THE CHALLENGES OF TREATING LARYNGEAL CARCINOMA IN JOS, NIGERIA

Abstract

Background

Laryngeal cancers are not uncommon with several factors affecting its management in our environment compared to the developed countries. Such factors include the time of presentation and diagnosis, co-morbid disease, finance, consent, treatment options, surgical expertise and the problems of follow up. Thus this results to a lot management challenges to both the patients and the care givers.

Aim

The aim of this paper is to highlight the challenges encountered in the management of laryngeal cancers at the Jos University Teaching Hospital, Nigeria.

Design of study

it is a retrospective study.

Setting

The study was carried out at the ENT department of the Jos University Teaching Hospital and Bingham (ECWA Evangel) Hospital Jos Nigeria.

Method

This was a 48-month (October 2005 – September 2009) review of laryngeal cancers seen and treated in these hospitals. Data extracted included age, gender, histologic diagnosis and treatment modality. Data was analyzed using simple descriptive method and the result presented in tabular forms.

Result

A total of twenty one (21) cases consisting of 20 males and a female were seen during the period. The age range was 30 years to 70 years. The average age was 56.14 years. The time of presentation ranged from 3 months (earliest) to 2years. Twenty cases (95.24%) were advanced diseases with only one early disease.

The histological types were 6 each for well and moderately differentiated squamus cell carcinoma respectively, 2 each for poorly differentiated and squamus cell carcinoma (uncharacterized) and 1 carcinoma insitu.

Two patients (a male and female) were seropositive for HIV type I.

Twenty (95.24%) of the patients had tracheostomy at presentation with two having peristomal spread in the course of the disease.

Eight (38.10%) patients had total laryngectomy out of which one was a salvage laryngectomy with subsequent right pectoralis major myocutaneous flap; 6 had concomitant chemoradiotherapy with one discontinuing after the first course and while the sixth total laryngectomee had no chemoradiotherapy.

Three (14.29%) had primary radiotherapy; 2 of the cases were advanced diseases and one early disease. Eight (38.10%) had no treatment.

Of the 6 laryngectomees, three had tracheo-oesophageal fistula post-operatively while one had disease recurrence and died.

The first laryngectomy case is still on follow-up, disease free four years now while the rest have been lost to follow up.

Conclusion:

Education and provision of standard oncologic treatment centres with trained personnel will help in alleviating theses challenges by providing treatment, data for assessment and improving the standard of our treatment.

Introduction

Laryngeal cancers amongst which the squamous cell carcinoma is the most common in the developed world are not uncommon in our environment1,2. However considerable variations exist in the incidence of this disease between various countries. Several factors appear to affect the management of this disease in our environment compared to other countries. Such factors include the time of presentation, diagnosis, co-morbid states, availability of finance, consent, treatment options and the problems of follow-up. 3,4

The management of laryngeal carcinoma therefore poses a lot of challenges to both the patients and the managing team.

Aim: It is thus the aim of this study to highlight the challenges noted in the management of this disease and suggest possible ways of improving the trend.

Design of study: it is a retrospective study.

Setting: Thestudy was carried out at the ENT department of the Jos University Teaching Hospital and Bingham (ECWA Evangel) Hospital Jos Nigeria.

Method:

The City of Jos is located within the North Central geopolitical zone ofNigeria. It has a population of five hundred and ten (510,000) people. This study was undertaken at two tertiary health facilities in Jos. Apart from Jos inhabitants, these two centers serve patients from a catchment area of over 280 kilometer radius. Only six out of about 135 Otolaryngologists in Nigeria are practicing in Jos. There is no speech pathologist/therapist presently practicing here.

Inclusion criteria:All laryngeal cancer patients who presented within the study period.

Exclusion criteria: Benign laryngeal diseases.

This is a 48-month (October 2005 – September 2009) retrospective review of twenty onelaryngeal cancers at the Jos University Teaching Hospital and Bingham (ECWA Evangel) Hospital Jos.

Data extracted included age, gender, duration before presentation, histological subtypes and treatment modality. The data collected were analyzed using simple descriptive method and results presented in tabular forms.

Results

A total of twenty one (21) cases consisting of 20 males and 1 female were seen during the period. The patients’ ages ranged from 30 to 70 years. The youngest patient was 30 years and the oldest was 70 years. The average age was 56.14 years. The duration of symptoms before presentation ranged from 3 months (earliest) to 2years. Twenty (95.24%) cases were advanced diseases while 1 was an early disease.20(95.24%) of the patients were T₄s with various nodal and metastatic status. That is; 9(37.50%) were T₄N_XM_X, whereas9(37.50%) wereT₄N₁M_X while 1(4.76%) each was T_1aN₀M_x, T₄N₁M₁ and T₄N₁M₁ respectively.

