EARLY DETECTION
going in Africa and aimed at the improvement of both
Figure 1: The group of five pathologists during the central review
diagnosis and research was sponsored by the International
Network for Cancer Treatment and Research (INCTR) and
included several African institutions all of which were visited
by several pathologists from European and American
institutions (Figure 1) to assess the infrastructure, audit the
diagnoses offered by the African investigators, introduce
capacity-building measures, provide logistical support for
telemedicine and assist with treatment protocols specifically
designed for the African setting. This review demonstrated
the considerable variation in infrastructure, including the
available equipment and personnel2. The annual biopsy
number varied from 1,500 to 16,000 among the pathology in situ hybridization and FISH, respectively, could be useful to
departments visited. Some of the departments had a address a diagnosis of BL, although these will require more
substantial cytology load and fine needle aspiration cytology resources and might only be used when the three-antibody
(FNAC) was widely utilized. The availability of equipment was system fails to make a definitive diagnosis4.
variable as was the quality of histology and cytology
preparations. In addition, although a proportion of the Performing research in developing countries: A
pathologists in sub-Saharan Africa had worked in centres challenge that can become a reality
abroad, the laboratory technical staff had not. Diagnostic As the susceptibility to and pathogenesis of lymphomas are
accuracy, after the review of lymphoma cases by these heavily influenced by genetic background, environmental
lymphoma experts, was shown to be 76% of BL cases in which exposure and lifestyle, there would be a considerable
only cytology was available. The diagnosis of other lymphomas advantage in including the developing countries in this effort,
in which histological samples were available was confirmed in since they are, in general, much more heterogeneous than
78% of cases, irrespective of the subtype. It was difficult to high-income countries, and may differ markedly from each
make diagnoses of specific lymphoma subtypes, as lymphoma other as well as high-income countries. In particular, the
subtyping had not been attempted in many cases partly due to causative role of infectious agents may be crucial in countries
the fact that basic immunohistochemistry was not available in such as Africa, where the burden of infectious diseases is quite
most centres2. high. Infectious agents, especially viruses, account for several
BL is particularly important, as it is endemic in equatorial of the most common malignancies – up to 20% of all cancers.
Africa, Papua and New Guinea, locations where the required Some of these cancers are endemic, with high incidence in
infrastructure and technical expertise are not currently certain geographic locations, but have sporadic/lower
available, and are unlikely to be in the near future. Because of incidence in other parts of the world. Lymphomas are very
this, the construction of a diagnostic algorithm that would common in Africa, a large number of which arise as a result of
ensure a reliable diagnosis of BL with greater ease and fewer infectious agents. Several pathogens and environmental
resources would be of great value. Such a systematic approach factors have been detected in association with lymphomas,
is also relevant in developed countries, as none of the including the Epstein-Barr virus (EBV), the Human
parameters currently used in the diagnostic evaluation can Immunodeficiency Virus (HIV), the Human Herpes Virus 8
clearly distinguish the entities BL, DLBCL/BL and DLBCL on (HHV-8), the causative agent of malaria Plasmodium
an individual basis. Therefore, in a collaborative study with falciparum, Helicobacter pylori and Chlamidia psittaci, just to
African colleagues we have proposed a scoring system-based mention a few, suggesting that they may contribute to
algorithm in which only three antibodies (CD20, CD10 and lymphomagenesis. They may have a direct role in
BCL2) are used to distinguish between BL cases and non-BL lymphomagenesis, through dysregulation of regulatory
3
cases . These three antibodies are relatively easy to use and mechanisms of the host cell, or promote an “indirect
can be employed in laboratories with limited experience in lymphomagenesis”, which involves sustained stimulation of
immunohistochemistry. We hope that this small panel of the immune system, eventually linked to malignant
antibodies would make a great impact in the setting of transformation. Mechanisms as pathogen-induced B-cell
developing countries, especially in Africa. In addition, other hyper-activation, B-cell stimulatory activity and alteration of
parameters such as EBV detection and MYC translocation by the expression of growth factors within the host cell, thus
CANCER CONTROL 2013 77