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 ::  Abstract
 ::  Case report
 ::  Introduction
 ::  Discussion
 ::  Acknowledgement
 ::  References
 ::  Article Figures

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ARTICLE
Year : 1977  |  Volume : 23  |  Issue : 4  |  Page : 193-196

Association of tuberculosis with malignancy


Department of Chest Medicine, K.E.M. Hospital and Seth G. S. Medical College, Parel, Bombay-400.012., India

Correspondence Address:
K C Patel
Department of Chest Medicine, K.E.M. Hospital and Seth G. S. Medical College, Parel, Bombay-400.012.
India
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Source of Support: None, Conflict of Interest: None


PMID: 615268

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 :: Abstract 

A case of bronchogenie carcinoma developing in a patient with pulmonary tuberculosis is described and literature reviewed.



How to cite this article:
Patel K C, Shah D P, Sheth S M, Kamat S R. Association of tuberculosis with malignancy. J Postgrad Med 1977;23:193-6

How to cite this URL:
Patel K C, Shah D P, Sheth S M, Kamat S R. Association of tuberculosis with malignancy. J Postgrad Med [serial online] 1977 [cited 2020 Dec 4];23:193-6. Available from: https://www.jpgmonline.com/text.asp?1977/23/4/193/42753



 :: Introduction Top


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. [18]


 :: Case report Top


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.


 :: Discussion Top


Bayle [2] 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. [23] Von Rokitansky [29] however stated empha­tically that the two diseases were incom­patible. Fried [9] 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 [6] (from a study of 2000 cases of tuberculosis.

(ii) 1.5% by Robbins et al [25] (from a study of 400 cases of tuberculosis.

(iii) 5-10 fold increase in risk of deve­loping cancer of lung, by Stei­nitz. [28]

B. Tuberculosis developing in pati­ents with bronchogenic carcinoma.

Incidences quoted in literature are:

(1) 8.6% (Carlson et al [4] )

(2) 3.8% (Farber et al [8] )

(3) 0.8% (Doll et al [5] )

(4) 56.8% (Shah-Mirany et al [26] )

(5) 2% (Le Roux [15] )

(6) 3.7% (Mc-Quarrie et al [17] )

(7) 38% (Aspevik [1] )

(8) 5.7% (Nagrath et al [19] )

(9) 2.5% (Guleria et al [12] )

(10) 12% (Nafae et a1 [18] )

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. [27] Centrally located bronchogenic carcinoma could readily cause a pre-existing pulmonary tuber­culosis to become active because of alter­ed circulation and bronchial stenosis. [20] Malignancy may invade old tuberculous lesion and liberate viable organisms with consequent spread of disease. [21]

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. [10],[14],[32] Accord­ing to some, high content of cholesterol. in areas of healed tuberculosis might initiate malignancy as cholesterol is a known carcinogen. [32] More over smoke containing tar would accumulate in tuberculous cavities and focci. Tar con­tains Benzpyrene-a potential carcinogen -which remains in contact with tuber­culous area for a longer time and hence can initiate malignancy. This is also true of air pollution.

Gofman et al [11] and Mackenzie [10] 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 [13] 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. [31] Shah-­Mirany [26] 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 [21] 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 [22] and Biancifiori et al [3] found that isoniazide induced tumors occurred in albino mice. This lead to spread of terror in medical literature. An editorial in Lancet [7] 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. [27],[30] One should suspect malignancy or malignancy associated with tuberculosis under following cir­cumstances. [10],[17],[21],[27],[30]

  1. Any patient above the age of 50 years.
  2. Dyspnoea out of proportion to the visible lesion in the lungs.
  3. Deep-seated boaring, relentless pain unrelated to phases of respir­ation.
  4. Clubbing developing in patients with tuberculosis.
  5. Persistant localized expiratory rhonchus.
  6. Clearing of pulmonary infiltrates in one area of lung during therapy while infiltrates progressing in another area.
  7. X-ray evidence of the progression of the disease with persistantly negative sputa for A.F.B.
  8. Progressively enlarging nodular densities arising during treatment.
  9. Sputum positive for malignant cells.
  10. Signs of carcinomatous neuro­pathy.


