Ahmed, M N

Islam, M U

Khalid, T R

Sheikh, M Y

Yousuf, A H

English

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eCommons@AKUDepartment of Radiology Medical College, PakistanNovember 1995Coexistent tuberculosis and carcinoma of the colonM Y. SheikhA H. YousufT R. KhalidM U. IslamM N. AhmedAga Khan University, nadeem.ahmad@aku.eduFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_radiolPart of the Radiology CommonsRecommended CitationSheikh, M. Y., Yousuf, A. H., Khalid, T. R., Islam, M. U., Ahmed, M. N. (1995). Coexistent tuberculosis and carcinoma of the colon.Journal of Pakistan Medical Association, 45(11), 305-306.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_radiol/164Coexistent Tuberculosis and Carcinoma of the ColonPages with reference to book, From 305 To 306 Muhammad Younus Sheikh, A. H. Yousuf, Tahir Rasheed Khalid, Muhammad Umar Islam, Muhammad Nadeem Ahmed( Department of Diagnostic Radiology, Aga Khan University Hospital, Stadium Road, Karachi. ) Colorectal cancer is currently ranked third in men after prostate and lung and second in women1. Itsassociation with inflammatory bowel disease is known. A cluster of case reports has accumulated onthe coexistence of colonic carcinoma and tuberculosis (CTCC) in the same location2. Association oflong standing tuberculosis with cancer has been documented for many organs. We present a case reportof coexistent carcinoma and tuberculosis involving the proximal colon and a review of literature.Case Report A 70 year old female presented with acute intestinal obstruction and a history of intermittent abdominalpain and occasional vomiting. Examination showed abdominal distension and an ill defined mass inright lumbar and hypochondriac region. Routine investigations were generally unremarkable. Plainabdominal film demonstrated features of intestinal obstruction. On barium enema a long stenoticsegment was seen involving the ascending and proximal transverse colon showing ulceration, rigidityand mucosal distortion (Figure 1).Colonoscopy and subsequent surgery showed a 15cm long stenosed segment engrossing the ascendingand proximal transverse colon and containing a large polypoid growth arising from caecum andascending colon with multiple satellite polyps. Histopathologically, there was a well differentiatedmucin secreting adenocarcinoma. Present within the tumour producing colonic tissue were granulornasshowing central necrosis and giant cells suggestive of tuberculosis. Regional mesentenc lymph nodesalso contained similar granulornas. A diagnosis of adenocarcinoma (Duke’s stage B2) with coexistenttuberculous colitis was made. Three years after right hemicolectomy and chemotherapy, the patient wasalive with as cites, secondaries in peritoneum, sigmoid and recurrence at anastomotic site (Figure 2 and3).Discussion Gastrointestinal tuberculosis most commonly involves the ileocecal region followed by jejunum andcolon. Multiple sites of involvement are common. Tanaka et al.4 have reviewed 27 cases of CTCC anddescribed common features like female preponderance (34:50), involvement of right colon, Welldifferentiated adenocarcinoma with a tendency to produce mucin being the commonesthistopathological type. All these findings are consistent with those in our case. The chances ofCTCCbeing a coincidence are highly unlikely, since a similar coexistence has been reported in theileum5. where the occurrence of carcinoma without Crohn’s disease is extremely rare. Moreover, thenumber of reported cases with CTCC is quite significant statistically (CTCC constituted 19% of allcases with colonic TB in the study of Jainet al). The site of occurrence of such carcinoma matches wellwith that favoured by tuberculous colitis. Another possibility, although less likely, is that carcinomapredisposes to tuberculous infection. Disruption of the integrity of mucosal barriers and impairment incell mediated immunity associated with cancerous growth are known to predispose to bacterialinfection2. However the evidence of TB in the colon at a site distant from carcinoma in at least twocases of Jain et al. contradicts the hypothesis of a secondary infection in a pre- existing tumor. Moruta.et al6 have postulated that ulcerative lesions of tuberculosis may be precursors of carcinomas, derivedfrom a chronic inflammatory process with repetition of erosion, ulcer and consequent regeneration.Role of bacteria in the causation of colorectal carcinoma has only been discussed in association withtoxic metabolite production through sterols secreted in the bile3. Whether my cobacteria have anysignificant bearing in this context is a matter of debate. There have been several claims during the lastfew decades that mycobacteria are responsible for a number of human diseases of unknown etiology,including Crohn’s disease7, the malignant potential of which has now been accepted. There have alsobeen recent reports of decreased natural killer (NK) cell activity8 and increased incidence ofchromosomal aberrations9 in association with tuberculosis. Specific relationship, of both acceleratingand controlling growth, exist between fibroblasts and epithelial cells10 and excessive fibroblasticactivity is a constant finding in long standing tuber culous process. In conclusion, there is not enoughevidence yet to affirm a positive etiological correlation between the two pathologies, but the availabledata certainly calls for further study. Clinical features of both tuberculosis and cancer may overlap e.g.,weight loss, constipation, occult blood in stool etc. and the radiologic picture of an extensive ileocecalregion and ascending colon tuberculosis, may be so dramatic as to mask a coexisting malignant processif not contemplated. This is especially true in an endemic region where the bias is predominantly infavour of tuberculosis. Careful endoscopy and biopsy of such “typical” looking colonic lesions isessential to rule out a coexisting carcinoma. The diagnostic possibility may also be considered on abarium enema showing overt malignancy of colon entailing an unduly long segment, particularly in theproximal colon.References 1. Cady, B., Stone, M.D. and Wayne, J. Continuing trends in the prevalence ofright sidedlesionsamongcolorectal carcinomas. Arch. Surg., 1993;128:505-509.2. lain, B. K., Chandra, S. S., Narasimhan, R. et at. Coexisting tuberculosis and carcinoma of the colon.Aust. N.Z. J. Surg., 1991 ;61 :828-31.3. Bresalier, R. S. and Kim, Y.S. Malignant neoplasms of the large and small intestine. In:Gastrointestinal disease 4th edo. (Ed. MI-I. Sleisenger and J.S. Fordtran), Chap. 81, Philadelphia. W.B.Saunders Philadelphia, 1989, PP 1519-60.4. Tanaka, K., Kondo, S., Hattori, F. et at. A case ofcolonic carcinoma associated with intestinaltuberculosis and an analysis of 26 cases reported in Japan. Gan. No. Rinsho., 1987:33:1117-33.5. Cooper, M.J., Williamson, R.C.N. and Smith, il-I.E Heal carcinoma and tuberculous ileitis. Postgrad.Med.J., 1987;63:145- 146.6  Moruta, K.. Tanaka, S., Nakamura. T et at. Carcinoma of the colon coexisting with tuberculosis .Report of 2 cases. Gan. No. Rinsho., 1983;29:448-453.7. Grange, J.M. Environmental mycobacteria and human disease Lepr. Rev., 1991;62:353-61.8. Restrepo, L.M., Barrera, L.F. and Garcia, L.F. Natural killer cell activity in patients with pulmonarytuberculosis and in healthy adults. Tubercle., 1990;71 :95-102.9. Gopal Rao, V.V. V.N., Gupta, E.E. V. and Thomas, I.M. Chromosome damage in untreatedtuberculosis patients. Tubercle., 1990;71 :169-172.10. Potter, J.D. Reconciling the epidemiology, physiology and molecular biology of colon cancer.JAMA., 1992;268:1573-77.

Coexistent tuberculosis and carcinoma of the colon

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Coexistent tuberculosis and carcinoma of the colon

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