Portal de Periódicos da CAPES

Pattern of Malignant Skin Tumors in Asir Region, Saudi Arabia

1993; King Faisal Specialist Hospital and Research Centre; Volume: 13; Issue: 5 Linguagem: Inglês

10.5144/0256-4947.1993.402

0975-4466

Khaled A. Bahamdan, Nader Morad,

Cutaneous lymphoproliferative disorders research

Original ArticlesPattern of Malignant Skin Tumors in Asir Region, Saudi Arabia Khaled A. Bahamdan and MD Nader A. MoradMD, FCAP Khaled A. Bahamdan Address reprint requests and correspondence to Dr. Bahamdan: College of Medicine, King Saud University, Abha Branch, P.O. Box 641, Abha, Saudi Arabia. From the Division of Dermatology, Department of Internal Medicine (Dr. Bahamdan) Search for more papers by this author and Nader A. Morad From the Department of Pathology (Dr. Morad), College of Medicine, King Saud University, Abha Branch, Abha. Search for more papers by this author Published Online:1 Sep 1993https://doi.org/10.5144/0256-4947.1993.402SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractThe current study describes the pattern of malignant skin tumors in 137 cases seen in Asir Central Hospital histopathology laboratory over a five year period (1987 to 1991). Ninety percent (90.5%) were Saudis and the mean age was 61.0 years with a male:female ratio of 1.6:1. Squamous cell carcinoma was the most common type of skin cancer presenting (41.6%), followed by basal cell carcinoma (36.5%), and then malignant melanoma (11.7%). Ninety-eight percent of basal cell carcinoma cases occurred on the head, compared to only 47.4% of squamous cell carcinoma; and 24.6% of squamous cell carcinoma cases occurred in the lower limbs. Eighty-seven pecent (87.6%) of malignant melanoma cases occurred in the extremities. The distribution of the other types of malignant skin tumors are also discussed. Our findings were compared with the very few studies from the Kingdom and other parts of the world. Ann Saudi Med 1993;13(5):402-406.IntroductionSkin cancer is the most common type of cancer among white populations [1–6] compared to black and dark skinned populations [1,7–10]. There have been indications of increased incidence of skin cancer in international literature [2,4,11–13]. Exposure to sunlight [4,5,11,14] and the fair color of the skin are thought to be important contributing factors in the most common types of primary malignant skin tumors [1–5,11]. In comparison to other malignant tumors, skin cancer has the great advantage of early recognition, as it appears in most cases as an easily recognizable skin lesion.The current study is the first to describe the pattern of skin cancer in the Asir region and to the best of our knowledge, there has been no detailed recently published study about malignant skin tumors in the Kingdom other than the preliminary study of the solar radiation effects on skin cancer in the proceedings at the first conference on biological aspects in Saudi Arabia at Riyadh, 1977 [15]. Many published studies have described the pattern of malignant tumors in general, indicating the order, frequency, percent, or only the number of skin cancer cases and several studies showed low frequencies of skin cancer in Saudi Arabia [16–21]. This can be explained by the fact that these studies were done in large referral centers in major cities where life-threatening malignant tumors are treated, which usually need radio and chemotherapy facilities; whereas most malignant skin tumors can be treated surgically in many hospitals which have no such facilities. Other studies have shown high frequencies of primary skin cancer [15,22–24], which were done in regional central hospitals such as King Fahad Hospital in Al Baha and Asir Central Hospital [22,23].One hundred and thirty-seven patients with primary malignant skin tumors were analyzed in our study. The purpose of this study is to demonstrate and describe the pattern of malignant skin tumors in the Asir region according to different histopathological types, anatomical locations affected, sex, and age distribution.PATIENTS AND METHODSThe pathology materials of 137 consecutive cases of malignant skin tumors received at Asir Central Hospital histopathology laboratory over