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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 2  |  Issue : 1  |  Page : 1-4

Pathologic characteristics and management of renal cell carcinoma in Zaria, Nigeria


1 Department of Surgery, Division of Urology, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
2 Department of Pathology, Ahmadu Bello University/Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria

Date of Submission15-Aug-2014
Date of Acceptance12-Jan-2015
Date of Web Publication17-Feb-2015

Correspondence Address:
Ahmed Muhammed
Department of Surgery, Division of Urology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Nigeria
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DOI: 10.4103/2384-5147.151559

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  Abstract 

Background: The incidence of renal cell carcinoma (RCC) has been on the increase. Small (early stage) RCC is potentially curable by surgery; however, advanced RCC has a very poor prognosis. Recent advances in the treatment of advanced/metastatic RCC have improved the hitherto gloomy outcome. Objectives: To determine the clinical presentation, pathologic characteristics and survival outcome of patients managed for RCC in our center. Materials and Methods: We retrospectively analyzed the data retrieved from case notes, operation registers and histopathology records of all the patients that underwent nephrectomy for RCC over a 10-year period (2004-2013). Details of the clinical presentation, evaluation, histopathologic characteristics, treatment and outcome were recorded. Data were displayed in charts and tables and survival analysis was done using Kaplan-Meier survival curve. Results: A total of 51 patients had nephrectomy for RCC during the period of study. The mean age was 43.1 years standard deviation 15.3 with a male-to-female ratio of 2:3. An unexpected finding was the relatively high incidence of right-sided tumors 35 (68.6%) compared to left side 14 (27.5%). Over 90% of the patients had advanced disease (T3 or greater). It was also observed that most of the young patients were females and had predominantly right-sided tumors. Clear cell RCC accounted for the most common histologic type 38 (74.5%). Only 6 patients had incidental (early) disease, and they had the best outcome. Overall survival was poor but patients who had adjuvant treatment fared relatively better. Conclusion: RCC remains a highly lethal urologic malignancy. Recent advances in targeted molecular therapies have improved the outcome of the advanced disease. In our environment, the outcome has remained dismal due to multiple factors, including late detection, cost and relative scarcity of the new treatment modalities.

Keywords: Characteristics, management, pathology, renal cell carcinoma, survival


How to cite this article:
Muhammed A, Ahmad B, Yusuf MH, Almustapha LA, Abdullahi S, Tijjani LA. Pathologic characteristics and management of renal cell carcinoma in Zaria, Nigeria. Sub-Saharan Afr J Med 2015;2:1-4

How to cite this URL:
Muhammed A, Ahmad B, Yusuf MH, Almustapha LA, Abdullahi S, Tijjani LA. Pathologic characteristics and management of renal cell carcinoma in Zaria, Nigeria. Sub-Saharan Afr J Med [serial online] 2015 [cited 2021 Jul 31];2:1-4. Available from: https://www.ssajm.org/text.asp?2015/2/1/1/151559


  Introduction Top


Renal cell carcinoma (RCC) is the most lethal of all urologic malignancies. [1],[2],[3] It account for 2% to 3% of all adult malignant neoplasms. [1],[3],[4] The incidence has been observed to be on the rise, [5] especially in recent times. This may be attributed to increasing use of more sensitive imaging modalities in the evaluation of patients presenting with unrelated conditions. The incidence is quoted as 12/100,000 population/year in the United States, with a male-to-female ratio of 3:2. [1],[2],[4],[5] It is predominantly a disease of the elderly with presentation typically in the sixth and seventh decades of life. [1],[3] Studies have shown a 10-20% higher incidence in African-Americans compared to other races, they also present at an earlier age with poorer prognosis. [1],[2],[5],[6] In Nigeria, the true incidence is unknown but it is thought to account for between 10% and 20% of urologic malignancies. [7],[8],[9],[10],[11],[12],[13] The incidence and biologic behavior of RCC among native Africans (blacks) may be different from the observations among African-Americans. Genetic, dietary and environmental factors may play a significant role.

Renal cell carcinoma is peculiar in its behavior and remains the prototype of chemo and radio-resistant tumors. Prognosis is heavily predicated on the stage at presentation while early (small and organ confined) lesions are curable by either nephron-sparing or radical surgery; late disease is largely incurable and unresponsive to conventional adjuvant treatment. [14] Although immune-based and more recently targeted molecular therapies have shown promise, the response rate remains low. [13] This study sought to evaluate the mode of clinical presentation, pathologic characteristics and management outcome of RCC in our center.


  Materials and methods Top


We retrospectively analyzed data retrieved from case notes, operation registers and histopathology records of all the patients that underwent nephrectomy for RCC over a 10-year period (2004-2013). Details of the clinical evaluation including presenting symptoms, signs, investigations, the treatment (pre- and post-nephrectomy) and response/survival data were extracted. Data of the histopathologic classification and grading were retrieved from the histopathology department. Histologic classification was consistent with the WHO 2004 histologic classification of urologic malignancies. [15] The results were displayed in charts and tables; and survival analysis was done using Kaplan-Meier survival curve.


