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Concomitant tuberculosis and metastasis in axillary lymph nodes: a diagnostic surprise

The association between breast cancer and tuberculosis has been reported before,1 but the coexistence of metastatic breast cancer in primary tubercular lymph nodes is extremely rare with only seven cases reported in the published work.2 We report a case of infiltrating ductal carcinoma of the breast, metastatic to axillary lymph nodes harbouring tuberculous lymphadenitis, wherein no evidence of primary tuberculosis was found elsewhere. A 53-year-old woman presented with a lump in her right breast first noticed 2months earlier, which was rapidly increasing in size. Examination of the breast lump showed a large, irregular mass measuring 6 cm · 5 cm in size, mobile, hard in consistency and occupying the central and upper outer quadrant with nipple retraction. Two lymph nodes were palpable in her right axilla, and both were hard and discrete on palpation. Left breast and axilla were unremarkable. General examination did not show any clinical evidence of primary tuberculosis. Supraclavicular, cervical or inguinal lymph nodes were not palpable. The patient was referred for fine-needle aspiration biopsy (FNAC) with the clinical diagnosis of carcinoma of the right breast with axillary lymph node involvement and clinical stage III (T3N1M0). FNAC showed cells with high nucleocytoplasmic ratio with features suggestive of malignancy, but frozen section was advised. The preoperative work-up consisted of a haemogram, erythrocyte sedimentation rate (ESR), chest radiograph and ultrasound examination of the abdomen. ESR was 53mm/h, whereas other investigations were within normal limits. Frozen section showed infiltrating ductal carcinoma of the breast. The patient was subjected to right-modified radical mastectomy. The modified radical mastectomy specimen consisting of overlying elliptical skin flap, areola and nipple measured 22 cm· 17 cm · 4 cm. On serial sectioning of the mastectomy specimen, a greyish white, solid tumour measuring 6 cm· 5 cm in size was identified. Skin overlying the nipple and the base of the tumour specimen shows tumour infiltration. Excluding this tumour no other lesion was noticed. A total of 10 lymph nodes were identified from the axillary dissection specimen. Microscopic examination of the tumour showed features suggestive of infiltrating ductal carcinoma. Metastasis was seen in all 10 lymph nodes. All 10 lymph nodes showed coexistent breast tumour deposits and tuberculous lymphadenitis in the form of epithelioid cell granulomas with Langhans giant cells (Fig. 1). The patient was started on antituberculosis therapy. The association of tuberculosis and cancer has been recorded in most of the organs and has been described and explained by many authors in many diverse ways. Kaplan et al. reviewed 58 245 patients with cancer and identified 201 cases of coexisting tuberculosis.1 Highest prevalence was seen in patients with Hodgkin’s disease (96/10 000 cases) followed by lung cancer (92/10 000), lymphosarcoma (88/10 000) and reticulum cell sarcoma (78/ 10 000).1 Among 14 742 cases of breast reviewed by them, only 28 had coexisting tuberculosis in breast, a prevalence of 19/ 10 000. No case of axillary nodal coexistence was identified in their series.1 The synchronous occurrence of tuberculosis and carcinoma is unusual and association of the two has baffled surgeons and physicians for more than two centuries. Coexistence of tuberculosis and metastatic carcinoma in axillary lymph nodes, without pulmonary or mammary tuberculosis is even rarer. Warthin first described the coexistence of tuberculosis and cancer in axillary node,3 five other cases have been reported between 1902 and 1992,2 Bayle first described the association of tuberculosis and carcinoma in 1810. The coexistence of breast cancer and tuberculosis has been described in more than 100 cases;4 however, its coexistence in the axillary node is rare. Only seven cases have been reported in the published work so far.5 Most of these cases reported breast cancer with axillary node showing tubercular foci, although our patient had a metastatic carcinoma and tubercular granulomatous foci in the same lymph node in the same high-power field with the absence of tubercular foci elsewhere. The case is being reported for its rarity. The present case is a coincidental, but noteworthy example, illustrating that such a possibility of coexistent disease should always be kept in mind, especially in endemic regions.