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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 43-46

A diary of endometrial malignancies in Zaria, Northern Nigeria


1 Reproductive Health and General Gynecology Unit, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
2 Gynecologic Oncology Unit, Usman Danfodio University Teaching Hospital, Sokoto, Nigeria
3 Department of Histo-Pathology, Usman Danfodio University Teaching Hospital, Sokoto, Nigeria
4 Department of Obstetrics and Gynecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
5 Department of Radiotherapy, Usman Danfodio University Teaching Hospital, Sokoto, Nigeria

Date of Web Publication29-Mar-2018

Correspondence Address:
Oguntayo O Adekunle
Department of O&G ABU Teaching Hospital Shika Zaria, Kaduna State
Nigeria
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DOI: 10.4103/ssajm.ssajm_19_16

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  Abstract 

Context: Endometrial malignancies are uncommon tumors in sub-Saharan Africa. However, it has been observed that the incidence of endometrial cancer may be increasing.
Objectives: To document the prevalence, clinical profile, and histological types of endometrial malignancies in Ahmadu Bello University Teaching Hospital Zaria, Northern Nigeria.
Study Design: Descriptive study.
Setting: Departments of Obstetrics & Gynecology and Histo-Pathology Ahmadu Bello University Teaching Hospital Zaria.
Materials and Methods: Data of histologically proven cases of endometrial malignant tumors from January 1992–December 2011 were extracted from case notes, cancer registry and histology forms/reports and analyzed using the Statistical Package for the Social Sciences version 17.0 software (SPSS Inc., Chicago, IL, USA).
Results: Seventy-seven cases were recorded during the period under review, and this constituted 5% of all genital tract malignancies. The number of cases seen in the first 10 years under review (1992–2001) were 24 (2.4 cases/year), while that of the second decade (2002–2011) were 55 (5.5 cases/year), reflecting more than two-fold increase. The mean age and parity of the patients were 52 ± 14.9 years and 7.4 ± 2.5, respectively. Over 67% of the cases were postmenopausal. Vaginal bleeding was the principal presenting symptom occurring in 100% of cases, and the uterus was enlarged in 82% of patients. Endometrial biopsy was the main method of diagnosis (60% of cases), and 89% of cases were diagnosed in clinical stages 1 and 11. Adenocarcinoma was seen in 78% of cases, while stromal sarcoma constituted 13% and mixed Mullerian tumor accounted for 9%. Total abdominal hysterectomy and bilateral salpingo-oophorectomy was the main treatment offered.
Conclusion: The incidence of endometrial carcinoma may be on the increase in our setting. High index of suspicion and endometrial biopsy will diagnose majority of cases.

Keywords: Adenocarcinoma, endometrial cancers, northern nigeria, postmenopausal, vaginal bleeding


How to cite this article:
Muhammad AA, Adekunle OO, Modupeola SO, Muhammad U, Zulaiha S, Abdullahi A. A diary of endometrial malignancies in Zaria, Northern Nigeria. Sub-Saharan Afr J Med 2017;4:43-6

How to cite this URL:
Muhammad AA, Adekunle OO, Modupeola SO, Muhammad U, Zulaiha S, Abdullahi A. A diary of endometrial malignancies in Zaria, Northern Nigeria. Sub-Saharan Afr J Med [serial online] 2017 [cited 2019 Oct 17];4:43-6. Available from: http://www.ssajm.org/text.asp?2017/4/2/43/228959