  Results Top


A total of 51 patients had nephrectomy for RCC during the period of study. The yearly incidence was relatively constant, averaging 5 patients/year with occasional fluctuations [Figure 1]. The mean age was 43.1 years standard deviation (SD) 15.3 with a male-to-female ratio of 2:3. A striking finding was the relatively high incidence of right-sided tumors 35 (68.6%) compared to left side 14 (27.5%). Over 90% of the patients had advanced disease (T3 or greater). Clear cell RCC accounted for the commonest histologic type 38 (74.5%).
Figure 1: Yearly incidence of renal cell carcinoma over 10 years

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The relatively younger patients in our series (<30 years) accounted for up to 27.5% (14). These patients were predominantly females 11 (78.6%), and the tumor was commonly on the right-side 11 (78.6%). A significant proportion (42%) of nonclear cell RCC were predominantly papillary, of the higher grade, and late stage disease with majority of the patients dying within 1-year of surgery.

Only 6 (11.8%) patients had incidental or early disease, and they had the best outcome. Overall survival was poor but patients who had adjuvant treatment appeared to fare relatively better. Four patients died within 48 h of surgery. These patients had huge tumors with marked neovascularization, and the deaths were mainly from uncontrollable or persistent perioperative hemorrhage. Majority of the patients were lost to follow-up 32 (62.8%) and of the few (37.2%) with follow-up records, 90% died within 1-year of nephrectomy as shown in the Kaplan-Meier survival curve [Figure 2]. All the patients with long-term survival (1-year and beyond) had early stage disease. It was also observed that 4 (7.8%) patients who had adjuvant treatment (immunotherapy or vascular endothelial growth factor (VEGF)-tyrosine kinase inhibitors) appeared to fare better.
Figure 2: The Kaplan-Meier survival curve in months for the patients with follow-up data

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  Discussion Top


The incidence of RCC is 10-20% higher in African-Americans, though reports from Africa suggest it is relatively uncommon. [8],[10],[11] The yearly incidence is generally low (4-5 patients/year) in all the quoted recent studies [7],[8],[9],[12],[13] carried out in Nigeria, and this is comparable to our findings. The reason for the apparently low incidence among native Africans compared to the African-Americans and other races are not clear, but several factors may be adduced to this including genetics, diet, environmental factors or simply underreporting.

Renal cell carcinoma is typically a disease of the elderly with the highest incidence in the sixth and seventh decades of life. [1] It is, however, seen at an earlier age among patients of African descent, [6] an observations also seen in this study (mean age: 43.1 years, SD 15.3), majority of our patients were in their fourth and fifth decades of life. This is consistent with reports by other workers in Nigeria [Table 1]. We had more female patients (male:female 2:3) against the commonly observed male preponderance worldwide of 3:2. Female preponderance was also reported by Tijani et al.[13] who found a male:female ratio of 1:1.7.
Table 1: Summaries of studies on RCC done in other centers in Nigeria

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Our patients tend to present late as it is still observed in most developing countries, consequently fewer incidental RCC were seen. Over 90% of our patients presented with advanced disease, similar to other studies in Nigeria [7],[8],[9],[12],[13] and Africa. [10] While only 6 patients (11.8%) were incidental, Tijani et al.[13] reported 1.6% incidental tumors compared to over 70% in the developed world. [4]

The clinical presentation was typical, hematuria, flank pain, flank mass and weight loss and other constitutional and paraneoplastic syndromes. Many patients (43.1%) had the triad of symptoms (hematuria, flank pain and flank mass) compared to 36% reported by Tijani et al.[13] The commonest histologic type was clear cell RCC (74%) as shown in [Table 2]. The interesting observations of a high number of female patients <30 years (78.6%) with right-sided tumors (78.6%) and nonclear cell histology (42.8%) could not be explained. This trend may need to be closely studied to establish its significance.
Table 2: The frequency of the histological types of RCC

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Majority of our patients were lost to follow-up. Of the few with available follow-up records (37.2%), overall survival was dismal. Over 90% were dead within a year as shown in the Kaplan-Meier survival curve [Figure 2]. The few patients with long-term survival and still alive at the time of this report were those with early stage or incidental disease. Therefore significant improvement in mortality from this disease will only be achieved if the disease is detected early and in this case facilitating any measure that will increase the finding of incidental disease.

Small and often incidentally discovered RCC are commonly of the lower stage, and amenable to increasing options of treatment with a trend toward nephron-sparing surgical procedures. Radical nephrectomy is reserved for bigger and more advanced tumors. [16],[17],[18],[19],[20],[21],[22] The development and subsequent introduction of targeted therapy including VEGF and mammalian target of rapamycin inhibitors, [3],[23],[24],[25] have revolutionized the treatment of advanced/metastatic RCC in the last decade. In our study, though there were clear indications for the use of these agents by almost all our patients, the drugs were not readily available, and when they were, the cost was simply prohibitive. The few patients, who could obtain the drugs and use them, appeared to do much better though the number was too small for any meaningful statistical verification.


