Concurrent ascending colon adenocarcinoma and colonic tuberculosis: a case report from Syria

Abstract

Introduction and importance:

Tuberculosis (TB) has been one of the most devastating diseases to humanity in recent decades; although pulmonary infection is the most common, infection of any other organ is familiar as well. Colon cancer is another disease affecting the gastrointestinal (GI) system and mostly targets people over 50. Only a few studies mentioned the co-existence of cancer and TB occurring at the same place and time. Hence, the authors report a rare case of concurrent ascending colon adenocarcinoma and colonic TB.

Case presentation:

A 49 -year-old man presented to our clinic with constipation and abdominal pain. Two colonoscopies were performed, and two biopsies were taken; the first one showed granulomatous inflammation consistent with TB, and the second one showed low-grade adenocarcinoma. Computed tomography showed annular thickening of the ascending colon with infiltrates around the lesions. A right hemicolectomy was performed, and the final pathology confirmed adenocarcinoma grade II and extensive TB granulomas involving the colon into the serosa and the lymph nodes. Anti-TB medications were administered after surgery.

Clinical discussion:

Due to appropriate diagnostic methods, TB and cancer were detected at an early stage. In our treatment protocol, no adjuvant chemotherapy was applied after surgery due to the possibility of drug interaction with anti-TB medications.

Conclusion:

The two diseases may co-exist; thus, diagnosing them may not be the easiest, not to mention the lack of a clear treatment protocol in case of their accompany.

Introduction

Highlights

• Although tuberculosis (TB) and colon cancer are common, only few prior studies mentioned the co-existence of both diseases occurring in the same place and time.

• Despite the difficulty of diagnosing colonic tuberculosis clinically and its symptoms overlapping with many other diseases, the development of diagnostic methods (colonoscopy, computed tomography) has helped in detecting the condition and revealing the presence of accompanying cancer at an early stage.

• Reporting on such cases in the future may help in finding an appropriate treatment protocol for the co-occurring of the two diseases.

Tuberculosis (TB) was one of the most devastating diseases to humanity in recent decades¹. Despite the development of antibiotics, TB is still one of the main causes of death in developing countries². Around 10 million people were estimated to be ill in 2018; the majority of them are in the Asian and the African countries¹. TB mainly occurs in the pulmonary system, infecting the lungs (pulmonary TB)³. If TB affects any other organ, it will be called extra-pulmonary tuberculosis (EXTB)^2,4. Although pulmonary infection is the most common one, the infection of any other organ is familiar as well. According to a Systematic Review done by King Abdullah medical city, gastrointestinal TB took first place for TB infection in the abdomen, and large bowel TB was ranked secondly in the gastrointestinal (GI) system after the ileocecal TB¹. Colon cancer is another disease affecting the GI system that mostly targets people over 50 unless it is hereditary, for example FAP (Familial Adenomatous Polyposis) and HNPCC (Hereditary non-polyposis colorectal cancer)⁵. According to a study done by Siegle et al.⁶, (153 020) individuals will be affected by CRC cancer in 2023. However, colon cancer is less common in the ascending colon. Although TB and colon cancer are common, only a few prior studies mentioned the co-existence of both diseases occurring in the same place and time. Hence, we sought to report a case of concurrent ascending colon adenocarcinoma and colonic tuberculosis. The case has been reported in line with the SCARE 2023 criteria⁷.

