Characteristics, management, and outcomes of patients with hepatocellular carcinoma in Africa: a multicountry observational study from the Africa Liver Cancer Consortium.

BACKGROUND: Hepatocellular carcinoma is a leading cause of cancer-related death in Africa, but there is still no comprehensive description of the current status of its epidemiology in Africa. We therefore initiated an African hepatocellular carcinoma consortium aiming to describe the clinical presentation, management, and outcomes of patients with hepatocellular carcinoma in Africa. METHODS: We did a multicentre, multicountry, retrospective observational cohort study, inviting investigators from the African Network for Gastrointestinal and Liver Diseases to participate in the consortium to develop hepatocellular carcinoma research databases and biospecimen repositories. Participating institutions were from Cameroon, Egypt, Ethiopia, Ghana, Ivory Coast, Nigeria, Sudan, Tanzania, and Uganda. Clinical information-demographic characteristics, cause of disease, liver-related blood tests, tumour characteristics, treatments, last follow-up date, and survival status-for patients diagnosed with hepatocellular carcinoma between Aug 1, 2006, and April 1, 2016, were extracted from medical records by participating investigators. Because patients from Egypt showed differences in characteristics compared with patients from the other countries, we divided patients into two groups for analysis; Egypt versus other African countries. We undertook a multifactorial analysis using the Cox proportional hazards model to identify factors affecting survival (assessed from the time of diagnosis to last known follow-up or death). FINDINGS: We obtained information for 2566 patients at 21 tertiary referral centres (two in Egypt, nine in Nigeria, four in Ghana, and one each in the Ivory Coast, Cameroon, Sudan, Ethiopia, Tanzania, and Uganda). 1251 patients were from Egypt and 1315 were from the other African countries (491 from Ghana, 363 from Nigeria, 277 from Ivory Coast, 59 from Cameroon, 51 from Sudan, 33 from Ethiopia, 21 from Tanzania, and 20 from Uganda). The median age at which hepatocellular carcinoma was diagnosed significantly later in Egypt than the other African countries (58 years [IQR 53-63] vs 46 years [36-58]; p<0·0001). Hepatitis C virus was the leading cause of hepatocellular carcinoma in Egypt (1054 [84%] of 1251 patients), and hepatitis B virus was the leading cause in the other African countries (597 [55%] of 1082 patients). Substantially fewer patients received treatment specifically for hepatocellular carcinoma in the other African countries than in Egypt (43 [3%] of 1315 vs 956 [76%] of 1251; p<0·0001). Among patients with survival information (605 [48%] of 1251 in Egypt and 583 [44%] of 1315 in other African countries), median survival was shorter in the other African countries than in Egypt (2·5 months [95% CI 2·0-3·1] vs 10·9 months [9·6-12·0]; p<0·0001). Factors independently associated with poor survival were: being from an African countries other than Egypt (hazard ratio [HR] 1·59 [95% CI 1·13-2·20]; p=0·01), hepatic encephalopathy (2·81 [1·72-4·42]; p=0·0004), diameter of the largest tumour (1·07 per cm increase [1·04-1·11]; p<0·0001), log α-fetoprotein (1·10 per unit increase [1·02-1·20]; p=0·0188), Eastern Cooperative Oncology Group performance status 3-4 (2·92 [2·13-3·93]; p<0·0001) and no treatment (1·79 [1·44-2·22]; p<0·0001). INTERPRETATION: Characteristics of hepatocellular carcinoma differ between Egypt and other African countries. The proportion of patients receiving specific treatment in other African countries was low and their outcomes were extremely poor. Urgent efforts are needed to develop health policy strategies to decrease the burden of hepatocellular carcinoma in Africa. FUNDING: None.

Appropriate use and diagnostic yield of upper gastrointestinal endoscopy in a tertiary referral hospital.

BACKGROUND AND STUDY AIMS: This is a prospective, descriptive, hospital-based study to evaluate the appropriateness and diagnostic yield of upper gastrointestinal (GI) tract endoscopy referrals to Soba University Hospital endoscopy unit using the American Society for Gastrointestinal Endoscopy guidelines for appropriate use of endoscopy. PATIENTS AND METHODS: All patients referred to Soba University Hospital for upper GI endoscopy during the study period were enrolled in the study after giving an informed consent. Statistical analysis was done using the Statistical Package for Social Sciences (SPSS) program to calculate frequencies and the X(2) test; P value was taken as significant at a level of less than 0.05. RESULTS: Overall, 220 patients were prospectively enrolled in the study, of which 126 (57%) were males, with a mean age of 46.5 ± 17.9 years. A total of 190 patients (86%) were appropriately referred and the overall diagnostic yield was 46.8%. Those with appropriate referral had a higher diagnostic yield (50%) when compared to those with inappropriate referral (23%). CONCLUSION: The diagnostic yield of upper GI endoscopy was higher when patients were referred appropriately indicating that detection of relevant finding is greatly enhanced by the utilisation of standard guidelines.

Epidemiology of HCV infection in Gezira state of central Sudan.

This is a cross sectional study carried out in Gezira state of central Sudan, an area with a high prevalence of Schistosoma mansoni infection, to determine the prevalence of hepatitis C virus (HCV) antibodies and risks factors for HCV infection. A total of 410 subjects in Um Zukra village were tested for HCV antibodies, 2.2% were reactive. The prevalence was highest in those between 11 and 20 years old with equal prevalence among males and females. No correlation was found between HCV infection and S. mansoni infection or parenteral antischistosomal therapy. It was concluded that HCV infection is of low seroprevalence and that schistosomiasis and parenteral antischistosomal therapy are not major risk factors for infection in the population studied.

Schistosomal colitis without granuloma formation in a kidney transplant recipient.

BACKGROUND: A 40-year-old male from the White Nile region in Sudan, who had received a kidney transplant 6 years previously, presented with fever, lower abdominal pain and diarrhea stained with blood of 5 months duration. He was on immunosuppressive maintenance therapy, consisting of ciclosporin 75 mg twice daily, prednisolone 10 mg once daily, and azathioprine 75 mg once daily. INVESTIGATIONS: Laboratory investigations, liver function tests, renal function tests, stool microscopy, stool culture, abdominal ultrasound, and colonoscopy. DIAGNOSIS: Severe, left-sided colitis due to Schistosoma mansoni infection, without granuloma formation. MANAGEMENT: Oral antischistosomal therapy with praziquantel at a dose of 40 mg/kg body weight.