a five year period, 1987 to 1991, were reviewed. Asir Central Hospital pathology laboratory is the only central pathology laboratory to receive all pathology specimens from different peripheral hospitals of the Ministry of Health in this region; therefore, all malignant skin tumors, if biopsied or excised, were included in this study. Only primary malignant neoplasms of the skin were considered in the current study. Only one biopsy per patient was included, even though the patient might have had more than one biopsy. The skin biopsies were taken from patients seen in Asir Central Hospital as well as from general hospitals located in Khamis Mushayt, Tathleeth, Bisha, Zahran Al-Janoub, Sarat Abidah, Ahad Rufidah, Rigal Alma and Muhayl. Data were sorted, compiled, and coded. Analysis was done on IBM compatible personal computer using SPSS PC+ software package. The results were tabulated and presented as percentages and frequencies. Student t-test and chi-square were used as tests of significance.RESULTSAmong the 137 patients were included 124 (90.5%) Saudi Nationals. Table 1 shows the distribution of 137 cases of primary skin cancer according to histopathologic types among various age groups. Squamous cell carcinoma (SCC) was the most common type of skin cancer (41.6%). Seventeen cases (29.8%) of SCC were secondary SCC; that means they developed from osteomyelitis skin sinuses (seven cases), keloids and traumatic scars (four cases), burn scars (six cases); those secondary SCC cases represent 12.4% of total malignant skin tumors. Basal cell carcinoma (BCC) represented 36.5% and malignant melanoma (MM) 11.7% of our cases. Malignant appendicular tumors were seen in 5.1% of our cases, including two cases of sebaceous carcinoma, two cases of sebaceous epithelioma, two cases of malignant clear cell hidradenoma and one case of eccrine porocarcinoma. Other miscellaneous primary skin cancer cases represented the remaining 5.1% of our cases and included three cases of dermatofibrosarcoma protuberans, two cases of Kaposi sarcoma, one case of atypical fibroxanthoma, and one case of mycosis fungoides. More than 50% of SCC and BCC occurred during the seventh and eighth decades of life, whereas more cases of malignant melanoma and malignant appendicular tumors occurred during the fifth and sixth decades of life.Table 1. Distribution of different types of malignant skin tumors among various age groups.Table 1. Distribution of different types of malignant skin tumors among various age groups.The mean age of all cases was 60.9 years with a male:female ratio of 1.6:1. Similar mean ages were seen in cases of SCC, BCC, and MM with male:female ratios of 2.4:1, 1.6:1, and 1.3:1, respectively (Table 2). Malignant appendicular tumors and other miscellaneous tumors occurred in younger age groups with mean ages of 50 and 53 years, respectively.Table 2. Distribution of primary malignant skin tumors according to different types, mean age, and sex.Table 2. Distribution of primary malignant skin tumors according to different types, mean age, and sex.Table 3 shows the distribution of various histopathologic types of skin cancer according to the affected body sites. Ninety-eight percent of BCC occurred in the head, compared to only 47.4% of SCC, 57.1% of malignant appendicular tumors and only 1% of malignant melanoma cases. Eighty-seven percent (87.6%) of malignant melanoma cases affected the upper and lower extremities, showing an acral distribution in 81.3% compared to 33.4% of SCC, 14.3% of malignant appendicular tumors and only 2% of BCC. Fourteen percent of SCC occurred in the anogenital skin and 28.6% of malignant appendicular tumors affected the trunk. The three cases of dermatofibrosarcoma protuberans were all females and all were located on the trunk. Two cases of Kaposi sarcoma occurred on the extremities of two elderly males. One case of mycosis fungoides affected the thigh of an elderly man and one atypical fibroxanthoma affected the leg of an elderly woman.Table 3. Distribution of various types of primary malignant skin tumors according to body sites affected.Table 3. Distribution of various types of primary malignant skin tumors according to body