All the 21(100%) patients presented with hoarseness, 20 (95.24%) had stridor and upper airway obstruction while only 2(9.52%) came in with neck pain and swelling. 15(71.43%) smoked, 16(76.19%) drank alcohol, 14(66.67%) were local farmers, 10(47.61%) had western education against 16(76.19%) who had no formal education while only 3(14.29%) were unmarried.

The earliest presentation was 3 months while the longest was 2 years.

The histological types were 8 each for well and moderately differentiated squamous cell carcinoma respectively, 2 each for poorly differentiated and squamous cell carcinoma (uncharacterized) and 1 carcinoma insitu.

Two patients (a male and female) were seropositive for HIV type 1.

Twenty (95.24%) of the patients had tracheostomy at presentation; with two having peristomal spread in the course of the disease.

Eight (38.10%) patients had total laryngectomy out of which one was a salvage laryngectomy with subsequent right pectoralis major myocutaneous flap; 5 had concomitant chemoradiotherapy with one discontinuing after the first course and while the sixth total laryngectomee had no chemoradiotherapy.

Three (17.65%) had primary radiotherapy; 2 of the cases were advanced diseases and one early disease. Eight (38.10%) had no treatment because of poor social economic back ground, illiteracy and refusal of consent.

Of the 6 laryngectomees, three had tracheo-oesophageal fistula post-operatively while one had disease recurrence and died.

The first laryngectomy case is still on follow-up, disease free four years now while the rest have been lost to follow up.

Table 1. Showing the age, sex, time of presentation, histological types and treatment options for the patients with laryngeal carcinomas

S/no.	Age (yrs)	TOP	Sex	Histological type	Treatment Outcome
1	45	6M	M	wdscc	TL, RTH, CT (alive)
2	43	8M	M	wdscc	metastasis (dead)
3	60	12M	M	scc	no treatment (unknown)
4	69	9M	M	cai	no treatment (unknown)
5	65	13M	M	mdscc	no treatment (unknown)
6	66	13M	M	mdscc	RT (alive)
7	65	15M	M	wdscc	TL, RTH, CT (alive)
8	65	17M	M	scc	TL, RTH, CT (alive)
9	70	24M	M	wdscc	RT, CT, STL, (died, TOF)
10	45	15M	M	wdscc	no treatment (dead)
11	70	18M	M	wdscc	no treatment (unknown)
12	65	12M	M	pdscc	TL (alive)
13	30	13M	M	mdscc	no treatment (alive)*
14	32	7M	M	pdscc	no treatment (dead)*
15	44	3M	M	mdscc	RTH (alive)
16	65	18M	M	mdscc	TL, CT, RT (alive)
17	60	9M	M	mdscc	no treatment (unknown)
18	70	12M	M	wdscc	TL (dead)
19	45	12M	M	wdscc	TL, RTH (alive)
20	55	8M	M	mdscc	CT (alive)
21	50	6M	M	mdscc	CT (alive)

ABBREVIATIONS

TL- total laryngectomy

STL-salvage total laryngectomy

RTH-radiotherapy

CT- chemotherapy

Wdscc- well differentiated squamus cell carcinoma

Scc- squamus cell carcinoma

Cai- carcinoma insitu

Mdscc- moderately differentiated squamus cell carcinoma

Pdscc- poorly differentiated squamus cell carcinoma.

TOF- Tracheo-Oesophageal fistula.

* HIV positive

TOP- time of presentation in months.

Conclusions

Government intervention to subsidize the high cost of investigations and treatment of these patients and public health enlightmentprogramme are a must for improved results to be obtained.

In addition the provision of standard oncologic treatment centres with trained personnel will help in alleviating theses challenges by providing treatment, data for assessment and improving the standard of treatment of these patients in our environment.

Discussion

The main findings were most of the patients were in the sixth to seventh decade(57.14%),advanced presentation (95.24%),lack of formal education (76.19%),lack of finance (38.10%),alcohol consumption(76.19%),smoking(71.43%) and chemoradiotherapy outside managing hospital(100%), delayed referral by physicians (14.29%) .

The age range and average age of the population studied were similar to the findings of Adeyemo5 at the University College Ibadan where the mean age and age range were 57.5 years and 28years to 84years respectively but in contrast to a previous study from same environment in Jos, Nigeria by Lilly-Tariah6 whose study population had a mean age of 47.7 years. Laryngeal cancers occur predominantly in the male gender all over the world as was also noted in this study.5,6,7,8,9. Significant differences exist in how laryngeal cancers affect the male and female gender and this has been speculated to be due to the different susceptibilities of the cancer cells to steroid hormones. The duration of symptoms before presentation ranged from 3 months to 2years. The advantage of early presentation is that of cure with less invasive therapeutic measures.10,11,12. All but one of the patients in this present study presented with advanced disease.13

The histological types were mainly squamous cell carcinoma with various grades of differentiation. Jaiswaland co workers14 also had similar findings with 99% of primary laryngeal carcinomas being squamous cell in type.

