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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 3  |  Page : 158-163

Histopathological characteristics of carcinoma of the uterine cervix in a tertiary hospital in southern Nigeria


1 Department of Pathology, University College Hospital, Ibadan, Oyo State, Nigeria
2 Department of Pathology, University College Hospital; Department of Pathology, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria

Date of Submission14-Nov-2019
Date of Acceptance30-Jan-2020
Date of Web Publication7-Oct-2020

Correspondence Address:
Dr. Mustapha Akanji Ajani
Department of Pathology, College of Medicine, University of Ibadan and University College Hospital, Ibadan, Oyo State
Nigeria
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DOI: 10.4103/smj.smj_60_19

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  Abstract 


Background: Carcinoma of the uterine cervix is the fourth-most common cancer among women worldwide, and the leading cause of cancer-related death for women in developing countries. Objective: Cervical carcinoma is a major cause of mortality in a developing nation such as Nigeria. This study provides an update on the prevalence of pathological variants of cervical carcinomas seen at the University College Hospital, Ibadan, Southwestern Nigeria. Materials and Methods: This is a retrospective study involving the review of all the histologically diagnosed cervical carcinoma in the Department of Pathology, University College Hospital, Ibadan between January 2012 and December 2016. The histologically diagnosed cancers and the relevant clinical and histopathological information relating to these tumors were extracted from the records of the department. All cases were treated as anonymous with strict confidentiality. The cases were classified using the World Health Organization histological classification of tumors of the cervix (2014). The obtained data were analyzed using the Statistical Package for the Social Sciences version 23. Results: A total of 294 cases were included in this study. The peak age of diagnosis was in the 6th decade. Two hundred and fifty-two cases (86.0%) were squamous cell carcinoma, 18 cases (6.1%) were adenocarcinomas, 16 cases (5.5%) were adenosquamous carcinomas, and 6 cases (2.2%) were adenoid cystic carcinomas, and one representing 0.3% was a neuroendocrine carcinoma. The most common histological grade was moderately differentiated (Grade 2). The large cell nonkeratinizing squamous cell carcinoma was the most common histological variant.Conclusion: A majority of cervical carcinomas are squamous cell carcinomas and are majorly the large cell nonkeratinizing variant.

Keywords: Carcinoma, histological variants, Ibadan, uterine cervix


How to cite this article:
Omenai SA, Ajani MA, Okolo CA. Histopathological characteristics of carcinoma of the uterine cervix in a tertiary hospital in southern Nigeria. Sahel Med J 2020;23:158-63

How to cite this URL:
Omenai SA, Ajani MA, Okolo CA. Histopathological characteristics of carcinoma of the uterine cervix in a tertiary hospital in southern Nigeria. Sahel Med J [serial online] 2020 [cited 2020 Oct 30];23:158-63. Available from: https://www.smjonline.org/text.asp?2020/23/3/158/297458




  Introduction Top


Carcinoma of the uterine cervix is the fourth-most common cancer among women worldwide, and it remains a leading cause of cancer-related death for women in developing countries, where >80% of cervical cancer occurs.[1] It is relatively uncommon in the United States and the Western world but is one of the most common female malignancies in developing countries.[2],[3],[4],[5] A 2-year period (2009–2010) analysis of data from Ibadan and Abuja population-based cancer registries revealed that cervical carcinoma age-standardized incidence rates were 36.0/100,000 and 30.3/100,000, respectively.[6] Cervical carcinoma was also shown from this analysis to be the second-most common female cancer after breast carcinomas.[6] It is much more common among grand multiparous women of low-socioeconomic status.[3],[7],[8] It is also the second-most common cancer after breast cancer in females in a review of the population-based cancer registry in Ghana.[5]

The age range at the presentation in most studies from Nigeria was from 38 to 87 years.[3],[9],[10] The modal age at presentation in a study in Nnewi southeast Nigeria was 60 and 69 years.[3] A study conducted in Northern Nigeria showed a median age at presentation to be 48 years, and the mean age of diagnosis from a study in Calabar, Nigeria, was 51.8 years.[2],[10] There is a significant wide age range of Nigerian women who are at risk for cervical carcinomas.

