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 » Introduction
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  Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 52  |  Issue : 4  |  Page : 551-555
 

Prevalence and clinical manifestation of lymphomas in North Eastern Nigeria


1 Department of Paediatrics, Bingham University Teaching Hospital Jos, Formerly, University of Maiduguri Teaching Hospital, Maiduguri, Nigeria
2 Department of Paediatrics, Federal Medical Centre Yola, Formerly, Department of Paediatrics, UMTH, Maiduguri, Nigeria
3 Department of Clinical Pharmacology, Faculty of Pharmacy University of Maiduguri, Maiduguri, Nigeria
4 Department of Paediatrics, UMTH, Maiduguri, Nigeria
5 Department of Hematology, Bingham University Teaching Hospital, Jos, Nigeria

Date of Web Publication10-Mar-2016

Correspondence Address:
Mava Yakubu
Department of Paediatrics, Bingham University Teaching Hospital Jos, Formerly, University of Maiduguri Teaching Hospital, Maiduguri
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.178435

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 » Abstract 

BACKGROUND: Lymphomas are one of the commonest childhood malignancies. Due to varied clinical features many patients are misdiagnosed and treated for other diseases. It is imperative to keep health workers informed about the current trend of lymphomas in northeastern Nigeria to facilitate prompt diagnosis and treatment.
OBJECTIVE: To evaluate the extent of lymphomas at presentation and to define the pattern of presentation in relation to gender and site. MATERIALS AND METHODS: Retrospective analysis of cases of lymphomas over a 15 year period was conducted. Structured questionnaires were used to document demographic characteristics and clinical features. The non-Hodgkin's lymphoma (NHL) and Hodgkin's lymphoma (HL) cases were categorized using standard classification schemes. Data were analyzed using the Statistical Package for Social Sciences (SPSS) software version 16, Illinois, Chicago, USA. Spearman's correlation and Student's t-test were applied where appropriate. A P value < 0.05 was considered significant. RESULTS: Fifty cases of lymphoma, 10 (20%) belong to HL and 40 (80%) belong to NHL. Lymphoma is common in male, though the male to female preponderance was not significant in both the cases (P = 0.107 and 0.320, respectively). Maxilla was the commonest site of primary malignancy (36%) and late presentation of patients were observed. New trend was noticed, the NHL patients present commonly with severe symptoms than HL (P = 0.038). HL was dominated by lymphocytic predominant type, while NHL was dominated by the small non cleaved cells (Burkitt's) lymphoma (70%). CONCLUSION: Childhood lymphoma in northeastern Nigeria has a slight shift in varied clinical presentation in favor of NHL. Patients in this study had late presentation.


Keywords: Children, lymphoma, Maiduguri, Nigeria, north-east


How to cite this article:
Yakubu M, Ahmadu BU, Yerima TS, Simon P, Hezekiah IA, Pwavimbo AJ. Prevalence and clinical manifestation of lymphomas in North Eastern Nigeria. Indian J Cancer 2015;52:551-5

How to cite this URL:
Yakubu M, Ahmadu BU, Yerima TS, Simon P, Hezekiah IA, Pwavimbo AJ. Prevalence and clinical manifestation of lymphomas in North Eastern Nigeria. Indian J Cancer [serial online] 2015 [cited 2019 Dec 16];52:551-5. Available from: http://www.indianjcancer.com/text.asp?2015/52/4/551/178435





 » Introduction Top


Lymphomas are distinct primary solid tumor of the immune system.[1] Lymphomas on broad spectrum can be classified into, Hodgkin's lymphoma (HL) and non-Hodgkin's lymphoma (NHL). Each of these displays characteristic behavioral, prognostic, and epidemiological features that is distinct, with varying response to therapy.[2],[3],[4] Several reports have indicated that NHL affects more males than females and the incidence increases with age.[4],[5],[6],[7],[8] There is high incidence of Burkitt's lymphoma (BL) in children in the tropical zone of Africa.[4],[9] Ibadan in Nigeria registered one of the highest incidences of lymphomas in the world.[10] There has been gradual decline since then, which was attributed to improved living conditions, greater control of malaria, and a decreasing infection by Epstein-Barr virus.[10],[11],[12] The gains achieved in the control of lymphomas within that period were reversed as a result of resurgence of lymphomas, due to its association with human immunodeficiency virus (HIV).[13],[14]

Due to the varied clinical features, many patients are misdiagnosed and treated for diseases like tuberculosis, systemic lupus erythematosus, etc., [15],[16] Clinically; NHL is divided into, low grade, intermediate grade, and high grade lymphomas. The Ann Arbor staging system [17] is the most popular system for classifying lymphomas into different stages. The aims of this study are: To evaluate the prevalence and extent of lymphomas at the time of presentation among all pediatric age groups, to define the pattern of presentation in relation to gender and site in children of northeastern Nigerian, and to compare the findings with other national and international studies; with the hope that this will contribute to health awareness and management of this condition in the population.


