Table of Contents

Original Articles

Cervical Cancer Incidence and Trends among Nationals of the Gulf Cooperation Council States, 1998-2012 .....................................06Eman Alkhalawi, Amal Al-Madouj, Ali Al-Zahrani

Vitamin D Receptor and Role of Vitamin D Supplementation in Advanced Gallbladder Cancer: A Prospective Study from Northern India ..................................................................................................................................................13Sanchit Mittal, Akshay Anand, Aarthi Vijayashankar, Abhinay Arun Sonkar, Nuzhat Husain, Abhijit Chandra

Total Parenteral Nutrition in Middle Eastern Cancer Patients at End of Life: Is it Justified? ..................................................................20Elie Rassy, Tarek Assi, Ziad Bakouny, Rachel Ferkh, May Fakhoury, Hanine Elias, Aline Tohme, Fadi El Karak, Fadi Farhat,

Georges Chahine, Fadi Nasr, Marwan Ghosn, Joseph Kattan

Implementation and Evaluation of Phantomless Intensity Modulated Radiotherapy Delivery Verification Using FractionCHECK .......25Buchapudi Rekha Reddy, Manickam Ravikumar, Chandraraj Varatharaj, Nathan Childress, Tirupattur Rajendran Vivek

Gastric Adenocarcinoma in a Moroccan Population: First Report on Survival Data................................................................................35N. Lahmidani, S. Miry, H. Abid, M. El Yousfi, D. Benajah , A. Ibrahimi, M. El Abkari, A. Najdi

Trends and Patterns of Primary Hepatic Carcinoma in Saudi Arabia .......................................................................................................40Fazal Hussain, Shazia Anjum, Njoud Alrshoud, Asif Mehmood, Shouki Bazarbashi, Aneela N. Hussain, Naeem Chaudhri

Trend and Characteristics of Endometrial Cancer in Lagos, Nigeria ........................................................................................................51Adeyemi Adebola Okunowo, Morakinyo Abiodun Alakaloko, Ephraim Okwudiri Ohazurike, Kehinde Sharafadeen Okunade, Rose Ihuoma Anorlu

Open Nephron Sparing Surgery for T1a Renal Tumors: Clinical Experience in an Emerging Country ....................................................59A. Fetahu, Xh. Çuni, I. Haxhiu, R. Dervishi, L. Ҫuni, S. Manxhuka, L. Shahini

Consumption Coagulopathy in Paediatric Solid Tumours: A Retrospective Analysis and Review of Literature ....................................65Yamini Krishnan, Smitha B, Sreedharan P. S.

Case Reports

Clinicoradiological Discrepancy in Multisystem Langerhans Cell Histiocytosis with Central Nervous System Involvement ...............71Hussein Algahtani, Bader Shirah, Mohammed Bajunaid, Ahmad Subahi, Hatim Al-Maghraby

Primary Ewing’s Sarcoma of Maxillary sinus: A Case Report ..................................................................................................................77Chauhan Richa, Trivedi Vinita, Kumari Nishi, Rani Rita, Singh Usha

A Diagnostic Dilemma of Sinonasal T Cell Lymphoma: Report of A Unique Case and Literature Review ..............................................82Selvamalar V, S.P. Thamby, Mohammad Ahmed Issa Al-Hatamleh, Rohimah Mohamud, Baharudin Abdullah

Conference Highlights/Scientific Contributions

• BookReview-IARCHandbooksonCancerPrevention,Volume17ColorectalCancerScreening ...................................................89

• NewsNotes ............................................................................................................................................................................................91

• ScientificeventsintheGCCandtheArabWorldfor2019 ..................................................................................................................95

52

Corresponding author: Dr. Okunowo Adeyemi Adebola, MBBS, Consultant, Department of Obstetrics &

Gynecology, College of Medicine, University of Lagos (CMUL) / Lagos University Teaching Hospital (LUTH),

PMB 12003, Lagos, Nigeria. Tel.: +234 803 561 1000; Email address: yemiokunowo@gmail.com