Presentation of case

A 49-year-old man with no previous medical or surgical history presented to the Department of General Surgery with constipation and abdominal pain for 6 years. The patient smokes at a rate of 60 pack/year. Blood tests showed an increase in lymphocytes, a decrease in neutrophils and an increase in L/N ratio (Table 1). A lower gastrointestinal series (Barium enema) showed contrast substance accumulation at the ascending colon, which got through to the small intestine only after placing the patient in a prone position. After the barium enema, hematochezia was noticed. The first colonoscopy showed an ulcerated neoplastic lesion that can’t be bypassed at the colonic hepatic flexure. A biopsy showed histopathological changes that refer to granulomatous inflammation most consistent with tuberculosis. After two weeks, a second colonoscopy was performed, and it showed a severe luminal-constricting ulcerative infiltrate that can’t be bypassed at the hepatic flexure. A biopsy from the ulcerative lesion showed atypical cells forming irregular lumens compatible with low-grade adenocarcinoma (Figs. 1, 2). Chest Computed tomography (CT) showed non-specific millimetre pulmonary nodules, and no suspected mediastinal nodular hyperplasia was observed. (Fig. 3) Abdominal and pelvic CT showed annular thickening of the ascending colon, with a maximum thickness of 1.3 cm with infiltrates around the lesion and nearby small nodes in neoplastic context confirming the colonoscopy results. No signs of intestinal obstruction were observed (Figs. 4, 5). Two weeks later, a laparotomy was performed. Upon investigation, an ascending colonic mass was found near the caecum. A Right radical hemicolectomy with lymph node dissection was performed. The final pathology showed adenocarcinoma grade II, ulcerated, invading muscularis, with no observed lymphangioinvasion. No metastasis to lymph nodes and lines of surgical resection were free, AJCCS (T2 N0 M0) Stage 1, Dukes A, Extensive tuberculosis granulomas were found involving the colon and reached the serosa and all lymph nodes, no TB granulomas were involved in the terminal. Lines of surgical resection were free of granulomas. The surgery was performed in June 2023. The patient was treated by anti-TB medications directly after surgery and is still receiving treatment until the present in November 2023. No adjuvant chemotherapy was applied after surgery due to the possibility of drug interaction with anti-TB medication. By following up with the patient monthly, the abdominal Ultrasonography and blood tests were within normal (Table 2). In November 2023, the latest blood test showed an increase in CEA 6.50 ng/ml (normal range is ≤4.50 ng/ml) and CA19-9 test result was 321.1 U/ml (normal range is ≤37 U/ml).

Table 1.

Blood tests before surgery

Test	Results	Reference range
White blood cells	8.9	4.0–11.0 (K/µl)
Neutrophils percent	31.4	40–70%
Lymphocytes percent	58.8	20–40%
Monocytes percent	7.7	2–6%
Eosinophiles percent	1.3	1–6%
Basophiles percent	0.8	1–2%
Red blood cells	4.49	4.5–5.5(M/µl)
Heamoglobine	15	13–16 (G/µl)
Haematocrit	44.7	38–53%
MCV	99.6	82–96 fl
MCH	33.4	27.5–33.2 pg
Plateletes	328	150–450 (M/µl)
Glucose	114	75–110 (mg/dl)
Urea	25	10–50 (mg/dl)
Creatinine	0.76	0.70–1.36 (mg/dl)
ALT	11	Up to 41 (U/l)
AST	15	0–38 (U/l)

ALT, alanine aminotransferase; AST, aspartate aminotransferase; MCH, Mean Corpuscular Hemoglobin; MCV, Mean Corpuscular Volume.

Figure 1.

Colonoscopy findings. A severe luminal-constricting ulcerative infiltrate that can’t be bypassed at the hepatic flexure.

Figure 2.

Colonoscopy findings. A severe luminal-constricting ulcerative infiltrate that can’t be bypassed at the hepatic flexure.

Figure 3.

Chest computed tomography showing non-specific millimetre pulmonary nodules.

Figure 4.

Computed tomography findings. (A) Annular thickening of the ascending colon, with a maximum thickness of 1.3 cm with infiltrates around the lesion. (B) Dilatation of the ascending colon beyond the point of annular stenosis.

Figure 5.

Computed tomography findings. (A) Annular thickening of the ascending colon, with a maximum thickness of 1.3 cm with infiltrates around the lesion. (B) Dilatation of the ascending colon beyond the point of annular stenosis.

Table 2.

