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| ORIGINAL ARTICLE |
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| Year : 2020 | Volume
: 28
| Issue : 1 | Page : 14-17 |
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Eye Cancers at the Guinness Eye Center Onitsha, Nigeria
Sebastian N. N Nwosu1, Chinasa A Nnubia2, Cyriacus U Akudinobi2
1 Department of Ophthalmology, Nnamdi Azikiwe University Awka (Nnewi Campus); Guinness Eye Center Onitsha, Nigeria
2 Guinness Eye Center Onitsha, Nigeria
| Date of Submission | 10-Nov-2019 |
| Date of Decision | 12-Mar-2020 |
| Date of Acceptance | 21-Apr-2020 |
| Date of Web Publication | 07-Sep-2020 |
Correspondence Address:
Prof. Sebastian N. N Nwosu
Guinness Eye Center, PMB 1534, Onitsha
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njo.njo_22_19
Objectives: To describe the hospital incidence and pattern of ocular and adnexal cancers at the Guinness Eye Center, Onitsha. Materials and Methods: The case files of all new patients seen with ocular and adnexal tumors at the Guinness Eye Center, Onitsha, between 2005 and 2017 were reviewed. Those with histological diagnosis of malignancy were selected and analyzed. Information obtained included age, sex, disease duration, diagnosis and co-morbidity. Results: There were 85 patients (0.1% of all the new patients), made up of 42 males and 43 females. The median age was 5 years; range: 5 months–70 years. The commonest cancers were retinoblastoma, 45 patients (52.9%) and conjunctival squamous cell carcinoma, 30 (35.3%). Twenty eight (93.3%) squamous cell carcinoma patients were HIV-positive. No child had squamous cell carcinoma. All retinoblastoma patients were aged ≤6 years. Conclusions: The incidence of ocular and adnexal cancers at the Guinness Eye Center, Onitsha, was low with retinoblastoma and conjunctival squamous cell carcinoma accounting for most of the cancers. While retinoblastoma would most likely be suspected in a child with ocular tumor, young adults with squamous cell carcinoma should be evaluated for HIV infection. Since these lesions threaten sight and life, the public should be educated on the early signs of the diseases and the need to report to hospital early.
Keywords: Adnexa, cancer, eye, incidence, Nigeria
How to cite this article:
Nwosu SN, Nnubia CA, Akudinobi CU. Eye Cancers at the Guinness Eye Center Onitsha, Nigeria. Niger J Ophthalmol 2020;28:14-7 |
| Introduction | |  |
Cancers of the eye and adnexa contribute to morbidity and mortality among Nigerians as evidenced from studies from different parts of Nigeria.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] These studies highlighted the cancers prevalent in particular geographic zones of Nigeria. While some focused on children,[3],[6],[7] others studied both adults and children.[2],[4],[15] On the other hand, some studies dealt with both benign and malignant lesions,[2],[3] while others dwelt only on orbito-ocular cancers[8],[10] and yet others dealt with specific cancers such as retinoblastoma.[1],[5],[9]
In one of the earliest studies, Olurin and Williams[2] reported retinoblastoma and Burkitt’s lymphoma as the commonest orbito-ocular tumors in Ibadan, western Nigeria. Later, Abiose et al.[3] while analyzing childhood malignancies in Kaduna, northern Nigeria, also observed the preponderance of retinoblastoma and noted the rarity of Burkitt’s lymphoma.
