|Year : 2016 | Volume
| Issue : 2 | Page : 56-61
Clinico-pathological characteristics of Skin Cancers at Benue State University Teaching Hospital, Makurdi, North Central Nigeria
Chukwukadibia N Ahachi1, Priscilla Denen Akaa1, Itodo C Elachi1, Daniel D Mue1, Joseph A Ngbea2, Ikenna N Anakebe3, Eunice O Onuh4
1 Department of Surgery, College of Health Sciences, Benue State University and Benue State University Teaching Hospital, Abuja, Nigeria
2 Department of Morbid Anatomy, College of Health Sciences, Benue State University and Benue State University Teaching Hospital, Abuja, Nigeria
3 Department of Surgery, Benue State University Teaching Hospital, Makurdi, Nigeria
4 Department of Surgery, National Hospital, Abuja, Nigeria
|Date of Web Publication||17-Mar-2017|
Chukwukadibia N Ahachi
Department of Surgery, College of Health Sciences, Benue State University, Benue State University Teaching Hospital, Makurdi
Source of Support: None, Conflict of Interest: None
Objective: To document the clinico-pathological characteristics of skin malignancies seen at Benue State University Teaching Hospital, Makurdi.
Materials and Methods: A 3-year retrospective study of patients with histologically-confirmed skin cancers presenting to our institution from April 1, 2012 to March 31, 2015 was done. Relevant data was extracted from the patients' records and subjected to statistical analysis.
Results: Records were available for 43 patients with a mean age of 46 ± 18 years. There were 21 males and 22 females with a male:female ratio of approximately 1:1. Squamous cell carcinomas were the most common histologic type seen (44.2%) followed by melanoma and Kaposi's sarcoma (25.6% each) while basal cell carcinomas accounted for 4.7%. Farmers (37.2%) and artisans (23.3%) were the most common occupations seen. Human immunodeficiency virus (HIV)-positive patients accounted for 27.9% of the total and albinos 18.6%. Majority of the patients (60.4%) had history of prolonged exposure to sunlight with little regard for protective measures. The average duration of symptoms before presentation was 28 ± 33 months.
Conclusion: The study suggested an association between skin cancer and prolonged, unprotected exposure to sunlight on one hand and HIV infection on the other. It highlights the need to promote basic preventive measures.
Keywords: Clinico-pathological characteristics, Makurdi, Nigeria, skin cancer, sunlight
|How to cite this article:|
Ahachi CN, Akaa PD, Elachi IC, Mue DD, Ngbea JA, Anakebe IN, Onuh EO. Clinico-pathological characteristics of Skin Cancers at Benue State University Teaching Hospital, Makurdi, North Central Nigeria. Nigerian J Plast Surg 2016;12:56-61
|How to cite this URL:|
Ahachi CN, Akaa PD, Elachi IC, Mue DD, Ngbea JA, Anakebe IN, Onuh EO. Clinico-pathological characteristics of Skin Cancers at Benue State University Teaching Hospital, Makurdi, North Central Nigeria. Nigerian J Plast Surg [serial online] 2016 [cited 2018 Apr 22];12:56-61. Available from: http://www.njps.org/text.asp?2016/12/2/56/202465
| Introduction|| |
Skin cancers are the most common malignancies worldwide.,, Two to three million nonmelanoma skin cancers (NMSC) and 132,000 melanomas are diagnosed annually. One in three cancers diagnosed annually are skin cancers with a higher incidence in Caucasians especially in Australia., The main aetiological factor is exposure to ultraviolet (UV) radiation, mainly from the sun (and tanning beds), especially in the fair-skinned.,,,, Some genetic diseases are known to predispose to NMSC and immunosuppressive states including human immunodeficiency virus (HIV) infection and postsolid organ transplantation immunosuppression are well-known causes.,,,
Skin cancers are less common in Nigeria than in some other parts of the world but are still a very important cause of morbidity and, to a lesser extent, mortality especially among albinos here.,,,,,,,,,,, It is estimated that there are 65,258 new cases of skin cancer in Nigeria annually giving a projected annual incidence of 52 in 100,000. We have observed a fairly high incidence of skin cancers in our practice and have set out to determine the pattern of skin cancers seen at our institution.
| Materials and Methods|| |
A retrospective study was carried out to review the records of patients presenting at Benue State University Teaching Hospital, Makurdi over a 3-year period: April 1, 2012 to March 31, 2015.
