It’s time to action,

Fight for TB & Lung Cancer !

TUBERCULOSIS &
LUNG CANCER
Haryati
INTRODUCTION
• Lung cancer and Tuberculosis (TB) are two major public health
problem associated with significant morbidity and mortality.

Causes more deaths than any

other cancer

One of the major causes of death

amongs infectious diseases
One-third of human population
estimate infected with M.tuberculosis

The correlation of TB and Lung cancer has attracted

attention for several years and has remained controversial
PATHOGENESIS
• The association between TB and cancer can occur in several ways.

• A chance coincidence without any apparent

relation
• Metastatic carcinoma developing in old TB lesion
• Secondary infection of cancer with TB
• Chronic progressive tubercle in which carcinoma
develops
• Simultaneous development of both TB and cancer
Tuberculosis as A Cause of Lung Cancer
• Bronchogenic cancer is one of the most unrecognised post
treatment problems among treated pulmonary TB patient
• The chances of restarting anti TB treatment in post TB patients, as
relapsed TB are high
• Easily misdiagnosed as an old lesion and delaying treatment
• Poor prognosis because of metastasis from relatively small lesions

Early detection and diagnosis of lung cancer in pulmonary & post

TB patient is critical for better treatment outcome
Sequence 0f Events in Enhancing Risk for Cancer from Chronic M. tuberculosis Infection
Inflammatory Process Facilitate the Development Cancer ?

Reactive oxygen or nitrogen species produced by activated neutrophils can bind to

DNA, leading to genomic alterations  DNA damaged in lung epithelial.

Tissue repair is associated with cellular proliferation, during which errors in

chromosomal replication might lead to further DNA mutation

Some proinflammatory cytokines (TNF, IL6) upregulate the expression of

antiapoptotic genes through the NF-KB pathway

Angiogenesis is common feature of tissue repair and also crucial for tumor growth

Inflammation may initiate and promote cancer

development

7
Lung Scar Carcinoma

Persistent infection by M.tuberculosis induced the production of TNF & leads to

inflammatory inflammation

is associated
Tissue repair process with cellular
characterized by aproliferation,
high level of during
activitywhich errors inwhich
of fibroblast,
chromosomal
synthesized replication matrix
extracellular might lead to component
(ECM) further DNA&mutation
produced fibrous scar

TB causes extensive pulmonary Scar such as those cause by TB have

fibrosis. IL3, IL4, TNF plays a key role been hypothesized to play an
in formation of fibrous wall etiologic part in lung cancer

8
 C0-existent Pulmonary Tuberculosis and Lung Cancer

• Clinical diagnosis of co-existing

TB and cancer is often
challenging
• Cause a delay in diagnosis and
CANCER
institution of appropriate
treatment and is associated
with poor prognosis
• It has been reported that in
patients with TB, the average
delay in the diagnosis of lung
cancer is 6 – 9 months
 C0nt’d.......
• Several plain radiographic features increase the suspicion of co-
existing lung carcinoma in patients with pulmonary TB (Ting et al.) :

 The progression of pulmonary infiltrate while the

patient is on anti-tuberculous drugs
 Infiltration or atelectasis in the basilar segments of the
lower lobes or the anterior segments of the upper lobes
 Homogeneous infiltration with no air bronchogram
rather than a mottled appearance with linear streaking
 Asymmetrical pleura density at the apex or
costophrenic angle while the patient is receiving anti-
tuberculous medication
 Unilateral hilar prominency
 A single pulmonary nodule with a diameter greater than
3 cm, and an irregular nodule wall and contour
 The impression that a mass is present in a displaced
lobar fissure
 C0nt’d.......
Clinical findings and chest radiographs
appear to indicate the concurrence of
lung cancer & TB

Lung CT-Scan
should be
performed

Biopsy for
pathologic
confirmation
Tuberculosis Complicating Lung Cancer
• TB has been known to complicate the course of cancer
• Patient with lung cancer are also vulnerable to develop
active pulmonary TB due to immunosuppression and
malnutrition resulting from the use of intensive
treatment modalities such as aggressive chemotherapy
CASES
 60-year-old male with a two-year history of pulmonary TB

A. Chest radiograph shows ill-defined patchy opacity (arrow) at the right apex.
Because acid-fast bacilli were present in sputum, anti-tuberculous medication
administered. Staining for acid-fast bacilli then proved negative
B. Chest radiograph obtained two years after A demonstrates increased opacity
(arrow), which was regarded by both the radiologist and the patient’s clinician
D. Follow-up CT-Scan obtained 10 months after B show a 3,5 cm-sized
mass (arrow) at the right apex
E. Photograph of a cut section of the resected specimen shows a hard
yellowish mass which proved to be a squamous cell carcinoma. Dark
pigmentation (arrows), within tumor were composed of tuberculous
granulomas
 64-year-old male who presented with sputum

A. Initial CXR reveals the presence of a large lobulated mass (arrow), proven by percutaneous
needle biopsy to be an active tuberculosis
B. The patient received anti-tuberculous medication, and a follow-up obtained six months showed
that lesion (arrow) was very much smaller
C. Follow-up CXR obtained seven months after B show an enlarged mass (arrows) in spite of anti-
tuberculous medication
D. Follow-up CT-Scan obtained seven months after B show
enlarged mass (arrow)
E. Photograph of a cut section of the resected specimen shows a
dumbbell shaped mass in the right lobe. Histopathologic
examination showed that squamous cell carcinoma surrounded
the scar tissue (arrow)
 60-year-old male who presented hoarseness

A. Initial chest radiograph shows consolidation (arrow) in the left upper lung zone and ill-
defined ground-glass opacity (arrowheads) in the left lower lung zone. Because acid-fast bacilli
were present in sputum, the patient underwent anti-tuberculous chemotherapy
B. CT-Scan obtained two months after A, due to persistent symptoms, shows cavitary lesions
(arrows) in the apicoposterior segment
D. CT-Scan obtained two months after A show segmental consolidation
(arrowheads) in the lingular division of the left upper lobe
E. Bronchoscopy demostrated adenocarcinoma in the lingular division. In
the pathologic specimen, a pinkish tumor, which proved to be
tuberculous granulomas, engulfed the pigmented area (arrows)
69-year-old male who presented with cough & dyspnea (had
been treated with antituberculous medication at age of 39)

A. Chest radiograph shows reticulonodular opacities in both upper lung

zones, suggestive of TB.
B, C. Anti tuberculous medication offered no improvement, however, and
the CT-Scan obtained ten months after A reveals a 3,0 cm sized,
irregularly marginated mass (arrows) at the right apex. Sputum
cytology showed that an adenocarcinoma was present
 Ny. SH, 48 th
RPS
KU : Batuk darah sejak 5 bln yll, 1 sdm/hari
Sakit dada kiri kadang2, sesak (-),
demam (-), nafsu makan baik, BB ↓ (-)
RPD :
Th 2002 TB paru (OAT 6 bulan)
Th 2005-06 TB paru (OAT 9 bulan)
Th 2007 batuk darah
Riwayat merokok (-), DM (-)
Foto toraks (20/04/07)
Bronkoskopi
21 – 9 - 2005 20 – 4 - 2007
we must
act now
to end TB
in our lifetimes