DOI: 10.31038/CST.2019414

Abstract

Background: The aim of this research is to figure out the effectiveness of the Sorush Cancer Treatment Protocol (SCTP) which is based on the Evolutionary Metabolic Hypothesis of Cancer (EMHC) and introducing the Specific Ketogenic Diet (SKD) plus Intravenous Ozone Therapy (IOT) in Phase (1) on 54 cancer patients, and combination of Hyperbaric Oxygen Therapy with vitamin/mineral and herbal supplementation beside the SKD and IOT in Phase (2) of this research on the remaining 31 cancer patients.

Introduction: Cancer based on the introduction of EMHC by Dr. Somayeh Zaminpira and Dr. Sorush Niknamian in 2017, is an evolutionary metabolic disease and through the incline of the Reactive Oxygen Species (ROS) and the Butterfly Effect in normal eukaryotic cells, the mitochondria become damaged or shut down. Cancer cells are primitive eukaryotic cells which have existed since around 1.5 billion years ago before the entrance of mitochondrion as endosymbiont.

Materials and Methods: Based on the researches from 1928–2016 and the experimentation of cancer treatments and protocols on cancer patients, we have reached a treatment and decided to test it on 54 voluntary cancer patients in the first stage of their disease. In this treatment we used a 5-day water fasting state, the Specific Ketogenic Diet (SKD) designed by ourselves and Intravenous Ozone Therapy (IOT) in the duration of 90 days (Phase 1) and another 90 days (Phase 2) with the entrance of Hyperbaric Oxygen Therapy (HBO2T) and several supplements which  have been effective in previous studies on cancer patients. We have used the measurement of saliva PH, the MRI device and statistical methods to test the shrinkage of the tumors.

Results: After Phase (1) of this research on 54 patients the average percentage decrease in the tumors was 58% and after Phase (2) on 31 remaining cancer patients the average percentage decrease in the tumors was 98.8%. The average saliva PH in the fasting state of the cancer patients improved from acidic to alkaline as well.

Conclusion:in conclusion, we have reached an effective cancer treatment based on SCTP by the usage of SKD, IOT, HBO2T and several supplements. There was an obvious improvement of cancer tumor decrease, lifestyle, saliva PH and we did not observe any side effects or cachexia in any of the patients.

Keywords

EMHC Hypothesis, SKD, IOT, ROS, HBO2T, SCTP

Introduction

Evolutionary Metabolic Hypothesis of Cancer (EMHC)

The first living cells on Earth are thought to have arisen more than 3.5 × 109 years ago, when the Earth was not more than about 109 years old. The environment lacked oxygen but was presumably rich in geochemically produced organic molecules, and some of the earliest metabolic pathways for producing ATP may have resembled present-day forms of fermentation. In the process of fermentation, ATP is made by a phosphorylation event that harnesses the energy released when a hydrogen-rich organic molecule, such as glucose, is partly oxidized. The electrons lost from the oxidized organic molecules are transferred via NADH or NADPH to a different organic molecule or to a different part of the same molecule, which thereby becomes more reduced. At the end of the fermentation process, one or more of the organic molecules produced are excreted into the medium as metabolic waste products. Others, such as pyruvate, are retained by the cell for biosynthesis. The excreted end-products are different in different organisms, but they tend to be organic acids. Among the most important of such products in bacterial cells are lactic acid which also accumulates in anaerobic mammalian glycolysis, and formic, acetic, propionic, butyric, and succinic acids [1]. The first cell on the earth before the entrance of the bacteria did contain  a nucleus and used the fermentation process to produce ATP for its energy. Then an aerobic proteo-bacterium enters the eukaryote either as a prey or a parasite and manages to avoid digestion. It then became an endosymbiont. As we observe, the fermentation process used the glucose or even glutamine to produce ATP, but the aerobic process used the glucose, fat and protein to produce more ATP than the previous one. The symbio-genesis of the mitochondria is based on the natural selection of Charles Darwin. Based on Otto Warburg Hypothesis, in nearly all cancer cells, the mitochondrion is shut down or is defective and the cancer cell does not use its mitochondria to produce ATP [2]. This process of adaptation is based on Lamarckian Hypothesis of Evolution and the normal cells goes back to the most primitive time of evolution to protect itself from apoptosis and uses the fermentation process like the first living cells 1.5 billion years ago.  Therefore, cancer is an evolutionary metabolic disease which uses glucose as the main food to produce ATP and Lactic Acid. The prime cause of cancer is the abundance of Reactive Oxygen Species produced by mitochondria that is a threat to the living normal cell and causes mitochondrial damage mainly in its cristae [3].

