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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 61-64

Pulmonary tuberculosis and Warthin's tumor: Is this a sign for the underlying malignancy?


1 Department of Pulmonary Medicine, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India
2 Department of Pathology, Dr. S N Medical College, Jodhpur, Rajasthan, India
3 Department of Pulmonary Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission28-Nov-2018
Date of Decision31-Dec-2018
Date of Acceptance02-Jan-2019
Date of Web Publication13-Mar-2019

Correspondence Address:
Dr. Swetabh Purohit
Department of Pulmonary Medicine, Room No. 3308, OPD Block, Adesh Institute of Medical Sciences and Research, NH-7, Barnala Road, Bathinda, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bbrj.bbrj_143_18

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  Abstract 


The enigmatic relationship between pulmonary tuberculosis (TB) and lung cancer has long been attracted clinicians and researchers alike. Knowing the dismal prognosis of advanced bronchogenic carcinoma, efforts are always made for its early diagnosis. Here, we report an interesting case of a 57-year-old patient in which three different disease entities, namely pulmonary TB, lung cancer, and salivary gland tumor, were present concurrently. Premature diagnostic closure led to delay in the diagnosis of bronchogenic carcinoma.

Keywords: Lung cancer, pulmonary tuberculosis, Warthin's tumor


How to cite this article:
Purohit S, Joshee V, Chauhan N. Pulmonary tuberculosis and Warthin's tumor: Is this a sign for the underlying malignancy?. Biomed Biotechnol Res J 2019;3:61-4

How to cite this URL:
Purohit S, Joshee V, Chauhan N. Pulmonary tuberculosis and Warthin's tumor: Is this a sign for the underlying malignancy?. Biomed Biotechnol Res J [serial online] 2019 [cited 2019 May 21];3:61-4. Available from: http://www.bmbtrj.org/text.asp?2019/3/1/61/254098




  Introduction Top


The co-existence of lung cancer and pulmonary tuberculosis (TB) has attracted attention for several years. Historically, this enigmatic interrelationship dates back to 1815 when Bayle reported three such cases and classified cancerous phthisis as one of his six subtypes of TB.[1],[2] Since then, subsequent attempts to relate these two diseases etiologically have varied from marked incompatibility or antagonism to direct cause and effect relationship.[3] As both diseases are common, several recent studies logically speculate this association to be a result of chance alone.[4] There is a considerable overlap among the clinical and radiological presentation between these diseases, making a diagnosis of lung cancer superimposed on TB difficult.[5] Very often, the diagnosis of lung cancer is delayed, probably until an advanced stage, resulting in increased morbidity and mortality. The diagnosis can sometimes be further complicated by the presence of a third comorbidity (in our case, a salivary gland tumor) that can be present concurrently and mimic either a metastasis from the primary lung cancer or be a manifestation of disseminated TB. Hence, clinicians need to be aware of the myriad manifestations of TB and resist the temptation of premature diagnostic closure.[6] Here, we report an interesting case in which three different disease entities, namely pulmonary TB, lung cancer, and salivary gland tumor, were present concurrently.


