HEAD AND NECK MALIGNANT TUMOURS IN GOMBE, NORTHEAST NIGERIA

Abstract

Background

Head and neck cancer is the 10^th most common cancer in the world constituting 5–8% of total cancer burden in Europe and America. However, it is difficult to appreciate the burden in Nigeria because of inadequate data. This retrospective study analysed the clinicopathological variables of head and neck malignancies seen over a 10-year period at a northeastern Nigerian referral centre.

Material and Methods

The demographics and clinical findings of the patients were obtained from the case files while histology reports were retrieved from the histopathology department of the hospital. Malignancies involving the eye, brain and thyroid were excluded.

Results

One hundred and ninety five cases of head and neck malignancies were recorded over the ten year study period. The mean age of the patients was 38.3years (+20 SD) while a male: female ratio of 1.3:1 was recorded for all cases. The neck was the most frequent site of tumours, accounting for 57(29%) cases. While epithelial malignancies were 56.9% of all cases, lymphomas constituted 21.5%, sarcomas constituted 10.3% and others malignancies accounted for 11.3%. There was no sex predilection for carcinomas (1:1), but there were slightly more lymphomas 26(23%) in males than 16(19%) in females. Carcinomas were more prevalent in those above 51years of age; sarcomas were most common within the 21-30year age group while 42.8% of cases of lymphoma were in the 2^nd and 3^rd decades of life.

Conclusion

While malignant head and neck tumours showed no sex predilection, carcinomas remained the most frequent head and neck malignancies in this study.

Introduction

Head and neck cancers include malignant tumours arising from a variety of sites in the upper aerodigestive tract with unique sets of epidemiologic, pathologic and treatment considerations1. They constitute the 10^th most common cancers in the world2and are important causes of morbidity and mortality. Prevalence in Nigeria however, cannot be fully ascertained as available reports are usually hospital-based and regional. Several histological types of tumours are found in the head and neck region; between 70%-90% are epithelial in origin1,3, mainly in the oral cavity, oropharynx, hypopharynx and the larynx. Lymphomas comprise the second most common primary malignancy in this region4while 15-20% of all sarcoma are diagnosed in the head and neck region. Tobacco and alcohol are the leading aetiological factors; other causes are genetic, nutrition and viruses1. Literature from Nigeria however shows less clear association between tobacco and alcohol3; the most well-established risk factors globally.

Despite improved treatment modalities, the diseases remain poor in outcome with a 50% five- year survival rate that has not improved in the last 2 decades5. This poor outlook is however dependent on histologic type and degree of differentiation, clinical staging, tumour site, age of the patient, co-morbidities and vascular invasion6. This study aimed to profile head and neck malignancies as seen in a tertiary institution in the Northeastern part of Nigeria.

Reports

Materials & Method

This was a retrospective study of clinical presentations, demographics and the histologic diagnosis of cases that presented over a ten year period. Clinical information was obtained from the case files while histology diagnosis and reports were provided by the histopathologist in the hospital. Malignancies involving the eye, brain and thyroid were excluded. Cases without adequate clinical and histopathology records were also excluded. Data was entered into the SPSS Inc version 19 for analysis. Quantitative data were summarized using means and standard deviation and qualitative data as percentages.

Results

One hundred and ninety five cases of malignancies were analysed, giving a mean of 19 cases per year. There were 111 (56.9%) males and 84 (43.1%) females (M:F ratio of 1.3:1) and the ages ranged from 2 weeks to 85 years, with a mean of 38.3 (+20 SD) years. The peak age incidence was in the 21-30 age group, accounting for 36(18.5%) of cases as shown in Table1. Swelling was the most frequent primary reason for presentation as was the case in 40.5% of the time with pain coming second as was the case in 15(7.7%) patients. Others were ulcers in 11(5.6%), intraoral bleeding in 4(2%) and nose bleed in 10(8%) respectively. Non-specific general feeling of being unwell accounted for 9(4.6%), though most had multiple symptoms at presentation. Lesions in the neck were the most frequent accounting for 57(29.2%) of cases which was followed by oral cavity in 38(19.5%) cases. The least frequently involved site was the ear in 2(1.0%) cases as shown in Table 2. Epithelial–type malignancies accounted for 111(57%) cases. There were 42 (21.5%) cases of lymphomas and 20(10.3%) sarcomas. Others malignancies recorded in this study were 22 accounting for11.3% of cases as indicated in Table 3. While there was no gender predilection for carcinomas (1:1), there were slightly more lymphomas in males (23.4%) than (19%) in females . Carcinomas were more prevalent in individuals above 51years; sarcomas were most common within the 21-30year age group while 42.8% of cases of lymphoma were in the 2^nd and 3^rd decades of life as shown in Table 4. The oral cavity; palate, floor, cheek and tongue accounted for 35(31.5%) cases of all carcinoma while lymphoma was almost exclusively a disease of lymph nodes (Table 2) . Less than 40% (n=61) of patients in this series received definitive treatment while a significant number were referred or discharged themselves (Table 5) .

