Prognosticators of Excision of Giant Intra-Oral Tumors in a Resource-Challenged Setting: A Case Report.

Minor salivary glands are widely distributed in the mucosal surface of the lips, palate, nasal cavity, pharynx, and larynx, thus can arise from any of these primary sites. Intra-oral minor salivary gland tumors (IMSGTs), while considered rare in the general population are relatively more common when compared to all the other extra-oral sites. Pleomorphic adenoma, as seen in the index patient, is the most commonly diagnosed benign IMSGT. Intra-oral minor salivary gland tumors are not uncommon and depending on their size, nature, and location can be associated with severe limitation of the Patient's ability to breathe, speak clearly, and/or swallow and consequent severe morbidity and even mortality. In addition to these deleterious effects, they present a major surgical challenge to the surgeon, who has to determine the safest, most feasible access to ensure complete, or near-complete excision, as well as to the anesthetist, who needs to secure a definitive airway through the nose or mouth, both of which could be significantly restricted by the presence of the tumor. The aim is to present our successful management of one of the largest intra-oral minor salivary gland tumors documented in the literature, highlighting the specific measures we undertook to tackle the peculiar surgical and anesthetic challenges we faced. It had been two years since surgery and the patient is thriving with a markedly improved quality of life and no features of recurrence. The patient is a 50-year-old male with a slowly growing painless, left palatal mass in the roof of the mouth of 10 years duration with recurrent spontaneous bloody discharge effluent and snoring. There was an associated history of dysphagia to solid with associated choking spells, a left-sided facial asymmetry with no cheek swelling, odynophagia, sore throat, or difficulty with breathing. There was ipsilateral loss of upper incisors and dental anarchy about two years before presentation. No other nasal, otologic, or ophthalmic symptoms were present. No neck swelling, stiffness, cough, or chest symptoms. The oropharyngeal physical examination was highly restricted due to the intra-oral size of the mass. Figure 1. There was facial asymmetry with a bulge of the left maxilla, left-sided levels 1b and 2 non-tender lymph node enlargements, freely mobile, not adhered to the skin. A craniofacial CT scan revealed extensive isodense heterogeneously enhancing intra-oral soft tissue mass occupying the entire palate/oral cavity and encroaching laterally on the masticator and the parapharyngeal space with erosion of the left maxillary floor and hyoid bone Figure 2. The patient had an excision biopsy of the palatal mass with a free margin. No frozen section at the time of surgery. Histology revealed Pleomorphic adenoma and was followed up for 2 years with no evidence of recurrence. Prognosticators are delay in presentation leading to an increase in size of the mass and severe limitation of the patient's ability to breathe, speak clearly, and/or swallow and consequent severe morbidity and even mortality, the surgeon not being overwhelmed, the skillful Anaesthesist that could maneuver the nasal cavity without us doing tracheostomy and the successful outcome of the surgery.