Surprisingly, a recent report from Nnewi (South East Nigeria) Cancer Registry[16] did not record any ocular and adnexal tumor; thus, giving the impression of the absence of these diseases in Anambra State or South East Nigeria. The present study reports the pattern of ocular and adnexal cancers over a 12-year period at the Guinness Eye Center Onitsha, Anambra State, Nigeria.
| Materials and Methods | | |
Approval for this retrospective study was obtained from the management of the Guinness Eye
Center, Onitsha. The case files of all new patients seen with ocular and adnexal tumors between 2005 and 2017 at the Guinness Eye Center Onitsha were reviewed. The out-patient, in-patient and theatre records of these patients were examined. Those with histological diagnosis of malignancy were selected and analyzed. Information obtained included age, sex, disease duration, diagnosis and co-morbidity. Care was taken to preserve the confidentiality of patients’ personal information. Being a descriptive study, the data obtained was analyzed and presented using descriptive statistics.
| Results | | |
Eighty-five patients (95 eyes) with histologically-confirmed ocular and adnexal malignancies were studied. During the study period, 99,437 new patients were attended to at the Guinness Eye Center Onitsha; thus, giving a hospital incidence of 0.1% for ocular and adnexal cancers. There were 42 males and 43 females with an age range of 5 months to 70 years and median age of 5 years. [Table 1] shows the age and sex distribution of the patients. The disease duration at presentation ranged from 3 weeks to 4 years with a median of 10 months.
Primary cancers occurred in 91 eyes (95.8%) while metastatic cancers were recorded in four eyes (4.2%). The commonest cancers in the 85 patients were retinoblastoma and conjunctival squamous cell carcinoma [Table 2]. Retinoblastoma occurred in 45 patients (52.9%), and 10(22.2%) of these patients had bilateral disease. In terms of eyes, retinoblastoma occurred in 55 eyes of 95 eyes (57.9%). Conjunctival squamous cell carcinoma was found in 30 patients (35.3%); all were unilateral.
The age range for retinoblastoma was 5 months to 6 years; median of 2.4 years. For conjunctival squamous cell carcinoma, the age range was 25–70 years; median of 33 years. Twenty eight out of 30 (93.3%) patients with squamous cell carcinoma of the conjunctiva were HIV-positive. The two non-HIV infected patients with squamous cell carcinoma were aged 69 and 70 years.
Retinoblastoma patients presented with the following clinical features: leukocoria in 18 patients (40.0%); proptosis/fungating mass in 18 patients (40%); regression/phthisis in five patients (11.1%) and distant metastasis in four patients (8.9%). Conjunctival squamous cell carcinoma had metastasized to the orbit and beyond in two patients. A 68 year old woman had primary orbital lymphoma. Blood cancer (leukemia) was associated with orbital infiltration, proptosis and retinal hemorrhage in two patients. Metastatic (secondary) cancers observed were nasopharyngeal and prostatic cancers, in one patient each. [Table 3] shows the anatomic sites of the lesions. The intraocular compartment and the conjunctiva accommodated 86 (90.5%) lesions.
| Discussion | | |
The results of the present study suggest that majority of the ocular and adnexal cancer patients in our hospital were children. Olurin and Williams[2] reported that two-thirds of their patients were children. The results of the present study agree but also differ in some respects with findings of previous studies on the subject from different parts of Nigeria and elsewhere. Retinoblastoma remains the commonest malignancy accounting for more than half of the cases in all the studies, including ours.[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14]
About four decades ago, Olurin and Williams[2] reported that retinoblastoma was the commonest orbito-ocular tumor in Ibadan; Abiose[3] while analyzing childhood orbito-ocular malignancy in Kaduna also recorded retinoblastoma as being commonest. More recent reports on the subject from Enugu,[6],[12] Kano,[5] Maiduguri,[10] Ilorin,[11] Lagos,[13] Benin City[14] and Zaria[15], all point to the predominance of retinoblastoma. Most of the retinoblastoma patients including those with bilateral disease reported late with massive tumors, extraocular extension, fungating lesions and distant metastasis to the jaw and the central nervous system; metastasis to the central nervous system was associated with seizures and paraplegia. Nonetheless, leukocoria remains a common clinical feature which in spite of late presentation was seen in 40% of the patients in the present study. Leukocoria should therefore be an ocular feature to be emphasized upon while educating parents and the public about retinoblastoma and the need for early presentation in hospital.