  Conclusion Top


Renal cell carcinoma, though less common compared to reports from other parts of the world, remains an important urologic malignancy in Nigeria. Despite increasing use of radiologic imaging in the evaluation of unrelated diseases, the incidence has remained static, and late presentation is still the norm. With the advent of targeted therapy, adjuvant treatment should be considered where indicated to improve the quality of life and/or survival of our patients.

 
  References Top

1.
Lipworth L, Tarone RE, McLaughlin JK. The epidemiology of renal cell carcinoma. J Urol 2006;176:2353-8.  Back to cited text no. 1
    
2.
Lipworth L, Tarone RE, McLaughlin JK. Renal cell cancer among African Americans: An epidemiologic review. BMC Cancer 2011;11:133.  Back to cited text no. 2
    
3.
Ljungberg B, Cowan NC, Hanbury DC, Hora M, Kuczyk MA, Merseburger AS, et al. EAU guidelines on renal cell carcinoma: The 2010 update. Eur Urol 2010;58:398-406.  Back to cited text no. 3
    
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Rini BI, Campbell SC, Escudier B. Renal cell carcinoma. Lancet 2009;373:1119-32.  Back to cited text no. 4
    
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Chow WH, Devesa SS, Warren JL, Fraumeni JF Jr. Rising incidence of renal cell cancer in the United States. JAMA 1999;281:1628-31.  Back to cited text no. 5
    
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Stafford HS, Saltzstein SL, Shimasaki S, Sanders C, Downs TM, Sadler GR. Racial/ethnic and gender disparities in renal cell carcinoma incidence and survival. J Urol 2008;179:1704-8.  Back to cited text no. 6
    
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Aghaji AE, Odoemene CA. Renal cell carcinoma in Enugu, Nigeria. West Afr J Med 2000;19:254-8.  Back to cited text no. 7
    
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Badmus TA, Salako AA, Arogundade FA, Sanusi AA, Adesunkanmi AR, Oyebamiji EO, et al. Malignant renal tumors in adults: A ten-year review in a Nigerian hospital. Saudi J Kidney Dis Transpl 2008;19:120-6.  Back to cited text no. 8
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Eke N, Echem RC. Nephrectomy at the University of Port Harcourt Teaching Hospital: A ten-year experience. Afr J Med Med Sci 2003;32:173-7.  Back to cited text no. 9
    
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Klufio GO. A review of genitourinary cancers at the Korle-Bu teaching hospital Accra, Ghana. West Afr J Med 2004;23:131-4.  Back to cited text no. 10
    
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Lawani J, Nposong EO, Aghaidiuno PU, Akute O. A twenty-year review of urologic tumours of the genito-urinary tract in Ibadan, cancers in Nigeria. Ib Trop Med Serv Univ Ib Press 1982; p. 67-74.  Back to cited text no. 11
    
12.
Nggada HA, Eni UE, Nwankwo EA. Histopathological findings in nephrectomy specimens - A review of 42 cases. Niger Postgrad Med J 2006;13:244-6.  Back to cited text no. 12
    
13.
Tijani KH, Anunobi CC, Ezenwa EV, Lawal A, Habeebu MY, Jeje EA, et al. Adult renal cell carcinoma in Lagos: Experience and challenges at the Lagos University Teaching Hospital. Afr J Urol 2012;18:20-3.  Back to cited text no. 13
    
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Benway BM, Bhayani SB, Rogers CG, Dulabon LM, Patel MN, Lipkin M, et al. Robot assisted partial nephrectomy versus laparoscopic partial nephrectomy for renal tumors: A multi-institutional analysis of perioperative outcomes. J Urol 2009;182:866-72.  Back to cited text no. 16
    
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Breau RH, Crispen PL, Jimenez RE, Lohse CM, Blute ML, Leibovich BC. Outcome of stage T2 or greater renal cell cancer treated with partial nephrectomy. J Urol 2010;183:903-8.  Back to cited text no. 17
    
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Carraway WA, Raman JD, Cadeddu JA. Current status of cryoablation and radiofrequency ablation in the management of renal tumors. Curr Opin Urol 2002;19:143-7.  Back to cited text no. 18
    
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Hillyer SP, Autorino R, Spana G, Guillotreau J, Stein RJ, Haber GP, et al. Perioperative outcomes of robotic-assisted partial nephrectomy in elderly patients: A matched-cohort study. Urology 2012;79:1063-7.  Back to cited text no. 20
    
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Karam JA, Wood CG. The role of surgery in advanced renal cell carcinoma: Cytoreductive nephrectomy and metastasectomy. Hematol Oncol Clin North Am 2011;25:753-64.  Back to cited text no. 21
    
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Karellas ME, Jang TL, Kagiwada MA, Kinnaman MD, Jarnagin WR, Russo P. Advanced-stage renal cell carcinoma treated by radical nephrectomy and adjacent organ or structure resection. BJU Int 2009;103:160-4.  Back to cited text no. 22
    
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Calabrò F, Sternberg CN. Novel targeted therapy for advanced renal carcinoma: Trials in progress. Curr Opin Urol 2010;20: 382-7.  Back to cited text no. 23
    
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