Dying Undiagnosed: Challenges of Management of Ovarian Tumours in a Resource-Poor Setting in North-western Nigeria
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This retrospective study in Nigeria found that 77% of patients with suspicious ovarian tumors lacked histologic diagnosis, highlighting management challenges including late presentation and resource limitations.
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This retrospective study analyzed 122 cases of ovarian tumors with high suspicion for malignancy at a tertiary hospital in North-western Nigeria over a three-year period. The findings revealed that 77% of these patients lacked a histological diagnosis, often resulting in undiagnosed deaths, while only two cases achieved complete surgical debulking among those who underwent surgery. The authors attribute these poor outcomes to systemic challenges including limited infrastructure, lack of health insurance, and insufficient training across multidisciplinary specialties. The paper does not explicitly discuss endometriosis or adenomyosis; it was included in the corpus via a keyword match in the upstream search index.
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Abstract
BACKGROUND: Ovarian cancer is the second most prevalent but most lethal gynaecologic malignancy in our institution. This study aimed at determining the rate of non-diagnosis in suspected lesions and reviewing the management challenges of ovarian tumours highly suspicious for malignancy in our hospital.
METHODOLOGY: A three-year retrospective review of patients' records from the ward, clinic, theatre, and histopathology laboratory was carried out. Cases with high indices of suspicion for ovarian cancer (ovarian tumour with malignant radiologic features with any of ascites, pleural effusion, as well as cachexia, anaemia, or evidence of metastasis) were included. In-depth interviews were carried out with a consultant from each specialty of Radiology, Radio-oncology, Pathology, and Gynaecologic oncology at the gynaecologic oncology multidisciplinary team meeting.
RESULTS: One hundred and twenty-two cases of highly suspicious ovarian malignancies were seen with a mean age of 40.6 years. Of these, 28 (23%) had surgery and 77% did not have any form of histological diagnosis. Of those that had surgery, 13 (46.4%) had upfront surgery and 15 (53.6%) neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). Only two cases had documented complete (R0) debulking. Among those that had upfront surgery, one case (7.7%) was an ovarian fibroid and one (7.7%) was a fibrosarcoma while two cases (15.4%) were borderline ovarian tumours. Chemotherapy was commenced based on malignant cells on ascitic or pleural fluid cytology in three cases. Of all the malignant cases, epithelial carcinomas were commonest accounting for 48%. Aside from the general late presentation of cases, insufficient funds for treatment, poor coverage of health insurance for cancer care, unavailability of routine immunohistochemistry, lack of germline and somatic testing, non-availability or prohibitive cost of some chemotherapeutic agents, unavailability of maintenance therapies, inadequate capacity to manage toxicities, inadequate skill across all specialties, unavailability / erratic function of computerized tomography scans and unavailable positron emission tomography, lack of interventional radiology facility amongst others were all identified as challenges to management.
CONCLUSION: Most patients with tumours highly suspicious for ovarian cancers did not get a histologic diagnosis and probably died undiagnosed. Management of ovarian cancer remains a challenge despite advances in surgical and chemotherapeutic options. Health insurance for all, infrastructure development, and training of all disciplines involved is recommended.
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Keywords
Dying undiagnosed, ovarian tumours, ABUTH, challenges, management, ovarian cancer, resource poor setting
Abstract
Background: Ovarian cancer is the second most prevalent but most lethal gynaecologic malignancy in our institution. This study aimed at determining the rate of non-diagnosis in suspected lesions and reviewing the management challenges of ovarian tumours highly suspicious for malignancy in our hospital.
Methodology: A three-year retrospective review of patients’ records from the ward, clinic, theatre, and histopathology laboratory was carried out. Cases with high indices of suspicion for ovarian cancer (ovarian tumour with malignant radiologic features with any of ascites, pleural effusion, cachexia, anaemia, or evidence of metastasis) were included. In-depth interviews were carried out with a consultant from each speciality of Radiology, Radio-oncology, Pathology and Gynaecologic oncology at the gynaecologic oncology multidisciplinary team meeting.
Results
122 cases of highly suspicious ovarian malignancies were seen with a mean age of 40.6 years. Of these, 28 (23%) had surgery and 77% had no histological diagnosis. Of those that had surgery, 13 (46.4%) had upfront surgery and 15 (53.6%) neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). Only two cases had documented complete (R0) debulking. Among those that had upfront surgery, one case (7.7%) was an ovarian fibroid and one (7.7%) was a fibrosarcoma while two cases (15.4%) were borderline ovarian tumours. In three cases, chemotherapy was commenced based on malignant cells on ascitic or pleural fluid cytology. Of all the malignant cases, epithelial carcinomas were the most common accounting for 48%.
Conclusion
Most patients with tumours highly suspicious of ovarian cancers did not get a histologic diagnosis and probably died undiagnosed. Management of ovarian cancer remains a challenge despite advances in surgical and chemotherapeutic options. Health insurance for all, infrastructure development and training of all disciplines involved is recommended.
References
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