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| Turkish Respiratory Journal | |||||
| December 2003, Volume 4, Number 3, Page(s) 147-149 | |||||
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| A Case of Inactive Tuberculosis Coexisting with Adenocarcinoma and Aspergilloma | |||||
| Esra Öztürk MD; Özlen Tümer MD; Armağan Hazar MD; Nihal Özseker MD; Zeynep Yalçın MD; Melahat Kurutepe MD | |||||
| Heybeliada Chest Hospital, Research and Training Center for Pulmonary Diseases and Pulmonary Surgery, İstanbul, Turkey | |||||
| Keywords: pulmonary aspergilloma, bronchial carcinoma, tuberculous cavity | |||||
| Summary | |||||
A patient treated at our hospital with the diagnosis of smear
positive pulmonary tuberculosis was rehospitalized six years
later for hemoptysis. The chest x-ray showed a nearly
homogenous opacity on the left upper zone. Computed
tomography revealed a fungus ball in a cavity on the left
upper lobe. The patient underwent left upper lobectomy
because of the recurrent hemoptysis. Histopathologic
diagnosis of the resected material was adenocarcinoma with the aspergilloma in the cavity on apicoposterior segment of
the upper lobe. The case was presented for it demonstrated,
in a patient with a background of tuberculosis, an
adenocarcinoma which had developed on the wall of a cavity
containing a fungus ball. |
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| Introduction | |||||
In regions where tuberculosis (TB) is endemic, aspergilloma
developing within a closed tuberculous cavity in the lung is not a
rare event. In a study screening 544 treated cavitary TB cases,
aspergilloma was diagnosed in 17% [1]. A small fraction of these
patients were asymptomatic, but the majority had hemoptysis. Many studies have drawn attention to the increase in the risk of carcinoma in cases with radiological evidence of TB sequelae. It has been reported that scar cancers develop in 25% of such cases [2]. This is the first report of a patient who developed both aspergilloma and adenocarcinoma within a treated tuberculous cavity. |
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| Case Presentation | |||||
A 52 year old male patient was referred with a history of chest
and back pain, hemoptysis, and fatigue which had developed
within the last month. He had been treated for active
tuberculosis in our hospital 6 years ago. Physical examination revealed decreased lung sounds on the upper and middle hemithorax. Eryhrocyte sedimentation rate was 57 mm/h, hematocrit 39%, hemoglobin 13.7 g/dl. The previous x-ray of the patient taken 6 years ago showed a nonhomogenous infiltration with multiple cavities on the right and the left middle lobes . After completion of the treatment, the x-ray revealed only a thin-walled cavity in the left upper lobe. The current x-ray showed a 6x4.7 cm nonhomogenous opacity. On the left lateral view there was a 1.5x2 cm cavitary image in the left apicoposterior segment. Thoracic computed tomography revealed cavitary lesions which contained three fungus balls (the largest about 2.5 cm diameter) and pleural thickening (Figure 1). Fiberoptic bronchoscopy revealed no endobronchial lesions. Bronchial lavage was nondiagnostic. The case was transferred to the surgical department with a tentative diagnosis of pulmonary aspergilloma. A left upper lobectomy was performed and the surgical material was pathologically examined. On the apical segment, a cavity filled with a gelatinous material belonging to the fungus was observed. And a marked increase of collagenous tissue was noted on the surface of the cavity. Microscopic examination revealed an adenocarcinoma developing on the cavity wall and not exceeding the visceral pleura (Figure 2). Peribronchial lymph nodes showed no metastasis. The case was evaluated as stage 1 non-small cell lung cancer (T1N0M0). Chemotherapy or radiotherapy were not considered necessary and it was decided to monitor the progress of the patient with no other treatment.
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| Discussion | |||||
Pulmonary aspergilloma is the most common clinical
condition caused by Aspergillus. Latent tuberculosis,
sarcoidosis, bronchiectasis, bronchial cysts, chronic abscess,
cavity of carcinoma, rheumatoid arthritis, intrapulmonary
sequestration and histoplasmosis are some of the underlying
conditions which facilitate infestation by the fungi [2]. In Turkey, aspergillosis is most commonly encountered in patients with pulmonary tuberculosis. Ölçmen et al reported pulmonary tuberculosis in 22 out of 26 cases who underwent surgery for aspergillosis. The underlying conditions in the remaining four patients were bullous lung, hydatic cyst, a previously operated hydatic cyst, and lung carcinoma [3]. The common symptoms in patients with aspergilloma are hemoptysis, cough and expectoration. Hemoptysis is found in 75-90% of patients. Massive hemoptysis, resulting from erosion of the bronchial arteries, was reported in a quarter of the cases [2] Weight loss, dyspnoea and chest pain were the accompanying symptoms. A radiological picture, described as a typical halo sign within the cavity, together with involvement of the parenchyma and of the pleura causing pleural thickening and calcification, was reported [3]. The chest x-ray findings of our patient agreed with this description. Histopathological examination is required for the definitive diagnosis of aspergilloma. This may be done on material obtained during surgery, or by transthoracic needle aspiration. Surgery is the treatment of choice in aspergilloma. Surgery is planned according to the underlying disease. Bronchial arterial embolisation is done in selected cases [1]. In regions where the disease is endemic, parenchymal scars in the lung are predominantly due to tuberculosis. In a study on cancer patients with a previous history of tuberculosis, the histological type was squamous cell in 60% and adenocarcinoma in 30% of the patients [4]. The most striking finding in our case was the histological diagnosis of adenocarcinoma developing on the cavity wall. Auerbach et al. [5] reported development of adenocarcinoma in 72% of 82 patients with scar cancer. In a study by Ueda et al (6), 3 out of 41 patients with pulmonary aspergilloma had died from lung cancer during follow-up and they concluded that patients with asymptomatic pulmonary aspergillomas should be clinically monitored for signs of lung cancer. Though our case was symptomatic for aspergilloma, the presence of the lung cancer was detected by postoperative pathological examination. By presenting this case we suggest that every case of pulmonary aspergilloma should be examined for malignancies. |
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| References | |||||
1) Fraser RG, Pare JAP, Pare PD, Fraser RS, Genereux GP. Diagnosis of Diseases of the Chest, 3rd edition Vol. II Philadelphia: WB. Saunders Company, 1989; 988-1016. 2) Sharma OP, Chwogule R. Many faces of pulmonary aspergillosis. Eur Respir J 1998; 12: 705-715. 3) Ölçmen A, Akın H, Dinçer I, Bekar I, Metin M, Ölçmen M, Taşçı O. Aspergilloma: 26 resected cases. Abstract Book of Second Congress of Turkish Thoracic Society 1998; 39. 4) Ferluga D, Rott T, Rutar Zupancic M. Pulmonary scar cancer and tumorlet. Prax Klin Pneumol 1979; 33(1): 15-21. 5) Auerbach O, Garfinkel C, Parks RV. Scar cancer of the lung: Increase over a 21 year period. Cancer 1979; 43: 639. 6) Ueda H, Okabayashi K, Ondo K, Motohiro A. Analysis of various treatments for pulmonary aspergillomas. Surg Today 2001; 31(9): 768-73. |
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