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| ORIGINAL ARTICLE |
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| Year : 2015 | Volume
: 18
| Issue : 5 | Page : 12-15 |
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Morphological patterns of primary skin Sarcoma in Benin-City, Nigeria
Gerald Dafe Forae, Adesuwa Noma Olu-Eddo
Department of Pathology, University of Benin Teaching Hospital, Benin City, Nigeria
| Date of Web Publication | 19-Jan-2015 |
Correspondence Address:
Gerald Dafe Forae
Department of Pathology, University of Benin Teaching Hospital, P.M.B. 1111, Benin City
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1118-8561.149497
Background: The purpose of this study is to determine the frequency and morphological patterns of primary skin sarcoma in University of Benin Teaching Hospital (UBTH), Benin City, Nigeria. Materials and Methods: Data of skin surgical received at the Department of Histopathology, over a 25 year period (1982-2007) were reviewed. Information derived from surgical day books includes socio-demographic data on age, sex, hospital numbers, clinical features and diagnosis. Corresponding slides and blocks retrieved were examined histological. Results: During the 25-year period of this study, 187 cases were malignant skin lesions. Of these, 64 constituting 34.2% were primary skin sarcomas. Kaposi sarcoma (KS) accounted for (n = 57; 30.5% and n = 57; 89.1%) of malignant skin tumours and primary skin sarcoma, respectively. Dermatofibrosarcoma protuberans (DFSP) accounted for (n = 7; 3.7% and n = 7; 10.9%) of all skin malignancy and primary skin sarcomas respectively. The peak incidence of KS and DFSP was in the 4 th and 3 rd decades respectively. The mean age for KS and DFSP was 47.5 ± 1.7 and 35.9 ± 5.9 respectively. The age range for KS and DFSP was 17-78 and 25-65 years respectively. KS and DFSP accounted for male to female ratio of 1.3:1. Of the 28 cases with recorded site distribution, 14 cases (50%) occurred in the leg and foot region. Of these 6 cases of DFSP with recorded site distributions, 4 cases (66.7%) occurred in the trunk. Conclusion: The burden of primary skin sarcoma particularly AIDS associated Kaposi sarcoma in developing countries is worrisome. In view of this, it is important that more awareness and effective HIV/AIDS screening be instituted to reduce the morbidity and mortality of this menace. So that at no distance time, there would be a drastic reduction of skin sarcoma in our society. Keywords: Biopsy, histopathology, malignant melanoma
How to cite this article:
Forae GD, Olu-Eddo AN. Morphological patterns of primary skin Sarcoma in Benin-City, Nigeria. Sahel Med J 2015;18, Suppl S1:12-5 |
| Introduction | |  |
The skin is heterogeneous and constitutes the most widely distributed organ in the body. [1] In spite of this, primary skin sarcomas remain relatively rare malignancies and are not listed among the first ten most common malignancies worldwide. Recent data indicate that its incidence is steadily increasing worldwide, due to increase prevalence of AIDS associated Kaposi sarcoma. However the exact incidence in most developing countries is unknown because most cases go unreported. [2]
Common primary skin sarcoma includes Kaposi sarcoma (KS) and Dermatofibrosarcoma protuberans (DFSP). Kaposi sarcoma was first described by Moritz Kaposi, in 1872. [3] KS is reported as the second most common skin malignancies accounting for 4.2% and 6.7% of all skin malignancies in Malawi and Tanzania respectively. [4] Recent data indicate a 3 and 20 fold rise in the incidence of Kaposi's sarcoma in South-Africa and Uganda respectively. [5] Kaposi sarcoma occurs in 4 clinical forms: Acquired immunodeficiency syndrome (AIDS) related Kaposi sarcoma, endemic (Africa) type, classic (European) type and transplant related Kaposi sarcoma. [6] Previous reports show that the AIDS related Kaposi sarcoma is of the increase worldwide although more commoner in Africa countries including Nigeria. In Nigeria KS prevalence occurred in 30% of AIDS patients [7] This has contributed tremendously to increase in its mortality and morbidity in Nigeria. Classic form is commoner in the Mediterranean countries of Greece, Italy and Middle East. [5],[7] The endemic type is commoner in African particularly among the Bantu ethnicity of South-Africa, Uganda and Zaire. [5],[6],[7]
Dermatofibrosarcoma protuberans is a rare skin sarcoma. It constituted 24.9% of skin sarcomas and 8.3% and 10.2% of malignant skin tumours in Lagos and Maiduguri respectively. [8],[9] It accounted for 3.05% of all malignant tumour in Maiduguri [9] It is a fibro-histiocytic tumour of intermediate malignancy. It occurs in dermis and spread to the subcutaneous tissue. [10]
This study is aimed at establishing the prevalence, age, sex, site distribution and histological types primary skin sarcomas in Benin. Data derived from this research would serve as baseline data for further research.
