|Year : 2018 | Volume
| Issue : 1 | Page : 20-25
Musculoskeletal tumors of the extremities: Challenges and outcome of management in a Nigeria Tertiary Hospital
ON Salawu, OM Babalola, GH Ibraheem, C Nwosu, AK Suleiman, DM Kadir, BA Ahmed, JO Mejabi, AA Fadimu, TO Adeyemi, WO Olawole
Federal Medical Centre, Birnin Kebbi, Kebbi State, Nigeria
|Date of Web Publication||2-Jul-2018|
O N Salawu
Department of Orthopaedic Surgery, Federal Medical Centre, Birnin Kebbi, Kebbi State
Source of Support: None, Conflict of Interest: None
Background: Patients with musculoskeletal tumors in developing countries often present late to the hospital and this poses serious challenges to the management, especially for malignant tumors. This study aims to highlight the various types of musculoskeletal extremity tumors seen in a Nigerian tertiary health center during the study period, the challenges encountered in managing them, and the outcome of the management. Materials and Methods: A prospective study in which all consenting patients with musculoskeletal extremity tumors who presented to the center from April 2015 to March 2017 were recruited. Results: Seventy-two patients were managed during the study period. The mean age was 22.1 ± 4.5 years and the age group most affected was the 11–20 years group, n = 22 (30.6%). Male-to-female ratio was 1.6:1. The femur was the most commonly involved bone. Forty tumors were benign while 32 were malignant tumors. Osteochondroma was the most common benign tumor while osteosarcoma was the most common malignant tumor. The challenges encountered during the management were a late presentation, poverty, and traditional bonesetter intervention before the presentation. Patients with benign tumor had excision with good outcome in all. Twenty (62.5%) of the patients with a malignant tumor had the ablative procedure, two of these 20 patients died within 6 months of treatment, while 12 (37.5%) of the patients with malignant tumor refused the treatment. Conclusion: Management of musculoskeletal extremity tumors is highly challenging in this part of the country, especially the malignant types, due to the challenges mentioned. There is a need for more awareness about the disease, the Government should subsidize the cost of management of this disease, and more specialty training of personnel is necessary for appropriate management of the diseases.
Keywords: Extremity, musculoskeletal, tumor
|How to cite this article:|
Salawu O N, Babalola O M, Ibraheem G H, Nwosu C, Suleiman A K, Kadir D M, Ahmed B A, Mejabi J O, Fadimu A A, Adeyemi T O, Olawole W O. Musculoskeletal tumors of the extremities: Challenges and outcome of management in a Nigeria Tertiary Hospital. Afr J Med Health Sci 2018;17:20-5
|How to cite this URL:|
Salawu O N, Babalola O M, Ibraheem G H, Nwosu C, Suleiman A K, Kadir D M, Ahmed B A, Mejabi J O, Fadimu A A, Adeyemi T O, Olawole W O. Musculoskeletal tumors of the extremities: Challenges and outcome of management in a Nigeria Tertiary Hospital. Afr J Med Health Sci [serial online] 2018 [cited 2019 Nov 15];17:20-5. Available from: http://www.ajmhs.org/text.asp?2018/17/1/20/235743
| Introduction|| |
Musculoskeletal extremity tumors are abnormal growths arising from the bone and soft tissue of the extremities. They could be benign or malignant. While benign bone tumors occur more frequently than the malignant bone tumors, malignant tumors are associated with high mortality and morbidity.,
The tumors could arise primarily from the bone, cartilage, or soft tissues in the extremities or they could be secondary deposits more commonly found in bone of the extremities. Secondary bone tumors commonly arise from thyroid cancer, lungs cancer, renal cancer, gastrointestinal cancer, breast, and prostate cancer. The primary bone tumor can occur in all age groups, but it is more common in the first and second decades of life., Management of musculoskeletal tumors of the extremities, especially the malignant ones, pose serious challenges to the clinicians.