sites affected.DISCUSSIONSkin cancer is the most common malignant tumor in the Asir region, representing 14.6% of all cancer cases [22]. The Asir region has an approximate population of 1,200,000 representing 20% of the total population of the Kingdom [25,26]. In Caucasians, skin cancer is the most common cancer, surpassing all other cancers combined [1] and reaching up to 30% of all cancer cases [6]. Among blacks, these tumors are not common [1,7–10] and range from 1% to 8% [7,9,10]. Studies of skin cancer in white populations showed male to female ratios ranging from 1.5:1 to 2:1 [1,15], in agreement with our findings of 1.6:1. In an African study, the male:female ratio was 3:1 [7].It has been estimated that 50% of all persons over 65 years of age will develop skin cancer in white populations [1]. In our study, ages ranged between 20 and 100 years with a mean age of 61, similar to findings from the Al Baha area [23]. The difference between mean age in males and females was statistically not significant. In a study from Nigeria, ages ranged from 13 to 82 with a mean of 41 years [7]. This lower mean age in the African study may be attributed to the fact that 57% of these patients were albinos.Table 4 compares our findings to those reported from the Al Baha area and an African study from Nigeria. Squamous cell carcinoma (SCC) was the most commonly seen skin cancer, representing 41.6% of our cases; this has also been noted in a preliminary study of the solar radiation effect on skin cancer in Riyadh [15]. In a study from Al Baha, SCC was the second common primary skin cancer, representing 27.9% of these cases [23]. In a Nigerian study, SCC represented 55.4% of all malignant skin tumors [7]. Other studies in blacks reported a high frequency of SCC reaching up to 66% [9,10]. These results are different when compared to the pattern of malignant skin tumors in white populations where SCC is the second most common malignant tumor, representing only 20% of these cases [1,2,4,11]. In our study, 17 of the 57 cases of SCC (29.8%) developed in chronic nonneoplastic skin lesions such as osteomyelitis skin sinuses, keloids, traumatic and burn scars and were considered as secondary SCC cases.Table 4. Comparison of present study with the Nigerian and Al Baha study in regard to the percentages of different types of malignant skin tumors.Table 4. Comparison of present study with the Nigerian and Al Baha study in regard to the percentages of different types of malignant skin tumors.Basal cell carcinoma (BCC) represented 36.5% of our cases. In white populations, BCC is the most common skin cancer and represented approximately 80% of all skin cancer cases [1,2,6], but it is rare in blacks, ranging from 2.5% to 12% of all skin cancers [9,10]. Ninety-eight percent of our BCC cases were on the head and neck region, and these were mainly around the eyes and nose. Three patients had multiple BCC; this was also noted in other studies [8,14]. The anatomic distribution is very similar in white and black populations, showing higher frequencies in the head and neck region [2,6,9,10,15].In our study, malignant melanoma represented 11.7% of all malignant skin tumors and showed a different localization than the other malignant tumors, mainly on the extremities in 87.6% and 81.3% showed acral distribution (palms, soles, and nailbeds). In a study of malignant melanoma at King Faisal Specialist Hospital, 54% of the cases showed acral distribution [27]; this was also noted in the Nigerian study [7] and others [9]. Although acral distribution is well known in blacks, ranging between 50% and 69% [7,9] and in Orientals, reaching up to 35% [28], our figure of 81.3% is much higher. In Caucasians, trunk, head, and lower limb distribution are much more common [1,2,12,13] and acral distribution of MM ranges between 6% and 10% [1,29].All malignant appendicular tumors in the current study occurred in the upper parts of the body, mainly the face (52%), and represented 5.1% of all our cases. Females were more affected than males and they showed lower mean age than the other types. Other studies showed also a comparable low frequency of these tumors [7,23,30]. Other