|Year : 2017 | Volume
| Issue : 4 | Page : 137-142
Renal cell carcinoma in Nigeria: A systematic review
Akinfenwa Taoheed Atanda1, Muhammad Sanusi Haruna2
1 Department of Pathology, Aminu Kano Teaching Hospital/Bayero University, Kano, Nigeria
2 Department of Morbid Anatomy and Forensic Medicine, Usmanu Danfodiyo University, Sokoto/Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||17-Apr-2018|
Dr. Muhammad Sanusi Haruna
Department of Morbid Anatomy and Forensic Medicine, Usmanu Danfodiyo University, Sokoto/Pathology Department, Aminu Kano Teaching Hospital, Kano
Literature on renal cell carcinoma (RCC) in Nigeria is characterized by lacunae in several important areas with resultant incomprehensiveness of data. This requires a review of the literature so as to streamline the data. Using internet search engines, data were extracted from a total of twelve studies reported in peer reviewed journals between 2000 and 2015 from various states of Nigeria including Kano. These were subsequently collated, analyzed, and then compared with those from other parts of the world. There is relatively low incidence rate of 0.3/100,000 population; slight male preponderance and affectation of younger age groups with average age at diagnosis of 45 ± 4 years. Significant smoking history, exposure to industrial dye, family history, and HIV associated immunodeficiency are major risk factors of RCC in Nigeria. A significant number of cases presented with triad of loin pain, hematuria, and loin mass; advanced disease and bulky tumors of up to 3.8 kg and 56 cm. The predominant histological subtypes were clear cell carcinoma 60%–85.7% and papillary carcinoma 23.8%–46.2%. In general, there has been poor overall outcome for RCC bearing patients in the country. RCC in Nigeria is characterized by earlier age at onset and poor outcome, thus necessitating more aggressive case identification at early stages so as to improve prognosis.
Keywords: Clear cell, Nigeria, renal cell carcinoma
|How to cite this article:|
Atanda AT, Haruna MS. Renal cell carcinoma in Nigeria: A systematic review. Sahel Med J 2017;20:137-42
| Introduction|| |
Nigeria, with 170 million people, has over 250 ethnic groups and is divided into 36 administrative entities called states and a federal capital territory, Abuja. It is traditionally divided into northern (including north-west, north-east, and north-central) and southern (comprising south-west, south-east, and south-south) Nigeria. Data from a population-based cancer registry in the country put age-standardized rates for cancer in Nigeria at 66.4/100,000 men and 130.6/100,000 women.
Worldwide, cancer of the kidney is ranked 13th among all cancers, 8th in England, and 7th in the United States (US).,, In Nigeria, it is ranked 20th based on analysis of data from two population-based cancer registries. Globally, renal cell carcinoma (RCC) accounts for about 3% of all adult cancers while in Nigeria, it has accounted for between 0.3% and 2.3%.,,,,, This is expectedly an underestimation as paucity of records on a national basis has militated against comprehensive data gathering. Cancer epidemiology in the country is also bedeviled by poor patronage of orthodox healthcare facilities because belief in spiritual etiology of diseases is rife. In the same vein, due to high rate of default from follow-up, mortality statistics are characterized by large gaps in data.
Following from the foregoing, different tertiary centers in Nigeria where cancer treatment is given, have concentrated mainly on highlighting different aspects of RCC demonstrable locally in their centers, without a clear picture emerging. This systematic review therefore seeks to synthesize data from our own center in Aminu Kano Teaching Hospital, Kano, with all studies on RCC from other centers in the country and then compare this with those from other parts of the world. This will serve to give a clearer picture of RCC in the country.
| Methods|| |
All studies on RCC in peer-reviewed journals from different parts of Nigeria between years 2000 and 2015 were included in the review. Pediatric nephroblastomas were excluded. Only the most recent of multiple studies from the same center was selected if the studies were on the same theme.
