[ ISSN : 2573-3680 ]
lung carcinoma, tuberculosis, lateral rectus palsy, trochanteric metastasis, fibrosis.
We report a case of large cell undifferentiated lung carcinoma in a middle aged patient with previously treated tuberculosis and scarring. 20 pack years of smoking history was noted. He presented with metastasis at multiple sites including trochanter, liver and acute bilateral lateral rectus palsy. Chest radiography showed fibrosis of right upper zone with homogenous opacity. Sputum examination for AFB was negative. Computerized tomography of the thorax showed an irregular heterogeneously enhancing mass involving right upper lobe with cavitation, necrosis along with lymph node involvement and the erosion of the 4th rib with liver metastasis. Radiography of hip joint was suggestive of lesser trochanteric metastasis. MRI brain was suggestive of mass at base of brain in parasellar area. Fine needle aspiration cytology and CT guided biopsy confirmed undifferentiated large cell carcinoma of lung. Tuberculosis and smoking may increase the risk of lung scarring and malignancy and pulmonary scarring may be associated with increased lung carcinoma in ipsilateral lung. Clinician needs to be more sensitive to look for malignancy association particularly in patient with or previously treated for tuberculosis and even more emphasis to be laid if scarring of lung is observed.
Fifth common cancer in India is lung carcinoma with 63,000 new cases detected per year [1]. Men and smokers have increased incidence [2,3]. Concurrent presence of tuberculosis and malignancy pose a diagnostic challenge [4]. Risk of malignancy increases with pulmonary tuberculosis diagnosed more than 20years as per studies [5]. Scarring was associated with increased lung cancer risk on the ipsilateral lung [6].
Tuberculosis (TB) presents a global threat in both developing and developed countries. Onethird of the world’s population is thought to have been infected with M. tuberculosis [7], and new infections occur in about 1% of the population each year [8]. In 2007, an estimated 13.7 million chronic cases were active globally [9], while in 2013, an estimated 9 million new cases occurred [10]. In 2013 there was between 1.3 and 1.5 million associated deaths [11], most of which occurred in developing countries [12]. Tuberculosis is the second-most common cause of death from infectious disease after HIV/AIDS [13]. The aim of the case report is to improve knowledge regarding malignancy in tuberculosis scar.
A 40 year old male patient, chronic smoker (20 pack years of smoking) and alcoholic (80 g per day for 20 years) who was treated successfully for sputum positive pulmonary tuberculosis 4 years ago (Figure 1), labourer by occupation, presented with pain in lower limbs and difficulty in walking and significant weight loss over a period of 1 month, double vision over a period of 10 days with no chest symptoms. Patient was tested negative for tuberculosis (sputum for Acid Fast Bacilli) on 3 occasions over these 4 years. Patient described pain as severe grade 8/10 aching type associated with tingling, numbness and heaviness of lower limbs. Patient has taken treatment from local clinic did not relieve his pain and double vision. He was on medications tramadol and multivitamins.
Figure 1: Chest radiograph of patient 4 years ago after successful treatment of TB.
On physical examination patient was emaciated, anaemic (Figure 2), with enlarged axillary nodes on right side, clubbing of both lower and upper extremities (Figure 3). Eye examination showed bilateral lateral rectus palsy (Figure 4). No Horner’s syndrome was noted. Chest examination showed loss of lung volume in right supraclavicular, suprascapular, infraclavicular areas compared to left. Lower limb examination showed loss of power 4/5. Muscle tone was difficult to assess due to pain. All reflexes were elicitable in clinical examination.
Figure 2: Patient’s examination showing emaciation.
Figure 3: Clubbing of upper and lower limbs.
Patient had 4 enlarged lymph nodes in right axilla and neck, 2×1 cm in size, firm in consistency, mobile, borders well made out, smooth surfaced. Sputum for AFB (Acid Fast Bacilli) and HIV tests were negative. Chest radiography showed parenchymal opacity in right upper zone (Figure 5). Computerized tomography of thorax showed irregular heterogeneously enhancing mass involving right upper lobe with cavitation and necrosis along with lymphnode involvement and erosion of the 4th rib postero-laterally and postero medially abutting part of transverse process of adjacent vertebra, ribs and transverse process of T1 (Figure 6).
