HISTOPATHOLOGICAL EVALUATION OF GYNAECOLOGICAL BIOPSIES FROM PATIENTS ATTENDING THE BRAITHWAITE MEMOEIAL SPECIALIST HOSPITAL RIVER STATE

1.1Background of Study

Hippocrates who lived from 460 – 370 BC described different types of biopsy, referring to cancer as carcinos meaning crab or crayfish in Greek (The History of Cancer, 2014), the name which is generated from the appearance of the cut surface of a solid malignant tumour (Moss, 1989). The oldest description of biopsies and their treatment is traceable to ancient Egypt and dates back to 1600 BC (Sudhakar, 2009).

Gynaecological biopsies are not rare in Rivers State, Nigeria, where they cause considerable reproductive morbidity. Biopsies of the female genital tract call for concern worldwide and especially in developing countries (Parkin et al., 1992), globally contributing significantly to morbidity and mortality (Pisani et al., 2002). Data on gynaecological biopsies in some developing countries show a preponderance of cancer of the cervix (Egwuatu and Ejeckam, 1980; Ozumba et al., 2011). Cervical carcinoma in developing countries, accounts for 80% of the estimated 231,000 deaths that occur from it annually (Pindiga et al., 1999; Seleye-fubara et al., 2003; Mohammed et al., 2006; Agboola et al., 2007). The incidence and prevalence of other female genital biopsies vary from one geographical region to another (Mazur et al., 2005).

Generally, cancer incidence in Nigeria appears low compared to developed countries, which may not truly reflect the burden. Similar to reports from other parts of the world, it is slightly higher in female. Squamous cell carcinoma is the most common (90-91%) histological type while adenocarcinoma represents 2.4% to 5.1%. HPV is a necessary cause of cervical cancer being present in 99.9% of cases. In a study of 233 cases of cervix cancer from Lagos, HPV 16 and 18 were present in 65.2%, this supports data that effective vaccination against these 2 types will reduce the cervical burden in Nigeria (Abdulkareem, 2009). The Federal Ministry of Health has already given license to bring in vaccines. Institution of organized screening programmes to detect the pre-cancerous stage has reduced the mortality and morbidity of this cancer in developed countries. This can also be done in Nigeria with strong commitments, which will reduce deaths in Nigerian women from obstetric complications. Data from Ibadan showed

common female cancers in 1960-69 as cervix and breast. In 1998, breast became the commonest followed by cervix and ovary. Current data shows that female cancers account for about half of the total, the common female cancers reported from the North are cervix, breast, ovary while from Enugu and Lagos breast is commonest followed by cervix both accounting for over 40% (Abdulkareem, 2009).

Persistent Human papillomavirus (HPV) infection is also a notable risk factor for both vulvar and vaginal cancers. In the United States, it has been reported that 40% of vulvar (Wu et al.,2008) and vaginal cancers (Saraiya et al., 2008) could be attributed to Human Papillomavirus (HPV), and HPV type 16 (HPV-16) was detected in 50-64% of high-grade vaginal intraepithelial biopsies (VAIN) (Wu et al.,2008).

Worldwide, vulvar and vaginal cancers are rare (Andersen et al., 2003). Independent reports from Nigeria, United Kingdom and the United States show these cancers to be rare (Human Papillomavirus and Related Cancers, 2009; Cancer Facts and Figures, 2009 ; Okolo et al., 2013; UK vulval cancer incidence statistics, 2016). In the United States, vulvar cancer accounts for 0.6% of all cancers in women (Saraiya et al., 2008), and vaginal cancer for 0.3% of all invasive cancers among women. Majority of these cancers occur in developing countries. It was reported that 60% of vulvar cancers and 68% of vaginal cancers occur in developing countries (Okolo et al., 2013).

Thomas et al. (2004) described the prevalence of HPV infection in Nigerian women as well as the distribution of various HPV subtypes among women with normal and abnormal findings on cytology or visual inspection with acetic acid. HPV 16 and 35 were the most common high-risk HPV types, and HPV 42 was the most common low risk type.

Worldwide and in the US, there has been profound excitement and concern surrounding the HPV vaccine. The excitement derives from the potential of the vaccine to reduce the burden of anogenital cancers in countries that have no screening infrastructure. However, if vaccine uptake is lower in those groups at highest risk of developing cervical cancer, current racial/ethnic or geographic disparities could increase (Okolo et al., 2013). For Nigerians, the HPV vaccine may be useful in reducing the burden of disease provided we can afford them and the same HPV subtypes (mostly HPV 16 and 18) targeted by these vaccines are important causes of cancer in

Nigeria. Wu et al. (2003) studied vaginal cancers among different races in the United States and showed that black, Asian Pacific Island, and Hispanic women as well as older women were more likely to be diagnosed with late-stage disease, and these groups had lower 5-year relative survival rates than their white, non-Hispanic, and younger counterparts.

With early detection, vulvar cancer is curable. When lymph nodes are not involved, the five-year survival rate is slightly higher than 90 percent. Even in developed nations, the management of vulvar carcinoma is hampered by the fact that diagnosis is delayed in most cases and by the choice of the proper surgical procedure. The greatest difficulty in surgical management is with primary wound closure and healing, and wound breakdown and sepsis occur commonly (Gharoro et al., 2001). Most studies from Nigeria show that most patients with vulvar and vaginal cancers are older than 50 years (Kyari and Nggada, 2004; Mohammed et al., 2006; Nwosu and Anya, 2004). In the United States of America, both cancers are also most commonly seen in persons older than 50 years (Wu et al., 2008).