The high incidence of conjunctival squamous cell carcinoma is where the results of the present study principally differ from previous reports.[2],[3] The up-shoot in conjunctival squamous cell carcinoma is due to the HIV/AIDS pandemic. Up until two decades ago, conjunctival squamous cell carcinoma associated with HIV infection was considered so rare that single cases were reported.[17] An earlier review in our hospital showed that squamous cell carcinoma occurred in 2.2% of HIV/AIDS patients.[18] Recent reports from different parts of Africa including Nigeria suggest that the tumor is becoming more common, aggressive, occurs more in younger age group and also commoner in women, especially those infected with HIV.[19],[20],[21] The high incidence (93.3%) of squamous cell carcinoma among HIV-positive patients is similar to the findings of Ogun et al.[19] in Ibadan; Osahon et al.[21] in Benin-City and Ateenyi-Agaba[22] in Uganda. Indeed, the emergence of HIV/AIDS has drastically changed the epidemiology of conjunctival squamous cell carcinoma: previously it was rare but common now; used to occur in the elderly but now more prevalent in the younger population; unlike in the past, it now runs an aggressive course.
Uvea melanoma, Kaposi sarcoma, rhabdomyosarcoma, primary orbital lymphoma and other tumors recorded in the present study were uncommon. However, a high index of suspicion is required and relevant investigations performed for accurate diagnosis and appropriate treatment in order to salvage sight and life.
No case of Burkitt’s lymphoma was recorded in the present study though a case of primary orbital lymphoma was documented in a 68 year old woman. This is different from the earlier experiences of Olurin and Williams[2] in western Nigeria as well as Abiose[3] in northern Nigeria. This may be related to geographic distribution of this disease in different parts of Nigeria. It could also be possible that cases of Burkitts lymphoma are now diagnosed and treated earlier by paediatricians in comparison with the experience in 1970s and 1980s when the above referenced studies were conducted. The Guinness Eye Center Onitsha is a stand-alone eye hospital with minimal interaction with paediatricians.
The Nnewi (South-East) Cancer Registry was established to gather and store information on cancers in that part of Nigeria. This job, it has performed for more than 20 years. However, in a recent review of cases in its data-base, no mention was made of ocular and adnexal tumors.[16] This is worrisome since the Registry is accommodated within the Nnamdi Azikiwe University Teaching Hospital of which the Guinness Eye Center Onitsha is the ophthalmic wing. Perhaps the physical separation of the eye hospital from the main teaching hospital campus where the Registry is based may have accounted for this lapse. But more importantly, the omission points to the inefficiency of documentation in our system which needs be strengthened. This lack of information on eye and adnexal cancers in the Nnewi Cancer Registry was a major justification for the present study. With the results of this study, it is expected that the cancer registry, and indeed other cancer registries around Nigeria, will update their records ensuring inclusiveness. It is also recommended that stand-alone eye hospitals should also maintain good records of cancer patients as a prelude to establishing a national ocular tumor registry in Nigeria.
Almost all the patients presented late thus making palliative care the only practical management approach. This experience has been reported in previous studies.[9],[15] Many factors affect health-seeking behavior and patronage of health services. In a survey of ocular cancers awareness, Ayanniyi et al.[23] reported that only half of the respondents were aware that cancers could affect the eyes and fewer knew of the possible symptoms and signs. They also found cost and long distance as factors militating against early presentation to hospital. These factors need to be addressed for improved patronage.
In conclusion, although the incidence of ocular and adnexal cancers in our hospital is low compared to ametropia,[24] cataract,[25] glaucoma[25] and AMD,[26] ocular and adnexal cancers need to be tackled early since they threaten sight and life. Most of the patients were children and young adults. Health education of patients and public on the symptoms and signs of eye cancer are required. Secondly, training and retraining of primary health workers and other health care providers on the clinical manifestations of eye cancers may aid early detection and presentation of patients.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]
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