Figure 4: Bilateral lateral rectus palsy in patient
Figure 5: Chest radiography showing right upper zone opacity.
Figure 6: Computerized tomography of thorax showing lung malignancy.
Antero-medially mass is found to be abutting superior vena cava and trachea with encasement right main bronchus. Irregular peripherally enhancing lesion in left lobe of liver noted (Figure 7). Computerized tomography of brain and MRI brain revealed mass in base of brain in parasellar area. Computerized tomography guided biopsy showed undifferentiated large cell carcinoma (Figures 8,9). Hip joint radiography showed metastasis in lesser trochanter (Figure 10). Immunohistochemistry was positive for CD45. Patient was referred to oncology centre for palliative treatment. Patient expired after 20 days.
Figure 7: Liver metastasis in CT scan.
Figure 8: CT guided fine needle aspiration cytology showing large cell carcinoma.
Figure 9: Large cell carcinoma.
Figure 10: Trochanteric metastasis in hip radiography.
According to the previous studies [5], risk of malignancy increases with severe tuberculosis. There are 14 case reports described regarding tuberculosis associated with cancer development and 47 case reports regarding coexistence of tuberculosis and malignancy [5]. Non-Small Cell Lung Cancer (NSCLC) accounts for approximately 85% of all lung cancers. In most series, large cell carcinoma comprises between 5% and 10% of all lung cancers [14]. Estimated odds ratio associated with smoking two or more packs/day for current smokers is 37.0 in men and 72.9 in women [15]. Scarring was more common in current and former smokers, related to cumulative amount of tobacco use [6].
Scarring is associated with increased cancer risk in ipsilateral lung [6]. Adenocarcinoma is the commonest malignancy in peripheral lung scars. Our patient’s presentation with acute bilateral lateral rectus palsy due to brain metastasis and trochanteric metastasis was rare. Large cell carcinoma in peripheral scar of lung is unusual. Brain metastases occur in 30-50% of Non-Small Cell Lung Cancer patients with worse prognosis and quality of life [16].
Lung Scar Carcinoma (LSC) was first reported in 1939 by Friedrich. The majority of lesions were localised to the upper lobe of the lungs in the periphery and were smaller than 3 cm. Male predominance was observed and adenocarcinoma is commonest peripheral lung cancer [17-19]. In adenocarcinoma, fibrosis or scarring (hyalinosis) may be present at the centre of the tumour [18].
Carbon powder decomposition and intensive fibrotic degeneration will be visible on the cut surface. Adenocarcinomatous cells are arranged in a single layer or in small nests. Few malignant cells may be localised to the subpleural area or interlobar pleura. LSCs have a tendency for early lymph-node metastasis and smallvessel invasion [17], which results in a lower 5-year survival rate (5%) than the general 5-year survival rate of adenocarcinomas (22%) and adenosquamous carcinomas (28%).
LSC should be suspected when a new lesion emerges in a lung scar or a focal scar shows enlargement in follow-up radiographic images. In study by Bakris GL, et al. [20] the comparison revealed scar carcinomas possess distinctive features: A higher histologic distribution of adenocarcinoma (58% versus 15% in non-scars) and the frequent presentation (53%) with only non-pulmonary symptoms and signs related to metastasis. In scar carcinomas both bronchoscopy and sputum cytology were ineffective as initial diagnostic tools since chest findings were absent or minimal. Lung scars usually occur secondary to bronchiectasis, tuberculosis, organized pneumonia, pulmonary abscess, trauma or infarction, with tuberculosis being the commonest cause [18].
The pathogenesis of LSC is not clear. It may be the result of chronic inflammation of a lung scar. Repeated injury and repair process over a prolonged period stimulates bronchial and alveolar epithelium, causing atypical hyperplasia or canceration of focal lesions. Fibrosis can block or disturb lymphatic drainage, resulting in pooling of cancer cells in the scar. This causes more extensive vascular and lymphatic seeding in scar cancer compared to regular adenocarcinoma or squamous cell carcinoma.
