Positive tumor margins in wide local excision of breast cancer: a 10-year retrospective study

Background. The safety of wide local excision as a standard surgical option for early stage breast cancer management in Ghana has not been evaluated. The aim of this study was to use retrospective histopathological descriptive study to evaluate the prevalence of positive tumor margins in wide local excision specimens and offer recommendations. Study design. We reviewed 147 breast lumps; following wide local excision; which were received in the Department of Pathology; for positive tumor margins. The data was analyzed using SPSS software (version 16). Results. A total of 2;751 female breast cancers were diagnosed during the study period; of which 147 (5.3%) were from wide local excisions (lumpectomies). Thirty-one (21.0%) had positive tumor margins. The mean age of women with positive margins was 53.4 (SD = 17.1) years. The mean size of primary tumor was 4.0 (SD = 2.1) cm; the majority (53.0%) of which were greater than 2.0?cm; but less than or equal to 5.0?cm (T2). A total of 26 (83.4%) of these tumors were invasive ductal carcinomas (NOS); 24 (92.3%) of the cases had combined Bloom-Richardson grading; and many; 10 (41.7%); were grade 1. Conclusion. Our study shows that 21.0% of all wide local excision biopsies had positive tumor margins; a figure that is comparable to those of other studies. Tumors with positive margins in this study were large; 4.0?cm (T2); and common in relatively young women. Treatment failure is therefore likely to occur in these patients

Pattern of breast diseases in Accra: review of mammography reports.

OBJECTIVES: To document the mammographic patterns in females seeking medical attention in Accra. DESIGN: An analytic retrospective study was conducted using data extracted from mammography request forms and corresponding radiological reports of 180 females. SETTING: The radiology departments of Korle-Bu Teaching Hospital the Trust Hospital and Medical Imaging Ghana all located in Accra. RESULTS: One hundred and eighty radiologic request forms for mammographic evaluations and their corresponding reports from the study period were reviewed. The mean age of the study population was 48.7 years (SD=10.0), and the median age group was the 41-50 group. There were more screening mammography evaluations (115 examinations) than diagnostic mammography evaluations (65 examinations). Most of the cases diagnosed as breast cancer were in the age group 41-50 years. Benign lesions were commoner than cancer (55 and 16 cases respectively). The commonest presenting complaint was of pain. CONCLUSION: The larger number of screening mammographic evaluations conducted for asymptomatic females during the study period, as compared to diagnostic mammographic evaluations for symptomatic females, suggests that educational programs on early breast cancer detection are having a positive impact on the target population. The observation that 22.8% of lesions had features suggestive of breast cancer in the study is significantly high to also warrant intensification of the existing awareness programs. As non-specific masses were the most common radiographically observed lesions, hospitals equipped with sonography and biopsy facilities that compliment their mammography are better suited for thorough breast disease evaluation.

Appropriateness of referrals for upper gastrointestinal endoscopy.

BACKGROUND: Uncomplicated dyspepsia has a low predictive value in diagnosing upper gastrointestinal organic disease making early endoscopy essential. OBJECTIVE: To assess the reliability of clinical information in the diagnosis of organic disease in patients referred for upper gastrointestinal endoscopy. METHODS: Patients who were referred for gastroscopy to the Korle Bu Teaching Hospital, in Accra between January and December, 2008 were interviewed and evaluated for this study. The patients' clinical data were correlated with the endoscopic findings to determine how appropriate the referrals were, based on the clinical information. RESULTS: One thousand, six hundred and forty three patients were studies of whom 372 presented with alarm symptoms. Uncomplicated dyspepsia was the principal presenting symptom in 1271 patients. Overall, 522 (31.8%) patients had organic disease, 440 (26.8%) inflammatory conditions and 681 (41.4%) were negative endoscopies. Two hundred and nine (56.2%) patients with alarm symptoms and 313 (24.6%) without alarm symptoms (p value, OR, 95% CI; <0.001, 3.92, 3.083-5.00) had organic disease. Presentations with bleeding and suspicion of malignancy showed statistical significance with the finding of organic disease while anaemia did not. Dyspepsia was strongly associated with negative endoscopy, 84% vrs 60%, p value <0.001. Gastric malignancies were associated with age 50 years and above. The three common benign diseases of peptic ulcer, gastric ulcer and gastritis showed strong similarity in presentation and were unpredictable clinically. CONCLUSION: Patients referred for endoscopy were young in whom there was a high prevalence of organic disease which were mostly benign.

