Zhang Cui-Cui, Chen Peng
Department of Thoracic Oncology, Tianjin Medical University Cancer Institute and Hospital, Tianjin 300060, China.
World J Clin Cases. 2022 Apr 26;10(12):3801-3807. doi: 10.12998/wjcc.v10.i12.3801.
Nontuberculous mycobacterium (NTM) refers to all mycobacteria except and , also known as environmental Mycobacterium. The patients with lung cancer and NTM are somewhat special; the two diseases are inevitably influenced by each other. It brings difficulties and challenges to the choice of treatment. Recently, cancer immunotherapy has been considered one of the pillars for the treatment of lung cancer. However, the clinical experience in the application of immune checkpoint inhibitors is scarce for lung cancer patients with pulmonary tuberculosis, and lung cancer with NTM is even more rare. Although it ameliorates lung cancer, immunotherapy with immune checkpoint inhibitors presents complications of infectious diseases, including tuberculosis and NTM.
A 61-year-old male patient visited a doctor in May 2019. His admitting diagnoses were: (1) Cancer of the left lung with a pathological diagnosis of poorly differentiated non-small cell carcinoma, likely poorly differentiated adenocarcinoma, clinical stage IIIb (T3N3M0); and (2) () infection. We chose to proceed with pembrolizumab treatment. After two treatment cycles, a chest computed tomography scan showed a new irregular subpleural mass in the anterior segment of the left upper lobe of the lung, a reduction in the mediastinal enlarged lymph node, and no other obvious changes. Next, an ultrasound-guided biopsy of the new tumor was performed. Pathological examination showed that a large number of carbon particles were deposited in the alveolar tissue with histiocyte reaction and multinucleated giant cell formation. The tuberculosis (TB) specialist suggested that anti-TB therapy be combined with continued antitumor treatment. The patient continued to be treated with pembrolizumab. After 14 cycles, the lesion shrunk by 79%, there was no recurrence of infection, and there were no intolerable adverse reactions.
We have observed that in cases of lung cancer complicated with infection, opportunistic pathogen infection recurrence can be overcome, and immunotherapy is most beneficial when TB doctors and oncologists cooperate to closely observe dynamic changes in and lung cancer. Treatment should be maintained with low dosage anti-TB drugs after general anti-TB chemotherapy for 1 year; this may prevent opportunistic pathogen infection recurrence during immunotherapy.
非结核分枝杆菌（NTM）是指除结核分枝杆菌和麻风分枝杆菌以外的所有分枝杆菌，也被称为环境分枝杆菌。肺癌合并NTM的患者情况较为特殊，两种疾病相互影响，给治疗方案的选择带来困难与挑战。近年来，癌症免疫疗法被视为肺癌治疗的支柱之一。然而，免疫检查点抑制剂应用于合并肺结核的肺癌患者的临床经验较少，而应用于合并NTM的肺癌患者则更为罕见。尽管免疫检查点抑制剂免疫疗法改善了肺癌病情，但会引发包括肺结核和NTM在内的感染性疾病并发症。
一名61岁男性患者于2019年5月就诊。入院诊断为：（1）左肺癌，病理诊断为低分化非小细胞癌，可能为低分化腺癌，临床分期为IIIb期（T3N3M0）；（2）（）感染。我们选择使用帕博利珠单抗进行治疗。经过两个治疗周期后，胸部计算机断层扫描显示左肺上叶前段出现一个新的不规则胸膜下肿块，纵隔肿大淋巴结缩小，无其他明显变化。接下来，对新肿瘤进行了超声引导下活检。病理检查显示肺泡组织中有大量碳颗粒沉积，伴有组织细胞反应和多核巨细胞形成。结核病（TB）专家建议抗结核治疗与继续抗肿瘤治疗相结合。患者继续接受帕博利珠单抗治疗。14个周期后，病灶缩小了79%，（）感染未复发，也没有出现无法耐受的不良反应。
我们观察到，在肺癌合并（）感染的病例中，可以克服机会性病原体感染复发的问题，结核病医生和肿瘤学家合作密切观察（）和肺癌的动态变化时，免疫疗法最为有益。在一般抗结核化疗1年后，应使用低剂量抗结核药物维持治疗；这可能预防免疫治疗期间机会性病原体感染复发。
