| Abstract|| |
Background: Upper gastrointestinal malignancy occurs in variable frequencies among different populations and there is an increasing epidemiological data in The Kingdom of Saudi Arabia. Aim of the Study: To determine the frequency of upper gastrointestinal malignancy in an endoscopic population in Gizan. Patients and Methods: A retrospective analysis of 63 patients who had esophageal or gastric malignancy among 2572 patients evaluated in a 6-year period ( July 1992 to June 1998) at King Fahad Central Hospital in Gizan. Results: Esophageal cancer was found in 39 patients (20 males and 19 females), whereas gastric malignancy in 24 (22 males and two females). The majority of the patients were in their seventh and eighth decade of life with male predominance. Seven patients had primary gastric lymphoma and one patient had primary malignant melanoma of the esophagus. Conclusion: Upper gastrointestinal malignancy represented 2.4% of 2572 endoscoped patients, occurring more commonly among elderly male
Keywords: epidemiological data, gastrointestinal malignancy, adenocarcinoma, gastric lymphoma, esophageal cancer, dysphagia, hematoxlin, stomach, malignant melanoma.
|How to cite this article:|
Gadour MO, Ayoola EA. The frequency of upper gastrointestinal malignancy in Gizan. Saudi J Gastroenterol 2004;10:16-21
Cancer has a tremendous psycho-social consequences and sufferings on the patients and their relatives. It has gained an increasing public awareness recently. The availability of modern medical endoscopic facilities has made the early detection and reliable diagnosis of upper gastrointestinal malignancy y (UGIM) possible. Gastric malignancy is one of the most common and virulent cancers with a poor prognosis, ranking as the second killing cancer worldwide  . Its incidence is alarmingly high in Costa Rica, Japan, South America, Eastern Europe, countries of the former Soviet Union and is the most common cancer in Korea, while it is uncommon in North America, Africa and India , . Although the exact incidence of UGIM in The Kingdom of Saudi Arabia (KSA) is not known, there is a high occurrence of cancer of the esophagus, whereas the relative frequency and rank of gastric malignancy vary widely , . The geographical distribution of the different patterns of disease even within the same country has indicated that environment and life style are the major factors for the development of the disease. However, other factors play a significant role. We report here the pattern of endoscopically diagnosed UGIM in a regional tertiary hospital in KSA in six years period.
| Patients and Methods|| |
Gizan region is located in the South Western part of the KSA, along the Red Sea. Its population is about one-million, scattered in villages and small towns. The health care is delivered to the residents by a network of primary health care centres, and general hospitals. All patients with serious diseases are referred to the regional referral medical center. King Fahad Central Hospital (KFCH) is located in the regional capital city (Gizan). The KFCH is a 500 bedded hospital with modern diagnostic and therapeutic facilities including computerized tomographic (CT) and magnetic resonance (MRI) scanner. It has the only fully-equipped endoscopy and histopathology facilities in the region and therefore, nearly all cases requiring endoscopy or histopathologic evaluation are referred to the hospital.
The UGI endoscopy included a general examination of the esophagus, stomach and duodenum. Endoscopic diagnosis of inflammations, ulcers, polyps and masses were made by standard criteria. Biopsies were obtained from all patients with polyps. gastritis, gastric ulcers suspected malignancies, esophageal ulcers, masses, strictures, significant erosive esophagitis and in patients suspected as having Barrett's esophagitis. In addition biopsies for histopathological detection of Helicobacter pylori tained from the gastric antrum and body as were indicated in these patients. The biopsy specimens were fixed in 10% buffered formalin and processed in standard manner for histological examination. Biopsy specimens were stained routinely by hematoxylin and eosin. Other special stains were applied as indicated. These included D-pas for mucin. alcian blue and Warthin Starry silver impregnation. Histologic interpretation was done by standard methods .
From all those who were evaluated by endoscopy for various UGI symptoms, patients were selected for detailed analysis if a biopsy had been obtained from the esophagus alone or in addition to samples from any other segment of the upper gastrointestinal tract. Information obtained from the medical records, endoscopy. database and the histopathology registry included age, sex, nationality, the indication for the procedure, details of endoscopy findings and histopathologic diagnosis.
| Results|| |
There were 2572 upper gastrointestinal endoscopies performed during the 6-year period (July 1992-Junel998). Biopsy specimens were obtained from different levels of the upper gastrointestinal tract in 776 (30.2 %) of all the patients. In 159 patients (110 males and 49 females) the biopsy was taken from the esophagus, the remaining biopsies were from the stomach. Sixty-three specimens obtained from 42 males and 21 females showed malignant lesions that were located in the esophagus (in 39 patients) and stomach (in 24 patients). [Table - 1] summarizes the histopathological pattern of upper gastrointestinal malignancy.
Equal frequencies of squamous cell carcinoma and adenocarcinoma of the esophagus are seen in these patients. Males predominated in gastric malignancy (22 of 24). with seven males having primary gastric lymphoma, five of these seven patients (71%) presented with abdominal pain. Strikingly, all anaplastic tumors of the esophagus occurred in males. A large number of patients with upper gastrointestinal malignancy were in the 7th and 8th decades of life. No significant age difference was seen between the various types. However, five of seven patients with gastric lymphoma were below 60 years of age. Only one patient was found to be <21 years of age [Table - 2]. The interval between onset of symptoms and the diagnosis ranged from 1 to 84 months with a mean of 13.78 months.