All studies were found by searching through electronic databases including Pubmed, Google, Google scholar, Saudi Journal of Kidney Diseases and Transplantation and African Journals Online. Search words employed were “RCC” followed by adding the individual names of all the 36 states in Nigeria and Abuja, the capital.
| Results|| |
Twelve studies met the search criteria, and from these, relevant data were extracted. There were five studies from the northern and seven studies from the southern parts of the country and one from Kano [Table 1].
|Table 1: Characteristics of renal cell carcinoma highlighted in studies from different regions of Nigeria|
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| Frequency|| |
Synthesizing data from the 12 centers and Kano,,,,,,,,,,,, approximately 45 cases of RCC, are diagnosed per year (Σn/year; [Table 1]) in Nigeria. However, this may be an underestimation because of hitherto-mentioned cancer registration lapses. Worldwide, in 2013, about 338,000 new cases of kidney cancer were diagnosed.
| Incidence|| |
Using standard census population, the incidence rate for RCC in the country is about 0.3 per 100,000 populations. This is low compared to worldwide rates that have ranged from as low as 6.1/100,000 in Brazil, Latin America to as high as 22.5/100,000 in parts of Europe. In Africa, it has ranged from 2.6/100,000 in southern Africa to as high as 3.3/100,000 populations in northern Africa. The global age-standardized incidence rate is 4 per 100,000 people per year. Karim-Kos et al. have proposed that these racial disparities in incidence may be attributable to differences in frequency of diagnostic imaging, access to health care, genetic background, and prevalence of lifestyle or environmental risk factors.
| Gender|| |
Males are slightly more affected in our population, evidenced by overall male:female ratio of 1.1 although this supports the general trend observed in most studies worldwide of a male preponderance, our ratio is quite low compared to ratio of 1.75 among an Arab population; 2.1 in North America; 2.1 among Australians; 2.2 among Brazilians of Latin America; 2.3 among Italians in Europe; and as high as 3.4 among Japanese in the Asian continent.,, Our ratio is also low compared to the trend across Africa with ratios of 1.4 in northern Africa and 1.9 in southern Africa.
| Age|| |
The age range from the studies in the country is between 8 and 89 years with an average age of 45 ± 4 years (peak age in the fifth decade).,,,,,,,,,,, This is about two decades less than the pattern described for western countries where the peak age incidence is in the seventh decade.,, Earlier age at onset was also documented in an analysis of data from a population-based cancer registry in Morocco, North Africa, Ghana in West Africa, Kenya in East Africa, and in India.,,, Reasons for this observed age-related variations are unclear but changing lifestyle and higher exposure to hazardous work environment among younger Africans may underlie this.
| Risk Factors|| |
Even though most putative risk factors for the development of RCC have been associated with conflicting data, several have shown sufficient evidence to warrant mention. Chow et al. have classified these into those with established association such as cigarette smoking, obesity, and hypertension and those with suspected association including diabetes mellitus, high parity, physical inactivity, alcohol consumption, and exposure to trichloroethylene.
Studies across Nigeria have only paid minimal attention to evaluating risk factors in published literature. However, Tijjani and Badmus in separate studies from southwestern Nigeria documented significant smoking history in 7.8% and 16.7% of cases, respectively., The former also identified exposure to industrial dyes in 4.7% and family history in 1.6% of their cases. Immunodeficiency from HIV infection was also reported in 9.5% of patients in Enugu, southeastern Nigeria.
The almost even gender-related pattern of RCC overall in studies from Nigeria would suggest that risk factors associated with the disease uniformly apply to both genders in the country. Hypertension, an established risk factor, has almost equal prevalence among males (6.2%–48.9%) and females (10%–47.3%) in our setting. Similarly, comparable with other countries, diabetes mellitus, with a prevalence of 5.27% (142nd of 193 countries) as at 2014, is relatively a low risk factor in Nigeria. Obesity among males in Nigeria is 5.9% (133rd worldwide) and 16.3% among females (133rd of 189 countries worldwide).
Cigarette smoking, on the other hand, may account for some of the earlier age of onset among our patients. The Global Adult Tobacco Survey for 2012 showed that about 4% of adult Nigerians smoked tobacco products at an average of 8 cigarettes per day. In northeastern Nigeria, where the prevalence was highest, rate of smoking peaked at age range 30–39 years, with 71% having started smoking between 13 and 15 years of age.
In addition to smoking, authors of an Indian study, where a significant number of their cases were also found to be younger than those in Europe and the US, have suggested poor nutrition as a risk factor to explain this. This may aptly explain the situation in our country based on reported adolescent underweight ranging from 18.7% to 22.4%.
| Clinical Presentation|| |
Among our patients, hematuria was found in 9–87% (mean 36%), loin pain in 14–94% (mean 50%), weight loss in 82–100% (mean 84%), and loin mass in 13–100% (mean 97%).,,,,, This pattern is similar to that described in developed countries over four decades ago, when clinical practice then more closely reflects what is obtainable in present day developing countries like ours. However, diagnosis of RCC has historically relied on the demonstration of a triad of symptoms including loin mass, hematuria, and loin pain. In this respect, 8–46% of our cases presented with this triad in contrast to 10–15% reported in developed countries. The high number of symptomatic cases in the country reflects late presentation and advanced disease.
