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CONCOMITANT BRONCHOGENIC CARCINOMA AND TUBERCULOSIS OF THE LUNG OCCURRING IN A SOLITARY COIN LESION
C O N C O M I T A N T BRONCHOGENIC CARCINOMA
AND
TUBERCULOSIS OF THE L U N G OCCURRING I N A SOLITARY COIN LESION Porter Mayo, M.D.*
Lexington,
Ky.
s early as 1810, concomitant bronchogenic carcinoma and tuberculosis of . the lung was discussed in the literature. In 1855, Rokitansky expressed the belief that the two diseases were antagonistic on the basis of pathologic studies. This was the popular or accepted theory until 1935 when Fried expressed the opinion that the diseases are not incompatible but probably are etiologically companionable in an undefined relationship. Even though this view is still not fact, there is no doubt that the concomitant existence of bronchogenic carcinoma and tuberculosis will be a common occurrence. This is due to the age group of persons who survive because of antituberculous chemotherapy and the rising incidence of bronchogenic carcinoma. To diagnose or even suspect carcinoma when tuberculosis already has been proved is unlikely; however, the purpose of this paper is to call attention to the necessity of directing treatment to the most serious disease and to act defini tively if one believes carcinoma is present. The physician often uses a 6 week culture period as a means of treating the patient while awaiting further defi nition of the disease. It is my belief that the 6 week period is absolutely ill ad vised if carcinoma is suspect. The progression or lack of change neither defines nor alleviates the problem. The case presented is an isolated instance; however, it particularly emphasizes the need to consider solitary nodules as malignant, especially in the adult group. Unfortunately, the discovery of a small, solitary, pulmonary lesion may be misleading simply because of the extremely common and persistent notion that most coin lesions are benign. A certain complacency is apt to develop when an etiologic agent, such as a tubercle bacillus, is isolated and the case diagnosed.1 The possibility of primary bronchogenic carcinoma being present is sufficient justification for exploration and histologieal identification of these solitary pul monary nodules. To await the obvious characteristic findings of cither disease is to forfeit the time of opportunity.
A
CASE REPORTS The patient was a 54-year-old white man. A mild productive cough of 3 months' dura tion was the only respiratory complaint. A fifteen pound weight loss had taken place during Received for publication July 8, 1963. •Address: 2134 Nicholasville Road, Lexington, Ky. 174
Vol. 47, No. 2
CAliCIXOMA AXI) TUBEKCULOSIS OF LUNG
175
February, 1%4
the past year. This man had smoked two and one half packages of cigarettes per day for approximately 40 years. The history was otherwise noncontributory. Physical examination revealed no significant abnormalities. Chest x-ray films were re viewed which had been made one year prior to the time of our initial examination. The only abnormality was that of a soft appearing nodular lesion, measuring 1 cm. in diameter, in the second anterior intercostal space on the left side. The roentgenologist had interpreted the x-ray film as revealing a nodule, presumably a tuberculoma, in the left apex. I t was be lieved to be of no significance and further studies were not deemed necessary by the attending physician.
Fig-. 1.—Left, A small nodular soft tissue density is present in the left second anterior intercostal space. There is no other abnormality. Right, The study made one year later shows an enlarged soft tissue lesion as indicated by the surrounding arroics.
The x-ray film made at the time of our initial examination revealed an increase in the size of the lesion, which now measured 3 by 4 cm. Bronchoscopy was performed and the only abnormality found was that of an acute bronchitis in the left main-stem bronchus near the upper lobe orifice. The smear concentrate was reported as positive for typical tubercle bacilli. The Papanicolaou examination was Class I. By x-ray study the lung tissue on the left side, other than the previously mentioned lesion, was completely normal and the right side was without evidence of abnormality. It had to be considered that the tubercle bacilli were originating from the nodular density in the left upper lobe. However, the age and sex of the patient, as well as the x-ray appearance of the lesion, suggested carcinoma as a distinct possibility. It was decided that the proper action was to proceed with an exploratory thoracotomy. Left thoracotomy was performed and the nodular disease was located in the posterior segment of the upper lobe. The tumor was not attached to the lower lobe or chest wall. Frozen section diagnosis of the lesion was reported as primary broneliogenic carcinoma. The left upper lobe was resected. A representative section of the lesion was made through its en tire substance and sent to the bacteriology laboratory for examination and the remaining tissue was sent to the pathologist. Typical tubercle bacilli were demonstrated on smear exami-
MAYO
176
J. Thoracic and
Cardiovas. Surg.
nation from the section of the tumor, and 6 weeks later a positive growth for acid-fast bacilli was reported. Also, the bronchial secretions were reported as positive at the end of the 6 weeks' culture for acid-fast bacilli. The pathology report by H. Davis Chipps, M.D., follows. Gross: Specimen consists of the lower lobe of the left lung from a 54-year-old male patient. The lobe measures 17 cm. in length and 7 by 7 cm. in average width and thickness. I t weighs 325 grams. Previously, there had been an excision of a part of the lobe that contained a neoplastic nodule. This previous piece of tissue measured about 4 cm. in diameter and in the center of it there was a firm nodule 2.5 cm. in thickness. A frozen section showed this to be a squamous cell carcinoma. No residual carcinoma is found in the second specimen. The hilar lymph nodes do not show any gross evidence of metastasis.
