 |
|
|
|
|
|
 |
 |
 |
 |
 |
|
Fine Needle Aspiration Cytology in Nigeria
Sani Abubakar Malami, M.B.B.S., F.M.C.Path., M.I.A.C., and Yawale Iliyasu, M.B.B.S., F.M.C.Path. Objective
Fine needle aspiration cytology (FNAC) is a simple, safe and cheap method for the screening and diagnosis of a variety of inflammatory and neoplastic conditions. Being a relatively new diagnostic technique in Nigeria, scant information had been published on it. We conducted a nationwide study to describe the availability, organization and utilization of FNA in the country.
Study Design A descriptive cross-sectional survey was done to describe the current state of the development of FNAC in Nigeria. The respondents were pathologists and heads of pathology departments in leading medical institutions.
Results It was found that the practice of cytology is widely disseminated throughout the country, with a growing number of pathologists who have taken an interest in cytology. But FNA in Nigeria faces many important challenges, not the least of which is the lack of opportunities for local training and continuing education in cytology.
Conclusion In our opinion, there is an immediate need for a comprehensive approach to cytopathology education in Nigeria. (Acta Cytol 2008;52:400–403)
Keywords: aspiration cytology, fine-needle; Nigeria.
 The strategies to improve FNA
services in Nigeria should encompass establishing fellowships and residencies in cytopathology, as well as establishing schools of cytotechnology. Fine needle aspiration cytology (FNAC) is widely used in the screening and diagnoses of a variety of inflammatory and neoplastic conditions.1-3 Several workers have also highlighted its suitability in the context of the developing world.4-7 In 2006, one of us (S.A.M.) received an invitation to address the local medical research society on the topic of FNAC in Nigeria. To contemplate such a discourse required an international comparison on the scope and practices of FNA with Nigerian data. But FNA happened to be a relatively new technique in Nigeria, and scant information had been published on it. Therefore, rather than merely presenting our own thoughts and to have a wider perspective, we sought the opinion of a wide range of colleagues and heads of Nigerian pathology departments who share a common interest in cytology. The purpose of this article is to present the results of that survey. We did not ask specifically about the use of FNA as a research tool, although a couple of scientific reports on FNA8 had been published in the past from some of the centers that were surveyed. The survey also was not designed by a statistician and was not meant to be a statistically or scientifically precise instrument, but rather was intended to provide a sense of the current FNA practices in Nigeria regarding its availability, organization and utilization.
Materials and Methods The survey design was a cross-sectional study. To prevent duplication, only one questionnaire was dispatched to each center. The FNA study instrument was developed to assess institutions’ background information, current status of FNA practices, availability of cytology personnel and facilities, data on FNA in the previous year (2005) and institutional variations in the indications and level of FNA activity among various centers. The FNA survey instrument was reviewed by an expert for clarity and relevance, resulting in minor changes to the form. Data collection commenced in May 2006. Structured questionnaires were sent by post to 32 pathologists who were identified through the register of the Nigerian chapter of the Anglophone West African Division of the International Academy of Pathology (AWADIAP). Each survey form included an introductory letter and the data collection form. The cover letter requested respondents to forward completed questionnaires to a specified address. Reminders were sent by e-mail after a period of 8 weeks. Data collection ended on 31 August 2006.
Statistical Analysis The completed surveys were coded, the responses entered into a Microsoft Excel Spreadsheet (Microsoft Corp., Redmond, Washington, U.S.A.) and descriptive analysis was done. We used Fisher’s exact test to test the hypothesis of association between FNA volume and types of hospital in 2
 2 tables, and results were considered significant if the p value was <0.05. Results Of 32 questionnaires distributed, 17 responses were received from pathology laboratories located in the 6 geographic zones of Nigeria, namely, northwest (2), northeast (2), north central (3), south south (4), south east (2) and south west (3). One form was received from a center in which FNA had not been introduced (1). The response rate was thus 53.1%. Not everyone answered all the questions in the questionnaires. Fifteen added comments and suggestions were received.
Background of FNAC The oldest FNA service in Nigeria, developed in 1982, is at Ahmadu Bello University Teaching Hospital in Zaria. Figure 1 shows the frequency distribution of the types of hospitals surveyed, which are, respectively, academic tertiary (10), nonacademic tertiary (5) and nonacademic community (2) hospitals. In other words, academic medical institutions outnumbered nonacademic hospitals in a ratio of 1.4:1.0 in the present survey.
Institutional FNA Preferences
FNA aspirates were routinely obtained in a special room in the pathology laboratory in 5 institutions, and doctors’ offices were informally used for sampling in the case of 11 hospitals. One center had not yet introduced FNA. No outpatient department FNA clinics were being run anywhere in the country.
Image-Guided FNA Facilities for ultrasonography, computed tomography (CT) and fluoroscopy existed in 14 (82%), 6 (35%) and 3 (18%) centers, respectively, but only 9 hospitals had the necessary expertise and offered image-guided FNA.
Personnel The staff strength varied between 1 and 5 pathologists (mean, 2.8; median, 3), and 1–6 technologists or biomedical scientists (mean, 2.8; median, 2).
Current FNA Volume The volume of FNA undertaken by the laboratories in the previous year ranged from 5 to 1,000 cases (mean, 307; median, 223). However, 47.1% of the hospitals were handling low volumes of FNA (<100 cases per annum). Two thirds of the hospitals with low volumes are in the nonacademic (tertiary or community) hospital category. The volume of FNA was found to be strongly correlated with hospital type (
 2, p=0.015).Formal Cytology Training At up to 60% of the institutions, it was found that the pathologists and technologists in charge of FNA had no formal training in cytology. Among these were some persons (10%) who had acquired their FNA skills through short-term fellowships at foreign institutions; the rest had learned the technique by self-instruction.