Les glandes salivaires mineures sont largement réparties à la surface muqueuse des lèvres, du palais, de la cavité nasale, du pharynx et du larynx, et peuvent donc survenir à partir de l'un de ces sites primaires. Les tumeurs des glandes salivaires mineures intra-orales (TGSMIO), bien que considérées comme rares dans la population générale, sont relativement plus courantes par rapport à tous les autres sites extra-oraux. L'adénome pléomorphe, tel que celui observé chez le patient index, est la TGSMIO bénigne la plus fréquemment diagnostiquée. Les tumeurs des glandes salivaires mineures intra-orales ne sont pas rares et, en fonction de leur taille, de leur nature et de leur emplacement, peuvent être associées à une limitation sévère de la capacité du patient à respirer, à parler clairement et/ou à avaler, avec une morbidité sévère et même une mortalité. Outre ces effets délétères, elles présentent un défi chirurgical majeur pour le chirurgien, qui doit déterminer l'accès le plus sûr et le plus faisable pour assurer une excision complète ou presque complète, ainsi que pour l'anesthésiste, qui doit assurer une voie aérienne définitive par le nez ou la bouche, tous deux pouvant être significativement restreints par la présence de la tumeur. L'objectif est de présenter notre prise en charge réussie de l'une des plus grandes TGSMIO documentées dans la littérature, mettant en évidence les mesures spécifiques que nous avons prises pour relever les défis chirurgicaux et anesthésiques particuliers auxquels nous avons été confrontés. Deux ans après l'intervention, le patient se porte bien avec une nette amélioration de sa qualité de vie et aucune manifestation de récurrence. Le patient est un homme de 50 ans présentant une masse palatine gauche en croissance lente et indolore dans le palais depuis 10 ans, avec des écoulements sanguins spontanés récurrents et des ronflements. Il y avait une histoire associée de dysphagie aux solides avec des épisodes d'étouffement, une asymétrie faciale du côté gauche sans tuméfaction de la joue, une odynophagie, un mal de gorge ou des difficultés respiratoires. Il y avait une perte ipsilatérale des incisives supérieures et une anarchie entaire environ deux ans avant la présentation. Aucun autre symptôme nasal, otologique, ophtalmique n'était présent. Aucun gonflement du cou, raideur, toux ou symptômes thoraciques. L'examen physique de l'oropharynx était fortement limité en raison de la taille intra-orale de la masse. Figure 1. Il y avait une asymétrie faciale avec une bosse du maxillaire gauche, des ganglions lymphatiques non douloureux des niveaux 1b et 2 du côté gauche, mobiles librement, non adhérents à la peau. La tomodensitométrie craniofaciale a révélé une masse tissulaire molle intraorale extensive, hétérogène, rehaussée de manière isodense occupant l'ensemble du palais/cavité buccale et empiétant latéralement sur les muscles masticateurs et l'espace parapharyngé, avec érosion du plancher du maxillaire gauche et de l'os hyoïde. Figure 2. Le patient a subi une biopsie d'excision de la masse palatine avec une marge libre. Aucune section congelée n'a été réalisée lors de la chirurgie. L'histologie a révélé un adénome pléomorphe et un suivi de 2 ans n'a montré aucun signe de récurrence. Les facteurs pronostiques comprennent le retard de la présentation entraînant une augmentation de la taille de la masse et une limitation sévère de la capacité du patient à respirer, à parler clairement et/ou à avaler, avec une morbidité sévère voire une mortalité, le chirurgien ne se laissant pas dépasser, l'anesthésiste compétent pouvant manœuvrer dans la cavité nasale sans avoir recours à une trachéotomie, et le succès de l'intervention chirurgicale. MOTS-CLÉS: Intraoral; Glande salivaire mineure; Excision; Tumeur; Pronostiqueurs.

Changing pattern of cancer distribution: experience from a tertiary health institution in Nigeria and review of literature.

Background: Over the years, epidemiological surveys have established that the five leading cancers in Africa (in descending order of prevalence) are cancers of the breast, cervix, prostate, liver, and colorectum.[1] However, a 10-year retrospective review of cases performed at the University of Ilorin Teaching Hospital (UITH) revealed some changes in the cancer incidence pattern in this region. Aims: The aim of the study was to determine the distribution of cancers managed at the UITH, a tertiary health care center in North Central Nigeria, in the past 10 years and create awareness of changing cancer prevalence patterns in this region. Materials and Method: This was a retrospective review of cancer epidemiology at UITH over a period of 10 years. Confirmed cancer cases within this period were extracted from the data in the Department of Anatomic Pathology and the Cancer registry. Descriptive and inferential statistics were applied to obtain rates and proportions for both sexes. Results: There were 2430 confirmed cases of cancer during the study period from January 2011 to December 2020. Out of these cases, 1310 (54%) were seen in females and 1120 (46%) were seen in males. The most common cancer recorded (in total) was prostate cancer, which accounted for 18% of all cases, constituting approximately one in six of all cancer cases. This was followed closely by breast cancer (16.6%). The most commonly diagnosed cancer in males was prostate cancer (four in ten cancer cases in males), whereas in females, it was breast cancer (approximately three in ten cancer cases in females). Cancers of the lungs and liver were rare in both sexes in this study. In children, the most common malignancies were retinoblastoma (38.3%), non-Hodgkin lymphomas (16.8%), and nephroblastoma (12.8%). Conclusion: There is a changing trend in cancer cases with some cancer cases now predominating compared to previous years. This may be because of increased awareness and/or better medical screening and diagnostic techniques.