All patients who met the following criteria were included in the study.
- Patients who presented with skin lesions histologically-confirmed to be malignant following a biopsy
- Patients whose records were adequate to meet the objectives of the study.
Having sought and received ethical approval, records of patients who met the inclusion criteria were retrieved and relevant data including age, sex, occupation, history of exposure to sunlight, clinical diagnosis, histological diagnosis was extracted. At the end of the study, the data was subjected to simple statistical analysis using Statistical Package for the Social Sciences version 21 (IBM Corp., Armonk, NY, USA).
| Results|| |
A total of 43 patients met the inclusion criteria for the study. There were 21 males and 22 females, giving a male:female ratio of approximately 1:1. The ages ranged from 20 to 78 years with a mean (±standard deviation) of 46 ± 18 years. The median age was 43 years. The 20–29 years group constituted the highest proportion of patients (ten patients, 23.3%), followed by the 40–49 years group whose nine patients constituted 20.9% of total [Table 1]. Farmers (37.2%) were more commonly affected than others and most patients were of the Tiv ethnic group. The duration of symptoms before presentation ranged from 1 to 168 months with a mean value of 28 ± 33 months.
Nearly half (44.2%) of the patients were found to have squamous cell carcinomas (SCCs) [Table 1] with a mean age of 43 ± 20 years. Melanomas and Kaposi's sarcoma (KS) each accounted for 25.6% of the cases with mean ages of 59 ± 12 years and 37 ± 12 respectively. There were two cases of basal cell carcinoma (BCC) accounting for 4.7% of the total. Both patients were female with a mean age of 51 ± 30 years. The other histologic types of cancer had a male to female ratio of approximately 1:1 [Table 2].
Of the 19 patients with SCC, seven (36.8%) were farmers, five (26.3%) were students. The five students were all albinos. Eight (72.7%) of the 11 melanoma patients were also farmers [Table 3]. KS was most common amongst artisans (six patients, 54.6%).
The SCCs were evenly distributed amongst the various ethnic groups but melanomas (eight patients, 72.7%) and KS (nine patients, 81.8%) were mainly found among the Tiv ethnic group [Figure 1].
In both patients that had BCC, the lesions were on the face as shown in [Table 4]. The SCCs were mainly on the face and lower limbs (42.1% and 36.6% respectively), while the melanomas were all on the lower limbs, specifically on the soles of the feet. Most of the KS (63.6%) were multifocal and involved the lymph nodes (72.7%). Only 36.8% of the SCCs and 36.3% of the melanomas had gross lymph node involvement.
Albinism was a co-morbid factor in 36.8% of the SCCs (seven patients) and 50% of the BCCs (one patient). All the albinos had head and neck lesions. One (2.3%) had a presternal lesion. None of the nonalbino patients had preexisting lesions. HIV was associated with 63.6% of the KS (seven patients).
Exposure to carcinogens
Most of the patients (26 patients, 60.4%) had a history of prolonged, unprotected exposure to sunlight as shown in [Table 5]. There was also evidence of infection with potentially-carcinogenic viruses (11 patients, 25.6%). Only five patients (11.6%) gave no history or sign of significant exposure to a potential cause of their skin cancers.
Thirty-two patients (74.4%) had excisional biopsies and subsequent wound cover mostly with split skin grafts. Twenty of them (46.5%) had other modalities of treatment in addition to the excisional biopsy [Figure 2]. Seven patients (16.3%) with KS and HIV infection were treated with highly-active antiretroviral therapy (HAART) only. One patient (2.3%) with SCC had a lower limb amputation.
