|Year : 2020 | Volume
| Issue : 2 | Page : 40-44
Histological analysis of colorectal cancer specimen in a tertiary hospital in Ghana: A retrospective study
Babatunde M Duduyemi1, William G Ayibor2, Emmanuel Asante1, Ebenezer Owusu1, Foster K Safo1, Lawrence K Appiah1, Francis A Yeboah2
1 Department of Pathology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
2 Department of Molecular Medicine, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
|Date of Submission||10-Apr-2020|
|Date of Decision||17-Apr-2020|
|Date of Acceptance||09-Jun-2020|
|Date of Web Publication||10-Dec-2020|
Dr. Babatunde M Duduyemi
Department of Pathology, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi
Source of Support: None, Conflict of Interest: None
Background: There are few publications on the histopathological spectrum of cancer arising from the colon and rectum in this country. Knowledge of the spectrum of findings from colorectal cancer (CRC) biopsies will help reveal the type of cancers, the most common grade and the most prevalent anatomical distribution, the demographical distribution as well as the association of clinical symptoms with various conditions. This will inform interventions to be made.
Methodology: The study employed a retrospective design with data and archived slides extracted from the Department of Pathology, Komfo Anokye Teaching Hospital, January 2009–September 2018. The slides were reviewed to establish diagnoses on colorectal biopsies.
Results: A total of 237 CRC cases were reviewed, and the mean age was 54.61 ± 17.62 years, with the modal age being 75 years. The age ranges from 5 to 91 years, with the age group of 50–59 years recording the most with 22.36%. The male-to-female ratio is 1:1.09. Rectal cancers were relatively more common constituting 48.10% of the cases compared to colonic cancers, which contributed 45.57% of the cases, and rectoanal cancers recorded 6.33% of the cases. Adenocarcinoma was the most common cancer type constituting 209 (88.19%) cases and squamous cell carcinoma accounting for 21 (8.86%) cases. There were 4 neuroendocrine cancers representing 1.62% of the cases and 2 non-Hodgkin's lymphomas contributing to 0.84% of the cases, with sarcoma contributing a single case (0.42%) of the total number of cancers.
Conclusion: CRC incidence is on the ascendency and continues to pose major health risk in this sub-Sahara African population. Females were at slightly increased risk and frequently located in the rectum, with most being high-grade CRCs.
Keywords: Clinical indication, colorectal cancer, colorectal lesion, histopathological analysis
|How to cite this article:|
Duduyemi BM, Ayibor WG, Asante E, Owusu E, Safo FK, Appiah LK, Yeboah FA. Histological analysis of colorectal cancer specimen in a tertiary hospital in Ghana: A retrospective study. Niger J Gastroenterol Hepatol 2020;12:40-4
|How to cite this URL:|
Duduyemi BM, Ayibor WG, Asante E, Owusu E, Safo FK, Appiah LK, Yeboah FA. Histological analysis of colorectal cancer specimen in a tertiary hospital in Ghana: A retrospective study. Niger J Gastroenterol Hepatol [serial online] 2020 [cited 2021 Apr 11];12:40-4. Available from: https://www.njghonweb.org/text.asp?2020/12/2/40/302899
| Introduction|| |
Colorectal cancer (CRC) continues to be a major public health concern and is the third most common cancer in men and the second in women globally. It is also the third leading cause of cancer-related deaths, with over 100,000 deaths annually.
Colorectal carcinoma is relatively uncommon in Ghana, compared to the developed countries, but the incidence is on the ascendency in recent times with the incidence rising from an average of 4.1 cases in the 1960s to a staggering average of 32 new cases in recent times.,
In 2008, CRC was the third most common cancer in males and the second in females worldwide. The mechanisms underlying CRC are still poorly understood, with a host of factors, suggesting that inherited and sporadic CRCs are caused by genetic and molecular as well as environmental or lifestyle events.
Histological analysis is usually done to ascertain the diagnosis and appropriate interventions made. More research and subsequent publications on the histopathological spectrum of CRCs in this region are very expedient to better understand the disease, thus providing a clue to treatment approach. Knowledge of the spectrum of findings from CRC biopsies will help reveal the most common lesions, the demographical distribution as well as the association of clinical symptoms with various conditions and early interventions made to avoid progression to higher grades and stages. Studies have shown that many premalignant lesions if screened and detected early can avert progression to CRC., A malignant tumor can spread to other parts of the body and damage them if no intervention is made.
Some research on the CRCs has indicated that early detection through screening and subsequent treatment of colorectal diseases can significantly improve upon treatment outcomes and rate of survival. Many patients, especially in this part of the world, however, present late because of a lack of knowledge about their condition and a feeling of embarrassment to seek help on their condition due to the uncomfortable nature of some of the screening.,,
This work has the aim of presenting information on the histopathological spectrum of colorectal malignancies in our center.
| Methodology|| |
The study employed a retrospective design with data and archived slides extracted from the Department of Pathology, Komfo Anokye Teaching Hospital.