Etiology of musculoskeletal tumors is multifactorial. Predisposing factors include genetic mutation, trauma, infection, and irradiation. Some benign musculoskeletal tumors may progress to malignant tumors.,,
Generally, patients with musculoskeletal tumors in this environment present late to the hospital for a variety of reasons including ignorance about the disease, poverty, spiritual beliefs, the trust they have in traditional bone setters (TBS), and fear of ablative surgery.
An accurate record of the prevalence of musculoskeletal extremity tumors is difficult to obtain in Nigeria, because many of these patients may not present in the hospital, some that present in remote hospitals may not have proper diagnosis due to either lack of expertise or inadequate equipment, and even for those who have a proper diagnosis, proper records keeping may be a challenge.
In Africa and other parts of the world, estimates for the incidence of musculoskeletal tumors is increasing; hence, there is need to allocate more health resources toward prevention, diagnosis, and treatment of these tumors as the most tumors have a better prognosis when diagnosed and treated earlier.,, This report aims to highlight the presentation of musculoskeletal tumors in this center and reveal the challenges encountered in managing patients with these tumors.
| Materials and Methods|| |
This was a prospective descriptive study carried out at the Federal Medical Centre, Birnin Kebbi, Nigeria, from April 2015 to March 2017. Approval was obtained from the Ethical Committee of the Institution. All consecutive patients who presented with musculoskeletal tumors of the extremities within the study period were included in the study after obtaining their consents. They were managed according to the hospital protocol for managing musculoskeletal tumors, which include clinical evaluation, biopsy for histology, and definitive surgical treatment, then referrer to nearby oncology center for radiotherapy and chemotherapy if indicated. Each patient was followed up for at least a period of 6-month postsurgery.
The patients' biodata, clinical presentation, characteristics of the lesions, previous treatment measures, histology of the lesion, challenges, and types of treatment given were recorded. Data collected were analyzed using Statistical Package for the Social Science software version 19. (IBM Inc., Chicago, IL, USA). Result presented using frequency tables and bar chart.
| Results|| |
During the study period, 72 patients with musculoskeletal tumors of the extremities were managed. The mean age of the patients was 22.1 ± 4.5 years ranging from 3 to 71 years. Most of the patients presented in the 2nd and 3rd decades of life as shown in [Figure 1]. There were 44 male and 28 female patients (m:f = 1.6:1). Twenty-seven of these tumors were located in the upper limbs while 45 of them were located in the lower limbs.
Forty of the tumors were benign while 32 were malignant. Osteochondroma was the most common of all the tumors, while osteosarcoma was the most common among the malignant tumors. Malignant melanoma and squamous cell carcinoma were secondary from the skin. The distribution of tumors is shown in [Table 1].
Osteochondroma which was the most common tumor in this report was found mainly among the 11–20 years age group which also had the highest number of tumors overall (n = 22). Osteosarcoma which was the most common malignant tumor was the highest among the 51–60 years age group (n = 9), followed by the 21–30 years age group (n = 5) as shown in [Table 2].
The most common location of the tumors was the distal femur (n = 21), followed by the proximal tibia (n = 13). The most common benign tumor (osteochondroma) and malignant tumor (osteosarcoma) were also located mainly in the distal femur and the proximal tibia. Anatomical distribution of the tumors is shown in [Table 3].
Average duration from the onset of symptoms to the time of presentation for benign and malignant tumors was 3.1 and 1.8 years, respectively.
The mean duration of hospital stay for patients with benign tumors was 14.4 ± 2.1 days, while the mean duration of hospital stay for patients with malignant tumors was 25.6 ± 7.3 days. No mortality recorded in patients with benign tumors, while four of the 20 patients that had treatment for a malignant tumor died within 6 months of their treatment.
| Discussion|| |
Musculoskeletal tumors, particularly the malignant ones, require early diagnosis and early treatment to improve outcomes.
Similar to the most previous reports, this study showed that musculoskeletal extremity tumors are more common in younger patients with the mean age at the presentation of 22.1 ± 4.5 years. This is similar to the findings of Inuwa et al.