Length of hospital stay
The average length of hospital (LOS) stay was 14 ± 15 days. The range was 0–63 days and the median LOS was 14 days. The least LOS was among the KS patients who were largely treated as day cases (10, 91%) and spent an average of 3.46 days. The SCC patients spent an average of 15 days in hospital with seven of them (36.8%) treated as day cases. The 11 melanoma patients were all treated as in patients and spent an average of 24 days in hospital.
All the patients failed to come for regular follow-up visits after the first 3 months of treatment. This includes patients that had commenced adjuvant therapy. Two patients (4.6%) died during the initial treatment. Out of the 41 patients on various forms of therapy, 34 (79.1%) totally defaulted from follow-up visits and 7 (16.3%) re-presented later with local recurrence (4.6%) and advanced disease (9.3%).
| Discussion|| |
Squamous cell carcinoma was the most common skin malignancy seen in our study. This study showed a higher prevalence rate among farmers and artisans. This may be related to the fact that their occupation predisposes them to longer periods of exposure to the sun, and by implication UV radiation. This supports a well-documented aetiological factor.,,, The impact of the HIV on the prevalence of skin cancer is also significant. This has contributed to the relative young age of the patients in our study, a worrisome trend in an agrarian state that depends heavily on the young and active segment of the population to maintain and improve productivity.
SCC accounted for 44% of the 43 cases studied, with a mean age of 43 ± 20 years. Ochicha et al. found SCCs to be the most common skin cancer in a 5-year study of 125 patients in Kano. They accounted for 40% of the cases. Gana and Ademola in a 20-year review of 494 skin cancer cases in Ibadan, found a preponderance of SCCs (40.5%). Samaila and Adewuyi in a 10-year study of 382 cases in Zaria found 62.9% to be SCCs while Datubo-Brown's 3-year study of 18 patients in Port Harcourt found 39% to be SCCs and slightly less than melanomas (39.7%).,,,, Asuquo and Ebughe studied 162 cases over 10 years in Calabar with SCCs (38.3%) being most common. Oseni et al. in a 4-year review of 98 cases in Oshogbo found SCCs (32.7%) significantly less common than melanomas (37.8%) while Forae and Olu-Eddo 25-year review of 187 cases in Benin found SCCs (24%) to be third most common with a mean age of 51 years., Our study had findings not too different from those done in Kano, Ibadan, Port Harcourt and Calabar. The results from Zaria, Oshogbo and Benin differed a lot more. The factors responsible for these variations have not been explained.
In our study and in the Benin study, the lower limbs were the second most common site of SCCs after the head and neck. Many other studies had the lower limb as being the most common site.,,,,
A significant number of the patients were albinos (26.3%), a common finding in some other studies., Opara and Jiburum in a study done in Orlu found 67% of their SCC patients to be albinos. This was also a youthful group of patients. Okoro's pioneering paper highlighted the near absence of protective care of Nigerian albinos and the negative impact of myopia on their academic performance usually leading to menial, outdoor jobs. These factors contribute to the early onset of skin cancers in the young or middle adulthood, reducing the life expectancy of albinos. This problem persists till date. Other studies have documented similar findings., Albinos are even more susceptible to UV radiation than Caucasians who have very high incidences of SCC though it is reported as being the 2nd most common skin malignancy in the US, Europe and Australia.,,
Melanomas accounted for 25.5% of our cases with a mean age at diagnosis of 59 ± 12 years and peaks at the fifth, seventh and eighth decades. A Benin study found a mean age of 52 years and a peak age range at the fifth decade. In the USA, the mean age is 62 years with a peak at the fifth decade. All the lesions in our study were on the sole of the foot. A predilection for the sole has been commonly found by many other studies of Negroid melanoma patients.,,,,,,,,, This has given rise to the theory of recurrent trauma as an aetiological factor for melanoma. The case for this theory is rather weak as it has been found that both unshod and shod individuals are at risk of developing melanoma on the sole of the foot. In Caucasians, the sun-exposed head, neck, trunk and legs are the commoner sites., Some studies from Port Harcourt (39%), Oshogbo (37.8%) and Benin (33%) had a preponderance of melanoma, while those from Kano (34%), Ibadan (25.1%) and Zaria (14.1%) had melanomas as the second and, Calabar (9.9%), third most common histologic type.,,,,, The Ibadan figures were closest to ours. Caucasians have much lower levels of the protective melanin pigment than blacks and other coloured people. Our local figures are vastly different from that of Caucasian populations. Melanoma is the most common form of cancer for young adults and the second most common form of cancer for young people in the United States.