 » Materials and Methods Top


Study site

This study was carried out at the department of pediatrics in a Nigerian Teaching Hospital. The Teaching Hospital is the main tertiary health center located in northeastern Nigeria. It serves as a referral site for the six northeastern states and neighboring countries of Chad, Cameroon, and Niger Republics. The hospital is located in semiarid zone lying on latitude 11.5°N and longitude 13.5°E, with temperature range of 36.6-41.9°C, and annual rainfall of 1.14-771.90 mm.


 » Materials and Methods Top


This is a retrospective study of all cases with histological or cytological diagnosis of lymphomas seen in the Department of Pediatrics, in a Nigerian Teaching Hospital over a 15 year period from January 1995 to December 2009. The records of patients diagnosed with lymphoma, over the study period, were retrieved and reviewed using a standardized structured questionnaire. The questionnaire covers the biological data, demographic characteristics, symptoms and finding on examination, staging, and outcome of the admissions. The NHL cases were categorized using the working formulation classification scheme, while the HL cases were classified according to the Rye classification. Immunohistochemical examination was not performed on these cases because of nonavailability of test facility in the institution during the study period. Also, HIV status of the patients was not recorded as part of this study, since there was no routine test for HIV during the study period.

Analysis of data

Data obtained were analyzed using Statistical Package for Social Sciences (SPSS) software version 16, Illinois, and Chicago, USA. Student's t-test and Spearman's correlation test were applied where appropriate. A P < 0.05 was considered significant. Tables were used appropriately for illustrations.

Ethical aspects

This study was carried out in compliance with the guidelines of the Helsinki Declaration on biomedical research involving human subjects. Confidentiality of the identity of the patients, with their personal health information was maintained.


 » Results Top


Of the 50 cases of lymphoma studied, 10 (20%) cases belonged to HL, with male to female ratio of 4:1; while 40 (80%) were diagnosed to have NHL with male to female ratio of 2.6:1. The distribution of HL and NHL, according to sex, was not statistically significant (P = 0.107 and 0.320), respectively [Table 1]. Hodgkin's disease is common in older age group of 11-15 years and very rare in preschool children between the ages of 1 and 5 years. Non-Hodgkin's lymphoma was observed to be common in age group of 6–10 years, followed by children aged 1-5 years. Despite this, the distribution of the lymphomas according to age was not statistically significant (P = 0.629).
Table 1: Age and sex distribution of HL and NHL

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The distribution of primary site of malignancies is presented in [Figure 1]. Maxilla was the commonest site of lymphoma (36%), followed by cervical lymphadenopathy (18%). The abdominal lymph nodes and para-aortic lymph nodes involvement accounted for 12%. Ovarian involvement in female patients was 6%. [Table 2] shows the clinical features of lymphomas which demonstrated that most of the patients had fever, weight loss, and abdominal distension. These features clearly demonstrated that most of the patients presented with B symptoms. There is a statistically significant difference in clinical features between NHL and HL in this study (P = 0.038).
Figure 1: Pie chart distribution showing primary sites of lymphomas. Maxilla was the commonest site of lymphoma (36%), followed by cervical lymphadenopathy (18%)

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Table 2: Clinical manifestation of lymphomas

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The subtypes of HL were dominated by the lymphocytic predominant type 3 (30%) though about three (30%) cases of HL were not specified as seen in [Table 3]. The NHL encountered were the small non cleaved cells (BL) 28 (70%). Seven cases (17.5%) of NHL were not specified. [Figure 2] shows four (40%) cases of HL, presented with stage II disease, while three (30%), two (20%), and one (10%) patients, presented with stage I, III, and IV diseases, respectively. On the other hand, majority of patients with NHL presented with stage III disease (13) (32.5%), while eight (20%), nine (22.5%), and 10 (24.6%) patients presented in stages IV, I, and II diseases, respectively. From this figure, it is evident that most patients presented with stage III disease. Out of the patients that received treatments, 28% survived [Table 4], but alarming is the number of patients, discharged on request, but never came back again for treatment (46%). There is good treatment outcome in patients with HL as compared to BL, as six out of the 10 cases of HL survived.
Table 3: Histology of Hodgkin's disease and non-Hodgkin's lymphoma

