British Journal of Radiology (2004) 77, 959-962
© 2004 British Institute of Radiology
doi: 10.1259/bjr/31864795
Coexistence of lung cancer and tuberculoma in the same lesion: demonstration by high resolution and contrast-enhanced dynamic CT
K Ashizawa, MD
1
N Matsuyama, MD
1
T Okimoto, MD
1
H Hayashi, MD
1
T Takahashi, MD
2
T Oka, MD
2
T Nagayasu, MD
2 and
K Hayashi, MD
1
1 Division of Radiological Science, Department of Radiology and Radiation Biology and 2 Division of Surgical Oncology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
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Abstract
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We report a case of coexistence of lung cancer and tuberculoma in the same lesion. The component parts of lung cancer and tuberculoma were identified on the basis of morphology on high-resolution CT as well as enhancement patterns and time–attenuation curves by contrast-enhanced dynamic CT.
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Introduction
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With the increasing incidence of pulmonary tuberculosis in older patients, the presence of concomitant tuberculosis and lung cancer has stimulated great interest. However, it is often difficult to identify the coexistence of lung cancer and tuberculosis. There have been several reports about these lesions in different lobes or even in the same lobe, at different locations [1–4]. We report a case of coexistence of lung cancer and tuberculoma in the same lesion. The parts of lung cancer and tuberculoma were demonstrated on high-resolution CT (HRCT) and contrast-enhanced dynamic CT.
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Case report
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A 72-year-old man was referred to our hospital for further examination and therapy for lung cancer. He was a chronic smoker, smoking 15 to 20 cigarettes daily for 50 years. Diagnosis of lung cancer was made at an outside hospital where the patient underwent surgery for abdominal aortic aneurysm. Transbronchial lung biopsy (TBLB) performed after the identification of an abnormal opacity in the left lung field on chest radiograph revealed adenocarcinoma. Previous chest radiographs had revealed the presence of this opacity and its size had not changed for the last 4 years.
At admission to our hospital, the patient was asymptomatic. Laboratory data were unremarkable except for elevation of cytokeratin to 19 fragment (CYFRA) to 2.5 ng ml–1 (normal<2.0 ng ml–1). Tuberculin test was positive. Bacteriology of sputum was negative for tubercle bacilli.
Chest radiograph at the time of admission showed an irregular opacity in the left lung mid zone (Figure 1a
). The lower portion of the opacity had a tubular outline while the upper portion was nodular. Chest CT revealed a mass in the subpleural region of the left lower lobe on multiple consecutive slices consistent with its tubular shape. Axial images on HRCT obtained at the upper portion of the mass showed two components; the anterior part with an irregular margin and convergence of peripheral vessels and the posterior part with a smooth margin, a cavity and calcification (Figure 1b).
Contrast-enhanced dynamic CT scans were obtained using iodinated, non-ionic contrast material (Omnipaque 300; Daiichi Seiyaku, Tokyo, Japan). A total of 50 ml of contrast agent was administered through the median cubital vein at a rate of 2.5 ml s–1. Five serial thin-section CT scans were obtained before, at 25 s, 45 s, 65 s and 150 s after the start of the infusion of contrast material. This CT scan protocol has been used for solitary pulmonary nodule at our hospital, and its efficacy was presented at the 11th Korea-Japan Radiology Congress (Ashizawa K, 2000, unpublished data). Contrast-enhanced CT showed different patterns of enhancement in the anterior and posterior parts of the upper portion of the mass; the anterior part with homogeneous enhancement and the posterior part with peripheral enhancement (Figure 1c
). On time–attenuation curve analysis, the central area of the posterior part showed no enhancement, while the anterior part showed gradual enhancement with peak enhancement at 65 s after the start of the infusion of contrast material (Figure 1c, d).
The patient underwent left lower lobectomy and regional lymph node resection. Coronal cut surface of the surgical specimen showed a yellowish-white tubular shaped mass with cavity in the subpleural area, and showed a whitish mass with irregular margin adjacent to the subpleural mass (Figure 1e). Photomicrograph of the pathological specimen demonstrates the coexistence of a moderately differentiated adenocarcinoma showing atypical tubular structures and typical tuberculous granuloma consisting of a central caseous necrosis, epithelioid histiocytes, Langhans' giant cells and lymphocytes (Figure 1f). Histologically, this carcinoma has developed from the peripheral area of the tuberculoma.
