Exploring serum and immunoglobulin G N-glycome as diagnostic biomarkers for early detection of breast cancer in Ethiopian women.

BACKGROUND: Alterations in protein glycosylation patterns have potentially been targeted for biomarker discovery in a wide range of diseases including cancer. Although there have been improvements in patient diagnosis and survival for breast cancer (BC), there is no clinically validated serum biomarker for its early diagnosis. Here, we profiled whole serum and purified Immunoglobulin G (IgG) fraction N-glycome towards identification of non-invasive glycan markers of BC. METHODS: We employed a comprehensive glycomics approach by integrating glycoblotting-based glycan purification with MALDI-TOF/MS based quantitative analysis. Sera of BC patients belonging to stages I-IV and normal controls (NC) were collected from Ethiopian women during 2015-2016. IgG was purified by affinity chromatography using protein G spin plate and further subjected to glycoblotting for glycan release. Mass spectral data were further processed and evaluated rigorously, using various bioinformatics and statistical tools. RESULTS: Out of 35 N-glycans that were significantly up-regulated in the sera of all BC patients compared to the NC, 17 complex type N-glycans showed profound expression abundance and diagnostic potential (AUC = 0.8-1) for the early stage (I and II) BC patients. Most of these glycans were core-fucosylated, multiply branched and sialylated structures, whose abundance has been strongly associated with greater invasive and metastatic potential of cancer. N-glycans quantified form IgG confirmed their abundance in BC patients, of which two core-fucosylated and agalactosylated glycans (m/z 1591, 1794) could specifically distinguish (AUC = 0.944 and 0.921, p ≤ 0.001) stage II patients from NC. Abundance of such structural features in IgG is associated with a decrease in its immunosuppressive potential towards tumor cells, which in part may correlate with the aggressive nature of BC commonly noticed in black population. CONCLUSIONS: Our comprehensive study has addressed for the first time both whole serum and IgG N-glycosylation signatures of native black women suffering from BC and revealed novel glyco-biomarkers with marked overexpression and distinguishing ability at early stage patients. Further studies on direct identification of the intact glycoproteins using a glycoprteomics approach will provide a deeper understanding of specific biomarkers towards their clinical utility.

Cervical cancer in Ethiopia: survival of 1,059 patients who received oncologic therapy.

BACKGROUND: Almost 500,000 women are newly diagnosed with cervical cancer (CC) every year, the majority from developing countries. There is little information on the survival of these patients. Our primary objective was to evaluate consecutive CC patients presenting over 4 years at the only radiotherapy center in Ethiopia. METHODS: All patients with CC from September 2008 to September 2012 who received radiotherapy and/or surgery were included (without brachytherapy). Vital status was obtained through telephone contact or patient cards. RESULTS: Of 2,300 CC patients, 1,059 patients with standardized treatment were included. At the end of the study, 249 patients had died; surviving patients had a median follow-up of 16.5 months; the 10% and 90% percentiles were 3.0 and 32.7 months, respectively. Mean age was 49 years (21-91 years). The majority of patients presented with International Federation of Gynecology and Obstetrics stage IIb-IIIa (46.7%). Because of progression during the waiting time (median 3.8 months), this proportion declined to 19.3% at the beginning of radiotherapy. The 1- and 2-year overall survival probabilities were 90.4% and 73.6%. If assuming a worst-case scenario (i.e., if all patients not available for follow-up after 6 months had died), the 2-year survival probability would be 45.4%. CONCLUSION: This study gives a thorough 4-year overview of treated patients with CC in Ethiopia. Given the limited treatment availability, a relatively high proportion of patients survived 2 years. More prevention and early detection at all levels of the health care system are needed. Increasing the capacity for external-beam radiation as well as options for brachytherapy would facilitate treatment with curative intention.

The prevalence of estrogen receptor-negative breast cancer in Ethiopia.

