Neuropathology Outreach in Ghana

Introduction/Objective

Ghana has a population of over 31 million people and approximately 15 neurosurgeons but is currently without a dedicated neuropathologist. Here we present a month of neuropathology outreach performed at the Komfo Anokye Teaching Hospital (KATH) in Kumasi and the Korle-Bu Teaching Hospital (KBTH) in Accra.

Methods/Case Report

In February of 2022, a second-year neuropathology fellow and a board-certified neuropathologist traveled to Ghana to give 40 approximately 1.5 hour neuropathology didactic and interactive teaching sessions. A two-week format of outreach was developed for each site in Ghana and consisted of didactic lectures and interactive sessions covering the WHO 2021 brain tumor classification system, neuroautopsy, neuroinfectious disease, neurodegenerative disease, neuromuscular disease, forensic neuropathology, neurodevelopment, and unknown case conferences. Meanwhile, a pathology trainee worked remotely to organize 12 one-hour virtual general pathology lectures and develop continuing outreach. A survey of 16 questions including 12 multiple choice questions and four short answer questions was used to assess each component and the overall satisfaction of the outreach.

Results (if a Case Study enter NA)

Eight brains were examined at four neuroautopsy conferences and ten case consultations were performed upon request. Survey results showed no statistical differences amongst the 20 sessions. Comments were positive and included one respondent planning to redesign their PhD research to focus on neurodegenerative disease in Ghana and several others commenting on the utility of molecular updates. Suggestions for improvement included quizzes, including more morphology and IHC in lectures, sending digital slides before future visits, teaching spinal cord removal, and the need for continuing outreach in neuropathology, dermatopathology, cytopathology and gynecologic pathology.

Conclusion

This experience provides a useful and well-appreciated approach to delivering international neuropathology outreach. Opportunities in neuropathology on an international level range from educational to clinical practice and research.

COVID-19 in Sub-Saharan Africa: A Multi-Institutional Survey of the Impact of the Global Pandemic on Cancer Care Resources

Purpose/Objective(s)

The COVID-19 pandemic has direct and indirect impact on patients with cancer. Low- and middle-income regions, especially sub-Saharan Africa, are especially vulnerable to a negative impact on cancer resources and outcomes. We report the initial indirect impact of COVID-19 on cancer care in the sub-Saharan Africa region approximately 14 months into the pandemic.

Materials/Methods

At the start of the pandemic, we created a consortium of African and North American cancer centers and NGOs for the distribution of factual and timely information and data on COVID-19 and cancer care. A survey was distributed to consortium members and other colleagues from the sub-Saharan Africa region to understand the impact of COVID-19 in cancer care resources. Survey respondents represent cancer experts from 8 centers in Ghana, Nigeria, Kenya, Ethiopia, South Africa, Rwanda, and Zimbabwe.

Results

All sites report SARS-COv-2 transmission amongst cancer patients and staff. A total of 48 staff developed COVID-19 infection with one site reporting a single death. Additionally, 62.5% of sites report loss of oncology physician or nursing staff due to redeployment for COVID-19 care resulting in minimal (20%), moderate (60%), or other (20%) impact on cancer care. All 8 sites report a government mandated lockdown with a median duration of 2.3 months (IQR .9-4.2 months). Impact of the lockdown on cancer care was reported as none (12.5%), minimal (12.5%), moderate (50%) and severe (25%). Additionally, we surveyed the impact of COVID-19 on resources in radiation, medical and surgical oncology services. A total of 25% of responders reported decreases in radiation resources while 37.5% reported changes in medical and surgical oncology resources. For radiation oncology, the most common impact was access to CT imaging for 3D-conformal planning (25%), access to brachytherapy (12.5%), and medical physics support (12.5%). For medical oncology, the most frequent impact was access to chemotherapy (37.5%) and blood products (12.5%), and loss of oncology ward space (12.5%). The most frequent impact for surgical oncology was access to operating rooms (37.5%), ventilators (12.5%), anesthesia (25%), blood products (25%), and other supply chain issues (25%). Of centers who reported impact on cancer care, severity of impact was none (50%) and moderate (50%) for radiation oncology; mild (25%) and moderate (75%) for medical oncology; and moderate (75%) and severe (25%) for surgical oncology.

Conclusion

Our survey identified diffuse impact of COVID-19 on all facets of cancer care across sub-Saharan Africa. Based on physician assessment of impact, the discipline of surgical oncology may be impacted the greatest. Additional studies measuring the impact of COVID-19 on cancer outcomes are ongoing.

