The Journal of Association of Chest Physicians

CASE REPORT
Year
: 2014  |  Volume : 2  |  Issue : 2  |  Page : 84--86

Typical bronchial carcinoid with local metastasis and coexisting tuberculosis in the same lung: A case report


Shalini Mullick1, Kumud Gupta1, Ravindra K Dewan2, Rohit Sarin3,  
1 Department of Pathology, National Institute of Tuberculosis and Respiratory Diseases, Aurbindo Marg, New Delhi, India
2 Department of Thoracic Surgery, National Institute of Tuberculosis and Respiratory Diseases, Aurbindo Marg, New Delhi, India
3 Department of Respiratory Medicine, National Institute of Tuberculosis and Respiratory Diseases, Aurbindo Marg, New Delhi, India

Correspondence Address:
Shalini Mullick
Department of Pathology, National Institute of Tuberculosis and Respiratory Diseases, Aurobindo Marg, New Delhi 110 030
India

Abstract

Bronchial carcinoids comprise of <3% of lung tumours. Though typical carcinoids are usually benign, they may, uncommonly, metastasise to regional lymph nodes as well as to distant sites, and a few cases have been associated with active tuberculosis. We report an unusual case of a typical bronchial carcinoid with regional metastasis and tuberculosis. The metastatic deposits were present in small lymph nodes, emphasizing the need for careful sampling, while grossing. In addition, coexisting tuberculosis in the same lung of the patient make the case an extremely rare one.



How to cite this article:
Mullick S, Gupta K, Dewan RK, Sarin R. Typical bronchial carcinoid with local metastasis and coexisting tuberculosis in the same lung: A case report .J Assoc Chest Physicians 2014;2:84-86


How to cite this URL:
Mullick S, Gupta K, Dewan RK, Sarin R. Typical bronchial carcinoid with local metastasis and coexisting tuberculosis in the same lung: A case report . J Assoc Chest Physicians [serial online] 2014 [cited 2022 Sep 29 ];2:84-86
Available from: https://www.jacpjournal.org/text.asp?2014/2/2/84/135120


Full Text

 INTRODUCTION



Bronchial carcinoids are uncommon, low-grade pulmonary neoplasms, which comprise 0.5-3% of lung tumors. [1] They are classified as typical, atypical and small cell lung carcinoma based on standard histological criteria. Although typical carcinoids usually have an indolent course, metastasis to regional lymph nodes, liver, bones, or brain is described in 4-5% cases. [2],[3] The coexistence of lung cancer with tuberculosis is well-known; however, there are few reports of bronchial carcinoid with active tuberculosis. [4],[5] In the literature only one such case has been reported from India. [5] However, these cases relate only to localized carcinoid without evidence of regional lymph node spread. To the best of our knowledge, there are no other reported cases of bronchial carcinoids with both local metastasis as well as coexisting tuberculosis.

 CASE REPORT



We report a case of a 26-year-old male with a carcinoid in the right lower lobe bronchus with local metastasis and active tuberculosis in the right lower lobe. The patient presented with low-grade fever and episodic dyspnea for the last 1 year, which had exacerbated over the last few months. The patient worked in a pharmaceutical company as a representative. There was no significant past history. The patients father had history of being treated with anti-tubercular therapy 3 years back. Initially, the patient was managed conservatively with antibiotic and bronchodilators, but his condition did not improve.

X-ray chest showed a few small consolidated foci in the right lower lobe sputum for acid fast bacilli (AFB) was negative. Bronchial washings, bronchoalveolar lavage, and brush cytology were negative for malignancy and AFB. Computed tomography (CT) scan thorax showed a few nodular opacities in right lower lobe and a rounded lesion measuring 3 cm × 3 cm in the left lower lobe. Bronchoscopy showed a rounded polypoidal lesion in the right lower lobe bronchus. The lesion was vasularised giving it a cherry red appearance. An endobronchial carcinoid tumor was considered as a likely diagnosis. An abdominal CT scan showed enlarged mesenteric lymph nodes. All viscera were within the normal limits. Routine hematology and biochemical investigations were normal. Hepatitis C virus and human immunodeficiency virus serology were negative. A sleeve resection of the tumor was planned and the patient taken up for surgery. Peroperatively, the tumor was seen at the junction of intermediate and lower lobe bronchi. Lower lobe was partially collapsed. As no tumor free margins of the right middle lobe bronchus were available for bronchoplasty, right lower and middle lobectomy was performed. The resection specimen comprised of the middle and lower lobes of the right lung. A greyish brown irregular mass measuring about 3.5 cm × 2 cm × 1 cm was seen protruding into the lumen from the right lower lobe bronchus. On sectioning, the tumor was seen chiefly in lower lobe bronchus, not involving the lung parenchyma. Grossly, the mass was well circumscribed, nonifiltartive and solid and there were no cysts or necrotic areas. This lobe also showed a few tubercles and a white necrotic area measuring 2.5 cm in diameter. Peribronchial lymph nodes were also identified together measuring about 1.5 cm × 1 cm. Microscopic examination of the tumor showed neoplastic cells arranged in nests, cords and broad sheets surrounded by thin fibrous septae. The cells had fine granular chromatin, scanty to moderate cytoplasm and minimal atypia and pleomorphism [Figure 1]a]. Numerous thin walled blood vessels were seen. In addition, the parenchyma showed many necrotizing epithelioid cell granulomata [Figure 1]b]. The Ziehl-Neelsen stain for AFB was positive. The neoplastic cells showed expression of CD56 [Figure 2]a] and synaptophysin. Mitotic activity was inconspicuous and there was no necrosis. Ki-67 staining revealed a low proliferative index [Figure 2]b]. The tumor was seen involving the bronchial wall, reaching up to the adventitia. A diagnosis of typical bronchial carcinoid was made. Two peribronchial lymph nodes, measuring 0.5 and 0.3 cm showed infiltration by the carcinoid tumor. Four other nodes showed reactive changes. A final diagnosis of typical bronchial carcinoid with regional lymph node spread and concomitant tuberculosis of the right lower lobe of lung was made.{Figure 1}{Figure 2}