Specific Ketogenic Diet (SKD)

Ketogenic diet is a kind of regime which uses high fat content and low carbohydrate. This diet changes the metabolic state into the condition called Ketosis. After several days, fat becomes your body’s primary energy source which causes an increase in the levels of compounds which are called “ketones” in the blood [4]. In general, a ketogenic diet used for weight loss is about 60–75% of calories as fat, with 15–30% of calories from protein and 5–10% of calories from carbs. However, when a ketogenic diet is being used therapeutically for the treatment of cancer, the fat content may be significantly higher that is up to 90% of calories, and the protein content lower [5]. The SKD contains 80% saturated fat, 15% protein with the lowest Glutamine content and 5% high-fiber carbohydrates mainly in the form of cruciferous vegetables.

Materials and Methods

Based on the researches from 1928–2016 and the experimentation of cancer treatments and protocols on cancer patients, we have reached a treatment and decided to test it on 54 voluntaries cancer patients. In this treatment we used a 5-day water fasting state to put the cancer patients body on cannibalism state. In this period of the experiment, normal body cells digest abnormal cancerous cells for food. Thomas N. Seyfried et al, 2012 After the water fasting period, we began the Specific Ketogenic Diet (SKD) designed by ourselves and Intravenous Ozone Therapy (IOT) in the duration of 90 days (Phase 1) and another 90 days (Phase 2) with the entrance of Hyperbaric Oxygen Therapy (HBO2T) and several supplements which have been effective in previous studies on cancer patients. We have also used the measurement of the saliva pH in the fasting state, the MRI device and statistical methods to test the decrease in size of the tumors. The dosage of the intravenous ozone therapy (IOT) which we used was: 42ug/cc on the first month, 56 ug/cc on the second month and 70ug/cc on the third month in the Phase (1) and 70ug/cc once per week and HBO2T twice per week in the Phase (2) of our research. This type of IOT was due to a decrease in the allergic reaction by the patients. Entering the vitamin/mineral, herbal supplements and probiotic foods benefited cancer patients in their mood and decreased the possibilities of depression and anxiety.

PHASE (1)

In Phase (1) of our research, there were two sessions of IOT on Saturdays and Tuesdays. There was no supplementation in this Phase of our experiment. The SKD is a type of Ketogenic Diet which consists of 80% saturated fat (Organic Cow Butter, Organic Cow Tallow and Coconut oil), 15% protein with lowest Glutamine content (Fish meat, shrimp, organic calf meat, organic whole eggs, organic chicken and low glutamine protein powder.) and 5% complex-high fiber carbohydrate (whole vegetables, cruciferous vegetables, lettuce, white mushrooms and dark green fruits). The consumption of any dairy, artificial sweeteners as well as stevia, vegetable oils, margarines, pig’s meat, soy products, sugar, alcohol, gluten and fruit juices were prohibited in this research. The Total calorie intake of this Diet should be 1200–1500 Cal/Day. The patients used fermented foods (Kimchee, Miso or Natto) every day for their benefits as probiotics to improve their digestion and absorbing important vitamins/minerals. For the improvement of the patients’ body pH and absorbing some important minerals, they have been given vegetable juice twice per day (500 ml/day). The intravenous ozone therapy (IOT) which we used was: 42ug/cc on the first month, 56 ug/cc on the second month and 70ug/cc on the third month. This type of IOT was done to decrease the allergic reaction by the patients. There was not any record of allergic reactions or side effects after the Phase (1) of the study.

The measurements and statistical data are as below:

Table (1) shows the number of patients, gender and the range of their age. As we can see, the highest number cancer types belong to the breast cancer and the lowest belongs to the kidney, colorectal, and lung cancer.

Table 1

As we can observe in the Table (2), the saliva pH of the cancer patients has improved by the SKD and IOT.

Table 2

Table (3) and Figure (1) shows that the tumor size average of the cancer patients is decreased by 58% after 90 days of the controlled trial.

Table 3

Figure 1. Blue line shows the average size of the tumors before the experiment begins and the orange line shows the tumor size of the patients after 90 days.