Since the emergence of retroviral disease, there has been an increase in the number of head and neck cancers, laryngeal cancers inclusive in HIV seropositive patients in our country and the world over.4,15,16 thus the findings in this study may be a reflection of this. One out of the ten HIV seropositive patients in Nwaorgu and co-workers study had laryngeal carcinoma.15 The two HIV seropositive cases in this study who were in the fourth decade of life had histologically poorly differentiated Squamous Cell carcinoma.

The clinical features were that of persistent hoarseness, followed by upper airway obstruction. All the 21(100%) patients presented with hoarseness, 20 (95.24%) had stridor and upper airway obstruction while only 2(9.52%) came in with neck pain and swelling.

Most of the patients had history of smoking and alcohol consumption.5,6,17

19(90.48%) smoked, 18(85.71%) drank alcohol, 16(71.43%) were local farmers, 9(42.86%) had western education against 16(76.19%) who had no formal education while only 3(14.29%) were unmarriedSometimes they were delayed referral as three (14.29%) cases were treated for Asthma and tuberculosis before referral. Similar medical cause of delay was noted by Teliet al.5,18

The high rate of tracheostomy in this study (95.24%) calls for concern. This apparently resulted from the need to relieve the obstructed upper airway on late presentation by the patients. It was thus easy obtaining consent for the procedure in contrast to the difficulty faced while seeking consent for total laryngectomy especially with the information on voice loss and dysphagia.19,20 It is however worthy of note that relief of upper airway obstruction was the commonest indication for tracheostomy in our centre while elsewhere steroid has been used in combination with radiotherapy.21, 22 The only non tracheostomized patient in this study presented early; was commenced on steroid intra-operatively during direct laryngoscopy and biopsy. In our environment sadly some of the tracheostomized patients decline from further treatment as soon as they are relieved of their obstruction. Some of the demerits of the presence of tracheostomy tube are the promotion of infections and fibrosis leading to difficult and prolonged operation time.

It is argued that tracheostomy aids peristomal spread,a feature which was also noted in this study.23, 24

Treatment depends on TNM stage as shown in table 2 below. Total laryngectomy followed by concomitant radio-chemotherapy was the major treatment modality as noted in this study with a better outcome. Other workers like Nishant25 et al had similar result as against the findings of Marcy et al26 and Anupam et al27 in other parts of the word.

Three (14.28%) had primary radiotherapy, 2 (9.52%) of the cases were advanced diseases and one (4.76%) early disease. Eight (38.10%) had no treatment.

The two advanced cases had residual disease meaning that radiotherapy for advanced laryngeal disease is not the best treatment option in our environment as against the good outcome in other countries by James, Arlene and coworkers. 28,29 Radiotherapy leads to difficult dissection, prolonged operation time; poor wound healing and increased post operative complications.30

From the fore going it is a sad fact a great majority of our patients present late with advanced laryngeal cancer. Poor knowledge of the disease, poverty (38.10% of patients in this study could not afford the cost of any form of treatment), lack of specialists in the field and poor referral system contribute to late presentation. In addition to these, appropriate and effective diagnostic (endoscopic tools, CT- scans, MRI) and treatment facilities (Chemo-radiation centers, experienced personnel) are few or lacking leading to poor outcome.

The few Radiotherapy centers have a deluge of patients on queue for treatment and thus over stretched. Our center does not have a radiotherapy facility. The closest tertiary institution with this facility where our patients are usually referred to is about 380 Kilometers. Thus attendance and compliance at this facility by the patients most likely will be far from satisfactory. There is the possibility that four of the total laryngectomy patients who were lost to follow- up as soon as they were referred may be in this category.

It is on note also that poverty of knowledge of the disease both on the part of the patient and the first contact physician contributed to the dismal outcome of the treatment in these patients, a feature also noted by some other workers.5,31

Primary haemorhage and tracheo-oesophageal fistula were the commonest complications noted in this study which have also been cited by other workers.32,33, 34

The first case is on follow up and disease free for four years now.35 The rest were lost to follow up for various reasons.

Table 2: The TNM staging of the 21 patients

Serial number	Tumour (T)	Nodes (N)	Metastasis (M)	Summary
1	4	1	X	T4N1MX
2	4	2a	1(chest/ribs/lungs)	T4N2aM1
3	4	X	X	T4NXMX
4	4	X	X	T4NXMX
5	4	X	X	T4NXMX
6	4	X	X	T4NXMX
7	4	1	X	T4N1MX
8	4	1	X	T4N1MX
9	4	1	X	T4N1MX
10	4	X	X	T4NXMX
11	4	X	X	T4NXMX
12	4	X	X	T4NXMX
13	4	1	1(thyroid)	T4N1M1
14	4	X	X	T4NXMX
15	1a	No	X	T1aN0Mx
16	4	1	X	T4N1MX
17	4	X	X	T4NXMX
18	4	1	X	T4N1MX
19	4	1	X	T4N1MX
20	4	1	X	T4N1MX
21	4	1	X	T4N1MX