| Materials and Methods | | |
Data of surgical biopsies of skin tumour received at the Department of Histopathology, University of Benin Teaching Hospital, (UBTH) Benin City, Nigeria over a 25 year period (January 1982 to December 2007) were scrutinized for this study. These specimens were sent from the Departments of Dermatology and Surgery in UBTH and other hospitals within Benin-City metropolis as well as neighbouring states of Delta, Anambra, Bayelsa, Kogi and Ondo. The original pathology request cards of the cases were retrieved to obtain socio-demographic data on age, sex, hospital numbers and clinical information. Corresponding slides were retrieved. Where such slides could not be recovered, the stored paraffin embedded tissue blocks in the archives were recovered and new slides prepared with routine standard Haematoxylin and Eosin (H/E) stain. Special stains including reticulin stain were used where necessary. Data were analyzed using SPSS version 16 statistical package.
| Results | | |
Demographic analysis
General
During the 25-year period (1982-2007) of this study, 187 cases were malignant skin lesions. Of these, 64 constituting 34.2% were primary skin sarcomas. The mean age for KS and DFSP was 47.5 ± 1.7 and 35.9 ± 5.9 respectively. The age range for KS and DFSP was 17-78 and 25-65 years respectively.
[Table 1] shows that Kaposi sarcoma accounted for 57 cases, (30.5%, 89.1%) of malignant skin tumours and primary skin sarcoma respectively. DFSP accounted for 7 cases (3.7%, 10.9%) of all skin malignancy and of primary skin sarcomas respectively. The peak incidence of KS and DFSP was in the 4 th and 3 rd decades respectively. KS accounted for 33 males and 24 females respectively constituting a male to female ratio of 1.3:1. DFSP accounted for 4 males and 3 females with a male to female ratio of 1.3:1 respectively.
In this study, [Table 2] the leg and foot region was the most prevalent site of occurrence for all primary skin sarcoma constituting 16 out of 34 cases (47.1%). The second majority was the trunk region accounting for 14 cases (41.1%). Of the 28 cases for Kaposi sarcoma with recorded site distribution, 14 cases (50%) occurred in the leg and foot region, this is followed by the trunk accounting for 10 (35.7%). The head and neck accounted for only 1 case (3.6%). Of these 6 cases of DFSP with recorded site distributions, 4 cases (66.7%) occurred in the trunk and 2 cases (33.3%) occurred in the leg and foot region respectively.
There was a marked variation in the trend of primary skin sarcomas. Kaposi sarcoma remains relatively constant in the early 80s to 2004. Thereafter there was a steep rise in its trend from 2005 to 2008 in 6 folds. However DFSP was relatively stable in trend from early 80s to 2008.
| Discussion | | |
This retrospective study shows that Kaposi sarcoma was the 2 nd most prevalent skin malignancy in our locality accounting for 30.5% of skin malignancies, a figure higher than the 8%, 11% and 16% recorded in similar studies in Kano, Jos and Maiduguri respectively. [1],[5],[7] Previous studies in Nigeria showed that KS accounted for 6.7% and 8.1% of skin malignancies in Lagos and Ilorin respectively. [6],[11] The reason for this variation is attributable to reports of the 1999 national HIV sentinel survey, where the north central, north east and north-north geographic zones where Jos and Maiduguri and Kano respectively belongs, have lower HIV infection rates of 7.0%, 4.5% 2.3%, respectively. [2],[9],[4] This may explain the relative lower rates of Kaposi's sarcoma in these areas. The reason for this increased incidence of Kaposi sarcoma in UBTH is as a result of high rate of HIV infections and AIDS. KS accounted for 4.2% and 6.7% of skin malignancies in Malawi and Tanzania respectively. [4],[5],[6]
Kaposi sarcoma (KS) is the most common primary skin sarcoma in this study. Our study reported a 6 fold rise in the incidence of Kaposi sarcoma. This is in relatively similar to recent reports of a 3 and 20 fold rise in the incidence of Kaposi sarcoma in South-Africa and Uganda respectively. [5],[6],[12] Since its association with AIDS, its incidence has risen 20 fold in the past 15 years in central African countries like Zimbabwe, Uganda and is now the most common cancer in men and the second most common in women in these countries. [12] A rise in the incidence of Kaposi sarcoma has also been observed in some parts of Nigeria. Reports have shown that AIDS related Kaposi's sarcoma occurs in as high as 30% of HIV/AIDS patients. [5],[12] KS is one of the common skin manifestations of AIDS with approximately 15% of all AIDS patients developing KS. Its incidence and demographic patterns therefore mimic trends seen for AIDS.