PHASE (2)

After Phase (1) of this research which took 90 days, 23 of the patients  left the experiment due to passing away because of old age, car accident or not having enough hope for the future treatment. Some of them wanted to live with their families or saying goodbye to them and some of them did not do exactly the diet so we decided not to continue the treatment on them.  We continued the treatment on the remaining 31 patients for the next 90 days. After Phase (1) of our study, we did not observe any cachexia in the patients.

The Phase (2) of the research is the same as the Phase (1) in the Diet and Intravenous Ozone Therapy (IOT). We decided to enter Hyperbaric Oxygen Therapy (HBO2T) and special supplementation including vitamins/minerals and some herbal supplementation in our treamtent. There was one session of IOT on Saturdays with 70 ug/cc, and two sessions HBO2T which took 60 minutes in Mondays and Wednsedays. We did not have any HBO2T chamber so we decided to give the patients the pure oxygen inhalation by the oxygen container for 60 minutes every session.

(Table 4, 5, 6) (Figure 2)

Table 4

Table 5

Table 6

Figure 2. The blue line shows the tumor size before the experiment begins. The orange line shows the tumor size after Phase (1) of the treatment. The white line shows the shrinkage and improvement of the cancer patients tumors after 180 days.

As we can see in Table (5), the saliva pH of the patients is improved from acidic into the alkaline.

Table (6) and Figure (2) show the improvement of the tumor sizes from the beginning of the research, after Phase (1) and after Phase (2). After 180 days of this experiment, we have copmpeletly shrunk the tumor in 4 types of cancer patients and the remaining two have had the tumor size profoundly reduced.

Although we tried to find the natural vitamin/mineral supplement, the only one was “Immunace” by “vitabiotics company”, which had the near dosage we wanted to give to the patients. They were given one tablet of this supplement every night with dinner. They were given 3000 mg of Ascorbic acid (500 mg every two hours), one cup of cottage cheese with 5 gr of flaxseed oil every night for dinner (Table 7).

Table 7. Specific doses for supplements given to the patients.

Results

This research was a controlled study on 54 cancer patients of several kind of cancers. We have put the study in two phases. Each phase took 90 days with different number of patients. In the Phase (1) there were 54 patients with 6 types of cancer: Brain cancer, Breast cancer, Colorectal Cancer, Kidney Cancer, Liver cancer and Lung cancer. We measured their saliva pH before the therapy in the fasting state which were totally acidic. We began the 5-day water fasting, SKD (with 1200–1500 Cal/Day) and IOT on the patients with no supplementation added. After 90 days we observed the tumor shrinkage obviously in all the patients as we can see in Table 3, and improvement in saliva pH from acidic into alkalinity in 90% of the patients.

In the Phase (2) of the study, the number of patients was reduced to 31 and we introduced supplemental vitamin/minerals, HBO2T and Herbal Supplements. The IOT reduced from two sessions to one session per week and HBO2T to two sessions per week to saturate the cancer cells with more oxygen and increasing the amounts of ROS in cancer cells. After Phase (2) which took another 90 days, the saliva PH of all patients became alkaline and several tumors disappeared completely: Brain cancer, Breast cancer, Kidney cancer and Liver.

In two types of cancer the tumor did not disappear completely but the tumors shrinkage improved obviously to less than 0.3 mm which was a marvelous result: Colorectal cancer and Lung cancer. The total survival of the patients was 99.7% and the improvement in the saliva pH was 100% in this research which shows the effectiveness of this methodology of cancer treatment.

Discussion

The effective diet introduced in this research is the Specific Ketogenic Diet (SKD) programmed by Dr. Somayeh Zaminpira and Dr. Sorush Niknamian. Normal cells use the sophisticated process of respiration to efficiently turn any kind of nutrient that is fat, carbohydrate or protein into high amounts of energy in the form of ATP. This process requires oxygen and breaks food down completely into harmless carbon dioxide and water. Cancer cells use a primitive process of fermentation to inefficiently turn either glucose from carbohydrates or the amino acid glutamine from protein into small quantities of energy in the form of ATP. This process does not require oxygen, and only partially breaks down food molecules into lactic acid and ammonia, which are toxic waste products. The most important result is that fatty acids or more generally, fats cannot be fermented by cells [6]. (Figure 3) shows the basic nutrition contents in the SKD.

Figure 3. The Specific Ketogenic Diet (SKD).

