Eur J Cardiothorac Surg 2001;20:211-213
© 2001 Elsevier Science NL
Lung cancer occurring with Mycobacterium xenopi and Aspergillus
Redha Souilamasa,
Claire Danelb,
Xavier Chauffoura,
Marc Riqueta
a Service de Chirurgie Thoracique, Hôpital Européen Georges Pompidou, 20 rue Leblanc 75015 Paris, France
b Laboratoire d'Anatomie Pathologique, Hôpital Européen Georges Pompidou, 20 rue Leblanc 75015 Paris, France
Received 27 November 2000;
received in revised form 16 March 2001;
accepted 30 March 2001.
Corresponding author. Tel.: +33-1-56093450; fax: +33-1-56093380
e-mail: marc.riquet{at}hop.egp.ap-hop-paris.fr
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Abstract
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Two cases which associate Mycobacterium xenopi pulmonary infection, aspergilloma and preoperative unsuspected lung cancer are related. To our knowledge, the association of these three pathologies has never been previously reported. These two cases, suggest that infected chronic lung lesions, especially in smokers, should be closely monitored and be surgically removed in order to prevent further complications.
Key Words: Scar cancer • Atypical mycobacteria • Aspergilloma
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1. Introduction
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The association of Mycobacterium xenopi (M. xenopi) pulmonary infection and aspergilloma has rarely been described. We are reporting two cases associated with unsuspected non small cell carcinoma (NSCLC) only discovered on lung surgical resections.
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2. Case reports
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2.1. Case 1
A 54-year-old man was admitted in June 1999 for surgical treatment of a pulmonary right upper lobe (RUL) destruction by Aspergillus and M. xenopi. Social history included a 30 packs/year smoking habit and alcohol abuse. Previous medical history began with M. xenopi pulmonary infection of the RUL in 1993, without underlying lung disease. After an anti infectious (clarithromycin, ofloxacine, ethambutol) medication during a 15 month period, full-recovery was observed. The patient was disease free until December 1998. At that time, he progressively complained of generalized weakness, cough and fever. Undernutrition was manifest. A chest X-ray demonstrated a RUL pneumonia. Relapse of pulmonary infection by M. xenopi was confirmed by positive sputum cultures in January 1999. Sputum cultures were also positive for Aspergillus fumigatus. Aspergillosis was confirmed by serology, and an IgG Lambda monoclonal gammapathy was also discovered.
Lung CT Scan showed a RUL destruction and cavitation (Fig. 1)
. Anti-infectious medication (clarithromycin, ofloxacine, rifabutine myambutol) was started in January 1999. In the meantime, renutrition and rehabilitation were undertaken. Cultures were negative for M. xenopi in March 1999. A right upper lobectomy was performed in June 1999, the surgical procedure was difficult with very dense pleural adhesions requiring extrapleural division. Microscopic analysis revealed extensive scarring fibrosis, A. fumigatus cavitations, granulomatous lesions and unresolved bronchopneumonia. Surprisingly it also showed a 12 mm adenocarcinoma located along the proximal area of scaring. Peribronchial and interbronchial nodes were disease free. The patient was treated with clarithromycine and ofloxacine until March 2000. Fifteen months later, the patient is going well with stable X-rays.
2.2. Case 2
A 46-year-old man was admitted with complaint of general weakness, hemoptysis and purulent expectorations without germs. Chest X-rays and CT scan revealed a non specific right upper lobe atelectasia without cavity but with chronic emphysema and regional lymphnodes. Social history included a 30 packs/year smoking habit. Previous medical history reported significant emphysema of the right lung, discovered few years ago on CT Scan. No lesion was detected on fiberoptic bronchoscopy, and biopsies were negative. Symptomatology remained unchanged after 3 months of unspecific antibiotherapy (Roxythromycine, Pristinamycine, Ceftriaxone and Metromidazole), the patient being allergic to penicillin. The patient underwent a right upper lobectomy in July 1999, as in case 1, the surgical procedure was difficult with pleural adhesions requiring extrapleural division. Microscopic analysis revealed necrotic lesions and cavitations. A 5 mm aspergilloma was found in a dilated bronchus as well as a 10 mm large cell carcinoma (Fig. 2)
. Lung cultures were also positive for M. xenopi. Twelve months later, the patient is going well under anti infectious treatment.