There was a male preponderance with a ratio of 1.6:1. No reason could be adduced for this, however, this is similar to the findings of Inuwa et al. and Solook et al. in their studies.,
This report showed a higher proportion of benign tumors than the malignant ones with osteochondroma being the most common benign tumor while osteosarcoma was the most common of the malignant tumor [Table 1]. Solook et al., in their study, also reported benign tumors being more common than malignant tumors. Inuwa et al., however, had more malignant than benign tumors in their report from Northern Nigeria. Benign musculoskeletal extremity tumors are generally known to be more common than malignant tumors. Benign tumors are however more likely to be asymptomatic or have seemingly innocuous symptoms like mild swelling. In our environment, where people have very poor health-seeking behavior, patients with extremity masses may not present to the hospital until they develop severe symptoms. This may be responsible for the higher incidence of malignant tumors presenting to the hospital in some hospital-based reports. An interesting finding from this study was that osteosarcoma was more common in the middle aged than in children and adolescents [Table 2]. This is contrary to reports from studies in other centers.,,, When osteosarcomas are found in middle-aged and elderly patients, they are more often secondary osteosarcomas. Further, histopathologic analyses of the tumors could not be done in our center to ascertain if these tumors were indeed secondary osteosarcomas. We, however, have no indication of a high incidence of bone diseases such as Paget's disease which may lead to secondary osteosarcomas in our environment.
Majority of the musculoskeletal tumors in this study was located in the lower limbs, especially around the knee joint (distal femur and proximal tibia) [Table 3]. This is similar to other reports of the anatomical distribution of bone tumors.
Late presentation was one of the major challenges encountered in the management of these patients. For benign tumors, the average time to presentation from the onset of symptoms was 3.1 years, while for patients with malignant tumors, it was 1.8 years. This delayed presentation is partly responsible for poor outcomes seen, particularly in malignant tumors, managed in this part of the country. Reasons adduced to this late presentation by patients include ignorance, poverty, and lack of health facilities in their immediate locality. Solook et al. reported that late diagnosis in their environment was due to a lack of familiarity of the general medical practitioner with the various nonspecific symptoms of early musculoskeletal tumors such as pain and swelling, since other musculoskeletal lesions also have this symptoms.
All patients with malignant tumors and most of those with benign types had initially presented to TBS for treatment before seeking orthodox care. They had scarification marks or other local practices done to “treat” the tumors. A common traditional practice of managing musculoskeletal tumors in this part of Nigeria is called “sekia” which is a process whereby a hot metallic object is inserted into the tumor, with the hope of casting out the “evil spirit” thought to be present within the tumor. As 'sekia' is usually done for symptomatic tumors which are often malignant, the patients usually develop fungating masses which bleed readily with contact [Figure 2] and [Figure 3]. When such patients present to the hospital, the long duration of symptoms and the initial local intervention ensure that they have already reached advanced stages of the disease process. This practice constitutes a great challenge in managing these patients and results in poor prognosis. The reasons given by these patients for initial presentation to TBS include the fact that the TBS practitioners live in the same locality with the patients, they speak the same language with them, they are easier to consult, and the patients are often afraid of huge bills they may receive in the hospitals. Most commonly, the patients believed that such lesions were caused by evil spirits which can only be cast away by the TBS.
Poverty is another major challenge in the management of these patients as none of them could afford magnetic resonance imaging for better preoperative planning, nor could they afford the required cytotoxic drugs which could limit the progression of the disease and improve the survival.
Lack of facilities for limb-sparing procedure is one of the major challenges, facilities for limb-sparing procedures for early stages of malignant tumors are lacking in this part of the country. Offering such limb-sparing procedures for patients with early stages of the disease will encourage other patients with similar symptoms to present early for treatment and will consequently improve the outcome of management.
Twenty of the patients with malignant tumors had ablative surgery, and were subsequently referred to the nearby oncology center in the country for further treatment, while the remaining 12 patients refused ablative surgery and left the hospital against medical advice.