Creating Models to Identify New Therapeutic Options for Aggressive African Breast Cancers

Background: Population-based incidence rates of breast cancer (BC) that does not express the estrogen receptor (ER), progesterone receptor (PR) or overexpress the human epidermal growth factor 2 HER2/ neu (triple negative breast cancer, TNBC) are higher among Africans compared with white women. However the underlying biologic and genetic differences among different ethnicities are poorly understood and there are currently very few ethnically diverse BC models available for identifying new therapeutic options. Aim: Establish an international collaboration to: i, characterize African breast tumors ii, create models for studying these tumors and iii, identify biomarkers for early detection and treatment personalization. Methods: We have collected tumors from 154 white Americans WA, 76 African Americans, AA, 190 Ethiopians, Eth, and 286 Ghanaian (Gh) BC patients. We then established a unique resource of patient derived xenografts (PDX) from these tumors. The PDXs were then fully characterized using whole exome and RNA sequencing for the primary tumor, matched normal DNA, and corresponding low passage PDXs. Using immunohistochemistry, we evaluated the ER, PR, HER2/ neu, androgen receptor (AR), and ALDH1 (cancer stem cell marker) expression among these tumors. Based on biomarker expression the PDXs were then tested against a panel of IND drugs, either alone or in combinations, in an ex vivo organoid culture system to discover potential new therapeutic options. Results: Mean age at BC diagnosis was 43; 49; 60; and 57 years for the Eth; Gh; AA; and WA patients, respectively. The proportion of TNBC was significantly higher for the AA and Gh patients (41% and 54%, respectively) compared with the WA and Eth patients (23% and 15%, respectively); P < 0.001. Significant differences were observed for distribution of AR positivity, which was 71%; 55%; 42% and 50% for the WA; AA; Gh; and Eth cases, respectively ( P = 0.008). The Gh breast tumors exhibited the highest number of loss of function and missense mutations that are likely to impact therapy with a high frequency of P53, APC, and FGFR mutations. These mutations were maintained in the corresponding PDXs that were developed, and were thus used as biomarkers for drug screening. These tumors exhibited a gene expression signature based on the ethnicity of the patients with 2385 genes differentially expressed between Gh and AA, 1573 between AA and CA and 1317 between GH and CA. Results from our ongoing drug screening and biomarker identification will be available soon. Conclusions: Establishing the molecular and genetic platform of aggressive breast cancers occurring in women with African ancestry will help in identifying biomarkers for early cancer detection and targeted treatment stratification for optimum patient outcome. The availability of tumor models based on tumors from diverse African populations is the important missing pieces that have to be incorporated into current drug discovery efforts.

Abstract P6-07-01: Withdrawn

This abstract was withdrawn by the authors.

Abstract P6-12-14: Comparative analysis of breast cancer phenotypes in African American, White American, and African patients- Correlation between African ancestry and triple negative breast cancer

Introduction: Population-based incidence rates of triple negative breast cancer (TNBC) are higher for African American (AA) compared to White American (WA) women, but it is unclear whether TNBC risk is genetically associated with African ancestry because AA women represent an ancestrally admixed population. Higher frequencies of TNBC have also been observed in sub-Saharan African breast cancer (BC) patients, but comparative analyses of biomarker expression among datasets that include AA, WA, and African women are sparse. We report findings from an international registry that features specimens from a diverse patient population in Detroit, Michigan as well as a hospital in Kumasi, Ghana.

Methods: The study dataset included formalin-fixed, paraffin-embedded invasive BC tumors diagnosed between 1998 and 2014 at the Komfo Anokye Teaching Hospital in Ghana and the prospectively-maintained/annotated Henry Ford Health System cohort in Michigan. All Ghanaian tumors underwent pathology confirmation and immunohistochemistry for estrogen receptor (ER), progesterone receptor (PR) and HER2/neu expression at the University of Michigan. Women were classified into five BC phenotypes and dichotomized into two age groups, &lt;50 and ≥50 years. Polychotomous multivariate GLM models were developed to estimate the risk for each BC phenotype. Statistical analyses were performed in SAS v. 9.0 (Carey, NC). This research was approved by the Institutional Review Boards of the participating institutions.