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Discussion
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There have been occasional reports about the coexistence of cancer and tuberculosis in the lung [1–4]. However, these lesions were located in different lobes or even in the same lobe, at different locations [1–4]. According to a recent report, the incidence of lung cancer among patients with pulmonary tuberculosis is 1.7% while the incidence of pulmonary tuberculosis among patients with lung cancer is 5.7% [1]. Suzuki reported that the characteristic features of these patients were that they were males over 60 years of age who smoked heavily [1]. Our patient was a 72-year-old, male and a heavy smoker.
The pathogenesis of the coexistence of tuberculosis and lung cancer is poorly understood. Several possible reasons such as depression of cellular immunity in patients, an increase in the numbers of older patients, the presence of scars and cavities in the lung, and smoking history have been suspected [1]. The development of lung cancer in a pulmonary scar is a well-known entity first described by Friedrich as "scar" or "cicatrical" cancer of the lung [5]. The scars that were associated with the carcinomas were predominantly subpleural in location [6]. Pulmonary scar carcinoma is associated with a high incidence of adenocarcinoma and many scars were thought to have been tuberculous [2, 3]. In our case, tuberculoma existed in the subpleural area and in proximity to an adenocarcinoma, so this carcinoma might have developed from the tuberculoma.
On imaging, it is often difficult to identify the coexistence of lung cancer and tuberculosis, especially in the same lesion, with a high degree of certainty, resulting in the potential delay in the diagnosis of lung cancer. In our case, the morphological information of HRCT and enhancement patterns of contrast-enhanced dynamic CT were helpful in differentiation of these lesions. The malignant part of the mass had an irregular margin and convergence of peripheral vessels on HRCT, and had homogeneous enhancement on contrast-enhanced CT. The time–attenuation curve showed gradual enhancement pattern. The benign part of the mass had a smooth margin and a cavity on HRCT, and had peripheral enhancement on contrast-enhanced CT. The time–attenuation curve showed no enhancement in the central area of the lesion. Some authors have reported the usefulness of contrast-enhanced dynamic CT in the work-up of a pulmonary nodule [7–9]. Yamashita et al reported that homogeneous enhancement of a nodule suggested lung carcinoma while capsular and peripheral enhancement pattern suggested tuberculoma and most of the hamartomas [7]. Swensen et al reported that most malignant nodules were well enhanced, while benign nodules showed less or no enhancement [8, 9].
In conclusion, we report a case of coexistence of tuberculoma and lung cancer in the same lesion. The possibility of concomitant lung cancer should be considered in patients with tuberculoma. HRCT and contrast-enhanced dynamic CT are helpful in the identification of lung cancer and tuberculoma in the same lesion.
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Acknowledgments
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We thank Dr Rashid Hashmi and Dr Aamer Aziz for their assistance in the preparation of this manuscript.
Received for publication August 29, 2003.
Revision received January 13, 2004.
Accepted for publication April 20, 2004.
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References
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- Suzuki T. Clinical investigation on patients with lung cancer and active tuberculosis. IRYO 1996;50:687–91. [In Japanese.]
- Limas C, Japaze H, Bunuel RG. "Scar" carcinoma of the lung. Chest 1971;59:219–22.[Abstract/Free Full Text]
- Jackson D, Greenberg SD, Howell JF. Pulmonary scar carcinoma. Cancer 1984;54:361–6.[CrossRef][Medline]
- Greenberg SD, Jenkins DE, Bahar D, Schweppe HI Jr, Block H Jr. Coexistence of carcinoma, tuberculosis of the lung. Am Rev Resp Dis 1964;90:67–76.[Medline]
- Friedrich G. Periphere Lungenkrebse auf dem Boden pleuranaher Narben. Virchow Arch Path Anat 1939;304:230–47.
- Yokoo H, Suckow EE. Peripheral lung cancer arising in scars. Cancer 1961;14:1205–15.
- Yamashita K, Matsunobe S, Tsuda T, et al. Solitary pulmonary nodule: preliminary study of evaluation with incremental dynamic CT. Radiology 1995;194:399–405.[Abstract/Free Full Text]
- Swensen SJ, Morin RL, Schueler BA, et al. Solitary pulmonary nodule: CT evaluation of enhancement with iodinated contrast material. Radiology 1992;182:343–7.[Abstract/Free Full Text]
- Swenson SJ, Viggiano RW, Midthun DE, et al. Lung nodule enhancement at CT: multicenter study. Radiology 2000;214:73–80.[Abstract/Free Full Text]
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Abstract
Introduction