Several histological types can be distinguished, but the most common stratification is into squamous cell carcinoma and adenocarcinoma both with different oncogenic mutations and different immunological microenvironments.[11],[12] The squamous cell carcinoma is the most common variant seen in Nigeria accounting for up to 89% which is consistent with the global picture.[2],[3],[13]

Cervical carcinoma is a unique gynecological cancer as the causative agent is known to be the human papillomavirus (HPV). HPV types 16, 18, 35, and 45 are the most common in Sub-saharan Africa.[14],[15]

The most common histological type of cervical carcinomas in various studies from Nigeria is the squamous cell carcinoma constituting between 80% and 90% of cervical cancers with the large cell nonkeratinizing morphological type being the predominant variant.[3],[7] The most common histological grade reported in a study by Ikechebelu et al. from Nnewi, Nigeria, as it is globally was the moderately differentiated squamous cell carcinoma variant,[3],[13] while in another study by Umezulike et al. in Abuja, Nigeria, the well-differentiated squamous cell carcinoma was more common.[7] A previous study from Ibadan conducted in 1978 showed that the well-differentiated squamous cell carcinomas were more common in patients older than 45 years.[16]

This study was conducted to update the pathologic parameters of cervical carcinoma among Nigerians, as seen in University College Hospital, Ibadan, using the 2014 WHO classification of tumors of the uterine cervix.


  Materials and Methods Top


This is a retrospective study involving the review of all the histologically diagnosed cervical cancers in the Department of Pathology, University College Hospital, Ibadan between January 2012 and December 2016. The histologically diagnosed cancers and the relevant clinical and histopathological information relating to these tumors were extracted from the records of the department. Selected cases with faded or missing slides were sectioned and re-stained with hematoxylin and eosin (H and E) stains. All the H and E stained sections were reviewed and histologically classified using the World Health Organization histological classification of tumors of the uterine cervix.[17] The Broder's grading which microscopically grades invasive squamous cell carcinomas based on the proportion of keratinized tumor cells with squamous keratin pearl formation and mitosis was used in grading squamous cell carcinomas.[13] These are the well-differentiated (grade 1), moderately differentiated (grade 2), and poorly differentiated (grade3). Adenocarcinomas of the cervix are graded based on architectural features.[13] The well-differentiated adenocarcinomas have <10% of the tumor composed of the solid sheet. The moderately differentiated adenocarcinomas have between 11% and 50% of the tumor composed of the solid sheet.

In the poorly differentiated adenocarcinomas >50% of tumor is composed of solid sheets of tumor cells.

The data obtained were analyzed using the IBM SPSS Statistics (version 23; IBM Corporation, Armonk, New York) and expressed as frequencies, median, means and mode. The Chi-square test of statistical significance was used for categorical variables. P ≤ 0.05 was considered statistically significant. All cases were treated as anonymous. Data collected were stored in a laptop that was secured by a password. Ethical clearance dated 4th July 2017 with protocol number IU/EC/17/0137 was obtained from the Joint Ethical Review Committee of the College of Medicine, University of Ibadan and the University College Hospital, Ibadan.


  Results Top


There were 294 cases of cervical carcinomas over the review period. Squamous cell carcinoma was the most common cervical cancer with 252 cases (86%), followed by cervical adenocarcinomas with 18 cases (6.1%). Other histological types seen were adenosquamous with 16 cases (5.5%), adenoid cystic carcinoma with 6 cases (2.2%), and a single neuroendocrine carcinoma representing 0.3%. The ages of patients ranged from 25 to 90 years, with a mean age of diagnosis of 56.7 (standard deviation: 13.1) years. The peak age of diagnosis of cervical carcinomas was during the sixth and seventh decades of life, which constituted 51.9% of cases [Table 1]. Squamous cell carcinoma was more common during the seventh decade with adenocarcinomas peaking a decade earlier at the sixth decade. The adenoid cystic carcinomas peaked in the eighth decade, while the adenosquamous carcinomas peaked in the sixth and seventh decades [Figure 1] and [Figure 2].
Table 1: Age distribution, histological subtypes, and grading of cervical carcinoma

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Figure 1: Bar chart showing the relationship between histological types of cervical carcinomas and age

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Figure 2: Bar chart showing the distribution of histological grading within age groups

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The most common histological variant of squamous cell carcinoma seen was the large cell nonkeratinizing squamous cell carcinoma [Figure 3] and [Figure 4]. The most common histological variant of cervical adenocarcinoma was the endocervical adenocarcinoma, usual type [Figure 5] and [Figure 6].
Figure 3: Plot showing the distribution of the variants of squamous cell carcinoma

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Figure 4: Photomicrograph showing keratinizing squamous carcinoma (H and E, ×100)

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Figure 5: Pie chart showing the frequency of histological variants of adenocarcinoma

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Figure 6:Photomicrograph showing adenocarcinoma of the uterine cervix (H and E, ×100)

