CASE REPORT - JOURNAL OF FUNCTIONAL VENTILATION AND PULMONOLOGY. VOLUME 12 - ISSUE 36. 2021

Last Updated: 20/08/2021

Case report of coexistence of lung adenocarcinoma and tuberculosis
Rapport de cas de coexistence d'adénocarcinome pulmonaire et de la tuberculose
A. Tahseen¹, P. Satya Dattatreya²,V. Vasini², M. Hidayath Hussain¹

¹: Department of Pulmonology. Shadan Institute of Medical Sciences. India
²: Medical Oncologist And Haemologist Omega Hospital. India

Corresponding author
Pr. Mohammed HIDAYATH HUSSAIN
Department of Pulmonary Medicine, Shadan Institute of
Medical Sciences. Hyderabad, India.
E-mail: drhidayathsims@gmail.com

DOI: 10.12699/jfvpulm.12.36.2021.56

Abstract
Full Text-HTML
Full Text-PDF
Figures-Tables
References
Article info

ABSTRACT

Lung carcinoma is the leading cause of cancer-related death and represents one of the major public health problems worldwide. Tuberculosis is very important cause of morbidity and mortality despite good prevention, diagnosis and effective therapy, especially in the poor and developing countries.Tuberculosis and lung cancer rarely coincide together but have been proven by different studies to have a definitive link. Here presenting a case diagnosed with lung adenocarcinoma and tuberculosis together.

He is a known case of hypertension and diabetes mellitus on regular treatment. On examination patient was conscious and coherent with stable vitals.

Routine blood investigations done , chest x-ray showed bilateral infiltrates in lower zones and right upper zone.

KEYWORDS: Lung carcinoma; Tuberculosis; Adenocarcinoma.

RÉSUMÉ

Les carcinomes pulmonaires sont la principale cause de décès liés au cancer et représentent l'un des principaux problèmes de santé publique dans le monde. La tuberculose est une cause très importante de morbidité et de mortalité malgré une bonne prévention, un bon diagnostic et un traitement efficace, en particulier dans les pays pauvres et en développement. La tuberculose et le cancer du poumon coïncident rarement, mais différentes études ont prouvé qu'ils avaient un lien définitif. Présentant ici un cas diagnostiqué avec un adénocarcinome pulmonaire et une tuberculose ensemble.

Un homme de 62 ans s'est présenté à l'hôpital avec des plaintes de toux sèche depuis 5 mois pendant 10 à 15 minutes après avoir pris de la nourriture ou de l'eau potable. Antécédents de perte de poids significative d'environ 17 kg au cours des 3 derniers mois Antécédents médicaux d'attaque vasculaire cérébrale - accident vasculaire cérébral ischémique a laissé une faiblesse fasciobrachiale avec dysphagie due à un infarctus de l'artère cérébrale moyenne, un infarctus lacunaire bilatéral et était sous sonde nasogastrique pendant 45 jours après l'AVC.

Il s'agit d'un cas connu d'hypertension et de diabète sucré sous traitement régulier. À l'examen, le patient était conscient et cohérent avec des signes vitaux stables.

Des examens sanguins de routine effectués, la radiographie pulmonaire a montré des infiltrats bilatéraux dans les zones inférieures et la zone supérieure droite.

MOTS CLÉS: Carcinome bronchopulmonaire; Tuberculose; Adénocarcinome.

INTRODUCTION

Tuberculosis (TB) and lung cancer are common diseases that cause substantial morbidity and mortality worldwide [3]. Coexistence of tuberculosis and lung cancers is not uncommon clinically [5,13]. The coexistence of Tuberculosis and lung cancer is estimated at 2% [4,5] and typically found in the upper lobes [15]. It has been proposed that pulmonary TB infection may exist as a chronic inflammatory process that is associated with an increased risk of lung cancer. This is because the pulmonary inflammation and fibrosis may induce genetic damage, which leads to carcinogenesis of the pulmonary parenchymal tissue [6,7,8,9]. It has been reported that some cases of lung cancer, usually adenocarcinoma in type, that arise from pulmonary scars were the result of healed pulmonary Tuberculosis infection [10,11,12]. A study conducted by the National Cancer Institute found that patients with pulmonary Tuberculosis had increased risk of lung cancer14and another estimated a twofold elevation in risk of lung cancer in men with Tuberculosis [3].

We present a case of 62-year male diagnosed as pulmonary tuberculosis in bronchoalveolar lavage specimen and pulmonary adenocarcinoma on lung biopsy and immunohistochemistry marker TTF 1 POSITIVE.

