ORIGINAL

Niger J Paed 2015; 42 (2): 116 –120

Chukwu BF

Ezenwosu OU

Ikefuna AN

Emodi IJ

A prospective study of childhood

malignancy in Enugu, Eastern

Nigeria (2011-2013)

DOI:http://dx.doi.org/10.4314/njp.v42i2.9

Accepted: 3rd February 2015

Abstract: Background: The re-

view of childhood cancers has

most times been done in retro-

spect by most authors and this has

its inherent limitations. Most re-

views in Africa show that lym-

phomas are the commonest malig-

nancies of childhood while acute

leukemia ranks much lower.

Objective: To do a prospective

audit of the pattern of childhood

malignancies in Enugu, southeast,

Nigeria.

cancer with a male: female ratio of

1.3: 1 and median age of 7 years.

Majority (63.1%) of patients were

from the rural area with low socio-

economic background. There was

a decline in the incidence of child-

hood lymphoma from 40% about

25 years ago to 34% in the present

study. Although lymphoma re-

mains the leading childhood ma-

lignancy, sarcomas and acute leu-

kemia rather than renal and eye

tumors ranked second and third

respectively among childhood can-

cers in the center.

(

)

Chukwu BF

Ezenwosu OU, Ikefuna AN, Emodi IJ

Department of Paediatrics,

College of Medicine, University of

Nigeria, Enugu, Campus

Email: barth.chukwu@unn.edu.ng

Methods: Demographic and medi-

cal information on patients aged 1

-

17 years admitted over a 36

Conclusion: There is a reversing

trend in the pattern of malignan-

cies of childhood in Enugu as

acute leukemia becomes one of the

leading malignancies of children.

month period for malignancies

was obtained and recorded in pre-

tested interviewed administered

questionnaire. Data was analyzed

using spss, 15 (Chicago II, USA)

software.

Key words: childhood, malig-

Results: A total of 103 patients

were admitted with diagnosis of

nancy, lymphomas, leukaemia

Introduction

retrospective studies may affect the result. The present

study is prospective and aims to identify any change in

the pattern and socio-demographic characteristics of

patients with childhood malignancies at The University

of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu,

Southeast Nigeria.

Childhood cancer is a leading cause of death in devel-

oped countries of the world, but ranks lower than infec-

tions and malnutrition in the etiology of childhood mor-

1

tality in Sub Saharan Africa . The pattern of childhood

cancer is almost the same in America and Europe with

2,3

leukemia and₄_,₅b_,₆rain tumors predominating . Although

some studies show that lymphomas are more com-

mon in developing countries, the true pattern of child-

hood cancer may not be available in those countries (due

to improper record keeping, lack of diagnostic facilities,

belief systems and non-presentation to the health facil-

ity). A previous study done by Onwasigwe et al from

our center 12 years ago also showed that lymphoma

constituted about 40% of all childhood malignancies

with Burkitt’s lymphoma constituting over 60% of the

lymphomas while leukemia was the fifth commonest

Subjects and Methods

The study was conducted in the pediatric medical wards

of the University of Nigeria Teaching Hospital, Ituku-

Ozalla, Enugu over a three year period ( 2011- 2013). It

was a cohort study of children aged 1- 17 years with a

histologically confirmed diagnosis of cancer and was

approved by the hospital Health Research and Ethics

committee with informed consent obtained from the

patients’ caregivers. The Hospital has facilities for bi-

opsy, histopathological and cytological investigations as

well as well-equipped laboratory for haematological,

biochemical and microbiological investigations. Treat-

ment facilities available include chemotherapy, surgery,

radiotherapy and palliative care. Information regarding

patient’s age, gender, socioeconomic class, place of

7

childhood malignancy . A similar pattern with lym-

phoma as the predominant childhood malignancy was

also noted in Kano, Northwestern and Ife, Southwestern

8

Nigeria by Shehu et al in 2012.

Most of these studies on the pattern of childhood malig-

nancies are retrospective and the peculiar limitation of

1

17

residence, symptoms, type of cancer and its anatomical

location was obtained using investigator administered

questionnaire. Place of residence was categorized into

urban or rural communities. Rural community refers to a

community where families reside in relatively small

areas and their main occupation and interests are farm-

ing and fishing while urban community is large with

people engaged in varied occupations such as manufac-

turing, commerce, professional works such as law,

medicine and engineering; or government jobs. Socio-

economic classification was done using Ogunlesi et al

Sixteen (94.1%) of the 17 patients with Burkitt’s lym-

phoma were from the rural area and 88.2% were from

the low socioeconomic class. 41.2% of the patients pre-

sented with jaw mass, 52.9% with intra-abdominal mass

while 5.9% presented with paraplegia and intra-

abdominal mass.