Suitable consecutive colon and rectal biopsies identified from January 2009 to September 2018 were extracted from the database. All histopathology request forms, reports, and hematoxylin- and eosin-stained slides of all colorectal biopsies received in our department during the study period were used for the study. A total of 372 CRC biopsy specimen (endoscopy and resection) slides were retrieved, covering the period January 2009–September 2018. The slides of samples were histologically screened and diagnoses established. Cases in which the slides confirmed the histological diagnosis after screening the slides were selected. A total of 356 positively diagnosed samples were obtained with 237 of them eligible for this study. Data on demographics were also retrieved from the archived request forms. Tumors were classified based on the WHO (2010, 4th edition) histological classification of tumor of the colon and rectum. All cases with adequate demographical as well as clinical coupled with histological information were included in the study, and the data were analyzed using SPSS version 23 (IBM Statistics, Chicago, IL, USA) and the results were put in charts and tables. Approval was obtained from the Committee on Human Research, Publications and Ethics, KNUST School of Medicine and Dentistry, and the Research and Development Unit, Komfo Anokye Teaching Hospital.
| Results|| |
Age and sex distribution
Explorative analysis of 237 cancer cases revealed a mean age of 54.61 ± 1.14 years, with the modal age being 75 years. The age ranges from 5 to 91 years, with the age group of 50–59 years recording the most with 22.36%. Females were slightly more constituting 51.90%, whereas males constituted 48.10% in a male-to-female ratio of 1:1.09. CRC affected more males in the early ages (0–59) and more females in the latter ages (60–99) than males. A summary of results of age and sex distribution is shown in [Table 1].
Trend of colorectal cancer
CRC cases were nonstationary with an upward trend. CRC incidence was on the ascendency with a stepwise rise from 2009 to 2013, where it fell to the lowest point of 14 cases in 2014. There was, however, a steady rise again from 2016 to 2018. [Figure 1] depicts the trend of colorectal occurrence in the past 10 years.
Anatomic site distribution
Rectal cancers were predominant with 114 (48.10%) of cases compared to colonic cancers, which contributed 107 (45.57%) of cases and rectoanal cancers constituting 15 (6.33%) cases. [Figure 2] summarizes the results of anatomic distribution of all the CRC cases.
Histological classification of tumors
Adenocarcinoma was the most common cancer type constituting 209 (88.19%) cases and squamous cell carcinoma accounting for 21 (8.86%) of cases. There were 4 neuroendocrine cancers representing 1.69% of the cases and 2 non-Hodgkin's lymphomas contributing to 0.84% of the cases, with sarcoma contributing a single case (0.42%) of the total number of cancers.
[Figure 3] represents the distribution of the cancer types.
Grading of colorectal cancers
There were predominantly moderately differentiated carcinomas (121, 52.84%) compared to well (65, 28.38%) and poorly differentiated (43, 18.78%) carcinomas. High-grade cancers, therefore, constitute the majority (164, 71.62%) of the number of cases studied [Table 2] and [Figure 4].
|Table 2: Histological grading of colorectal cancer with site, gender, and age|
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|Figure 4: Photomicrographs of well-differentiated (a); moderately differentiated (b); and poorly differentiated (c) colorectal carcinoma|
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| Discussion|| |
CRC incidence is on the rise in recent times in sub-Saharan Africa as can be inferred from the results of the current study.
The data of our study suggested a younger age population compared to a report from Crawford reported in Philadelphia in 1991. Data from Crawford emphasized that less than 20% of CRCs occur under the age of 50 years, but in our survey, 35.4% of the patients were below 50 years of age, which agreed with the one reported by Pahlavan and Kanthan who recorded 34.5%. In contrast to data from Crawford, wherein there was a preponderance of male distribution (male versus female, 2:1) for rectal cancer, we found no significant differences between gender distribution (1:1.09), and this is backed up by the same research done by Pahlavan and Kanthan in their findings.
