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East and Central African Journal of Surgery, Vol. 13, No. 1, March-April 2008, pp. 66-72 Childhood Bone and Soft Tissue Tumours: A review of 43 Treated at two University Teaching Hospitals in Rwanda (CHUB and CHUK) in RWANDA M. Makanga, J.P. Majyambere, I. Kakande Department of Surgery,
Butare Teaching Hospital. National University of Rwanda. *Presented at The Association of Surgeons of East Africa Conference at Mombasa December 2007 Code Number: js08011 Back
ground: Cancer represents one of the major
causes of death in the world estimated at 1 out of 10 deaths. Globally, 160,000
children are diagnosed to have cancer each year. In the developing countries,
one child out of two with cancer will die because of this disease mostly
because they present with advanced disease or due to limited resources for
proper management1,2. This study was aimed at determining the
prevalence, the histological types and the management outcome of childhood bone
and soft tissue tumours in
Rwanda Introduction Although, Cancer is rare in children aged less than 15 years1, it represents a main concern for parents, families, and health professionals to care for children affected with cancer. The problems confronting Paediatric oncology in Africa are many. They are linked to:
These lead to low survival and cure rates: The patients survival at 5 years is ≤ 50% in developing world whereas cure rates in developed countries represent 75-80 %1. In Rwanda there is no possibility of effective, efficient management of cancer after diagnosis is confirmed for lack of an established oncology Department. A review of literature shows that no specific study on cancer in children has bee reported from Rwanda. It was with such background that a study was undertaken on childhood cancers in Butare university Teaching Hospital. Methods A retrospective descriptive study of 43 histologically confirmed cases of bone and soft tissue tumours in children was done in the Surgery Departments of University Teaching Hospitals (CHUB and CHUK). The period of study was 6 years from January 2001 to December 2006. Only children aged 16 years or below were included in the study. Data was obtained from patients clinical files, pathology register and theatre registers. Information obtained was recorded using a special questionnaire; Data obtained was analyzed using Epidata 2.1b, SPSS 11.5 computer programs. Statistic test Pearson Chi-carré (P) was considered significant if P value was less than or equal to 0.05. Results During the 6 years under review, bone and soft tissue tumours accounted for 2% in CHUB and 1.8% in CHUK of paediatric surgery admissions. A total of 43 children we admitted to the two University teaching hospitals at Butare (CHUB) and Kigali (CHUK). The majority of 58.1% (n=25) were admitted in CHUB (Table 1). Table 2 shows the age distribution. The 10 to 16 age group years contributed 31 (72%0 0f all cases. Males were 28). The male to female sex ratio was 1.9: 1. Twenty four patients came from Southern province in which CHUB is located. The time interval between the onset of symptoms and consultation to the university teaching hospitals ranged between 2 and 36 months. Table2: Age group distribution
Table3: Patients clinical signs
Table 4. Distribution of Affected Long Bones
Table 5. Distribution of Malignant Tumours
Table 6. Distribution of benign tumours
A significant number (30.2%) consulted between 6 to 12 months. The average delay was 12 months. Clinical signs were mostly swelling in 100% (n=43) and pain in 67.4% (n=29). History of local trauma was elicited from 6 patients having malignant bone tumours (26%) with P=0.003. Bone tumours were 33 (76;7%) and soft tissue tumours were 10 (23). The long bones were affected in 28 (65.1% ) of the children with the lower limbs bones (Femur and tibia) being more involved than the upper limb (Table 4). Soft tissue tumours were mostly located on the shoulder (n=3), buttocks, arm and thigh (n = 2 each) and forearm (1 case). All patients had tumour biopsy. The bone X-rays were done in 34 (79%), chest X-ray in 26 (69.7%) and ultrasonography in 9 (20.9%). Table 7. Distribution of Bone Tumours