IntroductionCancer of the corpus uteri is the 6th most common

cancer in females and the 2nd most common female genital cancer worldwide.(1) Endometrial cancer arises from the endometrial lining of the uterus and it is the most common type of cancer of the corpus uteri, accounting for more than 95% of the uterine cancers.(2) It is the leading female genital tract malignancy in developed and high income countries with highest incidence rates seen in North America and Europe.(2,3) It is less common in developing countries such as Nigeria, where it is the third most common female genital tract malignancy, after cervical cancer and ovarian cancer.(4) Globally, the lifetime risk of a woman developing endometrial cancer by 75 years of age is 1%.(5)

Abstract

Background:Endometrial cancer occupies the 2nd or 3rd position in the hierarchy of common gynecological cancers in many low- and middle-income countries. However, little is known about its epidemiology, trend and characteristics in many African countries including Nigeria. The study aims to describe the trend in the prevalence, risk factors, symptomatology and types of endometrial cancers in Lagos, Nigeria.

Materials and Methods: A five-year descriptive retrospective study of the case records of women diagnosed with endometrial cancer at the Lagos University Teaching Hospital from 1 January 2008 to 31 December 2012. Relevant information was retrieved and data analysis was done using SPSS version 20.0.

Results: Endometrial cancer was the third most common gynecological malignancy (16.0%) with a rise in its prevalence rate, from 0.9% in 2008 to 1.4% in

2012. It occurred commonly in postmenopausal (81.8%) and parous women with mean age of 62.2 ± 5.5years, median parity of 4, and mean BMI of 32.3 ± 6.4kg/m2. Most women presented with postmenopausal bleeding (88.6%), vaginal discharge (36.4%), usually in stage I (45.5%) and III (22.7%) disease. The most common risk factors for endometrial cancer were advanced age (90.9%) and overweight/obesity (90.9%). Type 1 endometrial cancers accounted for 68.2% of cases, while serous papillary adenocarcinoma was the most common type 2 endometrial cancer.

Conclusion: There is a rising trend in the prevalence of endometrial cancer in Lagos, Nigeria, with type 1 endometrial cancer being the most common type. Most women present in the postmenopausal period with early stage disease.

Keywords: Endometrial cancer; Trend; Characteristics; Lagos; Nigeria

Original Article

Trend and Characteristics of Endometrial Cancer in Lagos, Nigeria

Adeyemi Adebola Okunowo1,2, Morakinyo Abiodun Alakaloko2, Ephraim Okwudiri Ohazurike2, Kehinde Sharafadeen Okunade1,2, Rose Ihuoma Anorlu1,2

1Department of Obstetrics & Gynecology, College of Medicine, University of Lagos/Lagos University Teaching Hospital, Lagos, Nigeria.

2Department of Obstetrics & Gynecology, Lagos University Teaching Hospital, Lagos, Nigeria.

According to GLOBOCAN statistics, there has been a steady increase in the global incidence of cancer of the corpus uteri from incident cases of 287,000 in year 2008(6) to 320,000 in year 2012(5) and 382,069 in year 2018.(1) Similarly, the incidence of endometrial cancer has been reported to be increasing in developed nations, which is said to be 10 times higher than that of developing

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G. J. O. Issue 31, 2019

nations. (2,3) In the United states of America, endometrial cancer is estimated to increase by 1-2% annually.(7) This increase has been attributed to increased life expectancy, obesity and metabolic syndrome in the population.(3, 8-10) Little is however known about the trend and incidence of endometrial cancer in many low and middle income countries, like Nigeria. This is probably because most of the available studies on gynecological cancers in Nigeria focus on either cervical cancer, which is the most prevalent gynecological malignancy or on ovarian cancer which is the most lethal gynecological cancer. In addition, the lack of efficient and functioning population cancer registries has not helped matters.

Endometrial cancer commonly presents in the later years of life during the postmenopausal period with abnormal uterine bleeding.(11) As a result, it is a common cause of postmenopausal bleeding in women even though only 20% of postmenopausal bleeding is due to malignancy. (11) It usually presents in the 6th and 7th decade of life,(3) with a mean age of 60 years in UK(11) and USA,(12) 56 years in Ghana,(13) 59 years in Gabon(14) and 56 years in Nigeria.(15) Despite its frequent occurrence during the menopause, approximately 15% of the disease still occurs in premenopausal women with 5% occurring before the age of 40 years(3,12,16) Majority of the disease are diagnosed at early stage with a resultant good prognosis and higher chances of survival.(3,12,17) These are type 1 endometrial cancers which are of endometrioid histological subtype and are oestrogen dependent, occurring as a result of chronic unopposed oestrogen stimulation of the endometrium. On the other hand, type 2 endometrial cancers are less common, more aggressive, and usually detected at late stage of the disease with poor outcome. They are non-oestrogen dependent tumours; occur in older women with background endometrial atrophy and are usually of non-endometrioid histological types such as serous papillary adenocarcinomas, clear cell adenocarcinomas, mucinuous adenocarcinomas, etc. (2,3,11,12)