The study revealed that colorectal carcinoma incidence rises with age, with the modal age being 75 years, and most of the cancers were recorded by the age group being 50–59 years for all the cancers under review (rectal, colonic, and rectoanal), 22.36%, which was similar to a previous study by Duduyemi et al., who also recorded similar incidence for both colonic and rectal carcinomas. It was observed that CRCs affect more females (123 representing 52.12%) than males (114 representing 47.88%), with the modal age of females being 70–79 years (n = 27) and that of males being 50–59 years (n = 29). This indicated that the peak CRC incidence for males falls within the modal age group even though females recorded higher occurrence of CRCs overall. Females recorded the highest prevalence in the later years of life (beyond the modal age group). This should be attributable to the higher life expectancy for females in this country compared to males and the fact that physiologically, women tend to “behave” like men post menopause due to the depleting levels of key female hormones such as the luteinizing and follicle-stimulating hormones that regulate estrogen.,, The slight female predominance from our findings correlated with a data review from the Ibadan Cancer Registry which noted that between 1981 and 1995, CRCs were the sixth most common malignancies in males and fourth most common in females. However, our data contradicted the findings by Gomez et al., who reported a high male-to-female ratio in a UK population. Another study by Duduyemi et al. and a host of previous studies from both developed and developing countries also showed a slight male predominance for colorectal carcinoma, with a male-to-female ratio generally ranging from 1:1–2.5:1. Another inference could be made from our finding that CRC incidence is higher in men of younger age as compared to females, and this finding correlated with the findings of White et al.
CRC incidence is nonstationary and has been on the rise, albeit occasional drops, as seen in this study. CRC yearly frequency of occurrence in our study correlated well with those reported by Dakubo et al., who found that the incidence rate of 32.6 per 100,000.
Our findings also revealed that the highest distribution of CRC was found in the rectum (48.10%). The record of rectal cancer in our study correlated with the findings of Agyemang-Yeboah et al. who also recorded a similar distribution (48.87%). With the distribution in the colon, it was seen that right-sided (proximal) cases were higher (55.56%) compared to left-sided cases (44.44%). This is in agreement with findings from North American population,, and Duduyemi et al. in Nigeria who also recorded a higher incidence of right-sided colonic carcinoma as well as previous studies done in developing countries., However, findings done by Gomez et al. in the UK, a European population, contrast with our findings with a report of high prevalence of left-sided cancers as compared to right-sided colonic cancers. This assertion is supported by a previous studies done in developed countries which also showed more of left sided cancers.
The vast majority of CRCs from this study were adenocarcinomas constituting almost 90% of all the CRC cases studied. This supported the findings of Duduyemi et al. who recorded 81.1% of the adenocarcinoma cases and also consistent with the range (60%–89.5%) reported in the review of cases of colorectal carcinoma in Nigeria by Irabor and Adedeji.
The study also recorded 4 (1.69%) neuroendocrine cancers. These cancers are usually very rare and aggressive and have a reported incidence of between 0.1% and 3.9%,, which agreed with the findings from this study. Neuroendocrine tumors of the colon and rectum are usually poorly differentiated and have poor prognosis.,
The study shows that high-grade cancers were prevalent in our population and contributed to 71.7% of the cases, with moderately differentiated type accounting for a chunk of that, compared to low-grade cancers. This agreed with work done by Chandler and Houlston, who also reported a high case of high-grade cancers in their findings. This suggested that more aggressive treatment regimens are required for treatment. Patients are advised to present very early to the hospital for screening for early detection of possible precursor lesions or low-grade and less advanced tumors.
| Conclusion|| |
The study revealed that high-grade cancers were prevalent in this population compared to low-grade cancers, suggesting that more aggressive treatment regimens must be employed for treatment. It is advised that patients present very early at the clinic for screening for early detection of possible precursor lesions or low-grade and less advanced cancers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Haigis KM. Molecular Pathogenesis of Colorectal Cancer. 8th
ed. New York: Springer; 2013. p. 316.
Badoe EA. Malignant disease of gastrointestinal tract in Korle Bu Hospital, Accra, Ghana, 1956-65. West Afr Med J 1966;15:181-4.
Dakubo JC, Naaeder SB, Tettey Y, Gyasi RK. Colorectal carcinoma: An update of current trends in Accra. West Afr J Med 2010;29:178-83.
Duduyemi BM, Akang EE, Adegboyega PA, Thomas JO. Significance of DNA mismatch repair genes and microsatellite instability in colorectal carcinoma in Ibadan, Nigeria. Am J Med Biol Res 2013;145-8.
Kriegl L. In situ
analyses of molecular mechanisms of colorectal carcinogenesis. Pathologe 2013;34 Suppl 2:269-73.
Austoker J. Screening for colorectal cancer. BMJ 1994;309:382-6.
Simon K. Colorectal cancer development and advances in screening. Clin Interv Aging 2016;11:967-76.
Ahlquist T, Lind GE, Costa VL, Meling GI, Vatn M, Hoff GS, et al
. Gene methylation profiles of normal mucosa, and benign and malignant colorectal tumors identify early onset markers. Molecular Cancer 2008;7:94.
Beeker C, Kraft JM, Southwell BG, Jorgensen CM. Colorectal cancer screening in older men and women: Qualitative research findings and implications for intervention. J Community Health 2000;25:263-78.