CASE REPORT

A 62 year old male presented to hospital with complaints of dry cough since 5months for 10 to 15 mins after taking food or drinking water. History of significant weight loss of around 17kgs over past 3 months past medical history of Cerebrovascular attack- ischemic stroke left fasciobrachial weakness with dysphagia due to Middle cerebral artery infarct, bilateral lacunar infarct and was on nasogastric tube for 45 days after stroke .He is a known case of hypertension and diabetes mellitus on regular treatment. On examination patient was conscious and coherent with stable vitals. Routine blood investigations done , chest x-ray showed bilateral infiltrates in lower zones and right upper zone. Chest HRCT showed patchy infiltrates and ground glassing in apical and posterior segments of bilateral upper lobes, superior segments of bilateral lower lobes with multiple miliary nodules scattered in both lungs with mediastinal lymphadenopathy with mild left pleural effusion and pott spine. Bronchoscopy was done and bronchoalveolar lavage was sent for tuberculosis analysis result came out to be positive for Mycobacterium Tuberculosis- Rifampicin sensitive. PET CT of whole body done showing Fluor deoxy glucose avid infiltrates in right upper lobe, basal segments of both lower lobes; multiple tiny nodules in both lungs; non fluorodeoxyglucose avid pleural and pericardial effusions ; multiple fluorodeoxyglucose avid sclerotic and lytic lesions involving multiple bones. Cryobiopsy of right upper lobe posterior segment done sent for histopathological examination which was suggestive of non- small cell carcinoma lung. Immunohistochemistry results consistent with pulmonary adenocarcinoma with marker TTF1 positive .Hence diagnosed as pulmonary Koch’s with pulmonary adenocarcinoma with pott spine. Patient was started on Anti tubercular drugs, meanwhile his saturation was dropping and developed hypotension. Patient and his attendants were not co-operative for any further treatment and investigations and unfortunately, we lost the patient.

DISCUSSION

Lung cancers are among the neoplastic diseases with the worst prognosis.

Etiology of lung carcinoma
The etiology of the disease has been associated with smoking, occupational exposure to arsenates, nitrosamines, asbestos, and aromatics, and indoor exposures to radon, and to fumes from fires or cooking stoves [16,17,18,19].

Outdoor air pollutions also substantially contribute to the burden of lung cancers in urban dwellers.
Inflammation processes have long been linked to cancer development 20,21.

Among intrinsic lung diseases with inflammatory components, chronic obstructive pulmonary disease (COPD)22 , asthma23, and pulmonary fibrosis24 have been linked to lung cancers.

Tuberculosis with more than 80% of the cases primarily affecting the lungs entails a chronic inflammatory process.

This is because the pulmonary inflammation and fibrosis may induce genetic damage, which leads to carcinogenesis of the pulmonary parenchymal tissue [6,7,8,9].

Coexistence of tuberculosis and lung cancers is not uncommon clinically [5,13].

Nevertheless, a clear association of tuberculosis with lung cancers remains to be established.

In the tuberculosis field cancer can develop or in cancer depleted patients tuberculosis develops secondary [32,33].

Association between lung cancer and tuberculosis opens a series of questions about the relationship between these two diseases.

Tuberculosis and cancer can be found in the lungs in the following relationship
Carcinoma occurs on the tuberculosis ground and reactivates the old focus of tuberculosis.

Carcinoma develops from the tuberculosis scars (scar carcinoma).
Carcinoma occurs by epithelium metaplasia of tuberculous cavities.

Both diseases are independent of each other and develop simultaneously or sequentially.
Metastatic carcinoma developing in an old Tubercular lesion.
Secondary infection of cancer with Tuberculosis [32-34].

The three most common forms most common forms are: cavern carcinoma, carcinoma of the drainage bronchus and peripheral lung scar cancer [32,33].

The changing incidence shows a trend of lung cancer shifting from developed to less developed countries [25,26], where tuberculosis poses a major health risk because of poverty, high population density, inadequate living environment, and less accessibility to health care. Patients with cancer are vulnerable to develop active Tuberculosis because of immunosuppression due to the use of intensive treatment modalities, such as aggressive chemotherapy, radiotherapy or to malnutrition31.It has been reported that some cases of lung cancer, usually adenocarcinoma in type, that arise from pulmonary scars were the result of healed pulmonary Tuberculosis infection [10-12]. Patients with pulmonary adenocarcinoma who had scar cancer or had old Tubercular lesions had a higher probability of having EGFR mutations, especially exon 19 deletions.