The exact aetiology of endometrial cancer is still unknown, but several factors have been identified as predisposing risk factors to endometrial cancers. These factors are largely oestrogen related, may be endogenous or exogenous and are usually associated with chronic unopposed oestrogen stimulation. The endogenous risk factors are increasing age, obesity, physical inactivity, early menarche, late menopause, low parity or nulliparity, infertility and polycystic ovarian syndrome. Others include family history of endometrial cancer, personal and family history of breast cancer, Lynch syndrome (hereditary non polyposis colorectal cancer), oestrogen secreting tumours, diabetes mellitus and hypertension.(2,11,12,18)

Exogenous factors include unopposed oestrogen alone

hormone therapy, tamoxifen therapy, dietary factors and previous exposure to radiotherapy.(2,11,12,18) On the contrary, high parity, cigarette smoking, use of combined oral contraceptive pills, depot medroxyprogesterone acetate or progesterone producing intrauterine devices have been found to be protective. (2,11,12,18)

There are few indexed studies on endometrial cancer in our environment and data from these studies suggest that endometrial cancer accounts for 5.1 – 10.1% (15,19,20) of gynaecological cancers in Nigeria. There is a huge gap in knowledge on the burden, epidemiology and characteristics of endometrial cancer in Lagos, Nigeria and Africa at large. The study aims to describe the trend in the prevalence, risk factors, symptomatology and types of endometrial cancer in Lagos, Nigeria. This will provide vital scientific information on the burden and epidemiology of the disease in our environment and serve as a platform for further scientific research on the subject matter.

Materials and methods

Study design and site of study

The study was a retrospective descriptive study conducted at the Lagos University Teaching Hospital (LUTH), Lagos, Nigeria. LUTH is one of largest federal tertiary hospitals in Nigeria and it is located in the south-western part of Nigeria. It is the largest hospital in Lagos with a 761-bed capacity and it is the main referral hospital for all government and private hospitals in Lagos state and its environs. It is the main referral centre for all cancer related cases, irrespective of the stage of the disease. The department of Obstetrics and Gynaecology of LUTH has a vibrant Gynae-oncology unit that runs a dedicated Gynae-oncology outpatient clinic every week; cytology and colposcopy clinics on daily basis during the week. It also has a dedicated lying-in-ward for the management of women with gynaecological malignancy. It offers preventive, therapeutic and palliative care to cancer patients.

Study population

The study participants were women with histological diagnosis of endometrial cancer who received care at LUTH between 1 January 2008 and 31 December 2012. Women without histological diagnosis and / or whose data were incomplete were excluded from the study.

Data collection

The study was conducted after obtaining ethical approval from the Health Research and Ethics Committee of LUTH (approval number ADM/DCST/HREC/APP/2901). The records at the Gynaecological out-patient clinic, gynaecological lying-in wards, gynaecological Accident

54

Endometrial cancer in Lagos, Nigeria, Adeyemi Adebola Okunowo, et. al.

cases of endometrial cancers. An average of 12 cases were diagnosed per annum.

Endometrial cancers accounted for 16.0% of all the gynecological malignancies managed during the study period. It was the third most common gynecological cancer after cervical cancer (42.8%) and ovarian cancer (33.1%) as shown in Table 1.

Table 2 shows the socio-demographic, menstrual and BMI characteristics of women with endometrial cancer. The mean age of women with endometrial cancer was 62.2 ± 5.5 years (range 39 – 80 years). More than 50% of women were between the age group of 60-69 years, and more than 90% of them were above the age of 49 years. All the women were parous with median parity of 4 (range 1 - 6). All the women with endometrial cancer had formal education, with 45.5% of them having tertiary level of education. Majority, 36 (81.8%) were postmenopausal. The mean age at menopause was 52.4 ± 3.6 years (range

& Emergency unit, operating theatre and Molecular and pathology departments were retrieved and cases diagnosed with endometrial cancer during the study period were identified. The case records of these women were retrieved from the medical record department for data collection. Using a well-structured study data form, data on the women’s socio-demographic characteristics, body mass index, reproductive and menstrual history were retrieved. Information regarding their medical history, use of oral contraceptive pills, symptoms at presentation and histopathology results were also retrieved. The total number of cases with gynaecological conditions and gynaecological cancers managed in the hospital during the study period was also obtained from the hospital’s medical records.