We put forward following statements based on our case report. Tuberculosis and smoking may increase the risk of lung scarring and malignancy. Pulmonary scarring may be associated with increased lung carcinoma in ipsilateral lung. Clinician needs to be more sensitive to look for malignancy association particularly in patient with or previously treated for tuberculosis and even more emphasis to be laid if scarring of lung is observed.
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13. Lawn SD, Zumla AI. Tuberculosis. Lancet. 378: 57-72.
19. Balo J, Juhasz E, Temes J. Pulmonary infarcts and pulmonary carcinoma. Cancer. 1956; 9: 918-922.
Sudulagunta SR, Kothandapani SK, Sodalagunta MB, Khorram H, Sepehrar M and Noroozpour Z. Carcinoma in Tuberculosis scar. SM J Clin Med. 2015; 1(2): 1008.
The purpose of this statement is none other than to highlight the importance of ethical standards and quality required in basic and applied research currently being done so we can subsequently inform health care professionals of new developments that are taking place in this area.
Ma. Esperanza Rodríguez-van Lier*
Chemotherapy is commonly used in cancer treatment. So far, chemotherapy agents can be categorized into three types: classical chemotherapeutic drugs, molecular target agents and cellular machineries target drugs.
Ziyou Wang1,2 and Zunnan Huang1,2*
Blood transfusion can cause some transfusion adverse reactions. In order to understand the incidence of adverse transfusion reactions, we performed a meta-analysis in Chinese hospitals. Of 809 literatures, seven studies involving a total of 211, 050 patients with blood transfusion treatment were included in this meta-analysis. Meta-analysis showed that the total incidence of adverse reactions was 0.4% [95% CI (0.2, 0.9), P < 0.0001]. Further subgroup analysis showed that the incidence of febrile and allergic reactions was 0.2% [95% CI (0.1, 0.5), P < 0.0001] and 0.2% [95% CI (0.1, 0.3), P < 0.0001], respectively. The common blood components caused adverse reactions were red blood cell, plasama, and platelet in clinical practice.
Yulu Gao1 , Qinyun Li2 , Zongshuai Gao2 , Yunxia Zhu4 , Yanqiu Liao5 , Changtai Zhu2 *# , Yongning Sun3 *#
Background: CT scanning remains one of the most routinely used diagnostic tools in a setting of Interstitial Lung Disease (ILD). New and improved technologies, such as High Resolution Computer Tomography (HRCT) have revolutionized the quality of imaging, leading to a prominent increase in number of incidental findings that may or may not be of any clinical significance. The aim of this study was to evaluate the prevalence of incidental findings on thoracic CT and their clinical significance.
Methods: Retrospective analysis was conducted on a cohort of 84 patients referred to our academic center as cases of ILD. Patients were referred for further evaluation between January 2000 and January 2014 and were followed over the disease course. CT scans were done annually as part of clinical management and patients were screened for any incidental findings. All incidental findings were reviewed, recorded in a clinical database and followed up on subsequent visits.
Results: 25 (30%) patients were found to have incidental findings. Liver abnormalities were found in 12 (14.29 %) patients. 11(13.10 %) patients were reported to have coronary artery calcifications. 5 (5.95 %) and 3 (3.57%) patients had thyroid abnormalities and renal cysts, respectively. A malignant lesion was found in 1 patient each in liver and thyroid abnormality subgroup.
Conclusion: Incidental findings are common on thoracic CT scans providing valuable and unexpected findings which warrant investigation by health care providers to exclude malignant processes.
Sonu Sahni1,2*, Sameer Verma1,2, Reeju S Thomas1 , Barbara Capozzi3 and Arunabh Talwar1,2
Hepatitis C Virus infection (HCV) is an increasing public health concern with an estimated 184 million people infected worldwide and approximately 350.000 yearly deaths from HCV-related complications.