One of the patients with a giant-cell tumor had recurrence of the tumor which was re-excised, while the rest of those patients with benign tumors had satisfactory outcomes [Table 4]. Two patients had superficial surgical site infection, they were treated by wound dressing and antibiotics according to the sensitivity pattern of the organisms isolated.
| Conclusion|| |
Management of musculoskeletal extremity tumors is highly challenging in this part of the country. Factors militating against good outcome, especially for malignant tumors, include a late presentation, ignorance, poverty, initial TBS intervention before seeking orthodox care, and lack of facilities for limb-sparing procedures.
There is a need for more public enlightenment about these conditions and an improvement in the general attitude of the populace toward seeking treatment. Hospitals also need to be made more accessible and affordable to the populace. On the part of the Government, efforts should be made to subsidize the cost of treatment of these conditions while improved workforce development is essential to achieving better care for patients with these tumors.
The authors would like to acknowledge all doctors in orthopedic unit, Federal Medical Centre, Birnin Kebbi.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Obalum DC, Giwa SO, Banjo AF, Akinsulire AT. Primary bone tumours in a tertiary hospital in Nigeria: 25 year review. Niger J Clin Pract 2009;12:169-72.
Mohammed A, Isa HA. Pattern of primary tumours and tumour-like lesions of bone in Zaria, Northern Nigeria: A review of 127 cases. West Afr J Med 2007;26:37-41.
Ode MB, Misauno MA, Nwadiaro HC, Onche II, Shitta AH, Amupitan I. Pattern and distribution of primary bone tumours in Jos, Nigeria. J Dent Med Sci 2014;13:9-12.
Coleman RE. Metastatic bone disease: Clinical features, pathophysiology and treatment strategies. Cancer Treat Rev 2001;27:165-76.
Iavarone A, Matthay KK, Steinkirchner TM, Israel MA. Germ-line and somatic p53 gene mutations in multifocal osteogenic sarcoma. Proc Natl Acad Sci U S A 1992;89:4207-9.
Dabezies EJ, D'Ambrosia RD, Chuinard RG, Ferguson AB Jr. Aneurysmal bone cyst after fracture. A report of three cases. J Bone Joint Surg Am 1982;64:617-21.
Huvos AG, Woodard HQ, Heilweil M. Postradiation malignant fibrous histiocytoma of bone. A clinicopathologic study of 20 patients. Am J Surg Pathol 1986;10:9-18.
Eyesan SU, Obalum DC, Nnodu OE, Abdulkareem FB, Ladejobi AO. Challenges in the diagnosis and management of musculoskeletal tumours in Nigeria. Int Orthop 2009;33:211-3.
Obalum DC, Eyesan SU, Ogo CN, Enweluzo GO. Multicentres study of bone tumours. Niger Post Grad Med J 2010;17:23-6.
Omololu AB, Okolo CA, Ogunlade SO, Oyebadejo TY, Adeoye AO, Ogunbiyi JO, et al.
Primary malignant bone tumours in Ibadan, Nigeria: An update. Afr J Med Med Sci 2009;38:77-81.
Pearce MS, Parker L, Windebank KP, Cotterill SJ, Craft AW. Cancer in adolescents and young adults aged 15-24 years: A report from the North of England young person's malignant disease registry, UK. Pediatr Blood Cancer 2005;45:687-93.
Inuwa MM, Zakariyau LY, Ismail DI, Friday ES, Ibrahim AA, Mohammed AA, et al.
Overview of extremity musculoskeletal neoplasms at the Ahmadu Bello University Teaching Hospital Zaria, Nigeria. Ann Afr Med 2017;16:141-4.
] [Full text]
Solooki S, Vosoughi AR, Masoomi V. Epidemiology of musculoskeletal tumors in Shiraz, South of Iran. Indian J Med Paediatr Oncol 2011;32:187-91. [Full text]
Bramer JA, Somford MP. The epidemiology of primary skeletal malignancy. Orthop Trauma 2010;24:247-51.
Omololu AB, Ogunbiyi JO, Ogunlade SO, Alonge TO, Adebisi A, Akang EE, et al.
Primary malignant bone tumour in a tropical African university teaching hospital. West Afr J Med 2002;21:291-3.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]