Colorectal carcinoma in children and young adults in Ilorin, Nigeria.

BACKGROUND: Colorectal carcinoma is thought to be rare among children and young adults among whom presentation is usually at a late stage with poor prognosis. OBJECTIVE: To review the demography, clinical presentation, morphology, and pathological stage of cases of colorectal carcinomas diagnosed in the children and adults. METHODS: This was a retrospective review of cases of histologically diagnosed colorectal carcinoma of patients aged 40 years and below, between 1979 and 2008, using the request cards and hematoxylin and eosin stained slides. RESULTS: Seventy-six (31.5%) of all cases of colorectal carcinoma were seen in patients aged 40 years and below. The mean age at presentation was 31 years and the youngest aged 16 years. The male : female ratio was 1.6 : 1. The dominant clinical presentations were bloody diarrhea and rectal bleeding. Fifty-one (67.1%) cases were localized to the rectum, nine (16.1%) cases in the sigmoid colon, and eight (10.5%) cases in the caecum. Adenocarcinoma was the most common histological variant. Mucin-producing tumours were seen in 25 (32.9%) cases. Almost all the patients presented at advanced pathological stage. CONCLUSION: Colorectal carcinoma is not rare among young Nigerians and it should be suspected when young patients present with chronic bloody diarrhoea. Digital rectal examination should be encouraged as part of clinical examination in this age group too since a large percentage of colorectal carcinomas is within the reach of the examining finger.

Nasal osteogenic chondrosarcoma: a case report.

BACKGROUND: Osteosarcomas and chondrosarcomas are the most common malignancies of the jaw bones. Nasal osteogenic chondrosarcoma is rarely reported. OBJECTIVE: To draw attention to a rare tumour, osteogenic chondrosarcoma. METHODS: A middle aged woman presented with a three month history of nasal blockade and mucopurulent discharge. She was fully clinically evaluated including anterior rhinoscopy and plain radiograph. RESULTS: Detailed history, physical examination and plain radiography showed features suggestive of antrochoanal polyp with differential diagnoses of sino nasal and nasopharyngeal tumour. At emergency tracheostomy, examination under anaesthesia, meticulous nasal and nasopharyngeal tumour clearance was done. Histopathological examination of the mass revealed osteogenic chondrosarcoma. CONCLUSION: Though rare, osteogenic chondrosarcoma affects nasal bones. Clinically the tumour mimicks an antro-choanal polyp and is associated with the challenge of recurrence.

Clinicopathological study of head and neck cancers in Ilorin, Nigeria.

Eighty-nine cases of head and neck cancers were studied over a 5-year period (1997--2001) at the University of Ilorin Teaching Hospital, Nigeria. The most common cancer affecting the head and neck region was carcinoma which constituted 70.8% of all the cases studied. It was followed by the lymphomas and blastomas which accounted for 20.2% and 9%, respectively. The nose/paranasal sinuses were the most common site of primary cancer (18%) followed by thyroid (12.4%), nasopharynx (11.3%) and larynx (4.5%). Other sites include a hypopharynx (3.4%), eye (2.2%), palate (2.2%), tongue (2.2%), skin (1.1%), lip (1.1%), salivary gland (1.1%), oropharynx (1.1%). Cervical lymph node metastasis with unknown primary lesion was seen in 10.1%. The peak age incidence was in the fifth decade of life. The improvement in locoregional control of head and neck cancers over the last decades does not appear to modify the final survival of these patients. It is crucial to understand as accurately as possible the risk factors for these malignancies in order to improve primary prevention.

The pattern of malignant tumours of the liver in a tertiary health institution in Nigeria.

