liposarcoma. However, liposarcomatous stromal differentiation in malignant phyllodes tumor is very rare. We report a case of an 18-year-old lady who presented with a 4-months history of recurrent huge rapidly growing ulcerated left breast mass. A clinical impression of ulcerated malignant phyllodes tumor was made. Simple mastectomy was necessary due to the recurrent nature of the lesion, presentation, and available facilities. Histological findings revealed a lesion exhibiting leaf-like pattern and composed of a highly cellular stroma demonstrating myxoid changes, liposarcomatous differentiation including lipoblasts and bizarre tumor giant cells. A histologic diagnosis of malignant phyllodes tumor with liposarcomatous differentiation was made. She had an un-eventful post-operative period and was discharged to follow up.

Cyto-morphologic correlation of equivocal C3 and C4 breast lesions

Background: National Cancer Institute (NCI) formulated a five-tiered system for reporting cytological smears from the breast. Of these, C1, C2 and C5 are usually unequivocal. The equivocal categories C3 (atypical probably benign) and C4 (suspicious probably malignant) need to be evaluated to determine their cyto-morphologic correlation and thus provide useful information on the degree of clinical weight that can be put on them in patient management. Patients and Methods: A retrospective study of cytological smears made from palpable breast lesions performed over a 5-year period from 2008-2012. The C3 and C4 smears were then compared with final histological diagnoses for these categories and their diagnostic value calculated. Result: There were 1,162 smears taken over the study period, and 200 (17.2%) had subsequent histology. Of the 200 smears, 20 were C3 and 27 were designated as C4. Subsequent histology upgraded 7 (35%) of the C3 cases to malignant and 23 (85%) of the 27 C4 cases were malignant. The difference between these two proportions is statistically significant (P < 0.005). The overall Suspicious Rate was 23.5% and C4 reports had a sensitivity of 76.7%, specificity of 76.5%, positive and negative predictive values of 85.2% and 65.0% respectively. Conclusion: A fair degree of clinical reliance can still be placed on cytologically categorized C3 and C4 breast smears. However, the rate of reporting of these categories can be reduced with availability of ancillary radiological techniques such as mammography and ultrasonography.