  Introduction Top


Globally every year, it is estimated that about 200,000 new cases of endometrial cancer are diagnosed, and majority of the cases (nearly two-thirds) are occurring in the developed world.[1],[2] Currently, endometrial cancer is the most common genital tract malignancy in Western Europe and North America with an annual incidence of 81,500 women in European Union and 40,000 in North America.[2] In sub-Saharan Africa, endometrial malignancy is probably the third most common malignant tumor of the genital tract. In a recent audit in Nigeria, endometrial cancer accounted for 4–11% of all genital tract malignancies.[3],[4] Yakasai et al. in Kano, Northern Nigeria documented that endometrial cancer accounted for 11% of genital tract cancers with a mean age of 62 years[3] while Ugwu et al. in Enugu, South East Nigeria reported a rate of 4%.[4] An incidence rate of 5.3% was documented in Gabon by Meye et al. with a mean age of 59 years at diagnosis.[5] In Ghana, endometrial cancer is the third most common genital tract cancer after cervical and ovarian malignancies with a mean age and parity at diagnosis of 56 years and five, respectively.[6] However, in North Africa (like in the Western world), endometrial cancer appeared to be the most common genital tract malignancy.[7],[8] The incidence of endometrial cancer is probably lowest among the black race and race appeared to be the most important singular factor responsible for the variation in its incidence.[9],[10],[11]

Endometrial cancers are more common among postmenopausal women and vaginal bleeding with or without discharge appeared to be the common symptoms.[5],[7],[12] Diagnosis is from endometrial sampling through hysteroscopy (gold standard) or less commonly from vacuum aspiration or fractional curettage. Pure adenocarcinoma (Type I endometrial cancer) is the most common histological variant accounting for 80% of cases while other variants such clear cell and papillary serous cancers accounted for 20% and are known as Type II endometrial cancers.[12] Endometrial sarcoma is rare and only seen in about 1% of cases in the western world.[13]

Recently, it is postulated that the incidence of endometrial malignancies may be increasing in sub-Saharan Africa probably because of improvements in diagnostics facilities notably ultrasonography and histopathological services. The increasing population of perimenopausal/menopausal women with low parity may be another reason.

Data are scarce on the current incidence of endometrial cancer and its detailed clinic-pathological pattern in our setting. In addition, most documentation of endometrial malignancies is restricted to carcinoma with a little or no information on endometrial sarcoma.

This submission documents the current incidence and the detailed clinic-pathological picture of endometrial malignancies in Ahmadu Bello University Teaching Hospital Zaria, Northern Nigeria.


  Materials and methods Top


This study was a descriptive study involving the extraction of data from the case files/cancer registry/histologic reports of all cases of histologically confirmed malignant endometrial tumors seen over a 20-year period from January 1992 to December 2011. Age, parity, menstrual status (pre or post-menopausal), main clinical findings, mode of diagnosis, stage of the tumor, and the histologic subtypes were recorded and analyzed using the Statistical Package for the Social Sciences version 17.0 software (SPSS Inc., Chicago, IL, USA).


  Results Top


During the period under review, there were a total of 1563 cases of genital tract malignancies (excluding gestational trophoblastic tumors), of which 79 cases were endometrial cancers, thus, giving a prevalence rate of the latter as 5.1%. However, only 60 case files were available for detailed analysis giving a retrieval rate (for case files) of 76%. In the first 10 years of review (1992–2001), 24 cases were documented (2.4 cases/year), while 55 cases (5.5 cases/year) were seen in the second half (2002–2011), indicating a two-fold increase in the 10-yearly incidence rate. In 2007 alone, 15 cases of endometrial tumors were encountered.

The mean age of the patients was 54 ± 14.9 years (range 27–80 years), and the mean parity was 7.4 ± 2.5 (range 0–13). Only two cases were nulliparous aged 50 and 70 years each.