miscellaneous tumors, which include dermatofibrosarcoma protuberans, Kaposi sarcoma and atypical fibroxanthoma, represented 5.1% of our cases (seven cases). This was also the case seen in the Al Baha study [23], but the Nigerian study showed a higher frequency of Kaposi sarcoma (10%) [7].Ultraviolet light plays a major role in causing skin cancer in Caucasians, especially BCC and SCC [1–5,11]. In our study, 78.1% of BCC and SCC cases occurred on the head and neck (exposed parts) and constituted 93.8% of all the head and neck malignant skin tumors. There is no doubt that prolonged sun exposure plays a major role in the development of these tumors, as 98% of BCC cases were present on the head and neck.Saudi Arabia has one of the highest sun intensities in the world [15]; therefore, it is expected to see a much higher frequency of skin cancer than in other parts of the world. Dark color of the skin, the way Saudis dress, and the avoidance of outdoor activities when sun intensity is high, have reduced the risk for developing skin cancer. Other factors such as mineral oil, coal, arsenic intake, and radiation exposure play a very little role in the Asir area because of the minimal industrialization in this region.About 75% of Asir region residents live in rural areas and are engaged in agriculture, trade, and government employment [26]. The Asir region lies in the southwest part of Saudi Arabia and stretches from the coastal plain at the Red Sea to a chain of rugged mountains extending up to 3,000 meters high. Climate is temperate with daily temperature ranging from 5°C to 32°C and annual rainfall of 450 mm [25]. Sunshine hours are less than other parts of the Kingdom, especially in the mountain areas, due to accumulation of clouds and fog, mainly in the winter.The question of whether SCC has a higher frequency in the Saudi population should be thoroughly investigated and studied. In our study, 56% of SCC patients had the lesion for more than one year and 29.8% of SCC were secondary SCC developing from underlying disease or pathology. Black population studies have also shown higher frequency of SCC, reaching 66% and from the same study, 39.5% were secondary SCC [9]. In our study, 47.4% of SCC occurred on the head and neck region compared to 98% of BCC. Therefore, ultraviolet light is not the only factor causing SCC but probably the major factor causing BCC. Unless a well planned prospective study of all new cases of SCC, including a good history and physical examination, is carried out, taking all risk factors into account, speculation as to why SCC ranks first in pigmented skin is a difficult task.We conclude by hoping that this study will open the way for more detailed studies in the different provinces of the Kingdom and to compare their results with ours in order to have a more specific knowledge of the exact pattern of malignant skin tumors in Saudi Arabia, which will alert our physicians to early identification of these tumors and refer them for early treatment.ARTICLE REFERENCES:1. Sherman CD, Calman KC, Eckhardt S, et al.. "UICC. Manual of clinical oncology" . Springer Verlag, 4th ed., 1987;144-55. Google Scholar2. Sober AJ. "Diagnosis and management of skin cancer." Cancer. 1983; 51:2448-52. Google Scholar3. Drake LA, Salache SJ, Ceilley RI, et al.. "Guidelines of care for basal cell carcinoma." J Am Acad Dermatol. 1992; 26:117-20. Google Scholar4. Kwa RE, Campana K, Moy RL. "Biology of cutaneous squamous cell carcinoma." J Am Acad Dermatol. 1992; 26:1-26. Google Scholar5. Aubry F, MacGibbon B. "Risk factors of squamous cell carcinoma of skin." Cancer. 1985; 55:907-11. Google Scholar6. Miller SJ. "Biology of basal cell carcinoma." J Am Acad Dermatol. 1991; 24:1-13. Google Scholar7. Ketiku KK, Fregene AO. "The incidence and management of skin cancer in Nigeria." African J Derm. 1989; 2:105-9. Google Scholar8. Abreo F, Sanusi ID. "Basal cell carcinoma in North American blacks." J Am Acad Dermatol. 1991; 25:1005-11. Google Scholar9. Flemming ID, Barnawell JR, Burlison PE, et al.. "Skin cancer in black patients." Cancer. 