Association of tuberculosis with malignancyKC Patel, DP Shah, SM Sheth, SR Kamat
Department of Chest Medicine, K.E.M. Hospital and Seth G. S. Medical College, Parel, Bombay-400.012., India
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 615268
Source of Support: None, Conflict of Interest: None
A case of bronchogenie carcinoma developing in a patient with pulmonary tuberculosis is described and literature reviewed.
In the presence of tuberculosis, especially active, the diagnosis of carcinoma is delayed or rarely suspected. Symptomatology and physical findings may be ascribed to tuberculosis alone whereas two conditions may co-exist. In addition, deterioration of the X-ray picture is attributed to the development of bacterial resistance. 
Age, a 52 year old male was admitted in July 1974 for pulmonary tuberculosis. He was working as an electric supervisor in railways, was non-smoker and non-alcoholic. At the time of admission he complained of cough with expectoration, low grade fever and loss of appetite. He never had haemoptysis then. His X-ray done then had revealed soft tissue infiltrations in the right upper and mid zones. His one of the three sputa examined was positive for A.F.B.
He was put on Streptomycin, INH and PAS. He took 120 injections of streptomycin and on his own stopped the oral therapy after 10 months only. Since he was better clinically and his sputa were negative for A.F.B. antituberculosis treatment was not restarted. Patient remained alright nearly for 1½ years when he started having dry cough, grade III dyspnoea and haemoptysis on two occasions. He was admitted for same on 17-9-1976.
Clinical findings consisted of moderate clubbing with normal pulse and blood pressure. Trachea was shifted to the right with area of dullness in the right lower lung, diminished air entry and variable vocal resonance in the same area. There were no other significant findings. Routine investigations revealed haemoglobin to be 12.8 gms.%, White cell count of 14800/c.m.m. with normal differential count. ESR was 33 m.m. at the end o£ 1st hour (Westerngren). Sputa were negative for A.F.B. and malignant cells on eight occasions. Urine, stool, blood sugar, electrolytes and arterial blood gases were normal.
X-ray chest PA See [Figure 1] on page 196A showed trachea shifted to the right, right upper lobe and middle lobe fibrosis with cystic changes and collapse consolidation of the right lower lobe. Minimal pleural effusion was also evident.
Pleural fluid contained 79 cells per c.m.m. all lymphocytes with protein content of 3.05 gm.%. Pleural biopsy was non-contributary. Bronchosy copy revealed compression of the right middle, and lower lobe bronchus from without.
This aroused a suspicion of malignancy. Bronchogam done see [Figure 2] on page 196A showed complete cut-off of dye in the middle and lower lobe bronchus.
Exploratory thorecotomy on 1-10-1976 showed right middle and lower lobe collapse with indurated pigmented hilar node compresing the bronchus. Pericardium was hard and thickened suggestive of infiltration inside. As he was having inoperable malignancy biopsy of hilar lymphanode was taken and chest closed.
Histopathology of this material showed adenccarcinoma of the lung. The mass which was present in the right lower lobe had spread to the lymphnode.
Bayle  in 1810, first stated that co-existance of tuberculosis and malignancy in the lung was definitely occurring more commonly than would occur by a chance. The first authenticated case of both conditions existing in the same patient at the same time was reported by Penard.  Von Rokitansky  however stated emphatically that the two diseases were incompatible. Fried  was bold enough to state that two diseases were not antagonistic and could be related aetiologically. There are two situations to be considered so far as interrelations are concerned.
A. Cancer developing in the patients with pulmonary tuberculosis.
Incidences of this type found out by various authors (compiled from literature) are as follows:
(i) 0.75% by Drymalski et al  (from a study of 2000 cases of tuberculosis.
(ii) 1.5% by Robbins et al  (from a study of 400 cases of tuberculosis.
(iii) 5-10 fold increase in risk of developing cancer of lung, by Steinitz. 
B. Tuberculosis developing in patients with bronchogenic carcinoma.
Incidences quoted in literature are:
(1) 8.6% (Carlson et al  )
(2) 3.8% (Farber et al  )
(3) 0.8% (Doll et al  )
(4) 56.8% (Shah-Mirany et al  )
(5) 2% (Le Roux  )
(6) 3.7% (Mc-Quarrie et al  )
(7) 38% (Aspevik  )
(8) 5.7% (Nagrath et al  )
(9) 2.5% (Guleria et al  )
(10) 12% (Nafae et a1  )
The etiology of tuberculosis developing in a patient with cancer is a matter of speculation. Lowered resistance and debility consequent to malignancy may be an important factor in the development of tuberculosis.  Centrally located bronchogenic carcinoma could readily cause a pre-existing pulmonary tuberculosis to become active because of altered circulation and bronchial stenosis.  Malignancy may invade old tuberculous lesion and liberate viable organisms with consequent spread of disease. 
Regarding the occurrence of malignancy in a patient with tuberculosis there are many postulations. It is stated that changes produced in the lung parenchyma and bronchi by tuberculosis as metaplasia, smouldering infection and chronic irritation by calcified lymphnode might initiate malignancy. ,, According to some, high content of cholesterol. in
Gofman et al  and Mackenzie  attributed development of malignancy to frequent fluoroscopies of the chest associated with the past extensive use of pneumothorex and pneumoperitoneum collapse therapy. This led Hammond et al  to conclude that frequent radiations like screening may induce cancer in a patient with tuberculosis.
Scar of tuberculosis may be a site for development of carcinoma especially the souamous cell carcinoma.  Shah-Mirany  stated that this scar theory might not be true because, in as many as 50% of the cases, the malignancy is usually located in the contralateral lung or some unrelated segment of the ipsilateral lung. They even stated that there could be peripheral tuberculosis with hilar malignancy.
Pompe  observed that risk of neoplasm arising in lupus vulgaris increased from 0.5 to 4..5% with the usage of I.N.H.
Peacock et al  and Biancifiori et al  found that isoniazide induced tumors occurred in albino mice. This lead to spread of terror in medical literature. An editorial in Lancet  expressed a great concern regarding the usage of isoniazid.
However, now it is proved beyond doubt that isoniazid is noncarcinogenic to human beings and is a life saving drug. Increased longevity amongst those suffering or having suffered from tuberculosis, together with the fact that tuberculosis occurs in older people coupled with increased incidence of bronchogenic carcinoma would account for both the conditions occurring in the same person.
A fact of vital importance is that if tuberculosis preceeds malignancy, the former blocks the lymphatics and prevents the spread of the latter.
An unusual course of tuberculosis should alert the clinician of associated malignancy. , One should suspect malignancy or malignancy associated with tuberculosis under following circumstances. ,,,,
Our patient developed malignancy in the same area of the lung, where initially tuberculosis exhisted. Hence we felt that the carcinoma has developed in the scar of the old tuberculous lesion. He had metastasis in the regional lymph nodes.Since he was inoperable, the chest was closed after biopsy. He is still followed in our Out Patient department.
We thank the Dean, K.E.M. Hospital for allowing us to publish this article.
[Figure 1], [Figure 2]