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Figure 2: Ann arbor staging distribution of HL and NHL. Shows four (40%) cases of HL, presented with stage II disease. On the other hand, majority of patients with NHL presented with stage III disease 13 (32.5%). NHL = non-Hodgkin's lymphoma, HL = Hodgkin's lymphoma

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Table 4: Treatment outcome of patients with lymphomas

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 » Discussion Top


Lymphomas constituted the third most common childhood cancer worldwide with considerable variation.[4],[18],[19] Lymphomas were the commonest tumors observed in Ibadan, Nigeria during 1960-1980[20] and one of the highest in the world.[10] This means that lymphomas have been a common tumor in Nigeria, the same country where the present work was carried out, except for the differences in geographical and climatic conditions. This present work was carried out in the northeastern Nigeria. In our present study, the prevalence of types of childhood lymphoma in pediatric age-group was for NHL (80%) and HL (20%). This data is similar to that reported by Al-Samawi et al., in Yemen,[21] Haddadin,[22] and slightly differs from the findings of Obioha et al.,[23] and Akang [24] from Nigeria and Saleh et al., from Pakistan.[25] The most likely reason for these variations are the geographical factors, criteria used for diagnosis, and number of cases recruited in the studies. A distinct male predominance in all histological types of NHL was seen in our study similar to the reports by other authors.[21],[23],[26],[27] Male preponderance was also observed in HL in many previous international studies. In our series, 80% of children with HL were male and the male to female ratio was 4:1, which appears similar to previous findings of some works done among all ages.[2],[4],[21],[25],[28] No reason was yet established to explain this male preponderance;[2] but it will be interesting to look into hormonal link and occupational hazards, especially use of chemicals such as herbicides and industrial chemicals, where males seem to dominate the workforce in those areas, especially in developing countries like Nigeria. The extranodal site of occurrence of NHL, in this study, was distributed in the jaw and abdomen, while the prominent extranodal site of NHL was reported in many literatures.[4],[21],[22],[28],[29] The explanation for prominent extranodal sites of NHL may be because of high prevalence of BL, which affects extranodal areas (African Burkitt's). A comparative study of nodal site between adult and childhood NHL showed predominance of nodal involving in adults.[30]

The clinical features of lymphoma, demonstrated in this study showed most patients presented with weight loss 62.5%, jaw swelling 60%, and lymphadenopathy 52.5% [Table 2]; while other presentations were fever, abdominal distension, bone pains, bleeding diathesis, ascites, and chest signs. These features were commonly observed in NHL than HL (P ≤ 0.05); this may be a slight deviation from generally observed presentation of NHL, especially BL, but it also shows that most patients in this review presented late to the hospital. To be noted also is that some of these features are common signs of benign and malignant disorders.[2],[31] It also demonstrated that most of our patients presented with B symptoms. These findings also affect the stage and extend of the disease. In our country, just like any other third world country, the tendency to go for regular medical checkup is very low. Self-medication or visits to traditional medicine practitioners prevent people to go for proper examination, so most of the patients are diagnosed when they have developed metastasis. No wonder, majority of our patients were diagnosed with NHL stage III (32.5%). This scenario has been reported by some authors,[2],[7] which makes the prognosis poor and rate of survival becomes very low.