Greiner KA, Born W, Nollen N, Ahluwalia JS. Knowledge and perceptions of colorectal cancer screening among urban African Americans. J Gen Intern Med 2005;20:977-83.
Chang L, Toner BB, Fukudo S, Guthrie E, Locke GR, Norton NJ, et al
. Gender, age, society, culture, and the patient's perspective in the functional gastrointestinal disorders. Gastroenterology 2006;130:1435-46.
Crawford JM. The gastrointestinal tract: Malignant tumors. In: Robbins SL, Cotran RS, Kumar V editors. Robbins Pathologic Basis of Disease. USA: WB Saunders Co Philadelphia; 1991. p. 897-902.
Pahlavan PS, Kanthan R. The epidemiology and clinical findings of colorectal cancer in Iran. J Gastrointestin Liver Dis 2006;15:15-9.
Duduyemi BM, Oluwasola AO, Akang EE, Thomas-Ogunniyi JO. A 16-year review of clinico-pathological pattern of colorectal carcinoma at University College Hospital, Ibadan. Niger J Gastroenterol Hepatol 2011;3:7-14.
Thomas JO. Cancer registration and diagnosis in Ibadan. Arch Ibadan Med 2000;1:5-6.
Mba CJ. Population ageing in Ghana and correlates of support availability. Gerontechnology 2007;6:102-11.
Prior JC, Hitchcock CL. The endocrinology of perimenopause: Need for a paradigm shift. Front Biosci (Schol Ed) 2011;3:474-86.
Ambler DR, Bieber EJ, Diamond MP. Sexual function in elderly women: A review of current literature. Rev Obstet Gynecol 2012;5:16-27.
Dalal PK, Agarwal M. Postmenopausal syndrome. Indian J Psychiatry 2015;57 Suppl 2:S222.
Gomez D, Dalal Z, Raw E, Roberts C, Lyndon PJ. Anatomical distribution of colorectal cancer over a 10 year period in a district general hospital: Is there a true “rightward shift”? Postgraduate Med J 2004;80:667-9.
Iliyasu Y, Ladipo JK, Akang EE, Adebamowo CA, Ajao OG, Aghadiuno PU. A twenty-year review of malignant colorectal neoplasms at University College Hospital, Ibadan, Nigeria. Dis Colon Rectum 1996;39:536-40.
White A, Ironmonger L, Steele RJC, Ormiston-Smith N, Crawford C, Seims A. A review of sex-related differences in colorectal cancer incidence, screening uptake, routes to diagnosis, cancer stage and survival in the UK. BMC Cancer 2018;18:906.
Agyemang-Yeboah F, Yorke J, Obirikorang C, Batu EN, Acheampong E, Frempong EA, et al
. Patterns and presentations of colorectal cancer at Komfo-Anokye teaching hospital Kumasi, Ghana. Pan Afr Med J 2017;28:121.
Axtell LM, Chiazze L Jr. Changing relative frequency of cancers of the colon and rectum in the United States. Cancer 1966;19:750-4.
Abrams JS, Reines HD. Increasing incidence of right-sided lesions in colorectal cancer. Am J Surg 1979;137:522-6.
Schub R, Steinheber FU. Rightward shift of colon cancer. A feature of the aging gut. J Clin Gastroenterol 1986;8:630-4.
Nomura AM, Kolonel LN, Hinds MW. Trends in the anatomical distribution of colorectal carcinoma in Hawaii, 1960-1978. Dig Dis Sci 1981;26:1116-20.
Meza R, Jeon J, Renehan AG, Luebeck EG. Colorectal cancer incidence trends in the United States and United kingdom: Evidence of right-to left-sided biological gradients with implications for screening. Cancer Res 2010;70:5419-29.
Malekzadeh R, Bishehsari F, Mahdavinia M, Ansari R. Epidemiology and molecular genetics of colorectal cancer in Iran: A review. Arch Iran Med 2009;12:161-9.
Irabor D, Adedeji OA. Colorectal cancer in Nigeria: 40 years on. A review. Eur J Cancer Care (Engl) 2009;18:110-5.
Saclarides TJ, Szeluga D, Staren ED. Neuroendocrine cancers of the colon and rectum. Results of a ten-year experience. Dis Colon Rectum 1994;37:635-42.
Saclarides TJ, Szeluga D, Staren ED. Neuroendocrine carcinomas of the colon and rectum. Results of a ten-year experience. Dis Colon Rectum 1994;37:635-42.
Chandler IP, Houlston RS. Interobserver agreement in grading of colorectal cancers-findings from a nationwide web-based survey of histopathologists. Histopathology 2008;52:494-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]