Data analysis

Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 20.0, IBM Corp. Armonk, NY, USA. Variables were expressed using frequency tables and descriptive statistics such as mean, median, standard deviation and percentage.

ResultsA total of 5,722 gynaecological cases were managed at

the hospital during the study period. This ranges between 1,104 and 1,178 cases per annum with an average of 1,144 cases per annum. Among these cases, 381 women (6.7%) had gynaecological cancers while 5280 (92.3%) were managed for benign gynaecological conditions. The total number and prevalence of gynaecological cancer cases managed per annum ranged between 63 (5.6%) and 85 (7.2%), with a mean of 76 (8.0%) cases per annum and a five year prevalence rate of 6.7%. A total of 61 women were diagnosed with endometrial cancer during the study period, accounting for a five-year prevalence rate of 1.1%. There was a rising trend in the prevalence of the disease during the study period with an increase in the annual prevalence rate, from 0.9% in 2008 to 1.4% in 2012 as displayed in Figure 1. Out of the 61 cases of endometrial cancer, only 44 case notes (72.1%) with complete data were retrieved and used for further data analysis. The data was said to be incomplete if the case note could not be retrieved or if a portion of the information required for data analysis is absent or missing in the case note.

Figure 2 shows the trend in the frequency of endometrial cancer cases diagnosed during the study period. The highest number of cases (16) was diagnosed in the year 2012 which accounted for 26.2% of the total cases managed, while the least number of cases (9) was managed in year 2009, which accounted for 14.8% of all

Figure 1: Prevalence of endometrial and gynecological cancers in Lagos, Nigeria

Figure 2: Trend in the distribution of endometrial cancer cases during the study period.

0.9% 0.8% 1.1% 1.1%

1.4% 1.1%

5.6%

6.6%

7.2% 7.1% 6.8% 6.7%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

Prevalence rate

Year

Prevalence of endometrial cancers during the study period Prevalence of Gynaecological cancers during the study period

2008

2009

2010

2011

2012

2008

-2012

0

2

4

6

8

10

12

14

16

18

2008 2009 2010 2011 2012

Endometrial cancer

Tota

l num

ber o

f cas

es o

f end

omet

rial c

ance

rs s

een

per a

nnum

55

G. J. O. Issue 31, 2019

48 – 56 years) and the mean duration of menopause was 6.2 ± 4.8 years (range 1 – 18 years). Majority, 22 (50.0%) of the women were overweight and 18 (40.9%) were obese. The mean BMI was 32.3 ± 6.4 kg/m2 and ranged between 18.3 and 37.2 kg/m2.

Table 3 illustrates the risk factors identified in the women with endometrial cancer. The most frequent risk factors identified were advanced age (≥ 55 years) in about 90.9% of cases, being overweight / obesity (90.0%), presence of hypertension (25.0%) and late onset of menopause (≥ 55 years) in 15.9% of the cases.

Table 4 shows the symptoms and stages of the disease at presentation. The symptoms associated with endometrial cancer at the time of presentation were abnormal vaginal bleeding (commonly in the postmenopausal period) in 88.6%, vaginal discharge (36.4%), weight loss (31.8%), abdominal pain (18.2%) and abdominal swelling (18.2%). Two-third (66.0%) of the women with endometrial cancer presented at early stage of the disease (stage 1 & 2) while the remaining one-third (34.0%) presented at advanced stage disease (stage 3 & 4). Most patients presented with stage 1 disease (45.5%), followed by stage 3 disease (22.7%).

