Keywords
tuberculosis - squamous cell carcinoma - pinna - cervical lymph node - antituberculosis
treatment
Introduction
Tuberculosis (TB) is a common health problem worldwide, especially in countries like
India. The disease affects the lungs commonly but can affect any other organ. Cervical
lymph nodes are the common site of extrapulmonary TB. They usually present as painless
mass, often at the posterior cervical triangle or upper jugular group of lymph nodes.
Diagnosis of TB of cervical lymph nodes is made by fine-needle aspiration cytology
(FNAC); occasionally, excision biopsy of the node may be required.
The coexistence of TB with squamous cell carcinoma is not very common. There are reports
of TB of cervical lymph nodes, which were resistant to conventional antituberculosis
treatment, which on further evaluation lead to the diagnosis of carcinoma.[1] However, the disease may be diagnosed only during histopathological examination
when surgery is performed in a diagnosed case of carcinoma. We report one such case,
where TB was an incidental diagnosis following surgery for carcinoma.
Case Report
A 60-year-old man presented with a painless swelling over the left pinna of 2 months
duration, which later ulcerated. Meanwhile, he developed a swelling behind the pinna
and swelling over the left side of the upper neck in the last month. He was in a good
general health state. An ulceroproliferative lesion was noted over the left pinna’s
helix, while the lower part of the helix and the lobule were dark in color ([Fig. 1]). There was a hard mass measuring ~3 cm × 4 cm noted in the left postauricular region,
with a discharging sinus on the top of the swelling. A firm mobile lymph node measuring
~3 cm × 3 cm was noted in the left level 2 region. Two smaller lymph nodes were palpable
adjacent to this lymph node. No other abnormalities were noted. The chest radiograph
showed healthy lung fields. All hematological parameters were within normal limits.
With a clinical diagnosis of malignancy of the pinna, a punch biopsy of the lesion
was performed. Histopathology was suggestive of well-differentiated squamous cell
carcinoma. A computed tomography scan of the neck showed an enhancing thickening of
the left external ear, extending to the external auditory canal, with enlarged left
level 1b, 2, 3, and 5 lymph nodes.
Fig. 1 Clinical photograph showing lesion over the pinna and postauricular region.
The patient underwent wide excision of the lesion on the pinna with modified radical
neck dissection. ([Figs. 2] and [3]). Histopathology showed features of squamous cell carcinoma in the pinna with secondaries
in the neck nodes. In addition to squamous cell carcinoma, the resected pinna and
24 out of 41 of the lymph nodes showed granuloma consisting of epitheloid cells and
Langhans giant cells, suggestive of granulomatous condition, most likely to be TB
([Figs. 4] and [5]).
Fig. 2 Wide excision of the tumor of the pinna.
Fig. 3 Modified radical neck dissection.
Fig. 4 Histopathology (H&E, 10×) showing features of squamous cell carcinoma and tuberculosis
(red arrow—Langhans giant cells; blue—keratin pearls; orange—tumor cells).
Fig. 5 Histopathology (H&E, 10×) showing tumor cells (orange) and epithelioid cells (black).
Sputum examination did not show acid-fast bacilli. The patient was treated initially
with antituberculosis treatment. After 2 months of intensive phase with four drugs—ethambutol,
isoniazid, rifampicin, and ryrazinamide—he was subjected to adjuvant external beam
radiotherapy of 60 gray along with continuation phase of antituberculosis therapy
with isoniazid and rifampicin for 4 months. The patient responded well to the treatment,
and he is free of both diseases in 18 months follow-up period.
Discussion
Because of the improved living environment, bacille Calmette-Guérin (BCG) vaccination,
and effective antituberculosis drugs, the incidence of TB has reduced in recent years.
The disease primarily affects the lungs, which is a well-known fact. Even in countries
where the prevalence of TB is high, cutaneous TB is uncommon. Cutaneous TB is less
common than other forms of TB but accounts for 1.5% of all extrapulmonary TB cases.
The source of mycobacterial infection and the host’s immune status determines the
clinical manifestations seen in cutaneous TB.[2] Different forms of cutaneous TB are lupus vulgaris, scrofuloderma, TB verrucosa
cutis, lichen scrofulosorum, erythema induratum, papulonecrotictuberculid.[3] Cutaneous TB may remain undiagnosed for an extended period because of the lack of
a typical form of presentation or the delay in seeking medical advice. In general,
cutaneous TB is expected in the head and neck region.[4] Biopsy and histopathological examination are the preferred investigation for diagnosing
the disease. The culture positivity is low, ranging from 0% to 57%.[2] Histologically, the lesions show caseating granuloma, but occasionally noncaseating
consisting of Langhans giant cells, epithelioid cells, and infiltration of chronic
inflammatory cells. In the absence of typical histological features, polymerase chain
reaction (PCR) helps identify mycobacterium tuberculosis DNA in the tissue when there is a clinical suspicion of TB.[5]
The coexistence of TB and metastatic carcinoma in lymph nodes is rare, even in countries
where the disease is common. Cutaneous malignancies of the head and neck are usually
basal cell carcinoma, which comprises 60%, while 50% of pinna malignancies are squamous
cell carcinoma. Squamous cell carcinoma may arise from an active or treated case of
cutaneous TB, called lupus carcinoma.[6] Gheriani et al reported a case of squamous cell carcinoma of pinna with tubercular
lymphadenitis in the neck along with secondaries in the neck.[1] Caroppo et al reported a case where squamous cell carcinoma of the buccal mucosa
presented with tubercular lymphadenitis along with secondaries in the neck.[7] Mezri et al reported an incident with simultaneous TB and undifferentiated metastatic
carcinoma of the nasopharynx, where the diagnostic dilemma is higher.[8] In our case, there were squamous cell carcinoma and TB in both the primary lesion
and the cervical lymph nodes. There is a possibility that the disease is carried to
the lymph nodes from the primary site, along with metastasis. However, as both the
primary and the metastatic lymph nodes had both TB and carcinoma, the staging of carcinoma
would not have altered, and the treatment would remain the same. We conclude that
in countries where the disease is endemic, careful histological examination of all
the resected lymph nodes, in case of head and neck malignancy, should look for the
coexistence of TB, particularly in elderly patients where there is a chance of cancer-induced
immune suppression.