The reason behind this kind of diet for cancer patients is to starve cancer cells and make them weak. Most patients cannot use cancer ketogenic diets due to gastrointestinal discomfort or high amount of fat which is 90%. SKD uses 80% fat in the form of saturated animal and coconut oil which are less likely to cause adverse side effects such as diarrhea.  Food restriction reduces the incidence of both inherited and acquired cancers in laboratory animals [7]. Most cancer cells grow best when they have access to a combination of glucose and the amino acid glutamine. But, there are some types of cancer cells which do just fine without any glucose as a food source, because they are especially good at burning glutamine. This is why both glucose from dietary carbohydrates and glutamine from dietary protein, need to be restricted in order to best target cancer cells. Therefore, a low-calorie ketogenic diet consisting of 90% fat, with the rest 10% being made up of protein plus carbohydrate maybe the best way to starve cancer cells. This diet forces normal cells to burn fat for energy. It contains enough protein for normal cells to function properly. Excess protein means excess amino acids and glutamine. The ketogenic diet does not have to contain any carbohydrate, However, it is not harmful if  it contains significant amounts of carbohydrate, as long as calories are kept low. Blood glucose levels respond more to calorie intake than to carbohydrate intake [8]. This is the reason for the lowest glutamine intake in the SKD (Figure 4).

Figure 4. Explanation of different Ketogenic Diets [9].

Ozone has been found to be an extremely safe medical therapy, free from side effects. In a 1980 study done by the German medical society for ozone therapy, 644 therapists were polled regarding their 384,775 patients, comprising a total of 5,979,238 ozone treatments administered. There were only 40 cases of side effects noted out of this number which represents the incredibly low rate of 0.000007% and only 4 fatalities. Ozone has thus proven to be the safest medical therapy ever devised [10]. Ozone therapy causes an increase in the red blood cell glycolysis rate. This leads to the stimulation of 2,3-diphosphoglycerate which leads to an increase in the amount of oxygen released to the tissues. Ozone activates the Krebs cycle by enhancing oxidative carboxylation of pyruvate, stimulating production of ATP. It also causes a significant reduction in NADH and helps to oxidize cytochrome C. There is a stimulation of production of enzymes which act as free radical scavengers and cell-wall protectors: glutathione peroxidase, catalase and superoxide dismutase. Production of prostacyline, a vasodilator, is also induced by O₃ [11].

Ozone administered at a concentration of between 30 and 55 μg/cc causes the greatest increase in the production of interferon and the greatest output of tumor necrosis factor and interleukin-2. The production of interleukin-2 launches an entire cascade of subsequent immunological reactions. [11] Ozone exposure induces a significant mean decrement in vital capacity. It significantly increases mean airway resistance and specific airway resistance but does not change dynamic or static pulmonary compliance or viscous or elastic work. It also significantly reduces maximal transpulmonary pressure. And further more significantly increases respiratory rate and decreases tidal volume [12–20].

There were no side effects like allergic reactions and gastrointestinal discomfort of this methodology of treatment recorded in this research and it was safe. HBO2T in combination with IOT and SKD reduced the acidity and pain in the patients as well.

We name this methodology used in this treatment the Sorush Cancer Treatment Protocol (SCTP). This protocol includes: 5-day water fasting, SKD, IOT, HBO2T, natural Vitamin/Mineral Supplements, Herbal Supplements, 3000–5000 mg ascorbic acid, probiotic foods and cottage cheese mixed with flaxseed oil. The total calorie intake by the patients should be 1200–1500 Cal/Day. The dietary restrictions in this protocol are: Dairy, Industrial Vegetable oils, Margarines, Alcohol, Gluten, Soy Products (Miso and Natto are exceptional), Artificial Sweeteners as well as Stevia, Fruit juices and any types of sugar including Honey.  The duration of the SCTP should not exceed 6 months to reduce the possibilities of ketoacidosis occurrence in patients.

Acknowledgement

This research is sponsored by the Violet Cancer Institute (VCI) and Weston A. Price Foundation (WAPF).

