Korean J Radiol.  2001 Sep;2(3):138-144. 10.3348/kjr.2001.2.3.138.

Coexisting Bronchogenic Carcinoma and Pulmonary Tuberculosis in the Same Lobe: Radiologic Findings and Clinical Significance

• Kim YI
• Goo JM
• Kim HY
• Song JW
• Im JG

• KMID: 754098
• DOI: http://doi.org/10.3348/kjr.2001.2.3.138

Abstract

OBJECTIVE
Bronchogenic carcinoma can mimic or be masked by pulmonary tuberculosis (TB), and the aim of this study was to describe the radiologic findings and clinical significance of bronchogenic carcinoma and pulmonary TB which coexist in the same lobe. MATERIALS AND METHODS: The findings of 51 patients (48 males and three females, aged 48-79 years) in whom pulmonary TB and bronchogenic carcinoma coexisted in the same lobe were analyzed. The morphologic characteristics of a tumor, such as its diameter and margin, the presence of calcification or cavitation, and mediastinal lymphadenopathy, as seen at CT, were retrospectively assessed, and the clinical stage of the lung cancer was also determined. Using the serial chest radiographs available for 21 patients, the possible causes of delay in the diagnosis of lung cancer were analyzed. RESULTS: Lung cancers with coexisting pulmonary TB were located predominantly in the upper lobes (82.4%). The mean diameter of the mass was 5.3 cm, and most tumors (n=42, 82.4%) had a lobulated border. Calcification within the tumor was seen in 20 patients (39.2%), and cavitation in five (9.8%). Forty-two (82.4%) had mediastinal lymphadenopathy, and more than half the tumors (60.8%) were at an advanced stage [IIIB (n=11) or IV (n=20)]. The average delay in diagnosing lung cancer was 11.7 (range, 1-24) months, and the causes of this were failure to observe new nodules masked by coexisting stable TB lesions (n=8), misinterpretation of new lesions as aggravation of TB (n=5), misinterpretation of lung cancer as tuberculoma at initial radiography (n=4), masking of the nodule by an active TB lesion (n=3), and subtleness of the lesion (n=1). CONCLUSION: Most cancers concurrent with TB are large, lobulated masses with mediastinal lymphadenopathy, indicating that the morphologic characteristics of lung cancer with coexisting pulmonary TB are similar to those of lung cancer without TB. The diagnosis of lung cancer is delayed mainly because of masking by a tuberculous lesion, and this suggests that in patients in whom a predominant or growing nodule is present and who show little improvement of symptoms despite antituberculous or other medical therapy, coexisting cancer should be suspected.

Keyword

Lung neoplasms; Lung neoplasms, CT; Tuberculosis, pulmonary

MeSH Terms

Aged
Carcinoma, Bronchogenic/*complications/radiography
Female
Human
Lung Neoplasms/*complications/radiography
Male
Middle Age
Tomography, X-Ray Computed
Tuberculosis, Pulmonary/*complications/radiography

Figure

• 

  Fig. 1 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 was administered. Staining for acid-fast bacilli then proved negative. B. Chest radiograph obtained two years after A demonstrates increased opacity (arrow), which was disregarded by both the radiologist and the patient's clinician. C. Follow-up CT scan obtained 10 months after B shows a 3.5 cm-sized mass (arrow) at the right apex. D. Photograph of a cut section of the resected specimen shows a hard yellowish mass which proved to be squamous cell carcinoma. Dark pigmentations (arrows) within the tumor were composed of tuberculous granulomas.

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  Fig. 2 64-year-old male who presented with sputum. A. Initial chest radiograph reveals the presence of a large lobulated mass (arrow), proven by percutaneous needle biopsy to be an active tuberculous lesion, in the right lower lung zone. B. The patient received anti-tuberculous medication, and a follow-up plain radiograph obtained six months after the initial study showed that the lesion (arrow) was very much smaller. C, D. Follow-up chest radiograph (C) and CT scan (D) obtained seven months after B show an enlarged mass (arrows) in spite of anti-tuberculous medication. E. Photograph of a cut section of the resected specimen shows a dumbbell-shaped mass in the right lower lobe. Histopathologic examination showed that squamous cell carcinoma surrounded the scar tissue (arrow). (From Lee KS, Im JG, Kang DS. Notes from the 1999 annual meeting of the Korean Society of Thoracic Radiology. J Thorac Imaging 2000; 15:30-35, with permission.)

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  Fig. 3 69-year-old male who presented with cough and dyspnea, and had been treated with antituberculous medication at the age of 39. A. Chest radiograph shows reticulonodular opacities in both upper lung zones, suggestive of TB. A large lobulated mass (arrow) in the right upper lobe was regarded as tuberculous granuloma rather than lung cancer. B, C. Antituberculous 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.

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  Fig. 4 60-year-old male who presented with 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, C. CT scans obtained two months after A, due to persistent symptoms, show cavitary lesions (arrows) in the apicoposterior segment and segmental consolidation (arrowheads) in the lingular division of the left upper lobe. D. Bronchoscopy demonstrated adenocarcinoma in the lingular division. In the pathologic specimen, a pinkish tumor, which proved to be tuberculous granuloma, engulfed the pigmented area (arrows).

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