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jhc-2019-jul-v-3-n-2-mesenteric-ms

Mesenteric Cystic Lymphangioma – Case Report

 

*Nazrin MS,1 Rahman DS2

 

  1. *Dr. Mosammet Suchana Nazrin, Professor & Head, Department of Pathology, North East Medical College, Sylhet, Bangladesh. nazrinsuchana@gmail.com
  2. Dil Shakira Rahman, Lecturer, Department of Pathology, North East Medical College, Sylhet, Bangladesh.

 

*For correspondence

 

Abstract

Cystic lymphangioma is a rare tumor of lymphatic origin. Incidence of intra-abdominal lymphangioma  accounts <5%. A 4 years old boy, admitted in the North East Medical College and Hospital, Sylhet, Bangladesh with the complaints of abdominal distension,  severe pain in whole abdomen, nausea, anorexia and vomiting. CT findings were suggestive of mesenteric cyst. At laparotomy, a cystic tumor was found in the mesentery, that  was attached to bowel loops. Histopathological examination confirmed the diagnosis of cystic lymphangioma.

 

[Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):172-174]

 

Key words: Lymphangioma, Cyst, Mesentery.

 

Introduction

Lymphangioma is a rare cystic tumors of lymphatic system, characterized by proliferating lymphatic vessels, occurs most commonly in the head, neck and axilla.1 Other sites include mouth, arm, mediastinum, lung, abdomen and viscera. Intra-abdominal cystic lymphangiomas are rare and comprises less than 5% of all cystic lymphangiomas.2 Differentiating cystic lymphangioma from other cystic growths by imaging techniques alone is often inconclusive and surgery followed by histopathological examination is required for final diagnosis. We are here reporting  a rare case of mesenteric cystic lymphangioma in a 4 years old male children.

 

Case report

A 4 years old boy, admitted in the North East Medical College and Hospital with the complaints of abdominal distension and severe pain in whole abdomen for 15 days, nausea and anorexia for 15 days and vomiting for 1 day. On physical examination, abdomen was hugely distended. Tenderness was present in whole abdomen. There was no organomegaly. Umbilicus was everted and transverse slit was present. The laboratory data presented no anaemia,  CRP was 10 mg/dl, serum creatinine 0.5 mg/dl, serum electrolytes showed Na+ 141 mmol/L, K+ 4.4 mmol/L, Cl– 105 mmol/L, HCO3–18 mmol/L. However, computed tomography revealed a large cystic mass of about 16x13x10.5 cm, which extended from right side of upper abdomen to pelvic cavity and displaced adjacent gut loops towards left. No soft tissue component or calcification was seen within the cyst. There was also right sided hydronephrosis, probably due to pressure effect of the cystic mass. Patient was diagnosed clinically as a case of mesenteric cyst.  Laparotomy was done under general anaesthaesia. On laparotomy, there was a mesenteric cyst in the abdomen. Aspiration was done. The fluid color was haemorrhagic, probably due to pressure effect and congestion of the blood vessels. The cyst was clinically designated as mesenteric cyst and sent for histopathological examination.

 

 

On gross examination, there was a cystic mass measuring 7x 6 x4 cm size. The surface was smooth. On cut section, it was multiseptate and multiloculated with various sized cystic spaces. Microscopic examination showed multiple cystic spaces separated by fibrocollageous stroma. The cysts were lined by single layer of endothelium. The lumens were filled with homogenous eosinophilic material with a few clusters of macrophages. The stroma was infiltrated with lymphocytes, forming lymphoid aggregates. Histopathological examination confirmed the diagnosis of mesenteric cystic lymphangioma. The post-operative period was uncomplicated and the patient was discharged on 6th postoperative day.