Conclusion

Using the Specific Ketogenic Diet (SKD) in combination with the Intravenous Ozone Therapy (IOT) resulted in the shrinkage in 6 cancer tumor types (Brain Cancer, Breast Cancer, Colorectal Cancer, Kidney Cancer, Liver Cancer and Lung Cancer) in vivo and improved the fasted saliva pH of the patients from acidic into alkaline after 90 days. By introducing the supplements including Vitamin/Mineral, Herbal supplements shown in (Table 7), Ascorbic Acid mega dosage (3000 mg/day) and Hyperbaric Oxygen Therapy (HBO2T) into our research, all the patients went into complete remission except colorectal and lung cancer in 180 days. The tumors of the remaining cancer patients decreased to less than 0.3 mm in size which shows the effectiveness of this cancer treatment protocol. There were no records of side effects including gastrointestinal discomfort and cachexia in this experiment. The pain related to the type of tumors in patients improved, the saliva pH of all patients became alkaline and the lifestyle of all patients improved after 180 day of the treatment. that the diet needs to be organic and that foods of the highest quality should be chosen. We suggest not using the SKD for more than 6 months to reduce the possibility of ketoacidosis in patients (Figure 5).

Figure 5. SCTP procedure in brief.

List of Abbreviations:

EMHC: Evolutionary Metabolic Hypothesis of Cancer

SKD: Specific Ketogenic Diet

IOT: Intravenous Ozone Therapy

ROS: Reactive Oxygen Species

HBO2T: Hyperbaric Oxygen Therapy

SCTP: Sorush Cancer Treatment Protocol

References

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DOI: 10.31038/CST.2019413

Abstract

Purpose: To determine the frequency of albino skin cancers and to describe the difficulties related to the diagnostic and therapeutic management of these patients in Guinea.

Material and methods: This was a retrospective cohort study on albinos attending Surgical Oncology Unit of Donka National Hospital for skin cancer from March 17, 2007, to December 17, 2016.

Results: We identified the 30 albinoes who presented 41 skin cancer lesions. There were 18 (60.0%) women and 12 (40.0%) men. The average consultation delay was 28.3 months. Patients were housewives in 10 cases (33%), merchants in 8 cases (26.6%) and students in 6 cases (20.0%). The primary sites were the face in 22 cases (73.3%), trunk in 4 cases (13.3%) and neck in 3 cases (10.0%). There were squamous cell carcinoma in 29 cases (96.7%) and sarcoma 1 case (3.3%). The clinical stage was localized in 16 cases (53, 3%), locally advanced in 13 cases (43.3%) and metastatic in 1 case (3.3%).  Wide surgical excision performed in 17 (56.7%) for 28 lesions. Wound closure was achieved by a myocutaneous flap in 15 cases, directed scarring in 7 cases, direct suture in 4 cases and skin graft in 2 cases. After a median follow-up of 8 months, 2 patients presented with relapse and 3 new tumor lesions and 9 (30.0%) died. At 24 months, overall survival was 29.0%.

Conclusion: The incidence of skin cancer is high among albinos. Late diagnosis and inaccessibility to means of treatment are factors limiting the management of this vulnerable group.

Keywords

skin cancers, albinos, squamous cell carcinomas, late diagnosis

Introduction

Albinism is an inherited genetic disorder characterized by hypopigmentation of the skin, hair and / or eyes due to a lack or reduced cutaneous production of melanin [1]. Albinos are very sensitive to sunlight damage to the skin [2]. There are two main types of albinism, oculocutaneous (eyes, skin, and hair) and ocular. Skin cancer is a major cause of morbidity and mortality in albinos. They develop precancerous and cancerous lesions at a young age and suffer from advanced skin cancers in the third and fourth decade of their life [3].

It is clear that there are social discrimination and stigma directed towards albinos. As a result of this social discrimination, they are severely limited in the search for medical care when they have significant deformities following advanced disease [4]. Few data exist on skin cancer in albinos in Guinea. The previous study in our unit showed that skin cancers accounted for 7.8% of cancers and 4 of the 84 cases were albinos [5].

These patients have very little access to prevention and care whereas they should be under dermatological screening. Surgical treatment is the only means of treatment available for healing in our settings. This study aimed to determine the frequency and discuss the management of skin cancers of this vulnerable population at Surgical Oncology Unit of Donka National Hospital.

Material and Methods

Settings

Data collection took place at the Surgical Oncology Unit (SOU) of Donka National Hospital, Conakry University Hospital. This unit, created since 2007, receives albino patients from the dermatology and other departments for the skin cancers treatment.

Study design

This was a retrospective cohort study of albino’s patients with cutaneous cancers at the SOU from May 17, 2007, to December 17, 2016. The consultation records, albino patient records, pathology reports, and the operating protocol register completed data collection forms.