This study aims at establishing the histopathological pattern of liver cancers reported in the Department of Pathology, University of Ilorin Teaching Hospital between January 1979 and December 1996. Histopathological slides and duplicate copies of reports were retrieved and re-examined while fresh sections were processed from original paraffin blocks when necessary. Liver cancers constituted 56.6% of all liver biopsies. Hepatocellular carcinoma, which was commonest in the fifth decade, occurred in 64.1%, while metastatic tumours, which were commonest in the sixth decade, accounted for 24.7%. Primary sites could only be determined in 5 out of the 35 metastatic tumours. The age range of patients with Burkitt's lymphoma was 6-17 years with an average of 10.8 years and a male/female ratio of 3:2. Overall, there was preponderance of hepatocellular carcinoma in males while metastatic tumours were commoner in females. The pattern of Burkitt's lymphoma demonstrated in this study agrees with what generally obtains for endemic Burkitt's lymphoma in this environment.

Histopathological and histochemical patterns of soft tissue sarcomas in Ilorin, Nigeria.

This research was carried out on soft tissue sarcomas processed in the Department of Pathology of University of Ilorin Teaching Hospital over a period of 18 years (1979-1996). Tumours in which pathognomonic features necessary for diagnosis were present on haematoxylin and eosin sections were diagnosed accordingly while special stains were employed to highlight characteristic features of some other tumours. Also a panel of special stains was performed on the poorly differentiated tumours. The three commonest tumours were fibrosarcoma, rhabdomyosarcoma and liposarcoma in decreasing order of frequency. Fibrosarcoma and leiomyosarcoma were commonest in middle age while rhabdomyosarcoma was commonest in childhood and early adult life. There was a male preponderance of the tumours with a male to female ratio of 1.3:1. With the use of special stains, typical diagnostic histological characteristics were found in 3 out of the 13 tumours initially diagnosed as poorly differentiated thereby reducing their number to 10. Plans are underway to do immunohistochemical studies and chromosomal analysis on the tumours through collaborative studies.

Histopathological assessment of the pattern of liver cirrhosis in a tropical population.

This study aims at establishing the pattern of liver cirrhosis. Histology slides and duplicate copies of reports were retrieved and re-examined while fresh sections were processed from original paraffin blocks when necessary. Cirrhosis was the second commonest cause of chronic liver disease after hepatocellular carcinoma. The commonest morphological type was macronodular cirrhosis. Micronodular cirrhosis is not as common in black Africans as among the Caucasians. This is not unexpected since alcoholic liver disease that is of aetiopathogenetic importance is also not as common as what is often found in Causasians. Biliary cirrhosis was reported in an 8 months old girl consequent upon congenital absence of gallbladder and biliary tree. There was male preponderance in the occurrence of cirrhosis with a male, female ratio of 2.5:1. The incidence gradually increased from early adult life but was highest in the middle age especially between the age group of 51-60 years and subsequently dropped sharply. Adequate diagnostic facilities should be provided to determine the incidence of hepatotropic viruses and their contribution to the incidence of chronic liver diseases. Case-controlled studies should be carried out to determine the role of local cultural practices on hepatocellular injury and the development of chronic liver disease.

Morphological features and organ distribution of schistosomal infection.

A total of 74 histologically diagnosed cases of schistosomiasis involving various organs and tissues were reported in the Department of Pathology of the University of Ilorin Teaching Hospital, Ilorin between January 1979 and December 1997. While some of the cases were incidental discoveries, others were the primary causes of patients' clinical problems such as infertility. The ages of patients in this study were relatively higher than the usual childhood or adolescence wherein schistosomiasis is commonest and this is thought to be due to the longer duration required for morphological changes to be established in tissues. A case of urinary bladder schistosomiasis with squamous cell carcinoma was found in a 55-year old man and this lends support to the claim that schistosomiasis of the urinary bladder may predispose to cancer in the organ. Findings in this study underscore the need for high index of suspicion in endemic areas wherein histological examination of appropriate tissue may be all that is needed in what otherwise appears to be a diagnostic enigma.

Analysis of the histopathological pattern of carcinoma of the cervix in Ilorin, Nigeria.

