REVIEW OF MANAGEMENT OF ORBITO-OCULAR MALIGNANCIES IN LAGOS UNIVERSITY TEACHING HOSPITAL (LUTH): A 15 YEAR REVIEW BY DR. ADEWUMI OLABIMPE ALABI (MBBS, IBADAN) AF/012/11/002/554 A PART II DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THE AWARD OF FELLOWSHIP IN RADIOTHERAPY, FACULTY OF RADIOLOGY, NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA. NOVEMBER, 2015 1 DECLARATION I declare that this study titled “REVIEW OF MANAGEMENT OF ORBITO- OCULAR MALIGNANCIES IN LAGOS UNIVERSITY TEACHING HOSPITAL (LUTH): A 15 YEAR REVIEW” was carried out by me and to the best of my knowledge contains no material previously published or written by another person, nor material which has been submitted or accepted for the award of any degree or Fellowship except where due acknowledgement has been made in the text. _______________________________ DR. ADEWUMI OLABIMPE ALABI (MBBS, IBADAN) 2 CERTIFICATION This is to certify that this research project “REVIEW OF MANAGEMENT OF ORBITO- OCULAR MALIGNANCIES IN LAGOS UNIVERSITY TEACHING HOSPITAL (LUTH) : A 15 YEAR REVIEW” was conducted in the Departments of Radiotherapy and Ophthalmology (Guinness Eye Centre), LUTH, Idi-araba, Lagos and Supervised by: Professor A. T. Ajekigbe Head, Department of Radiotherapy/Consultant Clinical & Radiation oncologist, Lagos University Teaching Hospital, Idi-araba, Lagos. Signature/Date: _____________________ Professor (Mrs) F. B. Akinsola Head, 3 Department of Ophthalmology/Consultant Ophthalmologist, Guinness Eye Centre, Lagos University Teaching Hospital, Idi-araba, Lagos. Signature/Date: _____________________ Department of Radiotherapy, Lagos University Teaching Hospital, Idi – araba, Lagos state. 2nd of August, 2015. This is to certify that this research project “REVIEW OF MANAGEMENT OF ORBITO- OCULAR MALIGNANCIES IN LAGOS UNIVERSITY TEACHING HOSPITAL (LUTH) : A 15 YEAR REVIEW” by Dr Alabi, Adewumi Olabimpe of the Department Of Radiotherapy, LUTH was conducted in the Departments of Radiotherapy and Ophthalmology (Guinness Eye Centre), LUTH, Idi-araba, Lagos State. Professor A. T. Ajekigbe (B.pharm (Hons), MBBS, DMRT, FWACS, FMCR) Head, 4 Department of Radiotherapy/Consultant Clinical & Radiation Oncologist, Lagos University Teaching Hospital/College of Medicine, Idi-araba, Lagos. DEDICATION This book is dedicated to God Almighty for His grace and favour and to my late Father Engr. Ganiyu Toye Layioye for laying a good foundation. 5 ACKNOWLEDGEMENTS I wish to acknowledge the Department of Radiotherapy, Lagos University Teaching Hospital, Idi -araba, Lagos for the privilege to undergo my training in Radiation Oncology. My Teachers and Consultants at Lagos University Teaching Hospital namely Prof K.K. Ketiku, Prof. F.A. Durosinmi-Etti, Prof A.T. Ajekigbe, Dr A.C. Sowunmi and Dr M.Y.M. Habeebu for their immeasurable contributions and inspiration. You gave me the best of your wealth of knowledge and time. Prof (Mrs) F. B. Akinsola for supervising the project and the motherly role you have played in my home. To my Teachers and Consultants in other Institutions namely Prof. O. B Campbell, Dr A.A. Adenipekun, Dr R.A. Oyesegun, Dr T.N. Elumelu-Kupoluyi, Dr A.A. Abdussalam, Dr A.I. Ntekim, Dr A.M. Folasire, Dr O. Ogunnorin, Dr Igbinoba, Dr N.Y. Okunnuga, Dr O. Iyare, Dr O. Salako and Prof M.A. Aweda. I say thank you for your 6 contributions to my training. You are all highly appreciated. I thank my colleagues and other members of the Department both medical and non-medical for their support and assistance during my period of study. My appreciation also goes to my darling husband (Dr Adegboyega Alabi) for his untiring love, support and encouragements all the way, my adorable sons: Timi and Temi, thank you for understanding and the sacrifices you made during the period of my study and to my wonderful Mother for always being there. Finally to the Almighty God without whom all this would have been impossible, you are Highly Honored. TABLE OF CONTENTS TITLE PAGE i DECLARATION ii CERTIFICATION iii DEDICATION v ACKNOWLEDGEMENTS vi TABLE OF CONTENTS vii SUMMARY viii 7 INTRODUCTION 1 AIM AND OBJECTIVES 4 LITERATURE REVIEW 5 MATERIALS AND METHODS 43 RESULTS 47 DISCUSSION 57 LIMITATIONS 60 CONCLUSION 61 RECOMMENDATIONS 62 REFERENCES 63 APPENDIX 68 SUMMARY Introduction: Orbito-ocular malignancies (OOM) generally are rare tumours1 with age adjusted incidence rate of 0.8per 100,000 per year in the United States2. Most ocular tumours are seen in adults with some peculiar to the paediatric age group. Uveal melanomas are the most common primary intraocular malignancies in adult in the United States and Europe3,4. Retinoblastoma is the commonest malignant intraocular tumour in 8 childhood with a potential for curative intent3,4. Studies in Nigeria, have shown prevalence of Squamous