BACKGROUND: In contrast with breast cancers (BCs) in other parts of the world, most previous studies reported that the majority of BCs in sub-Saharan Africa are estrogen-receptor (ER) negative. However, a recent study using the US SEER database showed that the proportion of ER-negative BC is comparable between US-born blacks and West-African born blacks but substantially lower in East African-born blacks, with over 74% of patients Ethiopians or Eritreans. In this paper, we provide the first report on the proportion of ER-negative BC in Ethiopia, and the relation to progesterone-receptor (PgR) status. METHODS: We analysed 352 female patients with ER results available out of 1208 consecutive female BC patients treated at Addis Ababa-University Hospital, Ethiopia, from June 2005 through December 2010. The influences of age, stage, and histology on the probability of ER-negative tumours were assessed by a log-linear regression model. RESULTS: Of the 352 patients, only 35% were ER-negative. The proportion of ER-negative tumours decreased with advancing age at diagnosis and was not affected by histology or stage. For age, the proportion decreased by 6% for each additional 5 years (stage-adjusted prevalence ratio PR=0.94, 95% CI: 0.89-1.00). About 31% were ER- and PgR-negative, and 69% were ER- and/or PgR-positive. CONCLUSIONS: Contrary to most previous reports in other parts of sub-Saharan Africa, the majority of patients in Ethiopia are ER-positive rather than ER-negative. These findings are in line with low proportions of ER-negative BCs from East African immigrants within the SEER database, and they have clinical implications for management of BC patients in Ethiopia and other parts of sub-Saharan Africa where ER-status is not ascertained as part of routine management of the disease. Since the majority of patients showed ER-positive BC, Tamoxifen-therapy should be given to all patients even with unknown ER status.

Left Ventricular Giant Aneurysm Caused by Congenital Syphilis Causing Severe Outflow Tract Obstruction.

We present the exceedingly rare case of an 18-year-old boy with recurrent syncope attacks and dyspnea at rest for 3 weeks. Transthoracic echocardiography showed a giant aneurysm dilatation occupying the left ventricular outflow tract. The intraoperative finding was a giant thick-walled unruptured aneurysm of the sinus of Valsalva from the right coronary cusp. The roof of the aneurysm was excised and the defect was repaired, sparing the aortic valve. Histopathology analysis from the roof of the wall of the aneurysm revealed features of endarteritis obliterans of the vasa vasora in keeping with syphilitic infection with aneurysmal dilation. A rapid plasma reagin test was reactive.

Mature Teratoma in the Right Ventricle.

We present an exceedingly rare case of right ventricular outflow tract obstructing mass in an adult patient who presented with dyspnea and dizziness. Transthoracic echocardiography and computed tomography angiogram of the chest showed a large mass in the right ventricle obstructing the outflow tract. A dual right ventriculotomy and right atriotomy surgical approach was taken to completely resect the mass from the interventricular septum, which subsequently confirmed histopathologically the mass as a mature cystic teratoma.

Diagnostic accuracy of Xpert MTB/RIF assay and non-molecular methods for the diagnosis of tuberculosis lymphadenitis.

BACKGROUND: Tuberculous lymphadenitis (TBLN) diagnosis remains a challenge in resource limited countries like Ethiopia. Most diagnostic centers in Ethiopia use smear microscopy, but it has low sensitivity in detecting tubercle bacilli in fine needle aspiration (FNA) specimens. FNA cytology (FNAC) is another widely applicable diagnostic option but it has low specificity for diagnosing TBLN. In 2014, WHO recommended Xpert MTB/RIF assay to be used in detecting TB from FNA specimen by considering the diagnostic limitations of microscopy and cytology. In Ethiopia, there is limited data on Xpert MTB/RIF performance in detecting TBLN from FNA. Therefore, this study aimed to evaluate the diagnostic performance of Xpert MTB/RIF assay and non-molecular methods (cytology, microscopy and culture) for the diagnosis of TBLN. METHODS: A cross-sectional study was conducted on 152 presumptive TBLN patients at St. Paul's Hospital Millennium Medical College (SPHMMC) from December 2015 to May 2016 in Addis Ababa, Ethiopia. FNA specimens were collected from each patient. Individual patient specimens were examined by microscopy (acid fast and auramine O staining), cytology, Xpert MTB/RIF and culture. Each specimen was directly inoculated and its sediment following decontamination procedure onto two duplicate Löwenstein-Jensen (LJ) media. Composite culture (specimen positive by direct or concentrated or both culturing methods) and composite method (positive by either one of the non-molecular methods) were taken as reference methods. The data was captured and analyzed using software packages SPSS version 20 (SPSS Inc, Chicago, Illinois, USA). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. RESULT: A total of 152 presumptive TBLN patients were enrolled in this study. Of these, 105(69%), 68(44.7%), 64(42%), 48(32%) and 33(22%) were positive for M. tuberculosis using composite method (positive by either one of the non-molecular method), composite culture, direct, and concentrated culture, respectively. TB positivity rate was 67.8%, 49.3%, 24.3%, and 14.5% using cytology, Xpert MTB/RIF, Auramine O (FM) microscopy, and Ziehl Nelson (ZN) microscopy, respectively. Using composite culture as reference, the sensitivity and specificity of Xpert MTB/RIF was 78% (95% CI: 73.7% to 82.3%) and 74% (95%CI: 69.4% to 78.6%), respectively. However, the sensitivity of Xpert MTB/RF improved from 78% to 92% using composite method as a reference. The high positivity rate observed in purulent (70%) followed by caseous (66.7%) type of aspirates by Xpert MTB/RIF. CONCLUSION: Xpert MTB/RIF assay has both considerable sensitivity and specificity; it may be employed for better diagnosis, management and treatment of presumptive TBLN patients.