In this study, unfortunately, the pathology reports were lacking the World Health Organization (WHO) grading, thereby making prediction about cell nature whether aggressive or indolent very difficult. The WHO recommended that morphological diagnosis of NHL should rely on cytological details, although new technologies have helped to define several clinical entities. The HL and some NHL, tend to be sclerotic, therefore need structural evaluation possibly with excision biopsy. Fine needle aspiration cytology (FNAC) though minimally invasive, produce suboptimal result and may reveal scanty neoplastic cells. Presences of lymphoid cells in FNAC are usually associated with diagnosis of lymphoma; but there are other lymphoid infiltrates that may be misleading such as tuberculosis, lymphoid infiltrates at extranodal sites, and neoplasms containing lymphocytes.[15],[32]

Our study revealed that the most common histological type using Rye classification of HL is lymphocytes predominant. Our study also revealed that most common variant of NHL is the small non-cleaved B cells (BL) and only one case of lymphoblastic lymphoma specified. An important finding in this study is that 30% case of the HL and 17.5% cases of NHL have no further clarification of types and therefore designated as not otherwise specified (NOS). [Table 3], in this study demonstrated BL to constitute 70% cases of NHL. This is very similar to study carried out in Yemen [21] and slightly lower than the finding in Thailand [33] and Nigeria.[24] Thomas et al.,[34] in Saudi Arabia reported a very high figure of 95%. Much lower figures were observed in Jordan [22],[35] and United Kingdom.[29] Our figures were in general intermediate between the previous findings. Diffuse large cell lymphoma was the second most common histological types in NHL in our series; this is in comparable to other studies.[29],[35],[36] Lymphoblastic lymphoma constituted 2.5% in our study, which is similar to report by Ojesina et al.,[11] but much lower than 24%, noted by international studies.[25],[29]

The HL in this study was conducted according to Rye classification. The most common histological type was the lymphocytes predominant (30%). This is in contrast to studies done in Yemen,[21] which showed mixed cellularity to be the commonest. Mixed cellularity and nodular sclerosis were second most common types in this study, 20% each. This is much lower than Yemen's study.[21] Childhood lymphocytes depleted were not seen in this study (0%). This is similar to previous findings, where it was generally reported to be very rare.[21] Generally speaking, while comparing the frequency of histological types of lymphoma in the present study to those of local and international studies, a divergence was observed; which could be explained in terms of diagnostic procedures, classification, techniques used in diagnosis, number of patients studied, culture, economic, racial, geographical, and immunological differences.

Stage III disease dominates in our series, this is similar to report from Pakistan,[2] another developing country like Nigeria. This delayed diagnosis, especially in NHL reveals unawareness of the importance of regular medical checkup in general population of the regions. Patients presenting with late stage diagnosis have poor prognosis and will have untold economic and social implication, by increasing the burden on national health budget and that of family income. Therefore, health awareness by both physicians and the general populace is highly required.

Chemotherapy was the main stay of management in our center and we used combination therapy. The role of surgery was mainly for diagnostic purposes and no radiotherapy was used in our center. The outcome of treatment was not encouraging as 46% of the patients requested for discharge and never showed up again for treatment after first course of cytotoxic drugs. The default rate from the treatment program was high due to factors associated with poor socioeconomic reasons; this was similar to cases reported by Amusa et al.,[37] in one of the Nigerian tertiary hospitals. Government should therefore make cancer treatment free in Nigeria, so as to increase the survival of these children.


 » Conclusion Top


Childhood lymphomas in northeastern Nigeria generally have similar patterns, gender, sites, and distribution, as that shown in local and international studies; but there is a slight shift in clinical presentation in favor of NHL, which in addition generally present late. There are needs for facilities to be available for proper diagnosis, so that studies using recent WHO classification are done, so as to reduce the number of unclassified cases; and to properly identify the doubtful ones. Government should make cancer treatment free to reduce default and increase survival.

Limitations

The prevalence of lymphoma has been changing especially with its association with HIV; unfortunately, HIV test was not routinely done in these patients during the study period. Equally, immunohistochemical examination was not performed on these cases because of none availability of test facilities in the institution during the study period; these might have been the reason for some of the unclassified cases encountered in the study. In addition, it has limited the ability to make diagnosis according to current WHO classification based on immunohistochemistry, immune flow cytometry, and cytogenetics.

Generalizing the findings of this work should be done with caution because the study was unicentered, with the sample rather small. This small population size of patients could negatively affect the statistical power of this work, which could possibly lead to type II error.

Recommendations

There is need for enough facilities to be available at histopathology laboratory for proper diagnosis, so that the studies using the WHO classifications of lymphomas are done; so as to reduce the number of unclassified cases and to properly identify the doubtful ones. There is routine HIV test being done now to all patients with malignancy or suspected malignancy, so there is need for further research, to see whether the presence of HIV may explain the shift in clinical features in patients with NHL observed in this current work.

 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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