The most common histological variant of endometrial cancer observed in the study was endometroid adenocarcinoma (68.2%), followed by serous papillary adenocarcinoma (20.5%), while the least common

histological subtypes were squamous cell carcinoma, mixed carcinoma and undifferentiated endometrial carcinoma (2.3% respectively). Type 1 endometrial cancer accounted for 68.2% of all the endometrial cancers while the type 2 accounted for 31.8% of the cancers as shown in Table 6. Most of the type 2 cancers were serous papillary adenocarcinomas (64.3%), followed by clear cell adenocarcinoma (14.3%). Majority, 78.6% (11) of women with type 2 endometrial cancer presented with advanced stage disease, while 73.3% (22) of women with type 1 endometrial cancer had early stage disease as seen in Table 5.

DiscussionGynecological cancers accounted for 6.7% of all the

gynecological cases seen in the hospital during the five-year study period. The rate is similar to that observed in Maiduguri (7.0%)(21) but varies across the country, with lower rates observed in Enugu (3.6%)(15) and Ilorin (4.6%)(22) and higher rates recorded in Ebonyi (8.4%)(20) and Kano (10.7%).(23) Endometrial cancer was the 3rd most common gynecological cancer seen among women in Lagos, Nigeria, after cervical cancer and ovarian cancer. This is similar to findings observed in other studies in Nigeria,(15,20,23) and in other developing countries,(13, 24-26) but contrary to those reported from high income countries, where it ranks as the most common gynaecological cancer.(2,11,18) Endometrial cancer accounts for 16% of

Gynecological cancers

Year Total

2008 N = 1,134

n (%)

2009 N = 1,104

n (%)

2010 N = 1,178

n (%)

2011 N = 1,155

n (%)

2012 N = 1,151

n (%)

N = 5,722

n (%)

All Gynecological cancers

63 (5.6) 73 (6.6) 85 (7.2) 82 (7.1) 78 (6.8) 381 (6.7)

Endometrial cancers

10 (0.9) 9 (0.8) 13 (1.1) 13 (1.1) 16 (1.4) 61 (1.1)

Gynecological cancers

Year Total

2008 n = 63

2009 n = 73

2010 n = 85

2011 n = 82

2012 n = 78

N = 381

Endometrial cancer

10 (15.9) 9 (12.2) 13 (15.3) 13 (15.9) 16 (20.5) 61 (16.0)

Cervical cancer 23 (36.5) 28 (38.4) 42 (49.4) 34 (41.5) 36 (46.2) 163 (42.8)

Ovarian cancer 22 (34.9) 28 (38.4) 26 (30.6) 28 (34.1) 22 (28.2) 126 (33.1)

Others* 8 (12.7) 8 (11.0) 4 (4.7) 7 (8.5) 4 (5.1) 31 (8.1)

Total 63 (100.0) 73 (100.0) 85 (100.0) 82 (100.0) 78 (100.0) 381 (100.0)

Table 1: Distribution and trend in endometrial cancers and gynecological cancers during the study period*Others include Sarcomas, vulvar cancers, vagina cancers and choriocarcinoma.

56

Endometrial cancer in Lagos, Nigeria, Adeyemi Adebola Okunowo, et. al.

Identified risk factors* Frequency ( n = 44) Percentage (%)

Advance age 40 90.9

Overweight/ Obesity 40 90.9

Hypertension 11 25.0

Late menopause 7 15.9

Diabetes mellitus 6 13.6

Family history of endometrial cancer

4 9.1

Others¥ - -

Symptoms at presentation*

Frequency (n = 44) Percentage (%)

Abnormal vagina bleeding

39 88.6

Vagina discharge 16 36.4

Weight loss 14 31.8

Abdominal pains.

Abdominal swelling

8

8

18.2

18.2

Stage of disease Frequency (n = 44) Percentage (%)

Stage 1 20 45.5

Stage 2 9 20.5

Stage 3 10 22.7

Stage 4 5 11.3

Total 44 100.0

Table3:Identifiedriskfactorsforendometrialcancer.*Multiple responses¥Others include nulliparity, early menarche, infertility, anovulation, polycystic ovarian syndrome (PCOS), unopposed estrogen therapy, use of tamoxifen, personal and family history of breast cancer, family history of colorectal cancer and presence of oestrogen secreting tumour.

Table 4: Associated symptoms and stage of endometrial cancer at presentation.

*Multiple responses observed

Table 2: Socio-demographic, menstrual and body mass index (BMI) characteristics of women with endometrial cancer.