In a recent review of skin soft tissue tumours, it was shown that blacks had a higher incidence of KS than Caucasians, (23.5 versus 17.5 per 100,000) while Asians had a much lower incidence rate of KS of 4.0 per 100,000 persons. [13] As a result of the HIV epidemic, the incidence of KS has also increased in countries where it was previously relatively rare, but where Kaposi sarcoma herpes virus (KSHV) was prevalent. KSHV is widespread in sub-Saharan Africa, with a seroprevalence rate of about 50% [14] Serological studies have shown that KSHV comparatively rare in Northern and Western Europe, but more common in countries bordering on to the Mediterranean, in particular, Southern Italy, Greece, the Mediterranean coast of North Africa, and Palestine/Israel, with reported sero-prevalence rates in the order of 10-30%. [14]
The mean age for Kaposi sarcoma was 47.5 years in this study. This report is slightly at variance with findings from the Lome, Togo where its mean age was 35.2 years. [15] However these two age bracket are consistent with the peak of sexual activities which is a risk factor to contacting HIV/AIDS. The leg and foot region was the most common site in our study. It is a tumour of vascular origin.
Clinical classification of KS may be the best prognostic indicator. Epidemic KS earlier on generated a lot of interest in the early eighties, because its aggressive form was associated with the onset of HIV/AIDS. It became more widely known as one of the AIDS defining illnesses in the United States and all over the world. [16] It is over 300 times more common in AIDS patients than the general population. Studies have shown that AIDS associated (epidemic) KS and endemic (African) KS have 3-year survival rate. [16],[17] Endemic (African) or lymphadenopatic KS is seen predominantly amongst native residents of equatorial Africa, where it composes about 10% of all malignancies. Endemic KS occurs more commonly in the Bantu region of South Africa and in Zaire, Uganda and Zimbabwe in East Africa. This high incidence of KS in these sub-Saharan African countries is due to the high rate of KSHV-8 infection in their general population. [16],[17]
Classic (chronic) KS also known as European type is a relatively indolent disease constituting about 90% of all KS seen in elderly males of Mediterranean region including Greece, Italy, and Eastern Europe. [17] Its prognosis appears to correlate with the degree of immune-suppression and older age. Transplant-related Kaposi Sarcoma has been described, but only rarely until the advent of calcineurin inhibitor such as cycloserin in the 1980. It occurs due to low immunity associated with mega-dose of immune-suppressive treatment for organ transplant. [16],[17]
Dermatofibrosarcoma protuberans is the least common malignant skin tumour recorded in this study accounting for 10.9% and 3.7% of skin sarcoma and malignant skin tumours respectively in UBTH, Benin City. It accounted for 24.9% of the skin sarcomas and 8.3% of all malignant skin tumours in Lagos. [8] Reports by Nggada et al. in Maiduguri shows that DFSP constitutes 10.2% of all malignant skin tumours. [9] Our report is at variance with these 2 reports. The reason for the observed lower figures in our environment may be partly attributed to ethnical variation, poor reporting, lack of awareness of cases and the fact that some cases may seek alternative therapy. [4],[17] In our study it is most common in the second and third decades of life with the overall male and female ratio of 1.3:1. This is comparable to similar retrospective studies done in Lagos and Kano. However this is at variance with reports by Nggada et al. where the peak age range was seen in the 4 th and 6 th decades of life.
| Conclusion | | |
In this study, Kaposi sarcoma was the most common primary skin sarcomas. This is similar to reports of other researchers in African and black America. In this study its trend has risen sharply over 600%. This is attributable to this era of HIV and AIDS. DFSP contrast has a relatively steady constant trend over the period of distribution.
| Acknowledgments | | |
We wish to acknowledge both Dr. A.N. Olu-Eddo and Prof. J.U. Aligbe for their constructive contribution towards the successful completion of this manuscript. We also acknowledge all staff of Pathology departments in one way or the other contributed to this manuscript. Finally we thank the Almighty God for the grace to put this piece together.
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[Table 1], [Table 2]
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