| Stage|| |
Results show that 80%–96% of our patients presented in advanced stages T3/T4. This contrasts with 37% in Brazil and 15% documented from an European cancer registry., Conversely, unlike findings in developed countries where over 50% of cases are incidental tumors, in Nigeria, these have been documented in only about 1.6%–11.8% of tumors recorded., This is similar to the pattern described in the study from Sudan, another African country, where only 10% of their cases were incidentally discovered. This may reflect illness behavior in economically challenged countries where nonorthodox care is first sought and then hospital care when all else fails. Inadequacy of ultrasonography and computed tomography scans as well as inadequacy of trained radiologists may also be a contributory factor. Average time from observation of first symptoms/signs to diagnosis could not be ascertained in every case; however, data from centers in the country which documented this information have shown that this ranged between 1 and 208 weeks (mean 45.8 weeks)., The advanced stage at presentation may also suggest that the tumors are more clinically aggressive in our patients.
| Tumor Size|| |
Various centers in the country have documented very bulky tumors with weights ranging between 0.48 and 3.8 kg and tumor widths averaging 18.7 ± 3.2 cm (15–56 cm).,,,, A study from Ghana, another West African country, also recorded tumor sizes with mean diameter of 16.8 ± 4.0 cm. In contrast, a large population-based study from Europe and a study from the US showed that tumors ≤7 cm accounted for 58.3% and 89.7% of cases diagnosed, respectively. Such bulky tumors as recorded among our patients support tardiness in presentation for treatment and may also suggest the tumors are aggressive. This is buttressed by the observation by Igor et al. that only 1% of all tumors <1 cm and 9.2% of all tumors <2 cm were high-grade malignancies. Similarly, most tumors encountered in western countries are <0.5 kg.
| Predominant Subtype|| |
Clear cell carcinoma (CCC) was the most common histological subtype with frequency ranging from 60% to 85.7%.,,,,, The predominance of CCC has also been reported from other regions of the world with frequencies of up to 85%.,, This group of tumors are derived from cells of the proximal tubules and majorly show 3p deletion. Similar to observations from most studies globally, the acinar subvariant was more commonly reported in Nigeria with sarcomatoid subvariant of it accounting for 2.2% in one of our studies.
Second in frequency to the CCC is the chromophilic (papillary) carcinoma. This ranged in frequency between 23.8% and 46.2%.,, This is higher than the 10%–15% quoted in western literature., This higher rate of papillary tumors highlights the need to more comprehensively investigate risk factors that may locally underlie this. Other histological patterns are relatively uncommon with collecting duct, sarcomatoid, and chromophobe subtypes accounting for 8.9%, 2.2%, and 2.2%, respectively, in one of our local studies. Xp11.2-related carcinoma was scarcely reported probably due to lack of facilities for its definitive diagnosis, but based on morphological appearance after sampling, two cases were reported in Kano.
| Outcome|| |
Even though data from most centers in Nigeria on outcome of patients with RCC are incomplete, available data demonstrate very poor outcome. Loss to follow-up was the most common clinical outcome, and this was recorded in 45.5%–67% of cases (Jos, Ibadan, Zaria, Lagos.,,, This high frequency may be a reflection of number of factors which include: long distance patients have to travel to the referral centers in the country; high cost of chemo and adjuvant therapy; inability to afford cost of cancer management; and illness behavior skewed in favor of patronage of alternative medicine practitioners and spiritual center.
High mortality rate has also been reported and has ranged from 40.9 to over 90%.,, Two centers , in the country report 1–5-year survival rates of 13.6% and 56% for patients managed with or without resection, chemotherapy, radiotherapy, and adjuvant therapy. Only 7.8% of patients in one of the centers  were able to afford adjuvant therapy including interferon. In addition to this, perioperative mortality, where documented, ranged between 6.3 and 7.8%, and these mostly resulted from hemorrhage and sepsis., This rate of perioperative deaths is higher than 2.8% documented in western countries. This probably highlights our inability to implement more modern treatment options such as nephron-sparing and laparoscopic surgery because of inadequate infrastructural support. In contrast to the foregoing, 1 and 5 year survival rates in Europe have reached 72% and 55%, respectively, while in the US, SEERs statistics puts survival at 73.2%.,
In spite of the dismal mortality figures highlighted from the foregoing, common denominators for those who had the best outcome from all the centers in the country were early stage tumors and ability to afford therapy.
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Conflicts of interest
There are no conflicts of interest.
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