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.


 :: Acknowledgement Top


We thank the Dean, K.E.M. Hospital for allowing us to publish this article.

 
 :: References Top

1.Asperik, E.: Coexisting carcinoma of the lung and tuberculosis. Abstracted in Ex­erpta Medica Chest Diseases, Thoracic Surgery and Tuberculosis, 25: 197, 1970, as quoted by Nafae A. et al. 18  Back to cited text no. 1    
2.Bayle. G. L.: Recherches Sur la Phthisis Pulmonaire Paris, 1810: 315 as quoted by Jackson et al., (1957). [14]  Back to cited text no. 2    
3.Biancifiori, C. and Severi, L.: The re­lationship of isoniazid and allied com­pounds to carcinogenesis in some species of small laboratory animals. Brit. J.Cancer, 20: 528-538, 1966.  Back to cited text no. 3    
4.Carlson, H. A. and Bell, E. T.: Stati­stical study of occurrence of cancer and tuberculosis in 11195 post mortem exam­ination. J. Cancer Res., 13: 126-135, 1929.  Back to cited text no. 4    
5.Doll. R. and Hill, A. B.: A study of the aetiology of carcinoma of the lung Brit. Med. J., 2: 1271-1286. 1952.  Back to cited text no. 5    
6.Drymalski, G. W. and Sweany, H. C.:The significance of pulmonary tuberculosis when associated with bronchogenic carci­noma. Amer. Rev. Tuber., 58: 203-206, 1948.  Back to cited text no. 6    
7.Editorial: "Isoniazid-How much a carci­nogen?" Lancet, 2: 1452-1453, 1966.  Back to cited text no. 7    
8.Farber, S. M., Me Grath, A. K. and Tibias, G.: Rev. Pan Amer. Med. Y. Cirug. Thor., 2: 1, 1949, as quoted by Jackson et a1. [14]  Back to cited text no. 8    
9. Fried, B. M.: Bronchogenic cancer com­bined with tuberculosis of the Lung. Amer, J. Cancer, 23: 247-266, 1935.  Back to cited text no. 9    
10.Gebel, P., Epstein, H. H., Fulkerson, L. L. and Sparger, C. F.: Concomitant Bronchogenic Carcinoma & Tuberculosis of the lung, Dis. of Chest., 41: 610-617, 1962.  Back to cited text no. 10    
11.Gofman, J. W. and Tamplin, A. R.. Fluoroscopic Radiation and Risk of Pri­mary lung cancer following pneumothorex therapy of tuberculosis, Nature (Lond.), 227/5255: 295-296, 1970.  Back to cited text no. 11    
12.Guleria, J. S., Gopinath, N., Talwar, J. R., Bhargava, S., Pande, J. N. and Gupta, R. G.: Bronchial Carcinoma; An analysis of 120 cases. J. Assoc. Phys. Ind., 19: 251-255, 1971.  Back to cited text no. 12    
13.Hammond, E. C., Selikoff, I. J. and Ro­bitzek, E. H.: Isoniazid therapy in rela­tion to later occurrence of carcinoma in adults and in infants, Brit, Med. J., 2: 792-785, 1967.  Back to cited text no. 13    
14.Jackson, A., Garber, P. E. and Post, G. W.: Co-existing pulmonary tuberculosis and malignancy. Dis. of Chest, 32: 189-197, 1957.  Back to cited text no. 14    
15.Le Roux, B. T.: Bronchial carcinoma, Thorax, 23: 136-143, 1968.  Back to cited text no. 15    
16.Mackenzie, I.: Breast cancer following multiple fluroscopies. Brit. J. Cancer, 19: 1-8, 1965.  Back to cited text no. 16    
