; Bronchogenic Carcinoma with Tuberculosis in Coexisting Active
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Bronchogenic Carcinoma with Tuberculosis in Coexisting Active


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									9 Junie 1979                                          SA       MEDIESE           TYDSKRIF                                              979

 Bronchogenic Carcinoma with Coexisting Active Pulmonary
               Tuberculosis in Urban Blacks
                                      A. SOLOMON,                S. HURWITZ,            A. A. CONLAN

                             SUMMARY                                                                  PATIENTS
  There is a significant incidence of active pulmonary                         There was radiographic evidence of pulmonary disease
  tuberculosis with coexisting lung cancer. It is likely that                  in the 6 documented patients. In Table [ the clinical
  the cancer activates dormant tuberculosis. In a popu-                        presentation is summarized. Mycobacterium Tuberculosis
  lation group beset by a high incidence of tuberculosis,                      was recovered from their sputa on more than one occasion,
  the heavy smoker who has attained his fifth decade                           and there was clinical and/or radiological evidence of an
  seems particularly vulnerable to the combined diseases.                      unusual presentation of tuberculosis. In view of this, and
                                                                               the well-documented evidence of coexisting active tubercu-
                                                                               losis and lung cancer,"· the patients were investigated for
  5. Atr. med. J. o 55, 979 (1979).
                                                                               bronchogenic carcinoma. Conversely, certain patients with
                                                                               bronchogenic carcinoma were also investigated for asso-
Tuberculosis remains a common problem at Baragwanath                           ciated active tuberculosis. Squamous carcinoma cells were
Hospital, which serves approximately I million Black                           recovered from 3 patients, while the remaining 3 had
patients in adjoining Soweto. However, Baragwanath                             adenocarcinoma.
Hospital autopsy figures, discussed by Isaacson et al. I for                     The clinical criteria that we felt required further in-
the period 1966 - 1975, reflect only 193 cases of lung                         vestigation included a history of heavy smoking, pleuritic
cancer. This sharply contradicts the figures reported by                       pain, unexplained neurological findings such as might be
Bradshaw and Harington' for deaths from lung cancer                            associated with carcinoma of the lung, and poor response to
among South Africans during the period 1949 - 1969; they                       antituberculosis therapy. Other findings suggestive of a
drew attention to the high death rate from lung cancer                         malignant neoplasm in tuberculous patients have been de-
among South African Coloureds and Whites. Although                             tailed by McQuarrie eT al."
Baragwanath Hospital's autopsy figures may not be a true
reflection of the situation, the difference is still striking.                    We considered certain radiological features to be un-
During the first 6 months of this year, 6 patients with                        usual for tuberculosis, and used this additional evidence to
bronchogenic carcinoma, revealed by cytological investi-                       exclude associated lung cancer. Involvement of the basal
gation of sputum or pleural aspirate, with associated                          or anterior lung segment is not usual in adult tuberculosis.'
active pulmonary tuberculosis, have come under our care.                       Progression of pulmonary infiltration while the patient was
Not all the patients with chest problems are referred                          being treated for tuberculosis was an indication for further
to the hospital's pulmonary unit, and there is a strong                        investigation. A large mass was considered inconsistent
                                                                               with tuberculosis of the lung, and hilar adenopathy with
possibility that many more such patients are admitted to
the hospital. It would appear that there is a suspiciously                     a lung lesion (Fig. 3) or an irregular walled cavity was
high incidence of bronchogenic cancer associated with                          considered unusual for tuberculosis.' In 1 patient rib
                                                                               cage involvement was the clue to the associated carcinoma.
active lung tuberculosis in our Black patients. This has
prompted us to share our experience and to draw atten-                         Unusual pleural opacities or increasing pleural effusion
                                                                               while the patient was receiving anti tuberculosis treatment
tion to what may not be obvious to practising clinicians,
                                                                               necessitated further investigation. Many of these features
namely, that there is a high incidence of coexisting lung
cancer and active pulmonary tuberculosis in Black South                        considered unusual for pulmonary tuberculosis were re-
                                                                               ferred to by Ting and Church in 1976.'
Africans. Accurate statistics for the incidence of lung
carcinoma or tuberculosis in Soweto are not available,                            None of the 6 patients was operated upon because
but our impression is that the diagnosis of carcinoma of                       extensive local tumour spread, and/or distant metastasis,
the lung is being made more frequently at Baragwanath                          and/or poor pulmonary function were demonstrated in
Hospital. We have personally verified 20 cases of lung                         every patient. Treatment directed at the carcinoma was
cancer in the last 2 months.                                                   entirely palliative, and consisted of X-ray therapy for pain-
                                                                               ful bone involvement and thoracentesis for symptomatic
                                                                               pleural effusion. Every patient was given antituberculosis
Departments of Radiology, Medicine and Thoracic Surgery,                       chemotherapy.
 Baragwanath Hospital and University of the Witwatersrand,
A. SOLOMON,          "'LB.   B.CH.,   DIP.   MED.,   O.M.R.   (D.),   M.MEO.                         DISCUSSION
  R.-\D. (D.)
S. HURWITZ,        M.B. B.CH., F.C.P. (s.....)                                   uessle' reported a 0,6% association of lung cancer and
A. A. CONLAN,         M.B. B.CH., F.R.C.S.                                     active tuberculosis in 1953. Ting and Church' referred to
Date received:   24 January 1979.                                              a similar association in 5% of their patients, and Holden
980                                       SA      MEDICAL             JOUR    AL                                 9 June 1979