Patients with lung cancer whose tumors exhibited EGFR-activating mutations had approximately 75% response rate when treated with EGFR-tyrosine kinase inhibitors (TKIs), whereas those patients without EGFR-activating mutations responded to EGFR-TKI poorly [28,29,30]. Diagnosis of concurrent Tuberculosis and lung cancer is important, but may be difficult. Tuberculosis lesions can mask lung cancers, delaying the diagnosis [5]. Patients who initially present with active Tuberculosis and lung cancer have lower survival rates than those having lung cancer without Tuberculosis [10]. Surgical resection for early-stage lung cancer with anti-Tuberculosis therapy is a potential treatment, however, there are currently no established guidelines [4,5]. One suggestion is that newly diagnosed Tuberculosis cases be followed up periodically with chest X-ray, bronchoscopy, and sputum cytology to enable early diagnose of lung cancer [5]. Some authors point out that increasing incidence of lung diseases is associated with increased incidence of lung cancer and therefore there should be oncological watchfulness in follow-up of patients with lung diseases or tuberculosis [35,36,37]. Although rarely occurring together, Tuberculosis and adenocarcinoma have an established connection. Diagnosis of simultaneous occurrence is difficult, given that one can mask the other, however, recognition of the diseases is important and can impact outcomes and patient treatment options. Even if tuberculosis is associated with lung cancers, more questions could be raised.

Does tuberculosis affect some types of lung cancer but not others?

Clinically, squamous cell carcinoma (SCC) was found in more than 50% of cases with coexistence of tuberculosis and lung cancers [5]. Squamous Cell Carcinoma of lung was also found in mice subjected to chronic infection of mycobacterial tuberculosis [27]. A recent meta-analysis of epidemiological data, however, revealed the association was only significant with adenocarcinoma but not Squamous Cell Carcinoma [2].

CONFLIT OF INTEREST

Non.

REFERENCES

1. Silva DR, Valentini Jr DF, Müller AM, de Almeida CP, DalcinPde T. Pulmonary tuberculosis and lung cancer:simultaneous and sequential occurrence. J Bras Pneumol. 2013; 39(4):484-9.

2. Liang HY, Li XL, Yu XS, Guan P, Yin ZH, He QC, et al. Facts and fiction of the relationship between preexisting tuberculosis and lung cancer risk: a systematic review. Int J Cancer. 2009;125(12): 2936-44.

3. M.S. Shiels, D. Albanes, J. Virtamo, et al, Increased risk of lung cancer in men with tuberculosis in the alphatocopherol,betacarotene cancer prevention study, Cancer Epidemiol. Biomarkers Prev. 20 (2011) 672– 678.

4. M. Sakuraba, M. Hirama, A. Hebisawa, et al, Coexistent lung carcinoma and active pulmonary tuberculosis in the same lobe, Ann. Thorac. Cardiovasc. Surg. 12 (2006) 53–55.

5. S. Cicenas, V. Vencevicius, Lung cancer in patients with tuberculosis, World J. Surg. Oncol. 5 (2007) 22.

6. Yu YH, Liao CC, Hsu WH, et al. Increased lung cancer risk among patients with pulmonary tuberculosis: a population cohort study. J Thorac Oncol 2011;6:32–37.

7. Wu CY, Hu HY, Pu CY, et al. Pulmonary tuberculosis increases the risk of lung cancer: a population-based cohort study. Cancer 2011;117:618–624.

8. Dheda K, Booth H, Huggett JF, et al. Lung remodeling in pulmonary tuberculosis. J Infect Dis 2005;192:1201–1209.

9. Coussens LM, Werb Z. Inflammation and cancer. Nature 2002;420:860–867.

10. Chen YM, Chao JY, Tsai CM, et al. Shortened survival of lung cancer patients initially presenting with pulmonary tuberculosis. Jpn J Clin Oncol 1996;26:322– 327.

11. Raeburn B, Spencer H. Lung scar cancers. Br J Tuberc Dis Chest 1957;51:237–245.

12. Auerbach O, Garfinkel L, Parks VR. Scar cancer of the lung: increase over a 21 year period. Cancer 1979;43:636–642.

13. Ashizawa K, Matsuyama N, Okimoto T, et al. Coexistence of lung cancer and tuberculoma in the same lesion: demonstration by high resolution and contrast-enhanced dynamic CT. Br J Radiol 2004;77:959–962.