  Case Report Top


A 57-year-old male patient, a known case of chronic obstructive pulmonary disease, presented with complaints of cough with early-morning, blood-tinged sputum; left-sided pleuritic chest pain; weakness; and loss of appetite for 3 months. He was a chronic smoker and smoked 30 cigarettes per day for over 40 years. There were no comorbidities. The patient consulted a general practitioner for the above complaints and was advised hemogram and chest X-ray. The hemogram was within normal limits. Chest X-ray showed a smooth-walled cavity in the left mid zone and left hilar prominence. Computerized tomography (CT) of the thorax [Figure 1] revealed a smooth-walled cavity in the left upper lobe, patchy air space opacity and bronchiectasis in the left upper lobe, and enlarged calcified left hilar node. Sputum examination for Ziehl–Neelsen stain done for acid-fast bacilli (AFB) was positive. The patient was started on antitubercular treatment (ATT) comprising four drugs, namely isoniazid, rifampicin, pyrazinamide, and ethambutol. After taking ATT, the patient had symptomatic improvement in cough, but his hemoptysis persisted. Following 3 months of ATT, the patient developed a low back ache, right leg pain, and hoarseness of voice. A repeat sputum examination for AFB was negative. A repeat CT scan was done which revealed a smooth thin-walled cavity in the left upper lobe, a calcified left hilar node, and a metastatic osteolytic lesion involving D8 vertebral body and the left pedicle. CT-guided biopsy done from the pedicle of D8 vertebra was suggestive of metastatic squamous cell carcinoma. With this background, the patient visited our outpatient services and was admitted for the evaluation of primary site of malignancy. Flexible bronchoscopy revealed a whitish cauliflower-like vascular growth [Figure 2]. Bronchial wash was negative for malignant cells. Endobronchial biopsy revealed a squamous cell carcinoma. Immunohistochemistry done showed that the tumor cells were strongly immunoreactive for p63 and negative for TTF-1, favoring squamous cell carcinoma [Figure 3]. During the course of admission, a painless cervical swelling was discovered. On further inquiry, the patient revealed that it has been present for the last 1 year. Fine-needle aspiration cytology done from the assumed metastatic lymph node surprisingly revealed a parotid tumor, that is, Warthin's tumor (WT) (papillary cystadenoma lymphomatosum) [Figure 4].
Figure 1: Computerized tomography scan of the thorax showing enlarged left hilar lymph node (white arrow) and thin-walled cavity in the anterior segment of the left upper lobe (black arrow)

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Figure 2: Bronchoscopic view showing endobronchial growth at the junction of the left upper and lower division bronchus

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Figure 3: (a) A tumor with pleomorphic cells with hyperchromatic nuclei (H and E, ×10). (b) High-power view of the tumor showing pleomorphic epithelial cells, with a cell having distinct squamous appearance (arrow) (×40). (c) Immunoreactivity of the cells to p63 antigen by immunohistochemistry is seen in the tumor cell nuclei. (d) Lack of immunoreactivity to thyroid transcription factor antigen by immunohistochemistry in the tumor cells (×10)

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Figure 4: Fine-needle aspiration cytology smear stained by Giemsa showing cohesive clusters of oncocytic cells in the background of proteinaceous material in which lymphocytes are scattered, typical of Warthin's tumor

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  Discussion Top


There are ample data to suggest that the incidence of lung cancer is greater in pulmonary TB patients when compared to the general population,[7],[8],[9] which has been reported to be 5%–6.4%[9],[10] As a result of improved health-care facilities and treatment, more pulmonary TB patients are now living into the cancer age group and possibly, the incidence of such cases is expected to increase.

The association between lung cancer and pulmonary TB can occur in several ways [Table 1].
Table 1: Possible association between cancer and tuberculosis

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The causal relationship between TB and lung cancer is not well established. It has been stated that, in the natural course of evolution of tubercular granuloma, an imbalance between tissue damaging and tissue-repairing mechanism generates a microenvironment that predisposes to malignant transformation.[11],[12]

The relationship between chronic irritation and cancer is well established. The mycobacteria may escape host immune response resulting in chronic persistent inflammation.[13] Experimental data suggest that Mycobacterium tuberculosis is capable of inducing DNA damage. Specifically, various mycobacterial cell wall components may induce the production of nitric oxide and reactive oxygen species. Both nitrative DNA damage and oxidative DNA damage have been implicated in inflammation-related carcinogenesis.[14]

The diagnosis of lung cancer in a patient with pulmonary TB is often challenging due to considerable overlap among the symptoms, signs, and radiological findings of the two diseases.[5] It is interesting that clinicians generally consider only one disease process at a time. In most cases, once the diagnosis is confirmed, active search ends for a second pathology that might present with similar clinical profile, but differ in management and prognosis. This might lead to premature diagnostic closure and delay in the diagnosis of the coexisting pathology. The average delay in the diagnosis of lung cancer in pulmonary TB patients has been found to be 6–9 months;[15] as in our case, after confirming the diagnosis of pulmonary TB, active search for malignancy ended with partial improvement in the patient's symptoms with ATT, who later on was diagnosed to be suffering from bronchogenic carcinoma.

