Lee Hwa Young, Kim Jin Woo, Yeo Chang Dong
Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
J Thorac Dis. 2017 Aug;9(8):E709-E713. doi: 10.21037/jtd.2017.07.31.
We report a first case of a patient experiencing reactivation of pulmonary tuberculosis (TB) during treatment of oral tyrosine kinase inhibitor (TKI) with non-small cell lung cancer (NSCLC). A 44-year-old male patient visited the hospital with cough. He had been treated with erlotinib (oral TKI) for 8 months after being diagnosed as NSCLC with sensitive epidermal growth factor receptor mutation in our clinic. At initial chest imaging, the patient had fibroatelectatic calcified granuloma in the right upper lobe (RUL) apex as well as 1.9 cm × 2.5 cm sized cancer mass encasing the RUL bronchus. He had not been treated for active pulmonary TB before. He had no known history of contact with active TB patients. During the past treatment period, he had shown overall stable response to erlotinib for 8 months. However, chest computed tomography taken for the fourth response evaluation showed increased number and size of nodules with bronchial luminal narrowing in RUL compared to the last exam, suggesting disease progression. We performed bronchoscopy to re-biopsy the cancer mass. Mucosal biopsy and bronchial washing fluid culture revealed active endobronchial pulmonary TB rather than lung cancer progression. Based on these study results, we started anti-TB medications without changing chemotherapy regimen. After 7 months of treatment for pulmonary TB with erlotinib maintenance, he has been shown successful regression of pulmonary TB with stable chemotherapeutic response. Previously, several reports have described the effect of anti-cancer therapy on the treatment of active TB. However, there has been no case report presenting TB reactivation during oral TKI treatment in NSCLC. Therefore, we suggest that the risk of TB reactivation should be considered in patients with solid organ malignancies even if targeted agents are used. Moreover, misdiagnosis of disease progression must be ruled out.
我们报告了首例在口服酪氨酸激酶抑制剂（TKI）治疗非小细胞肺癌（NSCLC）期间发生肺结核（TB）复发的患者。一名44岁男性患者因咳嗽前来就诊。在我院被诊断为具有敏感表皮生长因子受体突变的NSCLC后，他接受了8个月的厄洛替尼（口服TKI）治疗。初次胸部影像学检查时，患者右上叶（RUL）尖段有纤维性肺不张钙化肉芽肿，以及一个1.9 cm×2.5 cm大小的癌块包绕RUL支气管。他之前未曾接受过活动性肺结核治疗。他没有已知的与活动性肺结核患者接触史。在过去的治疗期间，他对厄洛替尼总体反应稳定达8个月。然而，第四次疗效评估时的胸部计算机断层扫描显示，与上次检查相比，RUL的结节数量和大小增加，支气管腔狭窄，提示疾病进展。我们进行了支气管镜检查以重新对癌块进行活检。黏膜活检和支气管冲洗液培养显示为活动性支气管内肺结核，而非肺癌进展。基于这些研究结果，我们在不改变化疗方案的情况下开始抗结核治疗。在使用厄洛替尼维持治疗肺结核7个月后，他的肺结核成功消退，化疗反应稳定。此前，有几份报告描述了抗癌治疗对活动性肺结核治疗的影响。然而，尚无在NSCLC口服TKI治疗期间出现结核复发的病例报告。因此，我们建议即使使用靶向药物，实体器官恶性肿瘤患者也应考虑结核复发的风险。此外，必须排除疾病进展的误诊。
