Case Report

Coexistence of Lung Cancer and Primary Lymph Nodes Tuberculosis Diagnosed by Cancer Staging: A Report of a Rare Case

Aysun Sengul1*, Sinan Arslan1, Fatma Tasolar1 and Oguz Kapicibasi2
1Department of Pulmonology, KocaeliDerince Education and Research Hospital, Turkey
2Department of Thoracic Surgery, IzmitSeka State Hospital, Turkey

*Corresponding author: Aysun Sengul, Department of Pulmonology, KocaeliDerince Education and Research Hospital, Kocaeli, Turkey

Published: 15 Sep, 2016
Cite this article as: Sengul A, Arslan S, Tasolar F, Kapicibasi O. Coexistence of Lung Cancer and Primary Lymph Nodes Tuberculosis Diagnosed by Cancer Staging: A Report of a Rare Case. Ann Clin Case Rep. 2016; 1: 1136.


Lung cancer (LC) and lymph node (LN) tuberculosis are two common entities around the world. 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography (PETCT) is frequently used in LC, because accurate lymph node (LN) staging is critical to choose appropriate treatment and to predict prognosis. However, increased 18F-FDG uptake is also seen in infected or inflammatory processes, such as tuberculosis. We reported a case of 57-year-old woman with lung cancer diagnosed by bronchoscopic biopsy with concomitant mediastinal and cervical LN involvement with malignant features due to the increased 18F-FDG uptake. However, mediastinal and cervical LN biopsies established the diagnosis of lymph nodes tuberculosis. There was no evidence of pulmonary tuberculosis. We concluded that NSCLC and primary LN tuberculosis was coexisted and the treatment approach was changed radically. The case is a good sample demonstrating vital importance of biopsying LN involvement with increased 18F-FDG uptake during lung cancer staging.

Keywords: Lung cancer; Tuberculosis; F-18 fluorodeoxyglucose; Positron emission tomography; Biopsy


Non-small cell lung cancer (NSCLC) is a major cause of cancer-related mortality on a worldwide scale. Accurate staging of lymph nodes (LN) is critically important for NSCLC treatment planning and predicting prognosis [1]. Positron-emission tomography/computed tomography (PET/CT) using the glucose analog 18F-fluorodeoxyglucose (FDG), is a useful method in distinguishing malignant lesions from benign lesions. However, increased 18F-FDG uptake is not specific to tumors, and can be seen secondary to increased glucose utilization by inflammatory cells and macrophages in certain infectious and inflammatory conditions such as tuberculosis, sarcoidosis, and pneumoconiosis [2-4]. We present a case with mediastinal and cervical tuberculous lymphadenitis with increased 18F-FDG uptake in PET/CT, diagnosed during staging of non-small cell lung cancer (NSCLC).

Case Presentation

A 57-year-old female patient presented at our outpatient clinic with cough, sputum, chest pain and dyspnea that lasted for the past 2 weeks. The patient, who was on oral antidiabetics for type 2 diabetes, was not a smoker, but had a history of exposure to second-hand smoke. In auscultation there were inspiratory rales in mid-lower left zone. A non-homogenous opacity was seen in the mid-lower left zone on posterior-anterior chest x-ray (Figure 1). Chest CT revealed a mass lesion obstructing the bronchus of upper left lobe surrounded by atelectasis in the periphery. An endobronchial lesion was detected in the aperture of upper left lobe and a biopsy was performed (Figure 1). Histopathologic evaluation of upper left lobe endobronchial biopsy revealed non-small cell carcinoma with features primarily suggesting squamous cell carcinoma (Figure 2). There was a centrally located hypermetabolic mass (SUVmax: 18.4) with malignant features on upper left lung, and images suggesting metastatic lesions (SUVmax: 9) in multiple mediastinal and cervical lymph nodes on PET/CT (Figure 2). Mediastinoscopy Mediastinal lymph node biopsies numbered 4L, 4R, and 7, and cervical lymph node biopsies revealed granulomatous inflammation with extensive necrosis (Figure 2) and, established the diagnosis of lymph nodes tuberculosis. There was no evidence of pulmonary tuberculosis at the diagnostic work-up. TNM staging was concluded as T3 N0 M0, stage IIB. The patient was diagnosed with NSCLC and primary tuberculous lymphadenitis, and started on antituberculous treatment. Surgery was planned for the malignancy.

Figure 1

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Figure 1
Sagital T1 weighted post gadolinium image showing a well defined enhancing pontine mass.

Figure 2

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Figure 2
Axial image showing the pontine mass to the right of the midline.


While there is an ongoing battle against tuberculosis in our country, incidence rate of tuberculosis in Turkey is still as high as 18 in 10000. Among all tuberculosis cases in our country, rate of extrapulmonary tuberculosis is 37.2% [5]. Most common presentation of extrapulmonary tuberculosis is tuberculous lymphadenitis.
Pulmonary tuberculosis and mediastinal lymph node tuberculosis are known to be associated with false positive 18F-FDG PET results. Increased lung cancer risk in patients with tuberculosis might be associated with immune suppression induced by infection [6]. Conversely, immune suppression induced by cancer may also cause increased rate of tuberculosis reactivation [7]. During cancer staging in our case, PET/CT showed lymphadenitis with high 18F-FDG uptake that initially suggested malignancy. While its existence initially suggests malignancy, importance of histopathologic evaluation should be highlighted.
Cervical and mediastinal lymph node enlargement may be usually linked to lymphoma, metastatic carcinoma, sarcoidosis, and direct infection or hyperplastic reactions due to infections [8- 13]. Mediastinal lymph node staging is important in lung cancer in selecting treatment approach and predicting prognosis. While surgery is an option when there is no lymph node involvement or distant metastasis, with lymph node involvement, treatment options are definitive chemotherapy and radiotherapy [14-16]. In lymph node involvement, invasive diagnostic approaches like image-guided biopsy (CT, endoscopic ultrasound), transbronchial lymph node biopsy, and thoracoscopic or mediastinoscopic biopsy should be used in distinguishing malignant lesions from benign lesions.
In conclusion, we presented a case of coexistence of mediastinal and cervical tuberculosis with lung cancer with a false positive result in 18F-FDG PET/CT. Tuberculosis can affect any organ. The most common presentation is lymph node tuberculosis. In patients with malignancies, tuberculosis can be missed because of increased 18F-FDG uptake, however, in countries where tuberculosis is common, evaluation should be meticulous and all lymph node groups should be histopathologically evaluated, because the treatment approach might be changed radically, as in our case. So, our case is a good sample demonstrating vital importance of biopsying LN involvement with increased 18F-FDG uptake during lung cancer staging.


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