Sub-Types and Treatment Outcomes of Adolescent and Adult non-Hodgkin Lymphomas in a Resource Poor Setting Dei-Adomakoh

Background: The diagnosis and treatment outcomes of NonHodgkin Lymphoma’s (NHL) in resource poor countries in the absence of routine molecular studies and immunohistochemistry is challenging. Methods: A retrospective review of case folders of NHL patients aged13 years and above. Information obtained from the case folders included age, sex, histological subtype, subtypes using the Working Formulation and WHO classifications. Treatment given and follow up information were also evaluated. Results: A total of 279 cases of NHL were identified within the study period. The mean age of the patients was 48.8 ± 17.0 years. The male to female ratio was approximately 1.5:1. The majority of cases seen (53%) were diffuse large Bcell lymphoma. Chronic lymphocytic leukaemia/ small lymphocytic lymphoma (22.2%) was the next most common subtype. Other sub types seen, in order of frequency, included diffuse mixed cell lymphoma (6.4%), gastric lymphomas (3.9%), mediastinal Bcell lymphoma (2.9%), Burkitt’s lymphoma (1.8%), splenic marginal zone B-cell lymphoma (1.1%), lymphoblastic lymphoma (1.1%), mucosaassociated lymphoid tissue (MALT) type Bcell lymphoma (0.7%) and follicular lymphoma (0.7%). Conclusion: This study provides an overview of the distribution of NHL subtypes and their outcomes in a resource constrained setting. Immunohistochemistry, cytogenetics and specific molecular studies which are important in characterization of NHLs, should be made affordable and accessible in low income countries. J O U R N A L O F H E M A T O L O G Y A N D O N C O L O G Y R E S E A R C H ISSN NO: 2372-6601 Research Article DOI : 10.14302/issn.2372-6601.jhor-17-1423 Corresponding author: Yvonne A. Dei-Adomakoh, Department of Haematology, Email: deiadom@yahoo.com


Introduction
Non-Hodgkin lymphomas (NHL) are clonal malignant diseases that arise from the lymphoid system. 1,2 It accounts for 4% of all cancers and represents approximately 10% of all childhood cancers 1 .
It accounts for 14-19 cases per 100,000 population in the West. 1,2 During the past few decades, incidence rates of NHL have risen 3 with an estimated rate of increase of 3-4% per annum In Europeans. 4,5 This has been attributed to an increase in mean age of the population, improvements in diagnosis, the HIV pandemic and immunosuppressive therapy. 6  proportions, ratios and percentages) and summarized in tables.

Results
Out of a total of 279 adolescent and adult cases of NHL patients folders reviewed, the mean overall age  (Table 1). Intermediate grade NHLs constituted the greatest proportion of all NHLs using the working formulation (Fig 2).
The age bracket shows 10 year-age intervals cross-tabulated against the frequency of new cases of Non-Hodgkin lymphoma per age group (Fig 1).
Whereas significant cases (43 cases; 15.4%) were in the young population (below 30 years of age); the incidence increased gradually in the adult population with over half the cases (148 cases) falling between the ages of 30 and 69 years; after which there was a drastic decline in the elderly (69 years and above). There was a peak incidence at age interval of 50−69 years. Figure 3 shows an increasing trend in number of NHL cases diagnosed over 5 years. interpretations were correct for most cases (Table 2).
However four required a change in diagnosis and treatment.
The study looked at first, second and third year outcomes for patients with NHL in a resource poor setting. Table 3  patients did not respond to first line chemotherapy and were given second line. Figure 4 shows the three year follow up of NHL cases post treatment. Survival rate of NHL in the first year was found to be high (98.6%).
Subsequent years showed a decline in follow up cases and thus a decrease in survival rates.

Discussion
In Ghana, NHL has been reported to be quite common among children. 9 The incidence of NHL from previous studies in developed and middle income countries is higher compared to Hodgkin's lymphoma (HL). 10-14 The is variation in incidence according to age, sex, race, socioeconomic status and histologic subtypes. 15 The male preponderance in this study is not different from previous studies. [16][17][18] The sex of an individual is one of the greatest known risks for contracting lymphomas and leukaemias. 19 It has been reported that the preferential male involvement in lymphoid cancer is most marked in the youngest age group in NHL as well as HL. 20 In 1998, an international      The Working Formulation may still be a good source of diagnostic and prognostic information and a tool for treatment planning in countries where immunohistochemistry is not available or unaffordable.
The major limitations were unavailability of immunohistochemistry and molecular studies to better characterize NHL, poor documentation, poor follow up data after the first year. Another limitation was the fact that the sample size was relatively small to be representative of Ghana plus the study was only done in one area in Ghana -the major referral and teaching hospital in Accra (KBTH) to arrive at a definitive conclusion.
In conclusion, this study provides an overview of