KS also accounted for 25.6% of our cases with a mean age of 37 ± 12 years and a peak at the forth decade. A mean age of 48 years was found in Benin. Studies in Calabar, Benin, Zaria, Ibadan, Kano and Oshogbo found KS accounting for 30.9%, 29.9%, 10.7%, 8.3%, 8% and 3.1% respectively.,,,,, This showed a very wide variation with some authors attributing it to regional variations in HIV prevalence. In our study, 63.6% of the KS patients were HIV-positive. Asuquo and Ebughe reported 64% in Calabar, while Ochicha et al. reported 50% HIV prevalence among the KS patients., All our patients were screened for HIV and treatment commenced with HAART for all those positive and not already on HAART irrespective of the CD4 count. Remission rates could not be ascertained as most patients were quickly lost to follow-up.
BCC is known to be the most common type of skin cancer worldwide (70%–80% in Caucasians). It accounted for only 4.7% of our cases with a mean age of 51 ± 30 years. A mean age of 66 years was reported in the US and 44 years in Benin., Studies in Port Harcourt, Benin, Ibadan, Oshogbo, Calabar, Kano and Zaria reported BCC prevalence rates of 22%, 10%, 6.7%, 5.1%, 4.9%, 4% and 3.9% respectively.,,,,,, These findings underline the fact that the high levels of melanin in the Negroid skin, while not conferring invincibility, offers protection from carcinogenic UV radiation leading to very low levels of BCC in the Negroid race.
| Conclusion|| |
The pattern of skin cancers seen at Benue State University Teaching Hospital, Makurdi is not much different from most other hospital-based studies done in Nigeria. The challenge we face now is to improve data collection in order to produce fairly-accurate population-based prevalence and incidence reports.
Our study has highlighted the susceptibility of sun-exposed farmers, artisans and albinos to skin cancers. The impact of the HIV pandemic has also been shown. While we strive to improve access to and quality of health care, it is important to promote basic preventive measures which have been shown to protect from carcinogenesis.
Prof. V. M. Ramyil, Department of Surgery, University of Jos. Dr. O. Audu, Department of Epidemiology and Community Health, Benue State University.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Guy GP Jr., Machlin SR, Ekwueme DU, Yabroff KR. Prevalence and costs of skin cancer treatment in the U.S 2002-2006 and 2007-2011. Am J Prev Med 2015;48:183-7.
Staples MP, Elwood M, Burton RC, Williams JL, Marks R, Giles GG. Non-melanoma skin cancer in Australia: The 2002 national survey and trends since 1985. Med J Aust 2006;184:6-10.
Wehner MR, Shive ML, Chren MM, Han J, Qureshi AA, Linos E. Indoor tanning and non-melanoma skin cancer: Systematic review and meta-analysis. BMJ 2012;345:e5909.
Brenner M, Hearing VJ. The protective role of melanin against UV damage in human skin. Photochem Photobiol 2008;84:539-49.
International Agency for Research on Cancer Working Group on Artificial Ultraviolet (UV) Light and Skin Cancer. The association of use of sunbeds with cutaneous malignant melanoma and other skin cancers: A systematic review. Int J Cancer 2007;120:1116-22.
Nikolaou V, Stratigos AJ, Tsao H. Hereditary nonmelanoma skin cancer. Semin Cutan Med Surg 2012;31:204-10.
