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Erich Fogg, PA-C, MMSc, DEPARTMENT EDITOR
Heather M. Asher Prince, MPA, PA-C; Jeffrey E. Hatter, MD, FACS, FCCP
Ms. Asher Prince and Dr. Hatter comprise Catskill Surgical PC, a general and thoracic surgery practice in Kingston, NY. The authors have indicated no relationships to disclose relating to the content of this article. Mr. Fogg is Assistant Professor in and Program Director of the Physician Assistant Program at the College of Health Professions, University of New England, Portland, Me.
CASE
A 56-year-old woman was referred to our practice for evaluation of a pulmonary nodule. She had stopped smoking 15 months before this visit but previously had smoked two to three packs of cigarettes per day. Her family had no chronic health problems, except that lung cancer had developed in both parents and her father had died of the disease 3 years ago.
Because of her strong family history of lung cancer and her personal smoking history, her primary care provider had followed her closely over the past few years with biannual radiographs. All had been normal, until her most recent chest film showed a suspicious new lesion in the right lower lobe. CT confirmed an 8-mm nodule above the right hemidiaphragm, with at least two small, hazy subpleural nodules located nearby.
 The patient’s weight was stable, and she was physically active without cardiac or respiratory symptoms. On examination, she was well developed and nourished and in no acute distress. Physical examination findings were within normal limits. Pulmonary function studies revealed a forced expiratory volume of 1.82 (78% predicted) and a diffusion capacity of 12.0 (73% predicted). Positron emission tomography (PET) alsoshowed a bilobulated subpleural nodule at the base of the right lung showing mild hypermetabolic activity (SUV [systemic uptake value] 2.0) (see Figure 1).
WHAT IS YOUR DIAGNOSIS?
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Lung cancer
- Histoplasmosis
- Blastomycosis
- Tuberculosis
- Granulomas
DISCUSSION
Because of its size and location, the lesion was not amenable to percutaneous biopsy. The patient underwent thoracoscopy, and an initial wedge believed to contain the larger 8-mm nodule was removed. This specimen was sent to pathology for a frozen section while we performed a second wedge resection containing the smaller two nodules. The frozen section report was consistent with malignancy. Her pathology report was issued on postoperative day two; the initial specimen was a 4-mm well-differentiated bronchioalveolar carcinoma with a 2-cm surgical margin (stage T1). The smaller two nodules in the second specimen were caseating granulomas with acidfast bacilli consistent with Mycobacterium tuberculosis.
Comment The concurrent diagnosis of lung cancer and tuberculosis (TB) is not well described. Whether the two conditions are independent is a matter of controversy, and some experts maintain that there is a higher incidence of lung cancers in areas previously scarred from TB.1 After TB, the lung tissue manifests an intense immune response that generates parenchymal fibrosis, decreased lymphatic clearing, impaired apoptosis, and increased angiogenesis that can lead to tumorigenesis.2 Historically, affected patients tend to be men in their 40s or 50s who are heavy smokers.3 TB can compound and impair the diagnosis of lung cancer until the cancer is disseminated.4 Patients can be treated with antituberculosis drugs until sputum conversion is successful, and they may ultimately have pulmonary resection and ancillary treatments as needed.
Our patient was placed in respiratory isolation, and an infectious disease specialist was consulted. The patient was discharged in conjunction with the public health department, who oversees her medication administration. She was briefly readmitted to the hospital the following week with an acute GI reaction to one of the medications. She will undergo a full year of treatment for TB. Her recovery from lung cancer has been remarkable. Follow-up chest films remain normal, and the oncologist has not recommended ancillary treatment for her very early stage T1 lung cancer. The TB diagnosis came as a surprise to everyone involved, especially because the suspicion of malignancy was high and signs and symptoms of TB were completely absent. Even the most thorough history and physical examination may produce an incomplete differential diagnosis, and PAs really can learn something new every day.
REFERENCES
- Kodolova IM, Kogan EA. Peripheral cancer of the lung and tuberculosis. Arkh Patol. 1986;48(3):52-60.
- Ardies CM. Inflammation as cause for scar cancers of the lung. Integr Cancer Ther. September 2003;2:238-246.
- Mok CK, Nandi P, Ong GB. Coexistent bronchogenic carcinoma and active pulmonary tuberculcosis. J Thorac Cardiovasc Surg. 1978;76:469-472.
- Gopalakrishnan P, Miller JE, McLauglin JS. Pulmonary tuberculosis and coexisting carcinoma: a 10-year experience and review of the literature. Am Surg. 1975;41:405-408.
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