cell carcinoma in adults and retinoblastoma as the commonest ocular malignancy and commonest orbital cancer in children5,6. The main goals of treatment for Orbito-ocular tumours (OOT) in order of importance include: to save life, to save the eye and preserve vision7. Aim and Objectives: To review the management of orbito-ocular malignancies in the Departments of Radiotherapy and Ophthalmology, Lagos University Teaching Hospital, between January 1997 and December 2011 in comparison to previous and recent studies globally. Methodology: This is a retrospective study of Orbito-ocular malignancies seen at the Departments of Radiotherapy and Ophthalmology, LUTH from 1997 to 2011. Case files and treatment cards were retrieved through the record departments and the information required was extracted with the aid of a data extraction form. Results: A total of 98 cases with histologically confirmed orbito-ocular malignancies seen during the 15 year study period were analyzed. The age range was to <1 – 83years, mean of 22.94years (SD 24.64years). Majority, 54 were children accounting for <10years of age. Retinoblastoma (52.0%) was the commonest histological type seen in children while Squamous cell carcinoma (25.5%) was the commonest in adult. The most common presenting complaints were proptosis seen in 47 patients followed by leucokoria seen in 20 patients. 17 patients had a combination of Radiotherapy, Surgery and Chemotherapy. 91 9 patients had surgery, 31% had enucleation while 34% had exenteration. 36 patients had Chemotherapy. 44 patients benefited from radiotherapy, radical treatment was offered to 24 patients. Total radical treatment dose was 35-65Gy in 20-35 fractions over 4-7weeks. 84 patients were lost to follow up. 5 died from disease progression and 4 are still alive and are seen in the clinic on follow up. Conclusion: This study showed that the use of multimodality treatment was implemented but did not improve survival because majority of patients presented late. The need for a collaborative effort in early detection and prompt referral for treatment of cancer cases cannot be overemphasized. INTRODUCTION Orbito-ocular malignancies (OOM) generally are rare tumours1,4 with age adjusted incidence rate of 0.8per 100,000 per year in the United States2. Most ocular tumours are seen in adults with some specific to the paediatric age group. These tumours are limited to malignancies developing from the eye, orbit or the lids. The eye consists of various anatomic and functional elements including the Conjunctiva, Cornea, Uvea, Lens, Vitreous, Retina and Optic nerve. All these structures can form malignancies with pathologic processes4. Secondary ocular malignancies are rare but are commoner than primary malignancies of the eye4. 10 Uveal melanomas are the most common primary intraocular malignancies in adult3 in the United States and Europe with incidence estimated at 7 per million per year1,4. Retinoblastoma is the most common malignant intraocular tumour in childhood with a potential for curative intent1. Its incidence is 1 in 15,000-20,000 live births1,2,4. It usually presents before 3 years of age1. A Nigeria based study by Annunobi et al showed that retinoblastoma is the most common ocular malignancy in all age groups5. It accounts for 85% of all Orbito-Ocular Tumours (OOT) in the South Western part of Nigeria5. It also showed Rhabdomyosarcoma as the most common orbital malignancy occurring in childhood in the South Western part of Nigeria5. In adults, Squamous cell carcinoma was the most common malignant conjunctiva lesion with a mean age of 45 years5. The age adjusted incidence rate for Orbito-Ocular malignancies from 2005-2009 was 0.8 per 100,000 men and women per year in the United States2. Overall 5 year survival rate was 83.1% and the life time risk was 0.08% (1 in 1256 persons)2. There is an increase in incidence of both primary and secondary malignancies in both pediatric and adult tumours owing to better diagnosis and increase awareness6. Better treatment options are now available which has helped in proffering better treatment outcomes. The main goals of treatment for OOM in order of importance include: to save life, to save the eye and preserve vision7. In retinoblastoma, cure can be achieved8. The awareness and knowledge of Orbito-Ocular malignancies in developing countries such as Nigeria is low due to suboptimal awareness programmes, poor health seeking attitudes, faith healing belief and etc. These had led to patients seeking alternative traditional 11 treatment thus increasing the number of patients presenting with advanced stage of the disease6,9. Various treatment modalities are available for different stages of disease. These include Surgery, Radiotherapy (External Beam Radiotherapy or Brachytherapy),