Laparoscopic cholecystectomy at the Korle Bu Teaching Hospital, Accra, Ghana: an initial report.

BACKGROUND: Laparoscopic cholecystectomy (LC) the preferred treatment for gallstones was not available in Ghana until 2005. OBJECTIVE: To report experience from Ghana of laparoscopic cholecystectomy in the treatment of galestones. METHODS: In a prospective study of patients with gallstones, information was obtained on demography, duration of various stages of the operation, analgesia and complication of patients with gallstones. All patients had general anaesthesia using endotracheal intubation, muscle relaxant and intermittent positive pressure ventilation. A standard four-trocar technique and maximum pneumoperitoneum pressure of 14 mmHg were maintained during surgery. RESULTS: There were 50 women and two men aged 17-72 years (mean 44.2 years). All had symptomatic gallstones treated by interval LC. The main indications were biliary colic 23(44%) and previous cholecystitis 15(29%). There were scars from previous abdominal surgery in 22 (42%), mainly pfannenstiel. The Verres needle was used to obtain pneumoperitoneum in 40 (77%). Only one patient (1.9%) had the operation converted to open cholecystectomy. Most patients, 47/51 (92%), were discharged in 24 hours. The mean durations of various stages were: anaesthesia (110 minutes), pneumo-peritoneum (67.5 minutes) and reverse trendelenburg (47.8 minutes). The mean operating time reduced from 81 to 68 minutes in the last 20 patients. Complications were sore throat 11(21.6%), infection of the umbilical wound 3(5.9%), right shoulder tip pain (3; 5.9%) and bile leak 1(2%). There was no peri-operative mortality. CONCLUSION: Elective laparoscopic cholecystectomy can be performed with good results in patients with symptomatic gallstones in Accra.

Profile of breast diseases at a self-referral clinic in Ghana.

BACKGROUND: Breast cancer is a common malignancy in Ghana, and many patients are referred with advanced disease and long duration of symptoms. OBJECTIVE: To determine the spectrum of breast disease diagnosed through patient self-referral in Ghana. METHODS: A breast clinic, where patients could walk in without referral, was started in the Korle Bu Teaching Hospital in 2001. A team of surgeons, radiation oncologists, oncology nurses, a clinical psychologist and a clinical pharmacist sat in conference once a week to see and discuss self-referred patients. RESULTS: Seven hundred and forty eight patients, mean age 38.6 (range 8-85) years, were seen during a four-year period. There were 741 females and seven males. The main complaints were pain 450 (50.2%), lump 257 (28.7%) and nipple discharge 62 (8.3%). Fifty (5.6%) came for check-up; 139 (18.6%) had more than one complaint. The mean (S.D.) duration of symptoms was; for nipple discharge 14.1 (10.5) months, lump 11.9 (7.7) months, and pain 11.3 (8.9) months. The main diagnoses were: Normal breasts 192 (27.7%), mastalgia 135 (18.1%), fibroadenosis 114 (15.2%), fibroadenomas 84 (11.2%), breast cancer 58 (7.8%), suspected breast cancer 25 (3.3%), galactorrhea 9 (1.2%), mastitis 8 (1.1%), musculoskeletal pain 8 (1.1%), duct ectasia 8 (1.1%), mondor's disease 7 (0.94%) and recurrent breast cancer 6 (0.8%). In patients with breast cancer, 42 (66%) had advanced disease, 6 (9.4%) had recurrent disease and 4 (63%) had metastatic disease. CONCLUSION: The number of self-referrals, detected breast cancers and duration of symptoms justify the need for self-referral clinics in Ghana.