Variables Frequency (n=44)

Percentage (%)

Age (years)

< 40 1 2.2

40-49 3 6.8

50-59 5 11.4

60-69 23 52.3

>70 12 27.3

Total 44 100.0

Educational status

Primary 12 27.3

Secondary 12 27.3

Tertiary 20 45.4

Total 44 100.0

Parity

0 - -

1 8 18.2

2 4 9.1

3 4 9.1

4 12 27.2

≥5 16 36.4

Total 44 100.0

Menopausal status Frequency (n=44) Percentage (%)

Premenopausal 8 18.2

Postmenopausal 36 81.8

Total 44 100.0

Duration of menopause (years)

Frequency (n=36) Percentage (%)

1 – 5 24 66.7

6 – 10 5 13.9

11 – 15 3 8.3

16 – 20 4 11.1

21 – 25 - -

Total 36 100.0

BodyMassIndex(kg/m2) Frequency (44) Percentage (%)

Underweight (<18.5) 1 2.3

Normal (18.5 – 24.9) 3 6.8

Overweight (25.0 – 29.9) 22 50.0

Obesity (≥ 30.0) 18 40.9

Total 44 100.0

all the gynecological cancers in our study. This is higher than the figures reported in other parts of the country such as Ibadan (3.1%),(27) Enugu (4.1 - 8.1%),(15,28) Zaria (5.1%),(19) Maiduguri (8.8%),(21) Ebonyi (10.1%)(20) and Kano (11.25%). (23) Our study further showed a rise in the prevalence and burden of endometrial cancer, as suggested by the rising trend in the annual prevalence and frequency of the disease. This rise in the trend and burden of the disease demands prompt public health attention before it reaches epidemic proportions bearing in mind that there is no reliable and acceptable screening strategy.

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G. J. O. Issue 31, 2019

Advance aged (≥ 55 years), overweight /obesity, hypertension, late menopause, diabetes mellitus and family history of endometrial cancer were the identified risk factors for endometrial cancer in our study. Others such as nulliparity, early menarche, infertility, anovulation, polycystic ovarian syndrome (PCOS), unopposed oestrogen therapy, use of tamoxifen, personal and family history of breast cancer, family history of colorectal cancer and presence of oestrogen secreting tumour were conspicuously absent in women with endometrial cancer in our study. Though these factors have been well documented in the literature (2,3,11,12,18,29) as risk factors for endometrial cancer, the strength of their association with the disease varies from one another. Studies have shown that overweight and obesity have a strong association with endometrial cancer. (3,12,30,31) It is therefore not surprising that overweight and obesity were the most common risk factors for endometrial cancer in our study with more than 90% of the women being overweight or obese. Similarly, more than 90% of the women with endometrial cancer were ≥ 50 years old, with mean age of 62.2 ± 5.5 years. This is consistent with finding in a study that showed that majority of the cases of endometrial cancer are diagnosed after 50 years of age.(12) The mean age observed in our study was similar to that observed in US,(12,18) UK(11) and

Kano, Nigeria(23) but higher than that observed in other parts of Nigeria such as Zaria (54 years),(19) Enugu (56 years)(15) and in other countries such as Ghana (56 years),(13) Gabon (58.8 years),(14) and India (59 years).(32) Similar to the findings in our study, endometrial cancer is a disease that occurs commonly in the post-menopausal period. Approximately eight out of every ten women with endometrial cancer in our study were post-menopausal, with only 18% of the women being pre-menopausal. This is congruent to findings in other studies where approximately 20% of women diagnosed with the disease were pre-menopausal, (3,14,18,32) but however contrary to findings in Zaria, Nigeria where 33% of the women were pre-menopausal. (19)

Parity is a well-known factor that significantly influences the risk of endometrial cancer. The presence of nulliparity has been well documented in the literature as a major risk factor for the development of endometrial cancer and it is said to be associated with a 3 fold increase in the risk of the disease.(2) Likewise, the chances of parous women developing endometrial cancer have been shown to be up to 40% lower compared with nulliparous women. (31,33) This is not consistent with the findings in our study where majority of the women with endometrial cancer were grand multiparous women and none was nulliparous. Similar pattern of high parity has been observed in several other studies in Nigeria, (15,19,20,22,28) and Ghana. (13) This is in contrast to findings in high income countries where women with endometrial cancer are predominantly nulliparous, with multiparity being a protective factor. (2,3,11,18,31,33)