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Fig. 2. Non small cell carcinoma (arrow) developed in a bronchectasia close to an aspergilloma (arrow head) (hematoxylin eosin; original magnification: x40).
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3. Discussion
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We reported two cases of NSCLC associated with M. xenopi infection and Aspergilloma. The first interesting point is that, despite the rarity of these associations, each pathology occurred differently in those two cases.
M. xenopi infection is frequent in Europe [1] and particularly in France [2]. M. xenopi pulmonary infection is favored by immune suppression [1] and underlying lung disease [1,2]. In case 1, monoclonal gammapathy and alcoholism [1] may have favored lung infection. In case 2, emphysematous bullae may have been the favoring factor [3].
Aspergilloma is a saprophytic infection which occurs as a colonizer of pre-existing cavity lesions such as sequelar tuberculosis or bronchiectasiae [4]. In case 1, the pre-existing lesion is sequelar M. xenopi infection. In case 2, pre-existing lesion is bronchectasia. Nevertheless apergilloma is rarely observed in active tuberculosis or M. xenopi cavitation [5]. Therefore, it appears that in case 2, active M. xenopi infection was concomitant and not due to colonization.
The frequency of lung carcinoma associated with tuberculosis has been stressed by Da Costa and Kinare [6]. There is a statistically significant association between tuberculous scars and lung carcinoma [7]. But neoplasm pathogenesis associated with scars is not clearly understood [8]. The pathogenesis could be explained by primary scar lesions leading to carcinoma after a period of time. Other studies report that scars associated with pulmonary neoplasia appear to be a host response to the tumor [9]. In case 1, lung cancer is more likely to be a scar cancer. In case 2, M. xenopi infection was still active with no scar lesions and the cancer appeared to be within a bronchectasia and therefore appears entirely coincidental. Smoking habits of these two patients may also have favoured the cancer.
Another interesting point in these observations concerns the fortuitous discovery of unsuspected NSCLC carcinoma in surgical resection performed for chronic infectious diseases. Such case reports support the idea that infected chronic lung lesions should be closely monitored and should be surgically removed in early complication stages, especially in smokers.
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Acknowledgments
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We thank D. Dusser and P. Buffet for referring the patients
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References
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-
American Thoracic Society. Diagnosis and treatment of disease caused by non-tuberculous mycobacteria. Am J Respir Crit Care Med 1997;156:S1-S25.
-
Parrot R.G., Grosset J.H. Post-surgical outcome of 57 patients with Mycobacterium xenopi pulmonary infection. Tubercle 1988;69:47-55.[Medline]
-
Bellamy J., Leroy-Terquem E., Duhamed J.P., Choffel C., Fraboulet G., Jubelem Gverdoux P. Infection a Mycobacterium xenopi dans des bulles d'emphysème. A propos de 4 cas opérés. Rev Mal Resp 1987;4:261-264.
-
Daly R.C., Pairolero P.C., Piehler J.M., Trastek V.F., Payne W.S., Bernatz P.E. Pulmonary aspergilloma, results of surgical treatment. J Thorac Cardiovasc Surg 1986;92:981-988.[Abstract]
-
Varkey B., Rose H.D. Pulmonary aspergilloma. A rational approach to treatment. Am J Med 1976;61:626-631.[Medline]
-
Dacosta N.A., Kinare S.G. Association of lung carcinoma and tuberculosis. J Postgrad Med 1991;37:185-189.[Medline]
-
Richardson S., Hirsch A., Ruffie P., Bickel M. Relationship between tuberculous scar and carcinoma of the lung. Eur J Radiol 1987;7:163-164.[Medline]
-
Lee B.Y., Guerra J., Cagir B., Madden R.E., Greene S.G. Pulmonary scar carcinoma: report of three cases and review of the literature. Mil Med 1995;160:537-541.[Medline]
-
Madri J.A., Carter D. Scar cancers of the lung: origin and significance. Hum Pathol 1984;15:625-631.[Medline]
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Abstract
1. Introduction