Gastro-duodenal peptic ulcer perforation.

OBJECTIVES: To determine the epidemiology of, and define the morbidity and mortality factors following emergency surgery for patients with perforated peptic ulcer disease in Accra, Ghana. DESIGN: A retrospective and prospective hospital-based study. SETTING: The general and paediatric surgical wards of the Korle-Bu Teaching Hospital. MAIN OUTCOME MEASURES: Demography, the systolic BP, pulse rate and haemoglobin on admission at ER, co-morbid conditions, site of perforation, surgical method and treatment outcome. SUBJECTS: A total of 326 cases treated for peptic ulcer perforation, 267 males and 59 females; ratio 4.5:1, with mean age of 40.9, SD 16.4 and range 4-87 years, were studied. RESULTS: The incidence of peptic ulcer perforation rose from 1.6% in 1998 to 5.3% in 2002 and stabilised at 5%, and overall accounted for 4.6% of acute abdomen. Co-morbid conditions were present in 48 (18.2%) of cases. Ulcerogenic substance intake was in 177 (67%) patients. One hundred and twenty two (46.2%) patients reported to hospital within 24 hours of perforation. There were 287 (88%) duodenal, 22 (7.1%) prepyloric, and 19(4.9%) type 1 gastric ulcer perforations. Simple closure with omental patch was performed in 299 (94.3%), truncal vagotomy and drainage in 10 (3.2%), and Billroth II partial gastrectomy in seven (2.2%). Post-operative complications occurred in 62 (19%); overall mortality was 36 (11%). Logistic regression analysis of the patients clinical variables showed that age less that 60 years (p-value, OR and 95% CI; 0.002, 3.964 and 1.668-9.420), duration of perforation of more than 24 hours before admission (p-value, OR and 95% CI; 0.011, 2.471 and 1.228-4.971), alcohol intake (p-value, OR and 95% CI; 0.009, 2.543 and 1.259-5.135) and resectional surgery (p-value, OR and 95% CI; 0.000, 8.25E and 74204908.138-9162648048.1) were statistically significant in determining postoperative complications. Age 60 years and above (p-value, OR and 95% CI; 0.018,4.359 and 1.284-14.802), alcohol intake (p-value, OR and 95% CI; 0.042, 3.238 and 1.046-10.021) and resectional surgery (p-value, OR and 95% CI; 0.000, 1.20E and 938112920.94-1.54E+ 11) were the factors that showed statistical significance in determining post-operative mortality. CONCLUSION: Perforated peptic ulcer disease is emerging as a frequent cause of acute abdomen in our centre and affects the youth commonly. Age 60 years and above, duration of perforation for more than 24 hours before admission, alcohol intake and resectional surgery were the variables that showed statistical significance in predicting post-operative morbidity and/or mortality.

Psychosocial aspects of breast cancer treatment in Accra, Ghana.

OBJECTIVES: To evaluate psychosocial influences and effects of breast cancer treatment. DESIGN: Cohort questionnaire survey. SETTING: Surgical Outpatient Department, Korle Bu Teaching Hospital (KBTH), Accra, Ghana. SUBJECTS: Women previously treated for breast cancer, including those still on hormonal therapy. MAIN OUTCOME MEASURES: Perception of quality of treatment and psychosocial support; and patients' felt needs for alternative treatment. RESULTS: Eighty nine women treated one to 22 years previously were interviewed. The majority (86%) had mastectomy. Chemotherapy was the most unpleasant aspect of treatment in 58 (65.2%), and 27 (30.3%) were not warned about complications of treatment. Thirty eight (42.7%) reported being afraid (frightened or terrified) at the diagnosis; other reactions were shock, devastation, weeping and depression. Twenty two (24.7%) received no counselling and 15 (18.5%) did not have opportunity to express their fears of death 55 (61.8%), mastectomy/deformity 27 (30.3%) and financial incapability 23 (25.8%). Forty four (49.4%) used alternate 'treatment', mainly prayer camps (25 cases) and herbs (22 cases), before and during hospital treatment. Use of alternate treatment led to delays in treatment in 23 women. They had complaints about the care they received: lack of sympathy and emotional support (16 cases), lack of information and communication (13 cases), lack of counselling (9 cases) and slow processes (8 cases). CONCLUSIONS: Many patients utilise prayer camps and herbs leading to delays in treatment. Breast cancer patients in Ghana (West Africa) are not receiving satisfactory emotional support, communication and counseling. Adequate psychosocial interventions need to be implemented.