14. A.V. Brenner, Z. Wang, R.A. Kleinerman, et al, Previous pulmonary diseases and risk of lung cancer in Gansu Province, China, Int. J. Epidemiol. 30 (2001) 118–124.

15. Y.I. Kim, J.M. Goo, H.Y. Kim, et al, Coexisting bronchogenic carcinoma and pulmonary tuberculosis in the same lobe:radiologic findings and clinical significance, Korean J. Radiol.2 (2001) 138– 144.

16. Samet JM. Radon and lung cancer. J Natl Cancer Inst 1989;81:745–757.

17. Alberg AJ, Samet JM. Epidemiology of lung cancer. Chest 2003;123:21S–49S.

18. Ahsan H, Thomas DC. Lung cancer etiology: independent and joint effects of genetics, tobacco, and arsenic. JAMA 2004;292:3026 –3029.

19. Yang GH, Zhong NS. Effect on health from smoking and use of solid fuel in China. Lancet 2008;372:1445–1446.

20. Balkwill F, Mantovani A. Inflammation and cancer: back to Virchow?Lancet 2001;357:539 – 545.

21. Mantovani A. Cancer: inflammation by remote control. Nature 2005;435:752–753.

22. Hopkins RJ, Christmas T, Black PN, et al. COPD prevalence is increased in lung cancer, independent of age, sex and smoking history. Eur Respir J 2009;34:380 –386.

23. Santillan AA, Camargo CA Jr, Colditz GA. A meta-analysis of asthma and risk of lung cancer (United States). Cancer Causes Control 2003;14:327–334.

24. Hubbard R, Venn A, Lewis S, Britton J. Lung cancer and cryptogenic fibrosing alveolitis. A population-based cohort study. Am J Respir Crit Care Med 2000;161:5– 8.

25. Toh CK. The changing epidemiology of lung cancer. Methods Mol Biol 2009;472:397– 411.

26. Youlden DR, Cramb SM, Baade PD. The International Epidemiology of lung cancer: geographical distribution and secular trends. J Thorac Oncol 2008;3:819–831.

27. Nalbandian A, Yan BS, Pichugin A, et al. Lung carcinogenesis induced by chronic tuberculosis infection: the experimental model and genetic control. Oncogene 2009;28:1928 –1938.

28. Bronte G, Rizzo S, La Paglia L, et al. Driver mutations and differential sensitivity to targeted therapies: a new approach to the treatment of lung adenocarcinoma. Cancer Treat Rev 2010;36(Suppl 3):S21–S29.

29. Zhu CQ, da Cunha Santos G, Ding K, et al. Role of KRAS and EGFR as biomarkers of response to erlotinib in National Cancer Institute of Canada Clinical Trials Group Study BR. 21. J Clin Oncol 2008;26:4268–4275.

30. Bell DW, Lynch TJ, Haseriat SM, et al. Epidermal growth factor receptor mutations and gene amplification in nonsmall cell lung cancer: molecular analysis of IDEAL/ INTACT gefitinib trials. J Clin Oncol2005;23:8081– 8092.

31. Harikrishna J, Sukaveni V, Kumar DP, Mohan A. Cancer and tuberculosis. JIACM. 2012; 13(2): 142-4.

32. Teventiyanon T, Ratanaharathorn V, Leoparait J. Mucoepidermoid carcinoma of the lung presenting as cavitary lesion.J Med Assoc Thai. 2004; 87(8): 988-91.

33. Yilmaz A, Gungor S, Damadoglu E, Axoy F, Aibatly A. Coexisting bronchial carcinod tumor and pulmonary tuberculosis in the same lobe: a case report. Tuberk. Toraks. 2004; 52 (4):369-72.

34. Lubarsch O. Ueber den primaren Krebs des ileum, nebstbemerhunge uber das gleichzeitgevorkommen von krebs und tuberculose. Virchows Arch. 1888; 111: 280-317.

35. Kodolova IM, Kogan EA: Morphogenetic ralationships between tuberculosis and peripheral lung carcinoma. ArkhPatol 1996, 3:52 -60.

36. Braude VI: High incidence of bronchogenic cancer in patients with pulmonary tuberculosis. ProblTuberk 1984, 8:55-58.

37. Belenkaja TJ, Federovitsh VS: Diagnosis and treatment of pulmonary tuberculomas. PtoblTuberk 1989, 9:68-69.