Silverberg MJ, Leyden W, Warton EM, Quesenberry CP Jr., Engels EA, Asgari MM. HIV infection status, immunodeficiency, and the incidence of non-melanoma skin cancer. J Natl Cancer Inst 2013;105:350-60.
Lanoy E, Costagliola D, Engels EA. Skin cancers associated with HIV infection and solid-organ transplantation among elderly adults. Int J Cancer 2010;126:1724-31.
Hanlon A, Colegio OR. The cutting edge of skin cancer in transplant recipients: Scientific retreat of international transplant Skin Cancer Collaborative and Skin Cancer in Organ Transplant Patients Europe. Am J Transplant 2014;14:1012-5.
Okoro AN. Albinism in Nigeria. A clinical and social study. Br J Dermatol 1975;92:485-92.
Opara KO, Jiburum BC. Skin cancers in albinos in a teaching hospital in Eastern Nigeria – Presentation and challenges of care. World J Surg Oncol 2010;8:73.
Onuigbo WI. Malignant melanoma in the Igbos of Nigeria. Br J Plast Surg 1975;28:114-7.
Datubo-Brown DD. Primary malignant skin tumors in Nigerians. J Natl Med Assoc 1991;83:345-8.
Yakubu A, Mabogunje OA. Skin cancer in Zaria, Nigeria. Trop Doct 1995;25 Suppl 1:63-7.
Nggada HA, Na'aya HU, Ali NA. A histological analysis of malignant tumours of the skin in university of Maiduguri teaching hospital, Nigeria. Highland Med Res J 2003;1:38-40.
Ochicha O, Edino ST, Mohammed AZ, Umar AB. Dermatological malignancies in Kano, Northern Nigeria. A histopathological review. Ann Afr Med 2004;3:188-91.
Samaila MO, Adewuyi SA. A histopathological analysis of cutaneous malignancies in a tropical African population. Niger J Surg Res 2005;7:300-4.
Gana JY, Ademola SA. Skin malignancies in Ibadan: A comparative study. Niger J Plast Surg 2008;4:1-6.
Asuquo ME, Ebughe G. Major dermatological malignancies encountered in the university of Calabar teaching hospital, Calabar, Southern Nigeria. Int J Dermatol 2012;51 Suppl 1:32-6.
Forae GD, Olu-Eddo AN. Malignant skin tumors in Benin city, South-South, Nigeria. Oman Med J 2013;28:311-5.
Oseni GO, Olaitan PB, Komolafe AO, Olaofe OO, Akinyemi HA, Suleiman OA. Malignant skin lesions in Oshogbo, Nigeria. Pan Afr Med J 2015;20:253.
Yakubu A, Mabogunje OA. Skin cancer in African albinos. Acta Oncol 1993;32:621-2.
Kromberg JG, Castle D, Zwane EM, Jenkins T. Albinism and skin cancer in Southern Africa. Clin Genet 1989;36:43-52.
Karia PS, Han J, Schmults CD. Cutaneous squamous cell carcinoma: Estimated incidence of disease, nodal metastasis, and deaths from disease in the United States, 2012. J Am Acad Dermatol 2013;68:957-66.
Buettner PG, Raasch BA. Incidence rates of skin cancer in Townsville, Australia. Int J Cancer 1998;78:587-93.
Boyle P, Doré JF, Autier P, Ringborg U. Cancer of the skin: A forgotten problem in Europe. Ann Oncol 2004;15:5-6.
Bleyer A, O'Leary M, Barr R, Ries LA, editors. Cancer Epidemiology in Older Adolescents and Young Adults 15 to 29 Years of Age, Including SEER Incidence and Survival: 1975-2000. Bethesda, MD: National Cancer Institute; 2006.
Wu S, Han J, Li WQ, Li T, Qureshi AA. Basal-cell carcinoma incidence and associated risk factors in U.S. women and men. Am J Epidemiol 2013;178:890-7.
Gloster HM Jr., Neal K. Skin cancer in skin of color. J Am Acad Dermatol 2006;55:741-60.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]