Breast cancer risk in patients with breast pain in Accra, Ghana.

OBJECTIVE: To determine the risk of breast cancer in patients presenting with breast pain in Accra, Ghana. DESIGN: Retrospective clinical study. SETTING: A self-referral breast clinic in Accra, Ghana. SUBJECTS: Patients with breast pain as a presenting complaint, between January 2001 and December 2005. INTERVENTIONS: Patients were investigated by triple assessment. RESULTS: There were 447 patients with pain, 322 as the only symptom and 125 in addition to other symptoms like breast lump and nipple discharge. Patients with pain only were found to have no detectable abnormality 203 (63%) and fibroadenosis 78 (24.2%) as the most common diagnoses. Breast cancer was found in four (1.24%) of them, all of whom had abnormality on clinical breast examination. In patients with pain as well as other symptoms the common diagnoses were fibroadenosis 25 (20%), breast cancer 20 (16%) and normal 18 (14.4%). CONCLUSION: The risk of breast cancer is significantly higher in patients presenting with breast pain in addition to other symptoms, compared to patients with breast pain as the only symptom (16% and 1.24% respectively P < 0.0001). Patients with breast pain should always have breast examination and not simply reassured. Women should be encouraged to do breast self examination.

Comparison of four-day and ten-day post-mastectomy passive drainage in Accra, Ghana.

OBJECTIVES: To determine the optimum period for passive post-mastectomy drainage in Accra, Ghana, comparing early (day 4) to late (day 10) drain removal. DESIGN: Randomised prospective clinical study. SETTING: Surgical Department, Korle Bu Teaching Hospital, Accra, Ghana SUBJECTS: Patients with breast cancer scheduled for total mastectomy and level 11 axillary clearance. INTERVENTIONS: Patients were randomised to one of the two groups: early (day 4) and late (day 10) passive drainage. MAIN OUTCOME MEASURES: Duration of hospital stay, seroma formation and postoperative wound infection. RESULTS: Forty five patients had 4-day drainage and 42 had 10-day drainage. Late removal of drains (Day 10) was associated with a significantly higher drainage (1123ml) than those with early (4-day) drain removal (571 ml); p=0.0019. Late removal, however, had fewer seromas (28.6% vs. 46.7%; p=0.2), smaller aspirate volumes (435ml vs. 563ml) and fewer number of aspirations (2.1 vs. 3.2). Early removal had a shorter hospital stay of 6.2 (+/-1.52) days compared to 11.07 (+/- 0.76) days for late removal, and a lower wound infection rate (2.2% vs. 9.5%). There was a low incidence of seromas when drainage was <30 ml/day at the time of drain removal. CONCLUSIONS: Post-mastectomy passive drains may be removed when drainage is <30 ml in 24 hours. When there is a persistent large volume of axillary drainage, patients should be counselled about the relative risks of early and late drain removal. For patients who do not find seroma aspiration unacceptable, early (day 4) removal appears preferable to late (day 10) removal of drains.