One Hundred Skull Base Meningiomas Operated at Black Lion Specialized Hospital, Addis Ababa, Ethiopia.

OBJECTIVE: After 10 years of training in their home country, neurosurgeons at Black Lion Specialized Hospital (Addis Ababa, Ethiopia) operated on skull base meningiomas independent of their external teachers. The present study used a retrospective design of an in-hospital series with short-term follow-up. METHODS: A total of 100 patients (mean age, 40.2 years; 80% women) had undergone surgery for skull base meningiomas from 2016 to 2017. Their symptoms included headache in 90%, impairment of vision in 47%, gait impairment in 25%, cognitive dysfunction in 29%, and seizures in 18%. Of the 100 tumors, 44% had a diameter >50 mm. Microsurgery was performed using the Hudson drill, Gigli saw, and conventional microsurgical instruments. RESULTS: A total of 59 complications in 39 patients occurred. Eleven patients had died within 3 months postoperatively. The cranial infection rate was 14%. The rate of Simpson grade I and II was 63%. We present the 3-12-month outcomes for 84 of the 100 patients. Of the 16 remaining patients, 4 were lost to follow-up (mean, 6.7 months) and 12 had died. Headache was noted in 65 of 74 patients preoperatively and in 20 during follow-up. Overall, 33 patients reported better vision, 48 reported similar vision, and 3 patients reported worse vision. Finally, 20 patients had gait difficulties preoperatively and 9 reported impaired gait during follow-up. CONCLUSION: A young faculty of neurosurgeons in a low income country was trained to perform neurosurgery for skull base meningiomas. The patients had presented at a young age with severe disabilities due to advanced disease. Surgery led to symptom improvement in a large proportion of patients; however, the complication and mortality rates were high.

Prevalence of human papillomavirus and Helicobacter pylori in esophageal and gastroesophageal junction cancer biopsies from a case-control study in Ethiopia.

BACKGROUND: Ethiopia lies in the high-risk corridor of esophageal squamous cell carcinoma in East Africa, where individuals with this malignancy often do not report established risk factors, suggesting unidentified etiologies. Here, we report the prevalence of mucosal human papillomavirus (HPV) and of Helicobacter pylori (H. pylori) detection in endoscopy-obtained esophageal and gastroesophageal junction biopsies and in oral cell specimens taken at the time of esophageal cancer diagnosis in a case-control study in Addis Ababa, Ethiopia. METHODS: DNA extraction was performed from fresh frozen tissue and oral cell pellets obtained with saline solution gargling subsequently fixed with ethanol. Mucosal HPV and H. pylori DNA was detected using highly sensitive assays that combine multiplex polymerase chain reaction and bead-based Luminex technology. The proportions of specimens testing positive were expressed as percentages, with binomial 95% confidence intervals. Agreement of results between tissue biopsy and oral cell specimens was estimated using the kappa statistic. Comparison of study participants' characteristics by test results was done using the Pearson chi-square test. RESULTS: HPV DNA was detected in 1 of 62 tumor specimens (2, 95% confidence interval (CI): 0-9%), corresponding to HPV16 type. HPV DNA was detected in the oral cavity of 7 cases (11, 95% CI: 5-22%) and 4 of 56 matched healthy controls (7, 95% CI: 2-17%), with multiple HPV types detected. Detection of H. pylori DNA was 55% (95% CI: 42-68%), and 20 of 34 H. pylori-positive specimens (59, 95% CI: 41-75%) were positive for the cagA gene. Agreement of detection rates between tissue and oral cells in cases was poor for HPV and for H. pylori. CONCLUSIONS: The prevalence of mucosal-type HPV was very low, whereas H. pylori was more commonly detected, with a high proportion testing positive for the pro-inflammatory gene cagA. These novel findings remain to be replicated in larger studies and with the addition of serological determinations to better understand their biological significance in the context of esophageal and gastroesophageal junction cancers.