Population and data collection

We included records of albino patients who had histologically confirmed skin cancers among other cases of skin cancer during the study period. Records of albino patients with histologically unconfirmed skin tumors or other types of cancer were excluded.

The socio-demographic data studied included age, sex, ethnicity, occupation, and residence. The history of skin cancer, actinic lesions, smoking, and alcohol consumption was recorded. Infection with the human immunodeficiency virus (HIV) was sought by retroviral serology.

Consultation delay from the moment that the patient observed the lesion and came for consultation was identified. Iterative excision was defined by this done before the patient came to the SOU. Clinical data included clinical appearance, tumor size in centimeters, number of lesions, and primary site.

Histological confirmation was obtained on an incisional biopsy specimen or on a complete excision sample. Histological types were classified according to the World Health Organization (WHO) [6]. Adjacent infiltration of muscles or bone was reported. Regional lymphadenopathies were checked by clinical assessment. The sparing assessment was completed by chest x-ray (looking for pleuropulmonary opacities) and abdominal and pelvic ultrasound (looking for hepatic hypoechoic images). The TNM clinical classification of the International Union against Cancer (UICC) 2010 [7] was used to classify skin cancers in this study.

The types of surgical excision, closure of the operative wound, excision margin status, operative complications, and hospitalization were described. Some patients benefited from palliative chemotherapy (5- Fluoro-uracil and cisplatin). There is no radiotherapy in our country. Follow-up time, rates of recurrence and appearance of new tumor foci, and survival were assessed.

Data analysis

Statistical data were analyzed with statistical package for the social sciences (version 21.0 for Windows, SPSS, Inc., Chicago, IL). Categorical variables were shown as the frequency and percentage (%), and continuous variables were presented as the mean (± standard deviation) and / or median and interquartile range (IQR). Patients lost to follow-up were included in the survival analysis. Factors associated with survival were studied in relation to surgical excision and clinical stage. Survival was calculated according to the Kaplan Meier method. The log-rank test was used to analyze prognostic factors. The cox model was used to search for independent prognostic factors. The test was significant if the p-value was less than 0.05.

Ethical considerations

The data analyzed in this study respected anonymous and confidential principles.

Results

From 2007 to 2016, we recorded 41 albinos with clinically suspected skin cancers. Eleven cases were excluded because of the absence of histological examination. We included the records of 30 patients who had histologically confirmed skin cancer. They accounted for 21.9% of 137 patients with skin cancer at the Donka SOU during the study period. Figure 1 shows the number of cases per year.

Figure 1. Number per year of albinos among patients presenting skin cancer

Sociodemographic Data

The age ranged from 17 to 76 years with an average of 31.6 years (± 14.0) and a median of 31.5 years (IQR 21.7–45.2). Patients aged 30 and under accounted for 50%. There were 12 men (40.0%) and 18 women (60.0%). Patients were housewives in 10 cases (33.3%), merchants or traders in 7 cases (23.3%) and students in 6 cases (20.0%). The patients were from Conakry region in 8 cases (30.0%), Kindia in 7 cases (23.3%) and Kankan in 6 cases (20.0%). Fulani accounted for 14 cases (46.7%), Mandingo 11 cases (36.7%), Soussous 4 cases (13.6%) and Kissi 1 cases (3.3%).

Risk factors

A patient has been previously treated for skin cancer. An actinic lesion has been found in one patient. Smoking and alcohol consumption were reported in the lifestyle of 5 (16.7%) and 3 (10.0%) patients, respectively. HIV infection was found in one patient.

Clinicopathological features

The median consultation delay was 12 months (IQR 8.5–46.0). Before admission, iterative excision was noted in 3 patients. For the 30 patients, there were 41 cancerous skin lesions or 1.4 lesions per patient. Patients had one lesion in 23 cases (76.7%), 2 lesions in 4 cases (13.3%), 3 lesions in 2 cases (6.7%) and 4 lesions in 1 case (3.3%).

The primary site was the face in 22 cases (73.3%), the trunk in 4 cases (13.3%) and the neck in 3 cases (10.0%).

The clinical aspect was nodular in one patient and ulcero-budding in 29 patients. The tumor size ranged from 1–47cm with a median of 5cm (IQR 3.0–12.0). The tumor infiltrated adjacent muscles in 6 cases (20.0%) and bone in 1 case (3.3%). There was regional lymph node involvement in 7 cases (23.3%) and hepatic metastases in one patient. The clinical stage, according to TNM classification of UICC 2010, was localized in 16 cases (53, 3%), locally advanced in 13 cases (43.3%) and metastatic in 1 case (3.3%). Table 1 presents sociodemographic data, the primary sites, and clinical tumor (T) classification.