The symptoms of endometrial cancer seen in this study are consistent with those documented in the literature (3,11,12,15,19,27) The most common symptoms reported by women with endometrial cancer in our study are abnormal vaginal bleeding occurring mainly in the post-menopausal period and vaginal discharge. This pattern of presentation is comparable to findings in other studies. (3,12,18,25)

Congruent to findings in our study, most women with endometrial cancer commonly present in the early stage of the disease.(3,11-14,18,19) However, the proportion of women with early stage disease (stage 1 & 2) was lower in our study compared with findings in developed countries(3,18) Less than half (45.5%) of all the cases of endometrial cancer were stage 1 disease compared to 72% - 80% reported in developed countries.(11,18) This may probably be due to better health awareness and good health seeking behavior among women in the developed nations which may prompt early presentation to the hospital. In addition, the fact that black women are known to have a relatively more aggressive type of endometrial cancer compared

Table 5: Histological subtypes and classification of endometrial cancer.

Histological type Frequency (n = 44)

Percentage (%)

Endometroid adenocarcinoma

30 68.2

Serous papillary adenocarcinoma

9 20.5

Clear cell adenocarcinoma

2 4.4

Squamous cell carcinoma

1 2.3

Mixed carcinoma 1 2.3

Undifferentiated carcinoma

1 2.3

Total 44 100.0

Classification Frequency (n = 44)

Percentage (%)

Type 1 Endometrial cancer

30 68.2

Type 2 Endometrial cancer

14 31.8

Total 44 100.0

58

Endometrial cancer in Lagos, Nigeria, Adeyemi Adebola Okunowo, et. al.

to non-black women could also explain the relatively lower proportion of early stage disease observed in our study. (12,34,35)

Endometroid adenocarcinoma is known to be the most common histological type of endometrial cancer among women.(2,18) This histological subtype is responsible for 68.2% of the endometrial cancers in Lagos, Nigeria compared to 80% observed in India(32) and up to 90% reported in the developed nations.(11,34) This is in keeping with the report of low prevalence of endometroid endometrial cancer and higher prevalence of non – endometroid endometrial cancers among black women.(18,35,36)Our study showed that type 2 endometrial cancers accounted for approximately one–third (31.8%) of all the endometrial cancers in Lagos, Nigeria. This is in contrast to findings in high income countries where type 2 endometrial cancers represent only 6% - 20% of all endometrial cancers.(2,34,37) The most common forms of type 2 endometrial cancers are usually serous papillary and clear cell adenocarcinomas,(2,11,18) and this is consistent with findings in our study; with serous papillary adenocarcinoma accounting for almost two-third of all the type 2 cancers. These cancers are very aggressive, metastasize early, usually present in higher stage of disease and have poor survival rate. (3,11,37) It is therefore not surprising that 8 out of every 10 women with type 2 endometrial cancer in our study presented with advanced stage disease.

One of the limitations of the study is the inability to retrieve all the case notes for full data analysis. This is a common limitation of retrospective studies in our environment which is not within the control of the researcher. The is a hospital-based study and as a result may not reflect the true burden of endometrial cancer in the population. However, it gives a relatively good representation of the disease condition in the environment, as the hospital serves as the main referral centre for all cancer related cases in Lagos state, irrespective of the stage of the diseases. Furthermore, the study, being a descriptive study did not examine the factors associated with endometrial cancer. Further studies will be required to investigate this research area.

ConclusionLagos, Nigeria has a relatively high burden of

endometrial cancer in the country, with a rising trend in the prevalence of the disease. The disease is common among elderly women, who are overweight or obese, post-menopausal and grand multiparous; with majority presenting with postmenopausal bleeding in early stage of the disease. Type 1 endometrial cancer with endometroid adenocarcinoma histological subtype accounts for two-

third of all endometrial cancer cases while serous papillary adenocarcinoma accounts for approximately two-third of all the type 2 endometrial cancers.

There is need to create public awareness about the risk factors of the disease due to the rising trend of the disease in our environment. More research on endometrial cancer is also needed in order to fully understand the unique epidemiology of the disease in the region. This will assist in curtailing the rising trend of the disease, bearing in mind the absence of any reliable and acceptable screening strategies.

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