 DISCUSSION



Carcinoid tumors are neuroendocrine tumors arising from Kultchitzsky cells. They can be central or peripheral, and on the basis of histological and cytological features, can be divided into two fairly distinct clinicopathologic types, typical and atypical. Both variants can be asymptomatic but central carcinoid often present with recurrent pneumonias or hemoptysis. Histologically, bronchial carcinoids are part of a spectrum of neuroendocrine tumors arising in the lung that are characterized by different biologic behavior. At one end of the spectrum are typical carcinoids, which are low-grade (well-differentiated), slowly-growing neoplasms. Typical bronchial carcinoids are usually considered benign tumors. However, occasionally, metastases do however occur, and up to 10% of the patients ultimately die from their disease. [4] At the other end of the spectrum are the high-grade (poorly differentiated) neuroendocrine carcinomas, as typified by small cell lung cancer (SCLC), which behave aggressively, with rapid tumor growth and early distant dissemination. The biologic behavior of atypical carcinoids, which are intermediate-grade tumors with a higher mitotic rate and/or necrosis, is intermediate between typical carcinoids and SCLC.

Carcinoid syndrome has been reported in association with very large bronchopulmonary carcinoid tumors or in the presence of metastatic disease. It is associated with <2% of pulmonary carcinoids. [2],[3] Carcinoids can produce a variety of biologically active peptides and hormones, including serotonin, adrenocorticotropin hormone, antidiuretic hormone, melanocyte-stimulating hormone. Excess serotonin production has been implicated in the development of carcinoid syndrome. This syndrome is characterized by a constellation of symptoms, including tachycardia, flushing, bronchoconstriction, hemodynamic instability, diarrhea, and acidosis. [2]

The metastatic deposits in our case were noted in very small nodes. This highlights the need for careful grossing and histopathological examination of all lymph nodes, irrespective of their size and nature of tumor. Tuberculosis has been described in association with various forms of lung malignancies. However, its association with carcinoids is less commonly described, possibly because the pulmonary carcinoid tumors are rare tumors. Yilmaz et al. [4] reported only one case among 24 cases of bronchial carcinoid tumor. Our case is especially rare as the carcinoid tumor was coexisting with both tubercular lesions in the same lobe, as well as regional metastasis.

The coexistence of pulmonary carcinoid tumor and pulmonary tuberculosis is very rare. Although new radiological imaging studies such as combined positron emission tomography and CT have enabled clinicians to make a more accurate diagnosis, the coexistence of these may present a serious challenge in the establishment of the diagnosis both at the clinical level as well radiological level. [6]

References

1Gustafsson BI, Kidd M, Chan A, Malfertheiner MV, Modlin IM. Bronchopulmonary neuroendocrine tumors. Cancer 2008;113:5-21.
2Rekhtman N. Neuroendocrine tumors of the lung: An update. Arch Pathol Lab Med 2010;134:1628-38.
3Ferolla P, Daddi N, Urbani M, Semeraro A, Ribacchi R, Giovenali P, et al. Tumorlets, multicentric carcinoids, lymph-nodal metastases, and long-term behavior in bronchial carcinoids. J Thorac Oncol 2009;4:383-7.
4Yilmaz A, Güngör S, Damadoðlu E, Aksoy F, Aybatli A, Düzgün S. Coexisting bronchial carcinoid tumor and pulmonary tuberculosis in the same lobe: A case report. Tuberk Toraks 2004;52:369-72.
5Dixit R, Gupta R, Yadav A, Paramez AR, Sen G, Sharma S. A case of pulmonary carcinoid tumor with concomitant tuberculosis. Lung India 2009;26:133-5.
6Darvishian F, Ginsberg MS, Klimstra DS, Brogi E. Carcinoid tumorlets simulate pulmonary metastases in women with breast cancer. Hum Pathol 2006;37:839-44.