A high risk of suspicion, especially in old-age patients who are chronic smokers, may aid in the early diagnosis of this dual pathology. Clinically, some of the warning signs and atypical presentation that raise a suspicion of malignancy in TB patients are persistent hemoptysis, localized unilateral wheeze, constant localized pain, persistent cough, paroxysmal dyspnea, prolonged low-grade fever, and inadequate response to ATT.

Lymph nodal metastasis is a common presentation of all malignancies including lung cancer. Cervical lymph nodes provide an easily accessible site for tissue sampling and diagnosis of cancer. Salivary gland tumors, especially WT, are frequently encountered in clinical practice and can be easily misidentified as enlarged cervical lymph nodes. A retrospective study at the University of Pennsylvania Health System showed that 19% of patients with WT had a diagnosis of lung cancer, compared to the general patient population, where 7.62% of males and 6.26% of females have a lifetime risk of developing lung cancer. Patients with WT are at heightened risk of lung malignancy; detection of WT may lead to earlier diagnosis of lung cancer.[16] If WT is detected in any patient presenting with pulmonary symptoms, an underlying lung cancer should be ruled out. This may aid in the early diagnosis of lung cancer and improve patient outcome. Coexistent lung cancer should always be ruled out in pulmonary TB patients presenting with atypical features or WT. Clinicians should refrain from premature diagnostic closure in pulmonary TB patients who are at risk of having lung cancer.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jacobs RE, Gu P, Chachoua A. Reactivation of pulmonary tuberculosis during cancer treatment. Int J Mycobacteriol 2015;4:337-40.  Back to cited text no. 1
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Gupta P, Rana S, Agarwal P. Peritoneal tuberculosis or carcinomatosis: A diagnostic conundrum. Int J Mycobacteriol 2018;7:198-9.  Back to cited text no. 3
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Carey JM, Greer AE. Bronchogenic carcinoma complicating pulmonary tuberculosis: A report of eight cases and a review of 140 cases since 1932. Ann Intern Med 1958;49:161-80.  Back to cited text no. 4
    
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Ting YM, Church WR, Ravikrishnan KP. Lung carcinoma superimposed on pulmonary tuberculosis. Radiology 1976;119:307-12.  Back to cited text no. 10
    
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Russell DG. Who puts the tubercle in tuberculosis? Nat Rev Microbiol 2007;5:39-47.  Back to cited text no. 11
    
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Saunders BM, Britton WJ. Life and death in the granuloma: Immunopathology of tuberculosis. Immunol Cell Biol 2007;85:103-11.  Back to cited text no. 12
    
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Mogga SJ, Mustafa T, Sviland L, Nilsen R. Increased bcl-2 and reduced bax expression in infected macrophages in slowly progressive primary murine Mycobacterium tuberculosis infection. Scand J Immunol 2002;56:383-91.  Back to cited text no. 13
    
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Sharma S, Sharma M, Roy S, Kumar P, Bose M. Mycobacterium tuberculosis induces high production of nitric oxide in coordination with production of tumour necrosis factor-alpha in patients with fresh active tuberculosis but not in MDR tuberculosis. Immunol Cell Biol 2004;82:377-82.  Back to cited text no. 14
    
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Mok CK, Nandi P, Ong GB. Coexistent bronchogenic carcinoma and active pulmonary tuberculosis. J Thorac Cardiovasc Surg 1978;76:469-72.  Back to cited text no. 15
    
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White CK, Williams KA, Rodriguez-Figueroa J, Langer CJ. Warthin's tumors and their relationship to lung cancer. Cancer Invest 2015;33:1-5.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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