Central Nervous System Tumor Distribution at a Tertiary Referral Center in Uganda Jeffrey Hatef 1 , Cory Adamson 3 , Oscar Obiga 2 , Blessing Taremwa 2 , Hussein Ssenyojo 2 , Michael Muhumuza 2 , Michael Haglund 3 , Kristin Schroeder 4 INTRODUCTION C ancer has become the leading cause of death and disability in the developing world, with more than 55% of the 12.7 million known cancer cases globally and 64% of the known 7.6 million cancer related deaths worldwide occurring in lower- and middle-income countries (LMICs) (43). Of these cancer diagnoses, up to 20% are central nervous system (CNS) tumors. Significant variation exists between the reported inci- dence of primary CNS tumors in the United States and other high- income countries (HICs) and LMIC worldwide: 20.1 per 100,000 and 3.2À3.9 per 100,000 respectively (3, 7, 15). Although there is known geographic variation in cancer incidence, the 5-fold lower comparative rate for global CNS tumors is likely an underestimate because of limited diagnostic health infrastructure in many LMICs (37). In East Africa, there is 1 neurosurgeon per 9 million people, compared with 1 per 62,500 people in the United States, with even fewer pathologists and radiation oncologists (9). In Uganda, before 2007 only 5 neurosurgeons were available to serve a population of more than 36 million people (12, 17, 22). With restricted neuro- surgical services, CNS tumor biopsies are not routinely performed, contributing to the limited availability of epidemiologic data and treatment options in the East African Population. In 2007, a collaborative effort between Duke University Department of Neurosurgery and Mulago Hospital in Kampala, Uganda, expanded neurosurgical capabilities with delivery of surplus equipment and establishment of neurosurgical training camps. As a result, Mulago Hospital began to offer more complex surgical treatment for patients, including an increased number of craniotomies for intracranial tumors (17). It is now the only neurosurgical referral center in Uganda, treating patients from all 13 municipalities, providing a more comprehensive patient pop- ulation to evaluate CNS tumor distribution. This study is a retrospective review of clinically diagnosed neurosurgical masses at Mulago Hospital in Kampala, Uganda from 2009 to 2012. We describe the distribution of identified masses by demographics, location, clinical diagnosis, and surgical treatment. This study identified key differences in CNS tumor distribution between the United States and Mulago Hospital and highlights the need for the development of a comprehensive CNS tumor registry. METHODS Admission records, clinic registries, and surgery registries from 2009À2012 were reviewed for patients seen in the Mulago Hospital neurosurgery clinic or admitted to Mulago National Referral Hos- pital in Kampala, Uganda. Individual medical records were further reviewed for patients identified as having intracranial or spinal cord masses presumed to be neoplastic, including the search terms “posterior fossa mass,”“intracranial tumor,”“brain tumor or mass” or “spinal tumor or mass.” Extracted data were then analyzed to determine the frequency of CNS tumors in the patient population at Mulago Hospital. Recorded data were deidentified but included demographic (age and sex), diagnosis, and treatment received. The presence of tumor was determined radiographically, and diagnoses were recorded as written in the medical record, with biopsy confirmation when available. These data were not available for every patient, with incomplete data for sex in 30% (n ¼ 123), age in 2% (n ¼ 10/411), and tumor location in 22% (n ¼ 91/411). Descriptive statistical analysis was performed on the dataset to determine the distribution of CNS tumors by sex, age, and year, and analyzed using the Pearson’s c 2 test (JMP Pro v10; SAS Insti- tute, Cary, North Carolina, USA). Additional analysis included the distribution of clinical diagnoses and tumor localization. RESULTS A total of 419 patients treated at Mulago National Referral Hospital from 2009 to 2012 had radiographically identified intracranial and spinal cord masses. Five patients initially suspected of having CNS Key words - Brain neoplasm - Developing countries - Neurosurgery - Uganda Abbreviations and Acronyms CNS: Central nervous system HIC: High-income country IQR: Interquartile range LMIC: Lower- and middle-income country NOS: Not otherwise specified From the 1 Duke University School of Medicine, Durham, North Carolina, USA; 2 Department of Surgery, Mulago Hospital, Kampala, Uganda; 3 Division of Neurosurgery, Department of Surgery, and 4 Division of Hematology-Oncology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA To whom correspondence should be addressed: Kristin Schroeder, M.D., M.P.H. [E-mail: Kristin.Schroeder@duke.edu] Citation: World Neurosurg. (2014) 82, 3/4:258-265. http://dx.doi.org/10.1016/j.wneu.2014.06.040 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2014 Elsevier Inc. 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