Table 1. Frequency distribution by age and gender

Age group (years)	Frequency (N=195)	Percentage
≤ 10	18	9.2
11-20	25	12.8
21-30	36	18.5
31-40	30	15.4
41-50	32	16.4
51-60	29	14.9
> 60	25	12.8
Mean age= 38.3+20 years	Minimum= 2 weeks	Maximum = 85years
Gender
Male	111	56.9
Female	84	43.1

Table 2. Anatomical distribution of histological types of head and neck cancers

		Histologic type
Anatomical site / ICD	Carcinoma	Sarcoma	Lymphoma	Others	Total
Maxilla ICD- C14.0	13 (11.7)	2 (10.0)	2 (4.8%)	0 (0.0%)	17 (8.7%)
Mandible ICD- C14.1	3 (2.7%)	6 (30.0%)	0 (0.0%)	0 (0.0%)	9 (4.6%)
Oral cavity ***	3 35 (31.5%)	2 (10.0%)	1 (2.4%)	0 (0.0%)	38 (19.4%)
Lip ICD-C00.8	3 (2.7%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	3 (1.5%)
Neck ICD- C76.0	15 (13.5%)	5 (25.0%)	0 (0.0%)	0 (0.0%)	20 (10.3%)
Lymph node ICD- C77.0	0 (0 %)	0 (0.0%)	37(88.1%)	0 (0.0%)	37(19.0%)
Nasopharynx ICD- C11.9	4 (3.6 %)	0 (0.0%)	0 (0.0%)	0 (0.0%)	4 (4.6%)
Scalp ICD- C44.4	7 (6.3%)	1 (5.0%)	1 (2.4%)	0 (0.0%)	9 (4.6%)
Nose ICD- C30.0	8 (7.2 %)	0 (0.0%)	0 (0.0%)	0 (0.0%)	8 (4.1%)
Face ICD- C44.3	8 (7.2%)	1 (5.0%)	0 (0.0%)	0 (0.0%)	9 (4.6%)
Ear ICD- C44.2	2 (1.8 %)	0 (0.0%)	0 (0.0%)	0 (0.0%)	2 (1.0%)
Salivary gland ICD- C08.9	13 (11.7%)	0 (0.0%)	1 (2.4%)	0 (0.0%)	14 (7.2%)
Others	0 (0.0%)	3 (15.0%)	0 (0.0%)	22 (100%)	25 (12.8%)
Total	111 (100%)	20 (100%)	42 (100%)	22 (100%)	195(100%)
Oral cavity (Palate, Cheek, Tongue, Oral-others), ICD-International Centre for Disease ***-C05.9, C06.9, C06.0, C02.9

Table 3. Frequency distribution of histological types of head and neck cancers

Histology	Frequency	Percentage
Carcinoma Squamous cell carcinoma Salivary gland carcinoma Basal cell carcinoma	11168358	56.9
Sarcoma Rhabdomyosarcoma Ostogenic sarcoma Kaposi sarcoma Liposarcoma*Others	2063326	10.3
Lymphoma Hodgkin’s Non-Hodgkin’s Burkitt’s **OthersMelanomaOlfactory neuroblastoma	422215 4121	21.51.00.5
***Others	19	9.7
Total	195	100.0
*diagnosed as Sarcoma **diagnosed as Lymphoma *** other malignancies

Table 4 Age and gender distribution of histological types of head and neck cancers

Age group(in years)	Carcinoma	Sarcoma	Lymphoma	Others	Total
≤ 10	2 (1.8)	2 (10.0)	6 (14.3)	8 (36.4)	18 (9.2)
11 – 20	9 (8.1)	3 (15.0)	9 (21.4)	4 (18.2)	25 (12.8)
21 – 30	17 (15.3)	8 (40.0)	9 (21.4)	2 (9.1)	36 (18.5)
31 – 40	19 (17.1)	4 (20.0)	6 (14.3)	1 (4.5)	30 (15.4)
41 – 50	19 (17.1)	2 (10.0)	7 (16.7)	4 (18.2)	32 (16.4)
51 - 60	25 (22.5)	0 (0.0)	3 (7.1)	1 (4.5)	29 (14.9)
> 60	20 (18.0)	1 (1.0)	2 (4.8)	2 (9.1)	25 (12.8)
Gender
Male	56 (50.5)	11 (55.0)	26 (61.9)	18 (81.8)	111 (56.9)
Female	55 (49.5)	9 (45.0)	16 (38.1)	4 (18.2)	84 (43.1)