Fig:. 2.—Poorly differentiated squamous cell carcinoma. Large nuclei with coarse chromatin which shows mitotic activity are evident. There is no Langhans' g"iant cell formation present.
DISCUSSION
It is quite interesting that acid-fast bacilli were also cultured from this pri mary bronchogenic carcinoma. Although the two diseases do occur together in the lung, it is unusual to find both diseases in a rather small primary nodule with no evidence of either disease elsewhere. The lymph nodes were negative for evidence of metastatic carcinoma. Streptomycin and Isonicotinic Acid Hydrazide (INH) were given to the patient postoperatively. He no longer resides in this state; however, when last examined one year from the time of the opera tive procedure, there was no evidence of either disease. REFERENCES
1. Kempter, A. H . : Tuberculosis Coexistent With Lung Cancer and Fungous Disease, J . Michi gan State M. Soc. 58: 1805-1806, 1959. 2. Miller, E. D . : Problem of the Asymptomatic Pulmonary Lesion, J . Lancet. 25: 118-11944a, 1955.
Vol. 47, No. 2
CARCINOMA AXD TUBERCULOSIS O F LUNG
177
tebruary, 1964
3. Davis, E. W., Peabody, J . W., Jr., and Katz, S.: The Solitary Pulmonary Nodule: A TenYear Study Based on 215 Cases, J. THORACIC SURG. 32: 728-771, 1956. 4. Gebel, P., Epstein, H. H., Fulkerson, L. L., and Sparger, C. F . : Concomitant Bronchogenic Carcinoma and Tuberculosis of the Lung, Dis. Chest 4 1 : 610-617, 1962. 5. Wayl, P . : Difficulties in the Diagnosis of Coexistent Bronchogenic Carcinoma and Active Pulmonary Tuberculosis, Dis. Chest 28: 568-573, 1955. 6. Iligginson, J . F*., and Hinshaw, D. B . : Pulmonary Coin Lesion, J . A. M. A. 157: 1607-1609, 1955. 7. Jackson, A., Garber, P. E., and Post, G. W.: Coexistent Pulmonary Tuberculosis and Malig nancy, Dis. Chest 32: 189-197, 1957. 8. Bender, F . : Primary Pulmonary Carcinoma Associated With Active Pulmonary Tubercu losis, Dis. Chest 30: 207-216, 1956.
AND
TUBERCULOSIS OF THE L U N G OCCURRING I N A SOLITARY COIN LESION Porter Mayo, M.D.*
Lexington,
Ky.
s early as 1810, concomitant bronchogenic carcinoma and tuberculosis of . the lung was discussed in the literature. In 1855, Rokitansky expressed the belief that the two diseases were antagonistic on the basis of pathologic studies. This was the popular or accepted theory until 1935 when Fried expressed the opinion that the diseases are not incompatible but probably are etiologically companionable in an undefined relationship. Even though this view is still not fact, there is no doubt that the concomitant existence of bronchogenic carcinoma and tuberculosis will be a common occurrence. This is due to the age group of persons who survive because of antituberculous chemotherapy and the rising incidence of bronchogenic carcinoma. To diagnose or even suspect carcinoma when tuberculosis already has been proved is unlikely; however, the purpose of this paper is to call attention to the necessity of directing treatment to the most serious disease and to act defini tively if one believes carcinoma is present. The physician often uses a 6 week culture period as a means of treating the patient while awaiting further defi nition of the disease. It is my belief that the 6 week period is absolutely ill ad vised if carcinoma is suspect. The progression or lack of change neither defines nor alleviates the problem. The case presented is an isolated instance; however, it particularly emphasizes the need to consider solitary nodules as malignant, especially in the adult group. Unfortunately, the discovery of a small, solitary, pulmonary lesion may be misleading simply because of the extremely common and persistent notion that most coin lesions are benign. A certain complacency is apt to develop when an etiologic agent, such as a tubercle bacillus, is isolated and the case diagnosed.1 The possibility of primary bronchogenic carcinoma being present is sufficient justification for exploration and histologieal identification of these solitary pul monary nodules. To await the obvious characteristic findings of cither disease is to forfeit the time of opportunity.
A
CASE REPORTS The patient was a 54-year-old white man. A mild productive cough of 3 months' dura tion was the only respiratory complaint. A fifteen pound weight loss had taken place during Received for publication July 8, 1963. •Address: 2134 Nicholasville Road, Lexington, Ky. 174
Vol. 47, No. 2
CAliCIXOMA AXI) TUBEKCULOSIS OF LUNG
175
February, 1%4
the past year. This man had smoked two and one half packages of cigarettes per day for approximately 40 years. The history was otherwise noncontributory. Physical examination revealed no significant abnormalities. Chest x-ray films were re viewed which had been made one year prior to the time of our initial examination. The only abnormality was that of a soft appearing nodular lesion, measuring 1 cm. in diameter, in the second anterior intercostal space on the left side. The roentgenologist had interpreted the x-ray film as revealing a nodule, presumably a tuberculoma, in the left apex. I t was be lieved to be of no significance and further studies were not deemed necessary by the attending physician.