Of the 32 patients whose HIV status was known, only 2 (4.6) were positive. Five (19.2%) of the s6 patients who had chest xrays already had pulmonary metastases on their admission. Malignant tumours were diagnosed in 26 (60%) (Table 5). Of these, osteosarcomas were 14 (54%). Osteochondromas were the commonest benign tumours (Table 6) In our study, most of bone tumours were malignant 69.7% (n=23).Osteosarcoma was the most frequent bone tumour 42.3% (n=14). Among malignant bone tumours, femur was the most affected bone in 50% (n=10), followed by tibia in 40% (n=8) and humerus in 10% (n=10). There was a significant relation between pain and bone malignant tumours. All patients having bone malignant tumours had pain (P=0.000). Among patients having bone and soft tissue tumours, the age group from 10 to16 years was the most affected 72% (n=31). Osteosarcoma was the most common tumour in this age group accounting for 12 {38.7%) of cases. Twenty (46.5%) of the patients had surgical treatment that included tumour excision for benign tumours; limb amputation in 13 (30.2%) or disarticulation in 7 (16.3%) of the patients with malignant tumours. Three patients (7%) in bad general conditions with metastatic malignant tumours had a palliative treatment (analgesics, oxygen). None of the patients received chemotherapy or radiotherapy. On discharge 30 (69.7%) of the patients had clinical improvement. There was a significant relation between the histological type of the tumour and death (P=0.042). Six patients all with malignancies died that is 14% of all cases or 23% of all malignancies. Four deaths had Osteosarcoma, one had Ewings tumour and one had a chondrosarcoma. The presence of distance disease extension was the determinant factor to patient death (P=0.001). All the 6 deceased patients had pulmonary metastases, 3 of them had also bone extensions. The length stay patients in hospital varied from 2 to 26 days. The average was 10 days for benign tumours and 16 days for malignant tumours. There was a significant relation between the long stay in hospital and the malignancy of the tumour (P=0,031).Patients follow up was difficult. only 11 patients (35.5%); 8 patients (25,8%) operated for benign tumours, 3 patients (9.7%) with malignant tumours, came back for review after discharge. Two patients had a referral for chemotherapy and radiotherapy abroad. The majority of patients were lost to follow up. It was therefore difficult to know if they were still alive or had died. Table 8. Age Group Distribution and Histological Types
Table 9. Patient Treatment Distribution
Discussion According to the literature review the age group from 10 to 16 years s the most affected3,4,5,6. The males are predominantly affected by bone and soft tissue tumours7,8,9,10. There is no clear explanation for the sex differences. Most of our patients had a long delay prior to coming for consultation. This is in contrast to reports from the more developed countries like USA11, Australia7, Serbia5 and Poland9,where patients consult earlier. The long delay among our patients may be explained by the low socio-economical of the affected families. For lack of funds for hospital fee and transport, many of our patients commonly choose to first consult traditional healers. The clinical features of malignant tumours in our study were similar to findings reported by Cleeman11 in USA, Bacci6 in Italy, Tanz7 in Australia, and Brown12 in Nigeria, on the bone predominant localisation of malignant tumours. The limited investigative capacities in our institutions characterized by lack of appropriate imaging facilities insufficient reagents for laboratory tests compounded by shortage of trained manpower are major contributory factors to delayed diagnosis and treatment. Our poor investigations are in contrast to what exists in other centres where CT scanner is used to guide biopsy and tom densitometry, bone scintigraphy and biochemical tests are performed13,14,15,16,17. The histological types found in our series and their predominance are similar to what other studies by Settakorn18 in Thailand, Cleeman11 in USA, Bacci6 in Italy, Brown12 in Nigeria, and Blakwell19 in Australia reported. Management of malignant tumours is poor and almost confined to surgical treatment whenever possible and palliative care for the advanced disease. Absence of an established oncology department in our two top referral centres is a major obstacle to proper management of our cancer patients. In other centres adjuvant chemotherapy and radiotherapy significantly affect the outcome of cancer treatment12,11,7,6. There an urgent need to improve the diagnostic facilities, to train more pathologists, oncologist and specialized personnel in palliative care. An Oncology Department should be established in Rwanda and a multidisciplinary approach to management of cancer patients (involving surgeons, oncologists, radiotherapists, palliative care specialists and nurses, counsellors and psychologists etc) should be promoted. Lastly, a National Cancer Registry should be set up.. All these measures will go a long way in improving the outcome of management of cancer patients in Rwanda. References
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