Abstract

Background: Association of granulomatous inflammation along with malignancy in the histopathological evaluation of surgical specimens is a known entity. In developing countries like India, where Tuberculosis (TB) is prevalent, one has to consider the possibility of concomitant TB and malignancy.

Case Report: A 49 year old man presented with multiple unilateral cervical lymph node enlargement, on evaluation was found to have metastasis of squamous cell carcinoma in nodes with unknown primary tumor. He underwent a comprehensive, functional neck dissection. On histopathology examination (HPE) the levels IIa and IIb nodes showed deposits of squamous cell cancer, levels IV and V nodes showed caseous necrosis, granuloma formation and acid-fast bacili (AFB) on Zeil Nielsen staining. After surgery he was started on anti-tubercular treatment, underwent external beam radiotherapy and is currently disease free and on follow up.

Discussion: The formation of stromal granuloma in lymph nodes represents a T-cell mediated immune response to surface antigens of a cell. The tumor cell surface antigens may be identified as the culprits for such a granulomatous reaction once other causes like TB, are ruled out. In the HPE slides a Zeil Nielsen staining should be performed to identify any AFB and confirm the diagnosis of TB. In this case of squamous cell carcinoma metastatic squamous cell carcinoma co-excisted with TB and both were treated successfully.

Conclusion: Carcinoma of unknown primary with neck secondaries is, in itself, an elusive disease and needs extensive work up and careful management. In endemic countries, co-existing caseous granulomatous necrosis should warrant confirmatory diagnosis of TB and treatment of both.