1975; 35:600-5. Google Scholar10. Rosen T. "Non-melanoma skin cancer in the black patient." Cancer Bull. 1986; 38:96-9. Google Scholar11. Johnson TM, Rowe DE, Nelson BR, et al.. "Squamous cell carcinoma of the skin (excluding lip and oral mucosa)." J Am Acad Dermatol. 1992; 26:467-84. Google Scholar12. Gallagher RP, Ma B, McLean DI, et al.. "Trends in basal cell carcinoma, squamous cell carcinoma, and melanoma of the skin, 1973 to 1987." J Am Acad Dermatol. 1990; 23:413-21. Google Scholar13. Glass AG, Hoover RN. "The emerging epidemic of melanoma squamous cell skin cancer." JAMA. 1989; 262:2097-100. Google Scholar14. Leong GKP, Stone JL, Farmer ER, et al.. "Non-melanoma skin cancer in Japanese residents of Kauai, Hawaii." J Am Acad Dermatol. 1987; 17:233-8. Google Scholar15. Sayigh AAM, Sebai ZA, Halleem A. "Preliminary study of the solar radiation effect on skin cancer." In: Proceedings of the first conference on biological aspects of Saudi Arabia. Riyadh, University of Riyadh,. 1977. Google Scholar16. Koriech OM, Alkuhaymi R. "Cancer in Saudi Arabia: Riyadh Al-Kharj Hospital Program Experience" ., Saudi Med J. 1984; 5:217-23. Google Scholar17. Amer MH. "Pattern of cancer in Saudi Arabia: a personal experience based on the management of 1,000 patients." King Faisal Specialist Hosp J. 1982; 2:203-15. Google Scholar18. El-Akkad SM, Amer MH, Lin GS, et al.. "Pattern of cancer in Saudi Arabs referred to King Faisal Specialist Hospital." Cancer. 1986; 58:1172-8. Google Scholar19. Ajarim DS. "Cancer at King Khalid University Hospital." Ann Saudi Med. 1992; 12(1):76-82. Google Scholar20. Mahboubi E. "Epidemiology of cancer in Saudi Arabia 1975-1985." Ann Saudi Med. 1987; 7(4):265-76. Google Scholar21. Sebai ZA. "Cancer in Saudi Arabia." Ann Saudi Med. 1989; 9(1):55-63. Google Scholar22. Khan AR, Hussein NK, Al-Saigh , et al.. "Pattern of cancer at Asir Central Hospital, Abha, Saudi Arabia." Ann Saudi Med. 1991; 11(3):285-8. Google Scholar23. Willen R, Pettersson BA. "Pattern of malignant tumors in King Fahad Hospital, Al Baha, Saudi Arabia." Saudi Med J. 1989; 40:498-502. Google Scholar24. Stirling GA, Khalil AM, Nada GN, et al.. "Study of one thousand consecutive malignant neoplasms in Saudis, 1975-1977." Saudi Med J. 1979; 1:89-94. Google Scholar25. Omar MS, Abu-Zeid HAH, Mahfouz AA. "Intestinal parasitic infections in school children of Abha (Asir), Saudi Arabia, Acta Tropica" . 1991; 48:195-202. Google Scholar26. Sebai ZA. "A new faculty of medicine at Abha, Saudi Arabia." Saudi Med J. 1983; 4:77-82. Google Scholar27. Mughal T, Ribinson WA. "Malignant melanoma of the skin, review and KFSH experience." King Faisal Specialist Hosp Med J. 1982; 2:167-74. Google Scholar28. Lin CS, Wang WJ, Wong CK. "Acral Melanoma: a clinicopathologic study of 28 patients." Int J Dermatol. 1990; 29:107-12. Google Scholar29. Hermanek P. Histologie und Klassifikation. Weidner F, Tonak J, eds. Das maligne melanome der Haut, Perimed verlag Erlangen. 1981;63-73. Google Scholar30. Wick MR, Goellner JR, Wolfe JT, et al.. "Adnexal carcinoma of the skin, I and II." Cancer. 1985; 56:1142-72. Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byAlSalman S, Alkaff T, Alzaid T and Binamer Y (2019) Nonmelanoma skin cancer in Saudi Arabia: single center experience, Annals of Saudi Medicine , 38:1, (42-45), Online publication date: 1-Jan-2018.Alshehri M, Ajao O and Abolfotouh M (2001) Mortality from Malignant Diseases in a Saudi Population in the Asir Region: A Four-Year Review, Annals of Saudi Medicine , 21:3-4, (248-250), Online publication date: 1-May-2001.Al-Mobeerik A (2019) Oral and Upper Aero-Digestive Tract Malignancy: A Review of a Five-Year Experience, Annals of Saudi Medicine , 18:3, (257-259), Online publication date: 1-May-1998.Al Saigh A, Allam M, Khan K and Al Hawsawi Z (2019) Pattern of Cancer in Madina Al-Munawara Region, Annals of Saudi Medicine , 15:4, (350-353), Online publication date: 1-Jul-1995. Volume 13, Issue 5September 1993 Metrics History Accepted1 December 1992Published online1 September 1993 ACKNOWLEDGMENTWe wish to thank Dr. Ahmed A. Mahfouz, Department of Family and Community Medicine, for the assistance in statistical work and Mr. Allan I. Agaton for typing the manuscript.InformationCopyright © 1993, Annals of Saudi MedicinePDF download