Fig-. 1.—Left, A small nodular soft tissue density is present in the left second anterior intercostal space. There is no other abnormality. Right, The study made one year later shows an enlarged soft tissue lesion as indicated by the surrounding arroics.
The x-ray film made at the time of our initial examination revealed an increase in the size of the lesion, which now measured 3 by 4 cm. Bronchoscopy was performed and the only abnormality found was that of an acute bronchitis in the left main-stem bronchus near the upper lobe orifice. The smear concentrate was reported as positive for typical tubercle bacilli. The Papanicolaou examination was Class I. By x-ray study the lung tissue on the left side, other than the previously mentioned lesion, was completely normal and the right side was without evidence of abnormality. It had to be considered that the tubercle bacilli were originating from the nodular density in the left upper lobe. However, the age and sex of the patient, as well as the x-ray appearance of the lesion, suggested carcinoma as a distinct possibility. It was decided that the proper action was to proceed with an exploratory thoracotomy. Left thoracotomy was performed and the nodular disease was located in the posterior segment of the upper lobe. The tumor was not attached to the lower lobe or chest wall. Frozen section diagnosis of the lesion was reported as primary broneliogenic carcinoma. The left upper lobe was resected. A representative section of the lesion was made through its en tire substance and sent to the bacteriology laboratory for examination and the remaining tissue was sent to the pathologist. Typical tubercle bacilli were demonstrated on smear exami-
MAYO
176
J. Thoracic and
Cardiovas. Surg.
nation from the section of the tumor, and 6 weeks later a positive growth for acid-fast bacilli was reported. Also, the bronchial secretions were reported as positive at the end of the 6 weeks' culture for acid-fast bacilli. The pathology report by H. Davis Chipps, M.D., follows. Gross: Specimen consists of the lower lobe of the left lung from a 54-year-old male patient. The lobe measures 17 cm. in length and 7 by 7 cm. in average width and thickness. I t weighs 325 grams. Previously, there had been an excision of a part of the lobe that contained a neoplastic nodule. This previous piece of tissue measured about 4 cm. in diameter and in the center of it there was a firm nodule 2.5 cm. in thickness. A frozen section showed this to be a squamous cell carcinoma. No residual carcinoma is found in the second specimen. The hilar lymph nodes do not show any gross evidence of metastasis.
Fig:. 2.—Poorly differentiated squamous cell carcinoma. Large nuclei with coarse chromatin which shows mitotic activity are evident. There is no Langhans' g"iant cell formation present.
DISCUSSION
It is quite interesting that acid-fast bacilli were also cultured from this pri mary bronchogenic carcinoma. Although the two diseases do occur together in the lung, it is unusual to find both diseases in a rather small primary nodule with no evidence of either disease elsewhere. The lymph nodes were negative for evidence of metastatic carcinoma. Streptomycin and Isonicotinic Acid Hydrazide (INH) were given to the patient postoperatively. He no longer resides in this state; however, when last examined one year from the time of the opera tive procedure, there was no evidence of either disease. REFERENCES
1. Kempter, A. H . : Tuberculosis Coexistent With Lung Cancer and Fungous Disease, J . Michi gan State M. Soc. 58: 1805-1806, 1959. 2. Miller, E. D . : Problem of the Asymptomatic Pulmonary Lesion, J . Lancet. 25: 118-11944a, 1955.
Vol. 47, No. 2
CARCINOMA AXD TUBERCULOSIS O F LUNG
177
tebruary, 1964
3. Davis, E. W., Peabody, J . W., Jr., and Katz, S.: The Solitary Pulmonary Nodule: A TenYear Study Based on 215 Cases, J. THORACIC SURG. 32: 728-771, 1956. 4. Gebel, P., Epstein, H. H., Fulkerson, L. L., and Sparger, C. F . : Concomitant Bronchogenic Carcinoma and Tuberculosis of the Lung, Dis. Chest 4 1 : 610-617, 1962. 5. Wayl, P . : Difficulties in the Diagnosis of Coexistent Bronchogenic Carcinoma and Active Pulmonary Tuberculosis, Dis. Chest 28: 568-573, 1955. 6. Iligginson, J . F*., and Hinshaw, D. B . : Pulmonary Coin Lesion, J . A. M. A. 157: 1607-1609, 1955. 7. Jackson, A., Garber, P. E., and Post, G. W.: Coexistent Pulmonary Tuberculosis and Malig nancy, Dis. Chest 32: 189-197, 1957. 8. Bender, F . : Primary Pulmonary Carcinoma Associated With Active Pulmonary Tubercu losis, Dis. Chest 30: 207-216, 1956.