Hodgkin’s disease constituted 22.8% of the lymphomas

and 7.8% of childhood malignancies. All the patients

were males with age range 8-16 years and peak age of

13 years. 62.5% were from the urban area while 37.5%

were from rural area. 37.5% each were from the middle

and lower socioeconomic group while 25.0% were from

the high socioeconomic group. Six (75.0%) presented as

neck mass while one (12.5%) each presented as intra-

abdominal and thigh masses. Ten (28.6%) of the lym-

phomas was non-Hodgkin’s lymphoma and made up

9

classification . Socioeconomic classification by

Ogunlesi et al is based on the highest educational attain-

ment, the occupation and income of parents and is clas-

sified 1 to 5 with class 1 being the highest level.

Statistical analysis

9

.7% of all the malignancies. Most (80.0%) of the pa-

Data was analyzed using a combination of statistical

software (SPSS 15, Graphpad prism 5). Categorical

variables were presented in form of tables and graphs

while discrete variables were presented as means or me-

dians. Also frequencies of categorical variables were

compared using chi square while means of discrete vari-

ables were compared using Student’s t-test. Level of

significance was set at p< 0.05.

tients were ten years and above with a male: female ratio

of 1.5: 1 and majority (80.0%) from the rural area. Four

(40%) of the NHL presented as intra-abdominal mass,

five as head and neck masses while one case presented

as breast mass.

Eighteen patients (17.5%) were diagnosed of sarcoma of

which rhabdomyosarcoma constituted the majority

(66.7%). Other sarcomas included osteosarcoma, angio-

sarcoma, fibrosarcoma, Kaposi sarcoma and embryonal

liver cell sarcoma.

Result

Among the acute leukemia, 68.8% was acute lym-

phoblastic leukemia while 31.2% was acute myeloid

leukemia. The mean age of the patients was 9.8 (3.7)

years with age range of 4 to 17 years. The male: female

ratio was 1.3:1. Ten (62.5%) resided in the urban area

while 37.5% resided in the rural area and majority (68.8)

belonged to the low socioeconomic class.In terms of

symptoms at presentation, (14/16) presented with fever,

A total of 103 patients were admitted with diagnosis of

cancer over the study period. The patients’ median age

was 7 years (range: 1-17) with a male: female ratio of

1

.3:1. Majority (56.3%) of the affected children be-

longed to the lower socioeconomic class. Table 1 shows

the general characteristics of the patients.

4

(25%) with bleeding disorder, 3 (19.0%) with bone

Table 1: General characteristics of subjects

and or body pains, one with bilateral proptosis of the

eyes, one with hearing impairment, 4 (25%) with head

and neck masses and one with intra-abdominal mass. All

the patients were pale on presentation.

Renal tumor was the third commonest tumor (13.6%),

affecting children 1to 5 years of age with peak age inci-

dence of 2-3 years and male: female ratio of 0.6:

1.Majority (92.8%) who had it were from the middle

and low socioeconomic group. Four (30.8%) of the pa-

tients had elevated blood pressure that required anti-

hypertensive medication.

Gender

Male

Female

5

8(56.3%)

45(43.7%)

11-15

Age

<5

5-10

>15 years

6(34.9%) 38(36.9%) 24(23.3%) 5(4.9%)

II III IV V

3

Socio-economic class

I

7

(6.8%) 9(8.7%) 32(31.1%) 36(35%) 19(18.4%)

Place of domicile

Rural

Urban

65(63.1%)

38(36.9%)

In the study, sixty five (63.1%) of the patients admitted

with cancer were from the rural area compared with 38

(

36.9%) from the urban area. The pattern of childhood

The fourth commonest tumor was retinoblastoma

(12.6%). It affected mostly the under five year olds with

peak age incidence 2-3 years. Seven (53.8%) of the 13

subjects were females with a M:F of 1: 0.9 Majority

(69.2%) of the affected patients resided in the rural area

and 61.5% were of low socioeconomic class while

38.5% were of middle class. Majority (69.2%) of the

patients presented with unilateral orbital mass, 23.1%

(3/13) presented primarily with leukocoria while one

patient presented with multiple scalp masses and bilat-

eral orbital mass.

malignancies over the period was shown in table 2. It

showed that lymphoma was the most prevalent (34.0%),

followed by the sarcomas (17.5%), acute leukemia

(

15.5%) and renal tumors (13.6%).

Burkitt’s lymphoma constituted 48.6% of the lympho-

mas and 16.5% of all malignancies among the patients.

