Diagnostic puzzles

I once heard Chitokoloki described as a ‘museum of surgical curiosities’ and it has not failed to meet expectations. We deal with a fascinating range of diseases, both surgical and medical. Our senior colleague Dr David McAdam has served as a missionary surgeon in Central Africa for nearly 30 years, but comments that he still sees something new almost once a week.  There are no filters as to what comes through our doors and this makes our work very interesting, but filled with many challenges in both diagnosis and management.

 

In the last few weeks, I (Stuart) had to make a difficult judgement call on how to treat a lady with a likely breast cancer. Many months back, she had presented to us with a lump, which was removed in order to get further pathological information (from examination of the specimen with a microscope). 

 

Out here in the bush, pathology is not routinely available to us. The government don’t provide this service, so our options are either to pay for expensive private analysis in Lusaka, or to use charitable help from outside the country. The quality of reports in-country is not consistent, so our preferred option is to use a generous free service from a pathologist in Canada. This gives us access to first-rate analysis, but clearly there are major difficulties. We are often unable to send large specimens, so have to decide which part of a biopsy to send away. We are also very limited by the turn-around time. My lady with the breast lump waited for over 6 months for her result to be available. In the UK, this would be unthinkable. Accurate, rapid and precise diagnosis, even for complex or rare conditions, is taken for granted. In the case of breast cancer, most women would wait less than 2 weeks for their diagnosis once they arrive at a breast clinic. Their mammograms would be read by two consultant radiologists and their biopsy specimens would be analysed by their hospital’s consultant pathologist. The nearest mammography unit to us is 500km away and our pathologist is 13,000km away! At present, Zambia does not have any specialised breast radiologists; indeed, there are only 5 qualified radiologists covering the entire Zambian public health service, so half of the public facilities with mammography services have their images interpreted either by the referring doctor or radiographer technicians (Bwanga et al).

 

For our lady, the earlier biopsy had not given us a clear picture… there was evidence of ductal carcinoma in-situ (pre-cancerous change), but when we examined her again, she had a larger lump with axillary lymphadenopathy (large lymph glands palpable in her adjacent arm pit, likely indicating cancerous spread). With the limited information available, our recommendation had to be for a mastectomy with axillary node clearance (removal of the whole breast, and all lymph glands from the adjacent arm pit). It is a mutilating operation to be recommending on limited evidence.

 

We hope that our surgery will prove enough to give this lady many more years of disease-free life. For some patients, our lack of ability to make a diagnosis can be fatal. Last weekend, we processed another sad death – a stoical 16 year old who had been having difficulty breathing and was sent to Chitokoloki from a neighbouring facility. His chest radiograph is below – why don’t you try your hand at interpretation?!

Those familiar with X-rays will recognise that this is a high-quality digital image. Chitokoloki is able to perform 'plain film' radiology to a high standard, thanks to a huge amount of support from a consultant radiologist based in Australia. Dr Rodney Strachan provides us with an exceptional and free service, reporting all our X-rays within 24 hours or less. This is an invaluable help and often Dr Rodney picks up on details that we will have missed. The chest radiograph above shows a complete ‘white-out’ of the right lung, with some deviation to the left of his chest structures. There is also some radiolucency (loss of normal bone density) in the right 3^rd rib. We initially interpreted this as demonstrating a pleural effusion (fluid between the lung and chest wall), but when we tried to remove fluid, there was none. The only other imaging modality available to us is ultrasound, and this suggested that sadly the lung had been largely replaced by tumour. Back in the UK, he would have been extensively investigated with CT and/or MRI scan, lung biopsy, possibly a bronchoscopy, and a battery of blood tests. Here in the African bush, there was little to do but cover him with antibiotics and anti-TB treatment, hoping that what we saw was just the result of infection. We only have occasional opportunity to refer to the few centres able to conduct more complex investigation and his family did not have means to travel for specialist input. He was with us for about a month before his breathing became much worse and he succumbed to an undiagnosed disease.

 

Global inequalities in surgical care have been well described. In 2014, the medical journal The Lancet created a ‘Commission for Global Surgery’, with the task of quantifying the scale and extent of unmet surgical healthcare needs in the world. The Commission reported in 2015 and made the landmark finding that 5 billion people around the world do not have access to safe, affordable surgical and anaesthesia care when needed. 

The 5 key messages from the Lancet Commission on Global Surgery

Previously, the development of surgical services has not had much prominence in healthcare development agendas, with far more effort expended in single infectious disease problems such as HIV. The Lancet Commission argued that rather than focusing on individual disease, the global health community should be working on broad-based systems solutions, and that,

 

“Surgical care has an incontrovertible, cross-cutting role in achievement of local and global health challenges. It is an important part of the solution to many diseases—for both old threats and new challenges—and a crucial component of a functional, responsive, and resilient health system. The health gains from scaling up surgical care in LMICs are great and the economic benefits substantial. They accrue across all disease-cause categories and at all stages of life, but especially benefit our youth and young adult populations. The provision of safe and affordable surgical and anaesthesia care when needed not only reduces premature death and disability, but also boosts welfare, economic productivity, capacity, and freedoms, contributing to long term development.” (Meara et al, 2015)

 

The wisdom of this ‘systems approach’ is illustrated by our diagnostic challenges. A functioning surgical service requires support systems which are also integral to success in many other disciplines. In the past few weeks, several friends back in the UK have been blessed by quick, definitive diagnoses of difficult problems. A correct diagnosis is a wonderful provision, and one which many people around our world cannot access. Zambia was first off the mark in sub-Saharan Africa to describe a national health policy focusing on the upscaling of surgical and anaesthesia services (described here). This is a good place to start, but the road ahead to healthcare equality is long and difficult.

 

Bwanga, O., Chanda, E., Sindaza, N., Nachalwe, M. Mammography Services in Zambia. International Journal of Medical Reviews, 2021; 8(1): 12-19. doi: 10.30491/ijmr.2020.239681.1124

Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet [Internet]. [cited 2015 May 1]; Available from: http://www.sciencedirect.com/science/article/pii/S014067361560160X