[Table 1] revealed main clinical findings of the cases. Sixty-seven percent of the patients were postmenopausal and all the patients presented with abnormal vaginal bleeding. Seventy-seven percent of the cases were diagnosed by endometrial biopsy, while 15 and eight cases were diagnosed by hysterectomy and polypectomy specimens, respectively.
Table 1: Main clinical findings of patients with endometrial cancers (n = 60)

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[Table 2] and [Table 3] showed the histological cell types and the variants of adenocarcinomas encountered during the period of review, respectively. Seventy-eight percent of the tumors encountered were adenocarcinomas while 22% were endometrial sarcoma (including mixed Mullerian tumor).
Table 2: Histological cell types of endometrial tumors (n = 79)

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Table 3: Histological variants of adenocarcinoma (n = 62)

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[Table 4] revealed the clinical stage of the cases documented. Two-third of patients presented in stage 1, while only 11% of cases presented in late stages of the disease (stages 3 and 4).
Table 4: Clinical stages of cases (n = 60)

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  Discussion Top


Although endometrial malignancies account for 5% of all genital tract cancers, the incidence rate may appear to be increasing. The incidence rate of the last 10 years is more than twice that of the first decade during the period under review. This confirms the observation that the incidence of endometrial cancer may be increasing in our setting.[3],[14] It is not clear whether it is due to better diagnostic facilities or true increase. Our figure of 5% is comparable with the Enugu data[4] and a previous study in our center (4.8%)[15] but lower than the 11% reported by Yakasai et al. in Kano, North-Western Nigeria.[3] The mean age of our patients (54 years) is in agreement with findings in Gabon[5] and Ghana,[6] but fell short of almost a decade with the data from United Kingdom and United States,[1],[12],[16] but comparable to reports from India and Thailand.[17],[18]

It is interesting to note that majority of our patients with endometrial cancers are of high parity, and this is consistent with previous reports in many parts of sub-Saharan Africa.[3],[4],[5],[6] In the developed countries, however, endometrial cancers are found commonly in women with low parity.[13],[16],[19]

All our patients presented with abnormal vaginal bleeding, and majority were postmenopausal. This is in conformity with the experience of Meye et al. in Gabon − Central Africa.[5] It should be noted that eight out of the nine patients, who presented with endometrial polyp, had endometrial cancer. Thus, postmenopausal women in our setting presenting with endometrial polyp should be considered malignant until proved otherwise.

Nearly 80% of our cases had adenocarcinoma, and this is consistent with previous reports.[5],[14] The rate of 20% for endometrial stromal sarcoma in this study is interesting, because endometrial stromal sarcoma has been found to account for only 1% of all uterine cancers in a recent systematic review by Rauh-Hain and del Carmen.[13] However, nearly all the data reviewed were from developed countries. It is probable that endometrial stromal sarcoma including mixed Mullerian tumor may be more common in our setting (and by extension developing countries) than that in the western world. In this study, almost half of the adenocarcinomas were moderately differentiated, while only about 20% were well differentiated. This may have negative prognostic implications. In the United Kingdom, over 50% of adenocarcinomas were well differentiated.[12] Our 6% rate for adenosquamous carcinoma is comparable to the 10% reported by Mordi and Nnatu in the eighties in Lagos, South Western Nigeria.[20] Nearly 90% of our patients presented in early stages (stages 1 and 11). This is consistent with previous reports.[5],[7],[12]

The limitations of this study like other studies based on case file data in our setting are readily palpable-apart from missing case files, there may be incomplete documentation and making analysis of data very limited.

It could be concluded that the incidence of endometrial carcinoma may be on the increase in our setting. Even though pure adenocarcinoma is the most common histologic variant, endometrial stromal sarcoma appeared to be more common in our environment. High index of suspicion and endometrial biopsy will diagnose majority of cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Ferlay I, Bray F, Pisani P, Parkin DM. GLOBOCAN 2002: Cancer Incidence, Mortality and Prevalence Worldwide. IARC Cancer Base No. 5 (version 2.0). Lyon: IARC Press Lyon 2004.  Back to cited text no. 1
    