FNA Policy Guidelines From the available data, only 3 centers (17.6%) were reported to be using standard operating procedures manuals for FNAC.
FNA and Histology Workload The average number of histology cases handled by the laboratories ranged between 100 and 4,000 per annum (mean, 1,531; median, 1,008). The correlation between FNA volume and histology volume was also studied. These variables showed a strong positive correlation. Pearson correlation: FNA volume and histology volume = 0.834, p=0.0001.
Aspirators Respondents gave multiple answers when asked to name who performed aspirations in their centers (Table I). The majority mentioned were pathologists, and the minority were radiologists.
Common Sites for FNA
Table II shows the frequency distribution of common sites at which FNA is performed at various Nigerian laboratories. Overall, the breast is the most common site, followed by the lymph nodes and thyroid gland.
 Discussion The paucity of simple, rapid and cheap diagnostic methods is a growing concern in developing countries, including, especially, Nigeria.9 In the last decade, there has been a growing body of evidence that FNA is a promising low-cost technology that can be easily adapted to address the peculiar challenges in these settings.4,5
The present study has shown that a growing number of Nigerian pathologists have taken an interest in cytology. However, the services of this enthusiastic group appear to be underutilized except in academic medical centers. This is quite similar to the experience in the United States, where it had been shown that the economic milieu at nonacademic institutions might actively discourage clinicians practicing at those institutions from fully utilizing FNA.10 In Nigeria, the situation could have been compounded by the lack of general support by the medical community for FNA arising from almost complete lack of awareness of its many advantages. Additionally, FNA faces many important challenges in Nigeria, not the least of which is the lack of opportunities for local training and continuing education in cytology.11 Hitherto a small number of interested persons had acquired cytology skills through short periods of clinical attachments in hospitals abroad. But economic considerations make this an unrealistic option today. Although it is briefly taught during residency training, obviously more commitment to clinical cytology is desired from the West African and National postgraduate medical colleges.
The pathologist is preferentially the first-choice aspirator in Nigeria, as opposed to the practice in the United States, where up to 63% of aspirations are performed by clinicians.10 In a British survey, surgeons and radiologists were the largest groups overall, with cytologists performing only 11% of aspirations.12 The contrast might be explained by the fact that the U.S. data did not separate aspiration of palpable (71%) from nonpalpable masses done at community hospitals by clinicians. The aspirator is a significant factor in the success of FNA in any given situation, and there are superior arguments in favor of pathologists (as is the practice in Nigeria) performing the aspirations themselves.13,14
To the extent that breast swellings and inflammatory lymphadenitis are the major indications for FNA in Nigeria, it is logical to say that the present practices are well adapted to the needs of the community, which had been previously highlighted.8 However, there is need for more commitment to FNA from departmental chairpersons and heads of pathology departments to ensure its steady growth. From our data, this is amply illustrated by the fact that only 5 institutions had a room specifically reserved for obtaining FNA samples, and pathologists do not provide outpatient FNA service anywhere in the country.
The strategies to improve FNA services in Nigeria should encompass establishing fellowships and residencies in cytopathology, as well as establishing schools of cytotechnology. The provision of comprehensive cytopathology education in Nigeria will increase its awareness, and thereby ensure the provision of quality care to the whole population.
Acknowledgments The assistance of our colleagues Drs. C. Anunobi, M. Nnoli and V. I. Onyiaorah with data collection and Dr. Z. Iliyasu with statistical analysis is highly appreciated. Gratitude is due to the following members of the Anglophone West African Division of the International Academy of Pathology (AWADIAP) who personally completed the FNA survey: Professors E. E. Akang (Ibadan), J. O. Ogunbiyi (Okada), S. Nwosu (Port Harcourt) and B. M. Mandong (Jos) and Drs. A. F. Banjo (Lagos), S. M. Shehu (Zaria), H. Ngadda (Maiduguri), V. I. Onyiaorah (Nnewi), B. A. Abimiku (Keffi), A. B. Umar (Kano), Seleye-Fubara (Port Harcourt), F. Iyare (Abakaliki), A. Dauda (Sokoto), N. Nwachokor (Warri), F. Ekanem (Benin) and A. A. Mayun (Gombe).
References
From the Department of Pathology, Faculty of Medicine, Bayero University, Kano; and Department of Pathology, Faculty of Medicine, Ahmadu Bello University, Zaria, Nigeria.
Dr. Malami is Head, Department of Pathology, Faculty of Medicine, Bayero University. Dr. Iliyasu is Consultant Pathologist, Department of Pathology, Faculty of Medicine, Ahmadu Bello University.
Address correspondence to: Sani Abubakar Malami, M.B.B.S., F.M.C.Path., M.I.A.C., Department of Histopathology, Aminu Kano Teaching Hospital, PMB 3452, Kano 700001, Nigeria (malamisa@yahoo.co.uk).
Financial Disclosure: The authors have no connection to any companies or products mentioned in this article. Received for publication January 11, 2008.
Accepted for publication February 16, 2008.
 0001-5547/08/5204-0400/$21.00/0 © The International Academy of Cytology
Acta Cytologica Send website comments to Webmaster@acta-cytol.com |
|||||||||||||