Follow-up results

Test	Results after surgery	Reference range
White blood cells	6.38	4.0–11.0 (K/µl)
Neutrophils percent	32.3	40–70%
Lymphocytes percent	57.5	20–40%
Monocytes percent	6.4	2–6%
Eosinophiles percent	3.4	1–6%
Basophiles percent	0.4	1–2%
Red blood cells	4.28	4.5–5.5(M/µl)
Heamoglobine	13.1	13–16 (G/µl)
Haematocrit	38.0	38–53%
MCV	88.7	82–96 fL
MCH	30.6	27.5–33.2 pg
Plateletes	238	150–450(M/µl)
Glucose	121	75–110 (mg/dl)
Urea	21.23	10–50 (mg/dl)
Creatinine	0.82	0.70–1.36 (mg/dl)
ALT	17	Up to 41 (U/l)
AST	11	0–38 (U/l)

ALT, alanine aminotransferase; AST, aspartate aminotransferase; MCH, Mean Corpuscular Hemoglobin; MCV, Mean Corpuscular Volume.

Discussion

Tuberculosis, in general, is a difficult disease to cure, especially when occurring in the abdominal region. The treatment takes an extensive amount of time. When accompanied by cancer, it makes the treatment protocol complicated more and more for medical staff. Due to the lack of cases in which the two diseases co-exist, no specific outlines are certified. In this case, we subsequently managed the patient with right hemicolectomy and anti-TB medication. In a study conducted by Park et al.⁸, anti-TB medication was given 2 weeks prior to hemicolectomy surgery. During their surgery, they noticed the resolvation of ulcerative lesions due to anti-Tb medication. However, in our case, during the surgery, the lesion was noted to be the same size as noted at the previous colonoscopy.

In our treatment protocol, adjuvant chemotherapy was postponed until the completion of ТB treatment to ensure that no drug interaction occurred, which led to an increase in tumour markers within less than 6 months after surgery. That indicates the possibility of tumour recurrence. However, if tuberculosis and cancer are combined, delaying adjuvant chemotherapy at the expense of anti-TB medications may lead to tumour recurrence.

In our patient, two colonoscopies were performed. The first one, which was poorly prepared, showed granulomatous inflammation, and the biopsy was consistent with TB. The remaining mucosa was normal under preparative conditions. As for The second colonoscopy, after well preparation, a severe luminal constructing ulcerative infiltration was noticed. The biopsy proved the co-existence of cancer.

Compared with a study done by Chakravartty et al.⁹, Colonoscopy with biopsy were performed. It proved the existence of cancer. According to that, a hemicolectomy was done. In the final pathology, they found granulomatous inflammation with caseous necrosis, which refers to TB. Thus colonoscopy is a useful diagnostic tool under several circumstances, including good preparation and taking several biopsies specially when suspecting TB or cancer, or the presence of both in the colon.

There is a lack of information about the primary disease that colonized the colon and whether one disease has a role in the development of the other one. However, TB is known to be a chronic inflammatory disease. And such diseases are considered a predisposing factor for tumours. There is a possibility that this patient suffered from TB first, which prepared a good environment for neoplastic growth. A meta-analysis done by Leung et al.¹⁰ showed that tuberculosis is associated with an increased risk of cancer at ten sites in adults (Gastrointestinal is one of them), from which they estimated that 2.93% (1.45–4.75%) of total cancer in men and 1.61% (0.78– 2.67%) in women could be attributed to tuberculosis in 2015.

Conclusion

Despite the difficulty of diagnosing colonic tuberculosis clinically and its symptoms overlapping with many other diseases, the development of diagnostic methods (colonoscopy, CT) has helped in detecting the condition and revealing the presence of accompanying cancer at an early stage.

Reporting on such cases in the future may help in finding an appropriate treatment protocol for the co-occurring of the two diseases. More studies should be conducted about the efficiency of using anti-TB medications in resolving the ulcerative lesion before colon cancer surgery and the drug interaction between adjuvant chemotherapy and anti-TB medications after surgery.

Ethical approval

This is a case report and there is no need for ethical committee approval. All informed consent is taken from the patient.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Source of funding

Not applicable.

Author contribution

B.A.: gathering information, literature review, writing manuscript, review manuscript. S.D.: gathering information, literature review, writing manuscript. S.T.: gathering information, literature review, writing manuscript. S.H.: gathering information, literature review, writing manuscript. B.A.: gathering information, literature review, writing manuscript. M.A.: performing procedure, writing manuscript, review manuscript, supervise whole work

Conflicts of interest disclosure

Not applicable.

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Guarantor

The correspondence author: Basel Ahmad.