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  Discussion Top


In this study, squamous cell carcinoma was the major epithelial cancer of the uterine cervix, accounting for 86% of the cases, adenocarcinoma was 6.1%, adenosquamous carcinoma was 5.5%, and adenoid cystic carcinoma was 2.0%. These findings are similar to other Nigerian studies. Umezulike et al. in their study in Abuja, reported squamous cell carcinoma to be 88.9% with adenocarcinoma representing 11.1%.[7] Ikechebelu et al. in Nnewi also found similar results with 89.3% of cervical carcinomas being squamous cell carcinoma.[3] In a Ghanaian study by Der et al. squamous cell carcinoma accounted for 88% of cervical carcinomas.[18] Similar findings were seen in Malawi with 93.7% of cervical carcinomas being squamous cell carcinoma. Hopkin et al. in the United States and Jesus et al. in Brazil also had similar findings in their studies.[19],[20],[21]

The age range of cases in this study was 25–90 years, with the mean age being 56.7 years. Similar findings were reported by Ebughe et al.,[22] Ezeet al.,[4] and Adewuyi et al.[10] while Okoye[23] in a study in Benin city, Nigeria, reported the youngest patient to be 18 years and the oldest to be 99 years. The peak age group of diagnosis was in the sixth decade (50–59 years), with more than a quarter (26.6%) of all cervical carcinomas occurring within this age group. Similar findings were reported by Okoye,[23] Silas et al.,[24] and Nkyekyer et al.[25] In Calabar, Nigeria, Ebughe et al.[22] reported a peak age group in the fifth decade, whereas Eze et al.,[3] Ikechebelu et al.,[4] and Umezulike et al.[7] reported a modal age group of diagnosis to be the seventh decade.

Large cell nonkeratinizing squamous cell carcinoma was the most common histological variant, with 68.6% of all cervical carcinomas and 79.8% of squamous cell carcinomas. Hutt et al.[19] had similarly reported large cell nonkeratinizing squamous cell carcinoma as the most common variant constituting 54% of the histological variant, but Der et al.[18] and Ikechebelu et al.[3] in their studies reported that large cell keratinizing variant was the most common and accounted for 73.3% and 42.7% of all cervical carcinomas, respectively. Large cell keratinizing squamous cell carcinomas in this study constitute 16% of cervical carcinomas and 18.6% of squamous cell carcinomas which is relatively low when compared to findings from Der et al.[18] and Ikechebelu et al.[3] who reported large cell keratinizing variant as the most common variant of squamous cell carcinoma.[3],[18] Large cell nonkeratinizing squamous cell carcinoma has been shown by some studies to have better survival outcomes compared to the keratinizing variant after radiotherapy.[13],[26] The other variant of squamous cell carcinoma seen in this study is the basaloid squamous cell carcinoma which is 1.0% of cervical carcinomas and 1.2% of all squamous cell carcinoma which is similar to the findings of Der et al.[18]

The most common histological grade in this study is the moderately differentiated squamous cell carcinoma which accounted for 52.8%, followed by 24.2% of poorly differentiated squamous cell carcinoma and 23.0% of well-differentiated squamous cell carcinomas. These findings are similar to the global picture[13],[17] but were quite different from an earlier study from Abuja, Nigeria, by Umezulike et al.[7] reported well-differentiated type as 36.2%, poorly differentiated type as 19.4%, and moderately differentiated as 11.1%. This observed difference might be because they analyzed the grades of the carcinomas as distinct histological categories.

Adenocarcinoma accounted for 6.1% of all cervical carcinomas in this study which is similar to other reported studies.[3],[7],[18],[19],[21],[23],[27] The most common histological variant noted in this study was the endocervical adenocarcinoma of the usual type, which accounted for 77.8% of adenocarcinomas and 4.8% of all cervical carcinomas. This is similar to the global picture.[17] Mucinous carcinoma was the next most common histological type representing 16.7% of adenocarcinomas and 1.0% of all cervical carcinomas.

A case of clear-cell carcinoma was seen in this study period representing 5.6% of adenocarcinomas and 0.3% of all cervical carcinomas. It is a rare tumor that is associated with in utero diethylstilbestrol exposure, with patients being averagely 19 years, although sporadic cases occurring in older patients aged averagely 49 years have been reported.[17] The case in the present study occurred in a 42-year-old patient.


  Conclusion Top


This study has shown, like previous studies, that squamous cell carcinoma is the most common histological type of cervical carcinoma. Large cell nonkeratinizing variant was the most common histologic variant seen in this study. Adenocarcinomas were mainly endocervical of the usual type.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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