The endoscopic findings and the major symptoms in the various groups of patients with upper gastrointestinal malignancy are shown in [Table - 3]. In addition to the respective malignant lesions, duodenal ulcers and duodenitis were present in five and two patients respectively. No duodenal lesions were seen in the remaining patients. Among 39 patients with esophageal malignancy 29 (74.1%) and four (10.1 %) had dysphagia and weight loss as presenting symptoms respectively whereas these symptoms occurred in one (4.2%) and ten (41.7%) out of 24 cases with gastric malignancy [Table - 4]. Fifty-nine of the 63 patients were referred to a higher center for further management. Of the four patients who had surgery in our hospital, one died postoperatively and three were well during the follow-up period of one, two, and five years. They were lost to follow- up thereafter.
| Discussion|| |
The relative frequencies of gastric malignancy vary widely in KSA and other Gulf countries, where it is a common cause of death ,, . In a report from the same region in 1992 it ranked eighth among all malignancies  . Gastric malignancy is a disease of the elderly peaking during the seventh decade of life and is rarely diagnosed before the age of 40 years  . However, one third of our patients were below 40 years of age. It is very rare in children representing only 0.05% of malignant paediatric gastrointestinal tumors. None of the 72 pediatric patients who had upper gastrointestinal endoscopy in our center during the same period had gastric malignancy  . Similar to other studies in KSA and United Arab Emirates our study showed male predominance in gastric malignancy , However, the male to female ratio of 11: 1 was markedly higher than the ratio of 2:1 reported earlier from the same center. It remains unclear why this change had occurred. Dyspepsia and weight loss are the most common symptoms at the time of diagnosis of gastric malignancy. Our findings are consistent with this pattern. Weight loss is attributed to anorexia, nausea, abdominal pain, early satiety, hypercatabolism and/or dysphagia. Among our patients with gastric malignancy dysphagia is uncommon affecting only 4% because the tumor did not involve the cardia or the gastroesophageal junction. Occult gastrointestinal bleeding with or without iron deficiency anemia is usual inpatients with this tumor. Melena or haematemesis are less common occurring in about 20% of cases. It was interesting that 41% of our cases presented with acute upper gastrointestinal bleeding.
The vast majority of gastric malignancies (90%) are adenocarcinomas, histologically. Only 50% of our patients have adenocarcinoma, this could be due to the relatively high frequency of anaplastic tumors and lymphomas, which constituted 21% and 29% respectively. The stomach is the most common site of primary extranodal non-Hodgkin's lymphoma  . The primary gastric lymphomas are those without systemic involvement until late in their course. They constitute 3-5%, rank second among gastric malignancy and account for 10% of lymphomas  . This is in contrast to the high frequency (29%) of lymphoma in this study. However, it goes with reports from other parts of KSA , . Gastric lymphoma usually peaks at the 6th decade of life. The commonest presenting symptom is pain  as was found in our patients. Seven patients in this series were found to have primary gastric lymphoma. They were all males, which contrasts with the slight male predominance of 1.7:1 reported elsewhere  . Primary esophageal lymphoma is extremely rareand none of our patients was found to have esophageal lymphoma.
Esophageal cancer is the second most common cancer in KSA  and is one of the ten most common malignancies in the world and is the third most prevalent of all gastrointestinal malignancies , . The geographical variations suggest the role of environmental and other factors in its etiology. For example in some Western countries such as France and Switzerland the high frequency is attributed to high alcohol consumption and smoking. Squamous cell carcinoma and adenocarcinoma usually account for more than 95% of esophageal malignant tumors with an almost equal prevalence as was found in our analysis. As had been previously reported from our center, it is likely that a proportion of the patients with adenocarcinoma had Barrett's esophagus as pre-cancerous lesions  . Adenocarcinoma and squamous cell carcinoma of the esophagus have similar clinical presentations despite their different locations. Dysphagia occurring in 72.5% of our patients, was the major presenting symptom in patients with esophageal cancer. Esophageal cancers may appear as strictures, ulcerated masses, circumferential masses or ulcers. Esophageal mass was the commonest endoscopic finding in our patients and malignant esophageal stricture was uncommon. A flat blackish spot seen in the esophagus of a 72 year-old male was proven histologically to be a primary malignant melanoma which is an extremely rare tumor  . The absence of melanotic lesions elsewhere in the body is essential for the diagnosis of this highly aggressive tumor. It is a disease of the elderly and is associated with a high mortality rate with an average survival of less than two months in untreated patients and a 5-year survival of 4.2% .
In conclusion, upper gastrointestinal malignancy represented 2.4% of 2572 patients who were examined endoscopically in our center over a period of six years. These malignant lesions occurred with higher frequencies in males and the elderly. It was associated frequently with dyspepsia, dysphagia and weight loss. The etiological factors in these patients were not known.
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Mohammed Osman Gadour
P. O. Box 68, Abu Arish
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2], [Table - 3], [Table - 4]