Table 1. Sociodemographic data, Primary sites and clinical primary tumor (T) classification (UICC 2010) of skin cancer in albinos (n = 41)

The diagnosis based on the histological examination of the biopsy specimen in 20 patients (66.7%) and the excisional specimen in 10 (33.3%) patients. This was squamous cell carcinoma in 29 cases (96.7%) and sarcoma 1 case (3.3%).

Treatment

A wedge surgical excision was performed in 17 patients (56.7%) for 28 lesions. Radical cervical lymph node dissection was performed in the second time in one patient. Wound closure was obtained by a simple suture in 4 cases, cutaneous graft in 2 cases, myocutaneous flaps in 15 cases and directed scarring in 7 cases. Excision margins were free in 7 documented cases. Infection of the operative site (1 case) and delay of healing (1 case) were complications observed. This intervention required hospitalization in 7 cases. The median hospital stay was 6.5 days (IQR 4.5–20.7). Salvage and palliative chemotherapy were performed in 2 and 1 patients respectively. The clinical response to this chemotherapy was disease progression in all cases.

Follow-up

Nine patients were seen once at the consultation. After a median follow-up time of 8 months [95% CI 2.3–13.7], we observed a relapse in 2cases (6.7%), the appearance of new tumor lesions in 3 (10%) patients and 9 (30%) patients had died. Figure 2 shows the old scars and new tumor lesions.

Figure 2. Old scars and new tumor lesions

Overall survival after a median follow-up of 8 months was 70.0%. At 24 months, overall survival was 29.0% (Figure 3). This survival was correlated with being operated upon (88.2% versus 46.2%) (p = 0.02). It varied according to the stage: 87.5% for the localized stage, 53.8% for the locally advanced stage and none for the metastatic stage (p = 0.056). None of the factors were independent after analysis by the Cox model.

Figure 3.  Overall Survival of skin cancers in Albinos (n = 30)

Discussion

The limitations of this study were the low number of histologically confirmed cases of skin cancer in albinos. Despite this, we showed the high frequency of skin cancer in albinos, which accounts for about one-fifth of all skin cancers in this study. This frequency was similar according to Kromberg et al [8] in South Africa. It was higher than that of Mabula et al [1] in Tanzania which was 13.2%. In an Imo State plastic surgery department in Nigeria, skin cancer in albinos represented 67.0% [9].

As in other findings [1,3,10], the patients are in their third decade.

The high frequency in the Conakry region and surrounding areas is related to the proximity of the reference services (Dermatology and Oncological Surgery Unit) in the management of skin cancers.

The socio-professional groups involved in this study were those (housewives, tradesmen, students) who were exposed to the sun. Patients working outdoors, under the sun accounted for 75.0% according to Opara and Jiburum [9]. The use of wide-brimmed hats, long-sleeved shirts, scarves on the neck, sunglasses, and sunscreens could reduce the occurrence of cancer in these areas of the body.

Smoking found in some cases would increase the risk of CCS [11]. Actinic lesions was reported only in one patient where is found by Emadi et al [12]in 37.7% of women and 29.1% of men.

HIV infection, diagnosed in a patient, would increase the frequency of cutaneous cancers in albino but the etiopathogenic mechanism is not known [13]. HIV infection was reported in 6.2% of albino patients in the Mabula et al [1] series.

Clinicopathological features

The long delay, varying from 3 to 120 months, was reported by Opara and Kiprono [3,9]. This late presentation was mainly related to poverty and ignorance. Treatment in peripheral hospitals and among traditional healers is mentioned in some studies [1]. Three of them were poor first management in peripheral health facilities, hence the need to improve continuing health professionals training on early detection. The multiple lesions were common in the same patient. The mean number of outbreaks was  1.4 per patient in our study and 1.9 lesions per patient according to Opara [9]. The part of the body (face, trunk, and neck) exposed to the sun, were the most common primary sites. Although none exist in our study, rare cases of localization on the genitals and the lower limbs have been described by Mabula et al [1].

The average size of 5cm is reported in other studies [1, 14].