17.Me Quarrie, D. G. Nicoloff, D. M., Van Nostrand, D., Rao, K. and Humphrey E. W.: Tuberculosis and carcinoma of the lung, Dis. of Chest, 54: 427-432, 1968.  Back to cited text no. 17    
18.Nafae, A., Misra, S. P., Dhar, S. N. and Shah, S. N. A.: Association of Pul­monary Tuberculosis and Lung cancer. Ind. J. Tuberc., 22: 31-36, 1975.  Back to cited text no. 18    
19.Nagrath, S. P., Hazara, D. K., Lahiri. B., Kishore, B. and Kumar, R.: Primary carcinoma of lung: clinicopathological study of 35 cases, Ind. J. Chest. Dis., 12/182: 15-24, 1970.  Back to cited text no. 19    
20.Nuessle, W. F.: Association of broncho­genic carcinoma and Active pulmonary tuberculosis, report of 4 cases. Dis. Chest, 23: 207-216, 1953.  Back to cited text no. 20    
21.Overholt, R. H.: Cancer, detected in sur­veys. Amer. Rev. Tubers., 62: 491-500, 1950.  Back to cited text no. 21    
22.Peacock, A. and Peacock, P. R.: The results of prolonged administration of iso­niazid to mice, rats & hamsters. Brit. J. Cancer, 20: 307-325, 1966.  Back to cited text no. 22    
23.Penard, M.: Bull, Soc. Anat., Paris, 21: 260, 1846, as quoted by Jackson et al. [14]   Back to cited text no. 23    
24.Pompe, K.: Derm, Wsch.: 133: 105, 1956 as quoted by Roe, F. J. C., Boyland, E. and Haddow, A., "Chemotherapy of Tuber­culosis" Editorial. Brit. Med. J., 1: 1550, 1965.  Back to cited text no. 24    
25.Robbins, E. and Silverman, G.: Co-exist­ing bronchogenic carcinoma and Active pulmonary tuberculosis, Cancer, 2: 65, 1949, as quoted by Jackson et al. [14]  Back to cited text no. 25    
26. Shah-Mirany, J., Reimann, A. F. and Adams, W. E.: Co-existing Bronchogenic Carcinoma and Tuberculosis, Dis. of Chest, 50/3: 258-264, 1966.  Back to cited text no. 26    
27.Shefts, L. M. and Hentel, W.: Broncho­genic carcinoma and Pulmonary tubercu­losis. Amer. Rev. Tubers., 61: 369-386, 1950.  Back to cited text no. 27    
28.Steinitz, R.: Pulmonary Tuberculosis and Carcinoma of the Lung. Amer. Rev. Resp. Dis., 92: 758-766, 1965.  Back to cited text no. 28    
29.Von Rokitansky, C.: A manual of Patho­logical Anatomy. London, 1: 311, 1854, as quoted by Gebel et al. [10]   Back to cited text no. 29    
30.White, F. C., Beck, F. and Pecora, D. V.: Co-existing pulmonary lung cancer and Pulmonary tuberculosis. A report of 15 cases discovered through a chest clinic and Hospital, Amer. Rev. Resp. Dis., 79: 134-141, 1959.  Back to cited text no. 30    
31.Woodruff, C. E. and Nihas, H. C.: Pul­monary tuberculosis, Bronchectasis and calcification as related to bronchogenic carcinoma, Amer. Rev. Tuberc., 64: 620-­629, 1951.  Back to cited text no. 31    
32.Woodruff, C. E., Sen-Gupta, N. C., Wal­lace, S., Chapman, P. T. and Martineau, P. C.: Anatomic relationship between bronchogenic carcinoma and calcified nodules in the lung„ Amer. Rev, Tuberc., 66: 151-160, 1952.  Back to cited text no. 32    


    Figures

  [Figure 1], [Figure 2]



 

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Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
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