Upper gastrointestinal endoscopy at the Korle Bu Teaching Hospital, Accra, Ghana

Objectives: To study the indications for endo-scopy, the endoscopic diagnosis and other lessons learnt.. Methods: A retrospective and prospective audit of all upper gastrointestinal endoscopies performed in the Endoscopy Unit of the Korle-Bu Teaching Hospital from January 1995 to December 2002 was performed. Results: A total of 6977 patients, 3777 males and 3200 females with age range 1 year 8 months to 93 years were endoscoped. The mean age of males was 43.5 + 0.5 and females 43.7 + 0.6 years. Epi-gastric pain (42.5%), dyspepsia (32.8%) and haematemesis and melaena (14.2%) were the commonest reasons for endoscopy. Chronic duo-denal ulcer (19.6%), acute gastritis (12.7%), duo-denitis (10.2%), oesophagitis (7.5%) were the commonest diagnoses. Normal endoscopy was reported in 41.1% patients, and was higher in the younger age group compared to the older (R = 0.973, P<0.001). Nine hundred and ninety (14.2%) patients were endoscoped for haematemesis and melaena of which chronic duodenal ulcer (32.1%), gastritis/gastric erosions (12.8%), oesophageal varices (9.8%), carcinoma of the stomach (6.4%), and duodenitis (4.2%), were the commonest causes. No lesion was found in 20.6% of these patients. Urease test was positive in 75% of all biopsy specimen and 85% in chronic duodenal ulcer, gastritis and duodenitis. Conclusion: The normal endoscopy rate is high and needs to be reduced in order to help prolong the lives of the endoscopes. Chronic duodenal ul-cer is usually associated with H. pylori infection and is the commonest cause of upper gastrointesti-nal bleeding

Position and susceptibility to inflammation of vermiform appendix in Accra, Ghana.

OBJECTIVES: To determine the normal (non-inflamed) position of the vermiform appendix in Ghana and carry out a pilot study to test the hypothesis "The retrocaecal appendix is less prone to inflammation". DESIGN: Retrospective autopsy study. SETTING: The pathology department and the department of surgery theatres of the Korle Bu Teaching hospital in Accra, Ghana SUBJECTS: Consecutive autopsies and inflamed appendices at appendicectomy. Deaths occurring from untreated appendicitis were excluded from the autopsy study. Conversely non-inflamed appendices and appendices from interval appendicectomy were excluded from the appendicitis study. RESULTS: There were 1358 autopsies and 323 inflamed appendices. In the autopsy study the retrocaecal position was the most common (914 [67.3%]). Other positions were pelvic (294 [21.6%]), preileal (66 [4.9%]), postileal (51 [3.8%]) and paracaecal (33 [2.4%]). These positions were similar in males and females. The positions of 323 inflamed appendices were: retrocaecal (183 [56.7%]), pelvic (66 [20.4%]), preileal (20 [6.2%]), postileal (15 [4.6%]) and paracaecal (39 [12.1%]). Comparing the nonretrocaecal to the retrocaecal position by chi square, the non-retrocaecal position was more prone to inflammation (p<0.001). CONCLUSION: The position of the normal appendix in Ghana differs from Western literature. The retrocaecal position appears less prone to inflammation in Ghanaians.

Eosinophilic enteritis--a diagnostic dilemma.

Eosinophilic enteritis is a rare condition of unknown aetiology, although it is generally believed to be due to intestinal allergy. It may mimic peptic ulcer, subacute (or chronic) intestinal obstruction, gastroenteritis, irritable bowel syndrome, and inflammatory bowel disease. The diagnosis is often difficult to make and most cases are only diagnosed after laparotomy/ laparoscopy and biopsy. It can be successfully treated with corticosteroids. We report a case of Eosinophilic enteritis in a 27 year old woman the symptoms of which appeared within six weeks of childbirth. With repeated episodes of abdominal pain, vomiting, occasional loose stools with weight loss, she was investigated and treated for many weeks in three hospitals without success. All investigations were inconclusive. Finally laparotomy revealed inflamed segments of small bowel, a biopsy of which showed Eosinophilic enteritis. The patient was subsequently treated successfully with Prednisolone.