This study was carried out to determine the histopathological pattern and age distribution of the 253 patients with carcinoma of the cervix whose specimens were processed and histological diagnosis made between January 1979 and December 1997 in the Department of Pathology of University of Ilorin Teaching Hospital, Ilorin, Nigeria. Well differentiated squamous cell carcinoma was the commonest tumour and constituted 60.1% while adenocarcinoma was the least and accounted for 2.4% of cases. The ages of patients ranged between 23 and 85 years with an average of 51.8 years. The frequency distribution of carcinoma of the cervix appears to have bimodal pattern with a peak age at the fifth and seventh decades of life. Yearly pattern of new cases shows a very slow rate of decline in the number of cases. It is necessary to establish many screening centres and educate the populace in order to raise the level of awareness. This will enable early detection of the preinvasive lesions and thereby reduce the incidence of the frank carcinoma.

Lymphoma in adult Nigerians.

A review of 143 cases of lymphoma seen in adult Nigerians within a period of 10 years at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. There were 95 males and 48 females patients with an age range of 17 to 88 years. There was male sex predominance both for Hodgkin's and non-Hodgkin's lymphoma. 74% of the cases were non-Hodgkin's lymphoma and 26% were Hodgkin's Nodular lymphomas were very few. Most cases of Hodgkin's disease were of the mixed cellularity subtype. Among non-Hodgkin's lymphomas the intermediate grade predominated, the commonest being diffuse large cell lymphoma. Cases of Burkitts's lymphoma were not common in young adults. Immunohistochemistry plays a vital role in lymphoma diagnosis and sometimes in the differential diagnosis with small blue cell tumours.

Peripheral lymphadenopathy in Nigeria.

A review was carried out on the histopathological diagnosis of peripheral lymph node biopsies processed and reported within a period of 18 years (1979-1996) in the Department of Pathology of University of Ilorin Teaching Hospital, Ilorin, Nigeria. A total of 751 cases from 468 male and 283 female patients within the age range of 1 year to 80 years were reviewed. Non-neoplastic lesions made up 50.8% while neoplastic lesions constituted 49.2%. Tuberculosis was the commonest cause of peripheral lymphadenopathy (31.4%) followed by metastatic lesions (19.3%). As a group, the lymphomas constituted 28.2% and were made up of Hodgkin's disease 12.6%, non-Hodgkin's lymphoma including Burkitt's lymphoma 15.6% (with Burkitt's alone constituting 3.3%). Few other infectious diseases found included toxoplasmosis, histoplasmosis and onchocerciasis. Non-specific reactive and inflammatory changes (both acute and chronic) collectively formed 17.6%. The primary sites of lymph node metastases could not be determined in 36.6% of netastatic lesions while the breast was the origin in 13.8% and was the highest incidence of metastatis. The commonest lymph node group affected was the cervical (42.6%) followed by inguinal (24.1%).

Histopathological analysis of carcinoma of the male breast in Ile-Ife, Nigeria.

Carcinoma of the male breast is said to be rare. A review of the records at the histopathology laboratory of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, confirms the universal assertion that carcinoma of the male breast is very rare. In over nineteen years of its existence, the laboratory recorded only 10 cases of carcinoma of the male breast. This gives an incidence rate of 1.9% of a total of 513 cases affecting both male and female breasts. All cases were infiltrating ductal carcinoma: there were two cases of papillary, one each of colloid and clear cell carcinoma while the remaining were "not otherwise specified". The age range was 40-80 years with an average of 56.9 years. There was left-sided preponderance with eight cases in the left breast and two cases in the right breast. Six cases had evidence of metastasis either at the time of initial diagnosis or some months after simple mastectomy.

Benign disease of the breast in Ile-Ife: a 10 year experience and literature review.

This study is a 10 year review of the benign diseases of the breast in Ile-Ife, Nigeria. A total of 362 cases were found. Three hundred and forty (95%) of the diseases occurred in females while 18 (5%) occurred in males giving a female-male ratio of 19:1. Fibroadenoma was the commonest lesion followed by fibrocystic disease. They accounted for 59.1% and 16.5% of benign breast diseases respectively. Acute and acute-on-chronic mastitis constituted 7.2%. These three lesions made up over 82% of the cases. Gynaecomastia was the commonest benign male breast disease and accounted for 3.8% of all the cases of benign breast disease. Apart from the atypical hyperplasia form of fibrocystic disease, benign diseases of the breast are not major predisposing lesions to malignant breast diseases.