                                                TABLE I. PRESENTATION

                            Smoking                                                                      Criteria for further
 Age           Sex           habits            Symptoms                            Signs                    investigation
  40            M         Moderate        Pleuritic chest pain.          Clubbing, hyperinflation.    Left lower lobe opacifica-
                                            Coughing. Previous             Bilateral basal crepita-     tion (Fig. 1)
                                            antituberculosis treat-        tions
                                            ment (incomplete)
  73            M         Moderate        Pleuritic chest pain.          Hyperinflation and airway    Lingular consolidation.
                                            Haemoptysis. Weight            obstruction. Proximal         Neurological signs
                                            loss                           myopathy and peri-
                                                                           pheral neuropathy
  54            M         Heavy           Pleuritic chest pain.          Hyperinflation. Right mid-   Right mid-lobe consolida-
                                            Haemoptysis                    lobe consolidation.          tion; myopathy
                                                                           Proximal myopathy
  58            M         Moderate        Pleuritic pain.                Left-sided effusion          Persistence of effusion
                                              Haemoptysis                                               despite adequate treat-
                                                                                                        ment for TB
  75            M         Moderate        Pleuritic pain. Haemop-        Clubbing, hyperinflation,    Neurological signs. Rib
                                            tysis. Weight loss.            airway obstruction.          erosion (Fig. 2)
                                            Weakness of legs               Right effusion, truncal
  46            F         Non-smoker      Pleuritic pain. Previous       Left-sided effusion          Failure to resolve on
                                            antituberculosis treat-                                     treatment

 Fig. 1. Pneumonic opacification in a basal lung segment
 was considered unusual for tuberculosis. An associated            Fig. 2. A large right hemithoracic carcinomatous mass
 carcinoma was present in this patient; Mycobacterium              with associated rib erosions. Further investigations con-
 tuberculosis was recovered from the patient's sputum.             firmed the coexistence of active tuberculosis.

et al.' commented on an 18,75% incidence in their group.          1959 predicted that a rising incidence of bronchogenic
Tuberculosis is, however, generally less prevalent in             carcinoma would result in a similar increase in cases of
America than in Africa. Christofordis and Browning" in            coexisting active tuberculosis and lung cancer. In 1960
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