The age of patients with this malignancy ranged from 4-

1

4 years with peak and mean ages of 5 and 7.25 (±2.23)

years respectively. Eight (47.1%) of the patients were

males while nine (52.9%) were females with male:

female ratio of 0.9: 1

Rhabdomyosarcoma, the fifth commonest tumor

1

18

(

11.7%) in this study shows a male predominance

72.7%) and affected mostly patients from the low so-

by Olesina et al in Ibadan₆_,₁a₇nd 19.6% by Tijani et al in

1

Lagos, Western Nigeria . This decline in the inci-

cioeconomic class (81.8%). However, the age group

varied widely from two to 16 years. Nine (75.0%) of the

twelve subjects presented with head and neck masses,

dence of lymphoma may be associated with improve-

ment in general living condition of the people as well as

improvement in the control of malaria; as poor living

conditions and high incidence of malaria and Epstein-

Barr virus infection are known risk factors for the occur-

1

6.7% as intra-abdominal masses and 8.3% as mass on

the anterior chest wall.

1

8

Other tumors included neuroblastoma 2(1.9%), osteosar-

coma 2(1.9%), chronic myeloid leukemia 2(1.9%), reac-

tive sinus hyperplasia with generalized lymphadenopa-

thy 2(1.9%) and germinoma, Kaposi sarcoma, fibrosar-

coma, angiosarcoma, embryonal liver cell sarcoma 1

rence of lymphoma, especially Burkitt’s lymphoma .

There is also a reversal of sex incidence of Burkitt lym-

1

9

phoma from a male: female ratio of about 2:1 to 0.9:1 .

The reason for this reversal may be due to increasing

awareness of the people on the need to pay equal atten-

tion to the education and health care of their male and

female children which may have increased the cancer

registration rate of girls.

(

0.97% each).

Among 21 patients whose tumors were staged, 15

71.4%) presented with stage 4 disease and only one

(

with stage 1 (4.7%) disease.

The sarcomas constituted the second commonest child-

hood malignancy (17.5%) in this study and this collabo-

rated with the study by Ocheni et al (15.2%) in 2005.

Table 2: Frequency of childhood malignancies

6

Tumor

N (103)

%

The rising relati₂v₀e frequency as previously documented

by Ocheni et al is maintained with rhabdomyosarcoma

remaining the most common childhood sarcoma.

Lymphomas

BL

NHL

HD

Acute leukemia

ALL

AML

Renal tumors

Retinoblastoma

Rhabdomyosarcoma 12

Others 13

35

17

10

8

16

11

5

34.0

48.6

28.6

22.8

15.5

68.8

31.2

13.6

12.6

11.7

12.6

It is noteworthy that leukemia which has hitherto been

reported in many studies to have low incidence in Africa

is the third commonest childhood malignancy in the

present study₁_,₂d₂isplacing renal tumor and retinoblastoma

2

14

13

in the trend . Onwasigwe and colleagues had earlier

reported leukemia as the fifth commonest childhood

malignancy in Enugu in 2002 while Ocheni et al from

same centre in 2005 and Ochicha et al in Kano, Nothern

Nigeria in 2012 reported leukemia to be the fourth an₇_,d₆_,

third commonest childhood malignancy respectively

Others: angiosarcoma (1), chronic myeloid leukaemia (2), embryonal

liver sarcoma (1), germinoma (1), fibrosarcoma (1), Kaposi sarcoma

(1), neuroblastoma (2), osteosarcoma (2), sinus histiocytosis with

2

3

. This shows that in our study centre, leukemia rose

generalized lymphadenopathy (2)

BL= Burkitt’s lymphoma; NHL= Non-Hodgkin’s lymphoma; HD=

Hodgkin’s disease

from being fifth commonest malignancy in 1989, to

fourth in 2005 and now third. Tables 3 & 4 compares

studies of childhood malignancies in the centre from

1

976 to present study period and it is noted that there is

an increasing frequencies of sarcomas and acute leuke-

mia rising from 7.6% in 2005 to 15.5% in the current

study period. It is also noted that the annual cancer inci-

dence has been decreasing from the first study to the

Discussion

The study showed sex predilection to cancer with a male

to female ratio of 1.3:1. This is comparable with 1.4:1

documented in Ile Ife by Shehu et al . However, the ra-

6

fourth with a rise from 14.4% observed by Ocheni et al

in the 1999-2004 review to 34.3% in the present study.

The present increase in cancer incidence may be because

of improved diagnostic techniques or because the cur-

rent study was prospective and cases of cancer were

actually looked out for. It is also observed that the sex

incidence has been relatively stable.