The diagnosis of cutaneous cancer was confirmed on the histological analysis of the biopsy specimen in 2/3 of the cases and the operative specimen 1/3 of the cases. In the first case, it is often advanced lesions, multiple or from other services with the results. In the second case, these are patients who have resectable lesions, who accept the surgical treatment after assessment; the resection is then both diagnostic and therapeutic.

Almost cases were squamous cell carcinoma in this study. This was reported by several studies [1,3,8,15]. There are no basal cell carcinomas and melanomas, but these forms reported [1,3,9]. In contrast, cutaneous sarcomas in albino are very rare; only one case in this study. Rare cases of sarcomas have been reported [16,17].

Adjacent muscle or bone, and cervical lymph node involvement indicate advanced stages in these patients. These lymphadenopathies were all related to SCC. Mabula et al [1] reported 12.5% of regional lymphadenopathies in 64 patients. In this study, liver metastases were present in one patient whereas Mabula et al [1] described liver, lung, bone and nerve metastases in 6 out of 64 patients.

Treatment

One of the limitations of this study was the small number of patients treated. Our 60% of patients treated were greater than those of a previous study in which 46 of 102 skin cancer patients were treated. [18]. This difference can be explained by the effect of the campaign of early detection and management of albinos in 2014. However, in Africa, black albinos often suffer social discrimination because of superstitious beliefs and the stigma associated with albinism. They are often rejected by their communities, with a resulting delay in the search and treatment of any precancerous or malignant keratosis lesions. Thus, at the time of diagnosis, the lesion is often advanced and has a poor prognosis [13].

Surgery has been reported as the mainstay of treatment for the majority of skin cancers in albinos [19,20]. Wide excision is the most important to prevent local recurrence. Good results can be achieved with radical surgery and optimal surgical margins as well as the reconstructive procedure when needed. In the current study, wide local excision, with skin flap closure or graft was the most performed surgical procedure as in many studies [1,4,9].

One patient underwent cervical dissection for regional lymph node relapse, after treatment of the primary lesion by wide excision. Mabula et al [1] performed a single lymph node dissection among the 64 patients in their study. We did not perform systematic lymph node dissection because we considered that the lymph node would be related to secondary infection. In addition, all lymph nodes decreased after the excision of the primary lesion.

It is often an outpatient surgery. But hospitalization may be needed as for 7 patients who underwent extensive resection and / or to avoid complications while Mabula et al [1] hospitalized more than 90.0% of patients for their treatment. Wound Infection and delayed healing were surgical complications observed in one patient. In addition to these complications, flap necrosis and skin graft loss have been described [1].

Three (3) patients received cisplatin and 5 fluorouracil-based chemotherapy and results were progression disease. Although cases of complete or partial responses have been reported after chemotherapy with adriamycin and platinum salts (carboplatin or cisplatin) [21, 22], there is not enough data to confirm the role of neoadjuvant chemotherapy in locally advanced skin cancers in albinos.

In this study, we had problems to follow-up these patients. The median time to follow up was 8 months. These follow-up problems have been reported by other authors as well [1,9]. Despite these follow-up problems, we were able to assess the local control by the recurrence rate which was 2 out of 17 cases, representing a relapse rate of 11.7%. This rate seems less than that found by Mabula et al [1] which was 30.0%. These differences could be explained by surgical margins status. In this study, surgical margins vary 1–2cm as reported in the previous study on skin cancer surgery in our unit [18]. Our patients did not receive radiotherapy, which is indicated in cases of unresectable locally advanced cancers, in the adjuvant situation and in cases of relapse [1,9]. In addition, radiotherapy can optimize local control after surgical excision of the lesion.

In this study, we noticed the appearance of new tumor lesions in 3 patients. Thus, multiple lesions, relapse, and new tumor lesion mean that albinos can undergo multiple skin surgeries during their lifetime [14].

Approximately one-third of patients died in this study while the mortality was 4 out of 64 patients in Tanzania [1]. This high mortality is related to not being operated upon and has been higher in advanced cases.

Conclusion

The incidence of skin cancer is high among albinos. Late diagnosis and inaccessibility to means of treatment are factors limiting the management of this vulnerable group.

Acknowledgment

We said thanks to Mr. Thierno Boubacar Balde for the patient records availability

Ethics approval and consent to participate: In this retrospective study, data were collected anonymously and confidentially. Patients signed the consent form for the use of data contained in their records.

Consent for publication: Patients signed the consent form for the use of data contained in their records.

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