Nesrine Gamal and Pietro Andreone*
Systemic Sclerosis (SSc) is a connective tissue disease characterized by fibrosis of the skin and internal organs, pronounced alterations in the microvasculature and frequent cellular and humoral immunity abnormalities. The rheumatic involvement of SSc is polymorphic and can reveal the disease or may appear during the course of its progression. Musculoskeletal involvement is dominated by non specific arthralgia, polyarthritis, and bony resorption especially acro-osteolysis. The diagnosis of these rheumatic manifestations is generally based on x rays examination. Musculoskeletal involvement in SSc is generally relieved with Non Steroidal Anti-Inflammatory Drugs (NSAID) or low dose of corticotherapy. The immunosuppressive therapy is used in corticoid-resistant or corticoid-dependent forms such us méthotrexate. The aim of our review is to presents an overview of the different osteoarticular and muscular involvement in SSc, their diagnosis and management.
Nessrine Akasbi*, Fatima Ezzahra Abourazzak and Taoufik Harzy
Sedigheh Mirhashemi1 , Mohammad Hosein Kalantar Motamedi1 *, Amir Hossein Mirhashemi2 and Hamid Reza Rasouli1
We encountered two autopsy cases of huge cardiomegaly with over 1000g in weight. Histochemical characteristics were examined using conventional staining including HE and Azan stains and immunohistochemical staining using antibodies against Complement Component 9 (CC9), RNA Binding Protein Motif 3(RBM3), Endothelial Type NO Synthase (eNOS) and Hypoxic Inducible Factor1α (HIF1). The reactive area with anti CC9 antibody, which presumed to be a marker of hypoxic change of myocardium, overlapped with eosinophilic area by HE and basophilic one by Azan. Although the reactive area with anti CC9 antibody showed relatively weak in the cytoplasm by anti eNOS antibody and no in the nucleus of cardiocytes with anti RBM3 antibody, outside of the reactive area with anti CC9 antibody there were intensive reactivity with anti eNOS antibody in cytoplasm and in a nucleus with anti RBM3 antibody. Anti HIF1 antibody showed weak reactivity with cytoplasm of endocardial cardiocytes and no with cytoplasm of cardiocytes in another area. The results obtained from the present cases revealed that the hypoxic change was equivalent even though the cause of cardiomegaly was deferred between two cases, and conventional staining such as HE and Azan utilized to detect hypoxic change in the heart and immunohistochemical studies seemed to be a useful tool for clarifying the cascade of hypoxic changes in the myocardium.
Satoshi Furukawa1,2*, Mayumi Kataoka1 , Satomu Morita1,2, Akari Uno2 , Masahito Hitosugi2 , Hiroshi Matsumoto1,3 and Katsuji Nishi1,2
A 45-year-old woman with multiple sclerosis was admitted to our hospital after out of hospital cardio-pulmonary resuscitation. The first ECG showed ventricular fibrillation. Following direct current defibrillation and mechanical reanimation, spontaneous circulation was restored and the ECG unremarkable without any signs of ischemia. Coronary angiography showed unobstructed coronary arteries Figure 1, (Panel A). Left ventriculography revealed apical wall obstruction, suggestive of apical aneurysm (Panel B, supplementary videos). Transthoracic echocardiography and Cardiac Magnetic Resonance Imaging (CMR) eventually lead to the diagnosis of a rare case of Apical Hypertrophic Cardiomyopathy (AHC) with ace of spades-form (Panel C,D). The patient underwent Cardioverter-Defibrillator Implantation (ICD) and amiodarone medical therapy for secondary prophylaxis. Patient’s family history and screening for HCM were unsuspicious.
Wiedemann S# *, Heidrich FM# , Speiser U and Strasser RH
We present the case of a 23-year-old female who was 23 weeks pregnant and presented to the emergency room of our Obstetric Department in nausea and vomiting that had been worsening over the course of 2 months with loss of eight kilograms in clinical presentation compatible with hyperemesis.
Elisa Picardo1*, Marco Mitidieri1, Marco Bozzaro2, Roberto Altieri2, Carlo Carmazzi1 and Saverio Danese1