International Association for Hospice & Palliative Care

International Association for Hospice & Palliative Care

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Promoting Hospice & Palliative Care Worldwide

International Association for Hospice & Palliative Care

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"Promoting Hospice and Palliative Care Worldwide"


2005; Volume 6, No 1, January





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Burkitt’s Lymphoma in Kenya:
Dr. J. N. Onyango

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A British Pathologist, Dennis Burkitt, who was then working at the Mulago Hospital in Kampala, first described Burkitt’s lymphoma in 1958. It was first described as a sarcoma of the jaws in African children because of its high occurrence in the facial area of the mandible and maxilla. It is a tumour mainly confined to a belt across the African continent approximately 15 degrees north and south of the equator and mainly located below 1500 meters above sea level, and where the rainfall is over 50cm per year and temperatures below 27 degrees Celsius. The frequency of Burkitt’s lymphoma in the above region is more than 50% of all the malignant tumours in children between the ages of 3 to 15 years, especially in East Africa, while in Nigeria it is said to be above 70% in the same age bracket.

The sites mostly affected are the jaws, the ovaries and retroperitoneal tissues in female children with the abdominal Burkitt’s lymphoma. The Central Nervous System is also involved in about 30% of all the new cases and is accompanied by cerebrospinal fluid (CSF) involvement. This means that 30% of the patients present with stage 4 disease. Recurrence in previously treated cases involving the CNS is also frequent.

The Nature of Burkitt’s lymphoma

Burkitt’s lymphoma is a very rapidly growing tumour with a potential doubling time of 24 hours. This means a tumour of 3 cm would grow to 6 cm in 24 hours. Histological appearance if the Burkitt’s lymphoma is characterised by the presence of undifferentiated lymphoreticular or primitive stem cells. Macrophages are frequently spread amid the tumour cells forming the so-called “starry sky” pattern.

Serological investigation by Dr. J. Onyango, (the author) and Prof. George Klein and Dr. Henle of Stockholm and USA respectively showed the presence of antibodies against the EBV (Epstein Barr Virus). This means that etiologically the Burkitt’s lymphoma is a viral disease that occurs in children whose immunity has been lowered by repeated malarial infections. This is the reason for the disease occurring after 3 years of age when the natural immunity has been affected by the malarial infections.


Burkitt’s tumour being a malignant lymphoma is expected to be very radiosensitive. However, routine daily fractional radiation therapy provides no regression of the disease because of its high rate of growth. It is because of this that Dr. J. Onyango and Dr. Torsten Norin, both working at the Kenyatta National Hospital in Nairobi, Kenya, developed a radiation protocol known as “Superfractionation” This means that the patient is given three fractions daily at 9am, 12 noon and 3pm, 5 days/week. This gives good results with complete regression of the tumour in almost 100% of the cases. It is, however, not possible to give radiotherapy in the Nyanza Provincial Hospital because of lack of a Radiotherapy Unit.

The second best treatment is chemotherapy. This started as a single drug therapy, but has now been developed into a multi-drug therapy. The patients are given 6 courses of intensive chemotherapy, usually consisting of cyclophosphomide (Endoxan), oncovine (Vinctistine) and adriamycin (Doxorubicin) at 3-weekly intervals. This is followed by maintenance doses, which may include drugs like Cylosar – Arabinocide, Prednisone and tablets of metacapurine. For CNS involvement, intrathecal methotrexate or total CNS irradiation is usually given.

Like most malignancies in Kenya, Burkitt’s lymphoma is in many cases diagnosed late, however a great number of children do benefit from palliative care of their disease. Severe pain is most common in all the affected regions. The majority of patients require initial pain control using strong analgesics while giving chemotherapy. In almost all cases, morphine administered by syringe is very useful until the tumour partially, or totally, regresses because of the chemotherapy. In very advanced cases, strong analgesics are required throughout for good palliation. Other drugs against various complications and good nourishment are also provided.


Patient visits at our Children’s Ward for chemotherapy – monthly reports.

Patient visits at our Children’s Ward for chemotherapy – monthly reports

As is seen in the above list, the ratio of male to female patients is 2:1 in our cases, and this is true all over Africa.

Our plan is to have a special ward for the management of malignancies of children including leukaemia. At present there is only a single room for them in the general children’s ward. This is inadequate and some children who have recovered from the acute illness are given chemotherapy as outpatients.