Background
According to the World Health Organization, tuberculosis is a global public health problem and about one-third of the world’s population is infected [
1]. In Morocco, 26,000 to 27,000 new cases of all forms of tuberculosis are detected annually and extra pulmonary tuberculosis accounts for 46% of tuberculosis cases, dominated by lymph node tuberculosis [
2]. In rare cases, tuberculosis and cancer can be detected at the same time, creating a real therapeutic challenge. Not only in Morocco, Africa, but all over the world and especially in Eastern Europe and the greater part of Asia, surgical and medical oncologists as well as pathologists should be aware of the possibility and associated treatment sequence.
Case presentation
We hereby present the rare case of a 29-year-old white woman married for 5 years gravida 1 para 1 without significant personal or family history who found during breast self-examination a left breast mass. Then she went to a high medical center where she received breast ultrasound and a mammogram that revealed the presence of a left breast cancer classified 5 in the Breast Imaging Reporting And Data System of the American College Of Radiology, that is to say highly suggestive of malignancy (more than 95%). The radiological report noticed a mammary nodule at the level of the supero-external quadrant of the left breast of 2 cm long axis with the presence of two homolateral axillary lymphadenopathies of 1.2 cm and 0.8 cm. Then she was referred to us and admitted to the National Institute of Oncology in Rabat. The clinical examination confirmed the presence of a mobile mammary mass at the level of the supero-external quadrant of the left breast of 2 cm long, without inflammatory or cutaneous signs, nor mammalian flow, with just one mobile axillary homolateral suspicious ganglion of 1 cm.
First, we performed a micro biopsy with pistol to confirm histologically the presence of the cancer which turned out to be a non-specific infiltrating carcinoma grade 3 (differentiation 3, anisonucleosis 3 and mitotic index 3) of the Elston-Ellis modified Scarff-Bloom and Richardson staging with no intraductal component nor intravascular tumor emboli. She then had a thoraco-abdominopelvic computed tomography as part of her extension assessment, which was negative. Taking into consideration all these elements, we were able to classify the tumor cT1N1M0. We therefore decided to offer conservative treatment to the patient as soon as possible given the diagnosis of cancer at a relatively early stage, which she accepted.
Three weeks later, the patient underwent lumpectomy with ipsilateral axillary dissection. The one-month follow-up showed that the wound had healed well. There was no significant complication in the short term. The histopathology report confirmed the presence of infiltrating ductal carcinoma (WHO 2003) measuring 2.2 cm long axis, grade 3 (differentiation 3, anisonucleosis 2 and mitotic index 2) of the Elston-Ellis modified Scarff-Bloom and Richardson staging, with no intraductal component nor intravascular tumor emboli, with healthy exeresis limits: non-tumorous deep plane at 0.8 cm, healthy lateral margins closest to 0.2 cm; and at the level of axillary dissection 12 N(−)/12 N. The pathological staging of the tumor was therefore pT2N0M0. On the other hand, the histological examination of the axillary dissection revealed the presence of several epitheloid and gigantocellular granulomas centred by a caseous necrosis, typical of follicular ganglionic tuberculosis. The immunohistochemical profile of the tumor could be elaborated and revealed a strong expression of hormone receptors (oestrogen and progesterone), a 30% ki67 without overexpression of HER 2. According to the genomic classification of breast cancer, we could therefore classify this tumor as a luminal tumor A [
3].
Her file was discussed in a multidisciplinary consultation meeting during which several decisions were made. First, TB case was notified and Directly Observed Treatment Short course was given.
She received her anti-tuberculosis treatment with a course of 6 months according to the latest WHO recommendations of 2HRZE/4HR (2 months of the Isoniazid, Rifampin, Pyrazinamide and Ethambutol association followed by 4 months of Isoniazid and ethambutol biotherapy) [
4]. Three weeks after the beginning of her anti-tuberculosis treatment, she began her adjuvant chemotherapy to prevent locoregional or general recurrence. This treatment was based on 3 courses of four-weekly FEC 100 (5-fluorouracil, Epirubicin, Cyclophosphamide) followed by 3 courses of four-weekly docetaxel. At the end of the chemotherapy she had an external radiotherapy by irradiation of the breast remaining after lumpectomy of 50 Gy with a complement of irradiation on the tumor bed of 15 Gy. Moreover, she also received an anti-estrogen hormone therapy (tamoxifen). Trastuzumab has not been proposed since the tumor does not overexpress HER 2 (human epitheloid growth factor receptor). Finally, given her young age, she had an onco-genetic consultation with search of genes BRCA-1 and BRCA-2, negative income for both.
Despite difficulties of therapeutic compliance, after 2 years the patient completed her cancer treatment and she cured of her tuberculosis. Being in remission, she is still on hormone therapy and consults every 3-months as part of her follow-up.
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