Results: A total of 234 Ghanaian cases with mean age 49 years (range 24-92); 271 AA with mean age 60 (range 27-87); and 321 WA with mean age 62 (range 31-91) (P=0.001) contributed to this study. Prevalence of histologic grade 3 was lowest in WA (n=107, 33.7%) which was statistically significant from the observed prevalence in AA (n=135, 50.4%) and Ghanaians (n=84, 53.8%) (P&lt;0.0001). ER-negative and TNBC were more common among Ghanaian and AA compared to WA cases (frequency ER-negativity 67.5%, 37.1%, and 19.8%, respectively, p&lt;0.0001; frequency TNBC 53.2%, 29.8%, and 15.5%, respectively, p&lt;0.0001). In the age group &lt;50 years, 82 women (42.5%) were diagnosed with ER+/PR+/HER2-, 65 (33.7%) with TNBC, 27 (14.0%) with ER+/PR+/HER2+, 14 (7.2%) with ER-/PR-/HER2+ and 5(2.6%) with ER-/PR+/HER2- phenotypes. In this young age group, prevalence of TNBC remained highest among Ghanaian women (50.8%), followed by AA (34.3%) and WA (15.9%); (P=.0006). In contrast, highest prevalence of ER+/PR+/HER2+ and ER+/PR+/HER2- phenotypes was observed in WA, followed by AA and Ghanaians. On multivariate analysis histologic grade 3 and racial heritage remained statistically significantly associated with the TNBC phenotype (OR for AA vs. WA with TNBC 1.87, 95% CI 1.15-3.04; OR for Ghanaian vs. WA with TNBC 10.63, 95% CI 5.32-21.25; OR for Grade 3 vs Grade 1 histology with TNBC 33.3, 95% CI 13.45-82.4).

Conclusions: This study confirms an association between the TNBC phenotype and African ancestry; furthermore, extent of African ancestry appears to be associated with an increased likelihood of having a TNBC tumor, since frequency of TNBC among AA patients was intermediate between WA and Ghanaian patients.

Citation Format: Newman LA, Jiagge E, Bensenhaver JM, Chitale D, Kleer C, Merajver S, Kyei I, Aitpillah F, Oppong J, Amankwaa-Frempong E, Adjei E, Wicha M, Awuah B, Stark A. Comparative analysis of breast cancer phenotypes in African American, White American, and African patients- Correlation between African ancestry and triple negative breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-12-14.

Breast cancer in Kumasi, Ghana

BACKGROUND

Breast cancer is the leading cause of cancer deaths in Ghanaian women.

OBJECTIVE

To describes the characteristics of breast cancer patients attending the Komfo Anokye Teaching Hospital in Kumasi, Ghana.

METHOD

The study was conducted at the Komfo Anokye Teaching Hospital. Between July 1st 2004 and June 30(th) 2009 patients presenting with breast lumps were assessed by clinical examination, imaging studies and pathological examination. Relevant clinical and pathological were recorded prospectively data on all patients with microscopically proven breast cancer. The cancers were graded according to the modified Bloom-Richardson system. Tissue immunoperoxidase stains for oestrogen, progesterone receptors and c-erb2 oncogene were performed with commercially prepared antigens and reagents.

RESULTS

Nineteen thousand four hundred and twenty-three (19,423) patients were seen during the study period. There were 330 (1.7%) patients with histologically proven breast cancer. The mean age was 49.1 years. A palpable breast lump was detected in 248 patients (75.2%). Two hundred and eighty-one patients (85.2%) presented with Stages III and IV, 271 (82.1%) invasive and 230 (85.2%) high grade carcinomas. Oestrogen and progesterone receptors were positive in 32 and 9 cases respectively. Her2 protein was positive in 11 cases.

CONCLUSION

In Kumasi, as in other parts of Ghana, breast cancer affects mostly young pre-menopausal who present with advanced disease. The cancers have unfavourable prognostic features and are unlikely to respond to hormonal therapy.

A giant guteal schwannoma with extension into the pelvis: a case report

BACKGROUND

Schwannomas are uncommon slow growing tumours arising from the nerve sheath or Schwann cell.

OBJECTIVE

To report a case and the surgical removal of a giant complex schwannoma and to highlight the value of extensive investigations including a preoperative histologic diagnosis in the successful surgical management of uncommon large benign tumours.

METHODS

A 39-year-old man presented with a 15-year history of a large mass in the right gluteal region. He was clinically evaluated, subjected to imaging studies and surgery.

RESULTS

Clinical examination revealed a 40 cm by 60 cm mass in the right gluteal region and continuous with a 25 cm by 15 cm pelvic mass. The ultrasound scan revealed a very complex (mixed solid and fluid containing) gluteal mass with extension to the pelvis. The CT scan showed a very large, well defined lobulated tumour with cystic spaces and enhancing nodules. The tumour extended through the ischiadic foramen into the pelvis and posteriorly into the thigh muscles. A Doppler scan of the pelvic vessels revealed that the right common and internal iliac arteries were both compressed but not occluded. An incisional biopsy was reported as a Schwannoma with xanthomatous changes and an immuno histochemistry profile of S-100+, Ki-67+ (less than 1% of the cells). A right foot drop following the surgery responded to physiotherapy. The duration of total hospital stay was 12 weeks.

CONCLUSION

The staged excision of large and complex schwannomas is safe. It is essential that a preoperative histological diagnosis is made to establish that the tumor is truly benign.