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  Table of Contents    
LETTER TO EDITOR  
Year : 2016  |  Volume : 59  |  Issue : 4  |  Page : 560-561
Co-existing tuberculosis and adenocarcinoma of colon


1 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication10-Oct-2016
 

How to cite this article:
Sharma S, Vijay Kumar AK, Kakkar N, Gupta V. Co-existing tuberculosis and adenocarcinoma of colon. Indian J Pathol Microbiol 2016;59:560-1

How to cite this URL:
Sharma S, Vijay Kumar AK, Kakkar N, Gupta V. Co-existing tuberculosis and adenocarcinoma of colon. Indian J Pathol Microbiol [serial online] 2016 [cited 2019 Aug 24];59:560-1. Available from: http://www.ijpmonline.org/text.asp?2016/59/4/560/191770


Editor,

Tuberculosis and adenocarcinoma coexisting in the large bowel are rare. [1],[2] Granulomas occurring in malignancy may be confused with sarcoid-like granulomas. We report a case with adenocarcinoma of the cecum and coexisting tuberculosis, highlight the diagnostic dilemma, and brief pathogenesis.

A 54-year-old female was admitted with complaints of pain abdomen, vomiting, and weight loss for 9 months. Colonoscopic biopsy in a government hospital was suggestive of tuberculosis, and antitubercular treatment was started. Due to persisting symptoms, contrast-enhanced computed tomography scan of the abdomen was done which showed asymmetrical thickening involving the small bowel, cecum, and ascending colon with deformed cecum. The possibility of tuberculosis versus malignancy was kept. A right hemicolectomy specimen was received, which on cutting open, revealed cecal ulceration with a stricture 4 cm from the ulcerated end. Sections from the cecal ulceration revealed a tumor arranged in the form of glands, infiltrating the muscularis. The areas adjacent to tumor showed epithelioid cell granulomas cuffed by lymphocytes, Langhans-type giant cells, and central caseous necrosis. One of the pericolic lymph nodes also showed caseous necrosis. Ziehl-Neelsen stain showed acid-fast bacilli in granulomas adjacent to the tumor as well as in the necrotic area in lymph node [Figure 1]. A diagnosis of adenocarcinoma of cecum with tuberculosis was given.
Figure 1: (a) Cecum showing mucosal ulcer with stricture 4 cm from the ulcerated end. (highlighted with arrows). (b) Low power to show tumor with areas of necrosis. (H and E, x40). (c) High power to show the tumor arranged in glands infiltrating the muscularis. (H and E, x200). (d) Areas adjacent to necrosis in cecum showing epithelioid cell granulomas with Langhans type of giant cells. (H and E, x200). (e) Pericolic lymph node showing caseous necrosis (H and E, x100). (f) Ziehl Neelsen stain on pericolic lymph node shows acid-fast bacillus (Ziehl Neelsen, x1000)

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The most common site of gastrointestinal tract tuberculosis is ileocecal region, [3] whereas adenocarcinoma usually occurs in the sigmoid colon. However, few cases have been reported with the coexistence of tuberculosis and adenocarcinoma of the large bowel. [1] Several theories have been given regarding its pathogenesis. [2] A possibility of coincidental occurrence of carcinoma and tuberculosis has been proposed. [4] However, the theory that adenocarcinoma arises from a preexisting tubercular lesion is the most favored. Tanaka et al. [2] supported the possibility that cancer arises in the background of tuberculosis, suggesting that chronic inflammatory conditions result in impaired immune response and development of malignancy. There are few opinions that malignancy reactivates old tubercular lesions. [5] However, tuberculosis in the colon at sites away from carcinoma contradicts this hypothesis. [4]

Clinical diagnosis of coexisting tuberculosis and cancer is difficult because of overlapping clinical features. However, the atypical course of tuberculosis should prompt the suspicion. If any abnormality is suspected on radiology, endoscopic biopsy of such lesions is essential. The pathologist may sometimes confuse these granulomas with sarcoid-like granulomas in response to tumor antigens. Such granulomatous reactions occur in lymph nodes draining carcinomas, and granulomas within the tumor stroma have been seen in breast, renal, and hepatocellular carcinomas. However, granulomas within the stroma of colon carcinoma are rare. Moreover, the presence of necrosis and Langhans-type giant cells favors the possibility of tuberculosis. This case highlights the need to keep a suspicion of coexistence of adenocarcinoma and tuberculosis both by the clinician and the pathologist.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Husain M, Sachan P, Khan S, Chauhan N, Kishore S. Co-existing abdominal tuberculosis and colon carcinoma: Case report with review of literature. Internet J Surg 2006;13:2.  Back to cited text no. 1
    
2.
Tanaka K, Kondo S, Hattori F, Yamashita Y, Matsuda M, Itoh K, et al. A case of colonic carcinoma associated with intestinal tuberculosis, and an analysis of 26 cases reported in Japan. Gan No Rinsho 1987;33:1117-23.  Back to cited text no. 2
[PUBMED]    
3.
Sharma MP, Bhatia V. Abdominal tuberculosis. Indian J Med Res 2004;120:305-15.  Back to cited text no. 3
    
4.
Jain BK, Chandra SS, Narasimhan R, Ananthakrishnan N, Mehta RB. Coexisting tuberculosis and carcinoma of the colon. Aust N Z J Surg 1991;61:828-31.  Back to cited text no. 4
[PUBMED]    
5.
Falagas ME, Kouranos VD, Athanassa Z, Kopterides P. Tuberculosis and malignancy. QJM 2010;103:461-87.  Back to cited text no. 5
[PUBMED]    

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Correspondence Address:
Nandita Kakkar
Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.191770

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