Vulvar cancer in Ethiopia: A cohort study on the characteristics and survival of 86 patients.

Vulvar cancer (VC) is strongly associated with human papilloma virus (HPV) infections and immunosuppression (e.g., HIV). However, there is limited information on VC patient characteristics and survival in parts of sub-Saharan Africa, including Ethiopia, where chronic HPV and HIV infections are prevalent. The aim of this study is to provide a first view on VC patient characteristics in a sub-Saharan African setting.We present a retrospective analysis of records of 86 VC patients diagnosed between January 2010 and October 2015 at Addis Ababa University Hospital and other major health facilities in Ethiopia. Follow-up for vital status was obtained by telephone contact with patients or relatives. The primary endpoint was all-cause mortality.The median age of the patients was 39 (range: 20-85) years, 83% with known HIV status were positive and 81% presented with FIGO stages 2 or 3. The median follow-up time for surviving patients was 17 months (range: 0.1-65.0 months). The 1- and 2-year survival rates were 80% and 51%, respectively. Approximately 37% of patients received surgery, 38% received radiotherapy, and 33% received chemotherapy. Patients who received therapy had better survival than those who did not [adjusted hazard ratios: surgery, 0.44 (95% CI, 0.19-1.03); radiotherapy, 0.36 (95% CI, 0.14-0.90); chemotherapy, 0.42 (95% CI, 0.15-1.12)].A substantial proportion of VC patients in Ethiopia present at a late stage and receive suboptimal treatment. HIV infections appear to be a common comorbid condition. These conditions result in poor outcomes.

Qat use and esophageal cancer in Ethiopia: A pilot case-control study.

BACKGROUND: Qat (Catha edulis) chewing is reported to induce lesions in the buccal mucosa, irritation of the esophagus, and esophageal reflux. Case series suggest a possible etiological role in oral and esophageal cancers. This pilot study aimed to generate preliminary estimates of the magnitude and direction of the association between qat use and esophageal cancer (EC) risk and to inform the logistics required to conduct a multi-center case-control study. METHODS: Between May 2012 and May 2013, 73 EC cases (including 12 gastro-esophageal junction cases) and 133 controls matched individually on sex, age, and residence were enrolled at two endoscopy clinics and a cancer treatment hospital in Addis Ababa. A face-to-face structured questionnaire was administered. Qat use was defined as ever having chewed qat once a week or more frequently for at least one year. Odds ratios were calculated using conditional logistic regression. RESULTS: Only 8% of cases resided in Addis Ababa. Qat use was more frequent in cases (36%) than in controls (26%). A 2-fold elevation in EC risk was observed in ever qat chewers compared with never users in unadjusted conditional logistic regression (OR = 2.12; 95% CI = 0.94, 4.74), an association that disappeared after adjusting for differences in tobacco use, consumption of alcohol and green vegetables, education level, and religion (OR = 0.95; 0.22, 4.22). Among never tobacco users, however, a non-significant increase in EC risk was suggested in ever qat users also after adjustment. Increases in EC risk were observed with ever tobacco use, alcohol consumption, low consumption of green vegetables, a salty diet, illiteracy, and among Muslims; the four latter associations were significant. CONCLUSIONS: This pilot study generated EC risk estimates in association with a habit practiced by millions of people and never before studied in a case-control design. Results must be interpreted cautiously in light of possible selection bias, with some demographics such as education level and religion differing between cases and controls. A large case-control study with enrolment of EC cases and carefully matched controls at health facilities from high-risk areas in the countryside, where the majority of cases occur, is needed to further investigate the association between qat use and EC.

Building capacity in laboratory medicine in Africa by increasing physician involvement: a laboratory medicine course for clinicians.

OBJECTIVES: To describe a 4-day laboratory medicine course for clinicians given at Addis Ababa University, Ethiopia, designed to improve the use of laboratory-based diagnoses. METHODS: Each day was dedicated to one of the following topics: hematology, blood bank/transfusion medicine and coagulation, chemistry, and microbiology. The course included lectures, case-based learning, laboratory tours, and interactive computer case-based homework. The same 12-question knowledge quiz was given before and after the course. RESULTS: Twenty-eight participants took the quiz before and 21 after completing the course. The average score was 5.28 (range, 2-10) for the initial quiz and 8.09 (range, 4-11) for the second quiz (P = .0001). Two of 12 and 8 of 12 questions were answered correctly by more than 60% of trainees on the initial and second quiz, respectively. CONCLUSIONS: Knowledge and awareness of the role of the laboratory increased after participation in the course. Understanding of laboratory medicine principles by clinicians will likely improve use of laboratory services and build capacity in Africa.