Table 5. Distribution of histological types by treatment types

Histological types	Treatment types
	Surgery	Surgery+ or chemotherapy	Not indicated	DAMA/LAMA	Referred	Total
Carcinoma	19(17.1%)	0 (0.0%)	5(4.5%)	67(60.4%)	20(18.0%)	111(56.9%)
Sarcoma	1(5.0%)	0 (0.0%)	0 (0.0%)	15(75.0%)	4(20.0%)	20(10.3%)
Lymphoma	2(4.8%)	4(9.6%)	7(16.7%)	(0%)	29(69.0%)	42(21.5%)
Others	5(22.7%)	7(31.8%)	4(18.2%)	4(18.2%)	2(9.1%)	22(11.3%)
+DAMA-discharged against medical advice LAMA-left against medical advice

Discussion

The pattern of presentation of cancers at various sites in the body differs from one place to another even in the same country. Squamous cell carcinoma has been the most prevalent histologic type of malignancies in the head and neck in most of the reports from Nigeria3,7^-12. This is in agreement with the literature worldwide13^-16. However, two studies from Nigeria have reported lymphomas as the most common cancers followed by squamous cell carcinoma17,18. The frequency of histologically diagnosed head and neck malignancies in the present study is approximately 19 cases per year which is low relative to that reported by Otoh19 in the same region in the country and those from other parts of the country 7,17,18, 20. These reports however may be due referral patterns, size of the population serviced, available expertise and resources at the different centres. Though head and neck cancer is essentially a disease of the elderly, the ages in this study ranged between 2 weeks and 85 years with a mean of 38 years (+20 SD). Previous reports from Jos and Maiduguri in Northern Nigeria 17,21 showed a peak incidence in the 3^rd and 4^th decades. In most studies from Nigeria, head and neck cancers affect more males than females, except the study from Ilorin in North central Nigeria11where females were affected more than males. The male to female ratio ranged from 1:1 to 2.3:17,8,10,11,17,20. A male to female ratio of 1.3:1 was however recorded in this study.

The most common reason for presentation at the hospital was swelling in 40% of cases, this was followed by pain in 8% of the patients. However, others complained of both pain and swelling while multiple symptoms were not uncommon at presentation. The mean duration of symptoms before presentation was 13.5months. This however was dependent on age and site; children presented averagely at approximately 6 months from the onset of symptoms. This further highlights the fact that late diagnosis remains a major challenge in the management of cancers in our environment as earlier reported17,19. Ignorance, poverty and lack of trained personnel capable of early detection and prompt and effective management are the major obstacles. Reports on the overall pattern of head and neck cancers from different regions of the country cited nasopharynx as the commonest site7,8,10,17. The nose and paranasal sinuses were the second most common reported sites7,19,20,21while the larynx was the third commonly affected site7,12,21. In contrast, Amusa et al 18 and Otoh et al19 reported differently that malignancy of the oral cavity was the commonest in Ile-Ife (South-west Nigeria) and Maiduguri (Northeast Nigeria). In this study however, the neck was the most commonly affected site, with the lesions being largely lymphomas. Bhatia et al17 also recorded a high prevalence of lesions in the neck. Lymphomas accounted for 42(21.5%%) cases in this series, partly explaining the large number of neck masses in this study as lymphomas in the head and region involve mainly lymph nodes22,23. Also the influence of HIV on this pattern could be significant. Sarcomas had an overall male: female ratio of 1.2:1. This finding is similar to the 1.3:1 male: female ratio reported by Adebayo et al24 in Kaduna State in Northern Nigeria. However, Adisa20 in Ibadan and Bentz et al25 in the United States reported a male: female ratio of 1.5 and 1:1 respectively. The 21-30 age group was most commonly affected.

Surgery, radiotherapy and chemotherapy either alone or in combination are the standard modalities of treatment of cancers26,27. However, treatment is influenced by several factors including the histologic cell type, the stage of the disease, co-morbidities, patient’s preferences, expertise and facilities available. Apparently, less than 40% of the patients in this series received treatment locally. Children and individuals with lymphoma were more likely to receive treatment than others. The non-availability of an otorhinolaryngologist within the institution in the earlier part of the study may partly explain this as well as the pattern of presentation of tumours, including the absence of some malignancies e.g laryngeal carcinoma, from this cohort. Discharge against medical advice and leaving against medical advice of hospitalized patients is an adverse clinical event that often results from a disagreement between the patient or an interested third party and the attending physician and/or the hospital environment, culminating in the patient’s withdrawal of their initial voluntary consent for hospitalisation, and abrupt termination of in-patient medical care 28,29. Finance and beliefs are important factors in reported rate in this study. Though there are few reports on the outcome of head and neck cancer treatment in Nigeria, the burden of managing this group of patients is enormous30.

Conclusions

Head and neck cancers are not uncommon in Nigeria. However, reports on the epidemiology of the disease make comparison difficult as different authors tend to include different tumours within the group. The presentation of head and neck malignancies in Northeast Nigeria is not different from reports in other parts of the country.