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Yakasai IA, Ugwa EA, Otubu J. Gynecological malignancies in Aminu Kano Teaching Hospital Kano: A 3 year review. Niger J Clin Pract 2013;16:63-6.  Back to cited text no. 3
[PUBMED]  [Full text]  
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Meye JF, Mabicka BM, Belembaogo E, Minko-Mi-Etoua DI, Engongah-Beka T, Minko-Mi-Etoua D. Endometrial carcinomas in Gabon. A study of 34 cases in 11 years: 1988–1998. Sante 2000;10:43-5.  Back to cited text no. 5
    
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Nkyekyer K. Pattern of gynecological cancers in Ghana. East Afr Med J 2000;77:534-8.  Back to cited text no. 6
    
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Missaoui N, Jaidene L, Abduelkader AB, Abdelkrim SB, Beizig N, Yaacoub LB et al. Cancer of the corpus uteri in Tunisia: Epidemiology and clinicopathological features. Asian Pac J Cancer 2011;12:461-4.  Back to cited text no. 7
    
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Zaki A, Gaber A, Ghanem E, Moemen M, Shehata G. Abdominal obesity and endometrial cancer in Egyptian females with postmenopausal bleeding. Nutr Cancer 2011;63:1272-8.  Back to cited text no. 8
    
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Beiki O, Allebeck P, Nordqvist T, Moradi T. Cervical, endometrial and ovarian cancers among immigrants in Sweden: Importance of age at migration and duration of residence. Eur J Cancer 2009;45:107-18.  Back to cited text no. 9
    
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Cronje HS, Fourie S, Doman MJ, Helms JB, Nel JT, Goedhals L. Racial differences in patients with adenocarcinoma of the endometrium. Int J Gynecol Obstet 1992;39:213-8.  Back to cited text no. 10
    
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Amant F, Dreyer L, Makin J, Vergote I, Lindeque BG. Uterine sarcoma in South African black women: A clinicopathologic study with ethnic considerations. Eur J Gynecol Oncol 2001;22:194-200.  Back to cited text no. 11
    
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Sudha SS, Suhail A. Malignant disease of the uterus. In: Shaw RW, Luesley D, Monga A, editors. Gynecology. 4th ed. London: Churchill Livingstone; 2011. p. 629-30.  Back to cited text no. 12
    
13.
Rauh-Hain JA, del Carmen MR. Endometrial stromal sarcoma: A systematic review. Obstet Gynecol 2013;122:676-83.  Back to cited text no. 13
    
14.
Kent A. Treating endometrial cancer. Rev Obstet Gynecol 2008;1:43-4.  Back to cited text no. 14
    
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Oguntayo AO, Zayyan M, Kolawole AO, Adewuyi SA, Samaila MO. Epidemiology of gynecologic cancers in Zaria, Northern Nigeria. Ital J Gynecol Obstet 2012;24:168-73.  Back to cited text no. 15
    
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Kitchener HC. Survival from endometrial cancer in England and Wales up to2001. Brit J Cancer 2008;99(Suppl 1):68-9.  Back to cited text no. 16
    
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Manhantshetty U, Aggarwal A, Ganesh B, Soaba S, Mullah S, Engineer R et al. Clinical outcome of early-stage endometrioid adenocarcinoma: A tertiary cancer experience. Int J Gynecol Cancer 2013;23:1446-52.  Back to cited text no. 17
    
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Tangjitgamal S, Srijaipracharoen S, Manusirivithaya S, Khunnarong J, Pataradool K, Thavaramara T. Endometrial carcinoma: Clinical characteristics and survival rates by the new compared to the prior FIGO staging systems. J Med Assoc Thai 2013;96:505-12.  Back to cited text no. 18
    
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Schonfeld SJ, Hartge P, Pfeiffer RM, Freedman DM, Greenlee RT, Linet MS et al. An aggregated analysis of hormonal factors and endometrial cancer risk by parity. Cancer 2013;119:1393-401.  Back to cited text no. 19
    
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Mordi VP, Nnatu SN. Endometrial carcinoma in Nigerians: A pathologic study. Cancer 1986;57:1840-1.  Back to cited text no. 20
    



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



 

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