Peripheral primitive neuroectodermal tumor presenting in the retroperitoneum: a case report with immunohistochemical study.

It is now believed that malignant peripheral primitive neuroectodermal tumor (PNET) form a distinct tumor entity from other malignant small round cell tumors exhibiting neuroectodermal differentiation by morphologic, immunohistochemical or electron microscopic analyses. A 17-year-old Ethiopian boy was found to have a big upper extra osseous retroperitoneal tumor mass not associated with peripheral nerve that had infiltrated the body of the pancreas. Histologic sections from excised biopsy showed neoplastic cells with a high nuclear-cytoplasmic ratio and had an indistinct cytoplasm with numerous Homer-Wright rosettes. Immunohistochemically, isolated tumor cells and the centre of rosettes disclosed strong positivity to neural markers, synaptophysin and chromogranin. To the best of our knowledge, this case report represents the first patient described in Ethiopia.

Upper gastrointestinal endoscopy: a review of 10,000 cases.

A total of 10,000 patients underwent upper gastrointestinal endosopy examination between August 1979 and October 1994 at Tikur Anbessa Hospital, Addis Ababa. The major indications were dyspepsia (59.4%), upper gastrointestinal bleeding (18%) and liver disease (10.8%). The other indications include dysphagia (2.2%), gastric outlet obstruction (2.1%), postoperative dyspeptic symptoms (1.9%), weight loss and/or anemia (1.4%), epigastric mass (0.6%) and odynophagia 0.2%. The mean age of the patients and their sex ratio was 36 years and 2:1, respectively. Twenty eight percent of the patients had normal findings. The commonest abnormal findings include duodenal ulcer (41%), esophageal varices (9%), acute gastritis (6%), duodenitis (3.4%), and reflux esophagitis (2.3%). Benign gastric ulcer was rare. The ratio of duodenal ulcer to gastric ulcer was 19.1%. Duodenal ulcer (45.6%), esophageal varices (15.6) and acute gastritis (5.7%) were found to be the commonest causes of upper gastrointestinal bleeding. The endoscopy or histology diagnosis of cancer in both the esophagus and stomach was 2.8% and 1.3%, respectively. The agreement between endoscopy and histology in the diagnosis of esophageal and gastric cancer was 80%. There was no major complication related to endoscopy or premeditation. Endoscopy is a fairly accurate and safe procedure and therefore should be available and applied widely for the diagnosis of upper gastrointestinal diseases in Ethiopia.

True hermaphrodite: very unusual type.

True hermaphrodite is one of the rare gonadal as well as genital abnormality due to a defect in sexual differentiation. Here, we are reporting the most unusual type of true hermaphrodite diagnosed at the age of 25 years during operation for undescended testis, presenting as a case of infertility and failure to ejaculate during sexual intercourse. The patient was found to have grossly as well as histologically proven left ovary, left fallopian tube and uterus as well as a well descended left testis, with totally absent either right fallopian tube and ovary or testis. Thus, this is unusual finding to ratify the occurrence of true hermaphrodite in the absence of ambiguous external genitalia.

Most common causes of natural and injury-related deaths in Addis Ababa, Ethiopia.

In Ethiopia, like many developing countries, autopsy is rare unless conducted in the medico-legal arena, making vital statistics that include pathological diagnoses sparse. To determine the most common factors contributing to death among individuals who died from natural or injury-related events in Ethiopia 200 consecutive autopsies were conducted in 2006 at the Forensic Medico-legal Pathology Department, Menelik II Hospital, Addis Ababa, Ethiopia. The results describe significant pathological observations, putative cause of death, age distribution, and gender ratios. Eighty-one percent of the cases were male, and the mean age was 38.9 (+/-15.5 years). Fifty-two percent of the individuals died from natural causes, including infections, and 48% died from injury-related events. In the natural deaths group, as determined by gross examination at autopsy pulmonary complications were the most commonly reported cause of death, with suspected tuberculosis accounting for 12%. Tuberculosis (21, 8%) and liver disease (14, 5%) were the most common histopathological findings in the natural and injury-related causes groups, respectively. In the injury-related group, automobile accident was the most common cause of accidental death (80%), and homicide by beating was the most common cause of death in the intentional injury group (31%). These data provide valuable unbiased analyses of causes of death among individuals in Addis Ababa, Ethiopia.