8

tio was less than 2.4:1 noted in Northern Nigeria by

1

0

Shehu et al as well as 1.8:1 from central Sudan . This

difference may be related to socio economic and cultural

factors as it has been observed that there is low cancer

registration among girls in countries or regions of the

world with low female education rates and poor health

Table 3: Comparison of annual incidence of childhood malig-

nancies from 1976-2013

1

system indicators .

The pattern of childhood tumors in Africa has been char-

Author

Year of

study

Annual

Inci-

dence

Age

inci-

dence

Peak

age

M:F ratio

acterized by high prev_,a₁₂lence of lymphoma and low

7

prevalence of leukemia . This is in contrast to the pat-

tern in develo₃p_,₁e₄d parts of the world where leukemia

1

predominates . In the present study, although lym-

Agugua

1976-1980

116.4

phoma is still more prevalent, it seems to be on a decline

with prevalence of 34%, in c₅ontrast to about 40% re-

Obioha et al 1978-1982

Onwasigwe 1989-1998

Ocheni et al 1999-2004

51.4

31.3

14.4

1.3

1.5

1.3

1

ported earlier by Obioha et al from our center about 25

Current

2011-2013

34.3 1-17

5-10

years ago and 42.8% by Huda et al in Gezira, Central

1

0

Sudan . Specifically, Burkitt’s lymphoma was noticed

to be decreasing in incidence as it constituted 16.5% of

the childhood malignancies when compared with 19.4%

1

19

Table 4: Comparison of relative frequencies of childhood

malignancies (1976-2013)

Among patients whose disease was staged, majority

presented at an advanced stage and this has been the

3

2

Frequency(%)

pattern in most parts of Africa . Advanced stage disease

is usually as a result of delay in presentation to cancer

treatment centre due to parents or health system delay.

Parents may delay to present their wards because of mis-

conception (either cultural or religious) about the disease

or due to financial constraint while the health system

may delay due to poor referral services or lack of diag-

nostic facilities. Delay may also be due to intrinsic char-

acteristics of tumor itself (such as slow growth or ab-

sence of systemic symptoms) which will definitely cul-

Type of

cancer

Agugua

(1976-

Obioha(1978-

1982)

Onwasigwe

(1989-1998)

Ocheni

(1999-

2004)

Current

(2011-

2013)

1

980)

All lymphoma 49.4 39.3

Burkitt’s

38.3

41.2

34.0

lymphoma

37 26.5

25.3

8.6

1.9

12.1

14.7

24.1

7.6

5.1

7.6

15.2

16.5

15.5

13.5

12.6

17.5

Acute Leukemia 5.5 12.9

Renal tumour 5.6 3.0

Retinoblastoma 2.9 6.2

Sarcomas

10.4 4.3

3

minate in delay in diagnosis and poor prognostication .

In conclusion, although lymphomas remain the com-

monest childhood malignancy in Enugu, the prevalence

seems to be on the decline with an increasing incidence

of sarcomas and acute leukemia and this may be related

to increasing urbanization and more inclination to West-

ern life style. In general, males are more affected by

cancer with majority of the patients from the rural area

and of low socio-economic status as well as presentation

with advanced stage disease.

The rising incidence of leukemia may be linked with

improved diagnostic techniques and exposure to high

tension electricity cables due to rapid electrification of

urban centers . Report by Draper et al in England and

Wales noted an increased risk for development of child-

hood leukemia in children who were delivered within

2

4

25

2

00 meters from power lines. Other studies from Canada

and Sweden also found increased risks for childhood

2

6

27

leukemia in children residing close to power transmis-

sion lines. However, some other₃s₀tudies from Den-

2

8

29

mark , Norway and United States did not show in-

creased risk for childhood leukemia in children living

near high-voltage power lines. Most affected patients in

this study resided in the urban area. Also similar to the

study by Huda et al in Central Sudan. Leukemia affected

mostly children above 5 years in our centre unlike in

America and Europe where most affected children are

Authors contributions

Conception and design of study by IJ and AN, data col-

lection by OU, data analysis and writing of manuscript

by BF. All authors read and approved the final manu-

script.

Conflict of interest: None

Funding: None

1

0,31

.

less than five years

The renal tumors and retinoblastoma remain disease of

the under five children (because they are embryonal

tumours), affecting mostly children of low socioeco-

nomic class. However, it is noted to be affecting more

females than males unlike in western countries of the

world where the sex incidence is similar . The reason

for this apparent tilt towards female gender preference

may need to be authenticated by further studies.

Acknowledgment

The authors wish to acknowledge the resident doctors

and House officers for their contribution in data

collection.

3

1

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