Discussion

Lymphangioma, a rare cystic tumors of lymphatic system. It is  a benign, slow-growing lesions, characterized by proliferating lymphatic vessels, preferentially located in the head & neck (75%), axilla (20%). Incidence of intra-abdominal lymphangioma (accounts <5%), have been reported in the mesentery, genitourinary tract, spleen, liver & pancreas.3 Abdominal cystic lymphangiomas arises from mesentery (59% – 68%), omentum (20-27%), and retroperitonium (12-14%).4 Abdominal cystic lymphangioma is  more frequent in boyes (5:2) with mean age at 2 years.5 Intra-abdominal cystic lymphangiomas is most commonly presented with abdominal mass and distension, loss of appetite, nausea and vomiting.1,2,6 Ultrasound findings are not specific, the computed tomographic scan allows the initial diagnosis.1 The diagnosis of cystic lymphangioma can only be confirmed by histological examination.

 

Conclusion

Cystic lymphangioma is a rare benign tumor that may be arises in various sites. Confirmatory diagnosis of this lesion includes laparotomy followed by histopathology.

 

Reference

  1. Chaker K, Sellami A, Ouanes Y, et al. Retroperitoneal cystic lymphangioma in an adult: A case report. Urol Case Rep. 2018;18:33-34.
  2. Karkera PJ, Sandlas GR, Ranjan RR et al. Intra-abdominal cystic lymphangioma in children: A case series. Arch IntSurg 2012;2:91-95.
  3. Bhavsar T, Saeed-Vafa D, Harbison S etal., Retroperitoneal cystic lymphangioma in an adult: A case report and review of literature. World Journal of Gastrointestinal Pathophysiology. 2010; 1(5):171-176.
  4. Muramori K, Zaizen Y and Nogushi S. Abdominal lymphangioma in children: report of three case. Surgery today. 2009; 39: 414-417.
  5. Kati O, Gunor S, Kandur Y. Mesenteric cystic lymphangioma: Case report. Journal of Paediatric Surgery 2018;35:26-28
  6. Rami A, Mahmoudi A, EiMadi A, et al., Giant cystic lymphangioma of mesentery: varied clinical presentation of 3 cases. Pan Afr Med J. 2012; 12:7
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jhc-2019-jul-v-3-n-2-multilocular-islam-f

Case Report

Multilocular Cystic Nephroma in an Adult Patient: A Case Report

*Islam F,1 Begum A,2 Kamal M3

 

  1. *Dr. Farhana Islam, Assistant Professor, Department of Pathology, Popular Medical College, Dhaka. ifarhana2006@gmail.com
  2. Afroza Begum, Associate Professor, Department of Pathology, Anwer Khan Modern Medical College, Dhaka.
  3. Mohammed Kamal, Professor of Pathology, BSMMU, Dhaka.

 

*For correspondence

 Abstract

Multilocularcystic nephroma is relative rare, cystic neoplasm of the kidney and is usually benign. There are two peaks in the incidence of the tumor, with a bimodal distribution presenting in the first 2 to 4 years of life, and again in 40 to 60 years.They are usually incidentally found as an asymptomatic abdominal mass. Radiologically, it is difficult to differentiate between cystic nephroma and cystic RCC in adults. The exact diagnosis primarily depends on the histopathologic examination. We present a 35-year-old male patient with a palpable mass over the right upper quadrant of the abdomen, which was gradually increasing in size. A Right sided  nephrectomywas performed on thispatient. Microscopically, the tumor composed of variable-sized cysts lined by a layer of flattened or cuboidal cells thatconfirmed a diagnosis of Multilocular cystic nephroma.

[Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):167-171]

 Key words: Multilocular cystic nephroma, Kidney, Benign renal tumor

Introduction

Multilocular cystic nephroma (MLCN) is a rare, benign cystic neoplasm of the kidney. It was first described in 1892 as cystic adenoma of the kidney and over 200 cases have been reported in the literature so far.1 MLCN is an uncommon, benign cystic lesion of the kidney with bimodal age distribution, occurring in both infants and adult population. Although it has been described in neonates, MLCN is more commonly seen in the age group of 2–4 years (of which 73% are in males). Below 4 years of age, male to female ratio is 3:1 and boys are affected more than girls. In adults, it is seen in the 4th–6th decade with its male to female ratio being 1:8.2 The main complaint in children is abdominal mass, while in symptomatic adults predominant complaints are abdominal distension, and pain, recurrent urinary system infection, and hematuria.3 However, most of the patients with cystic nephroma are asymptomatic and usually found incidentally. Herein, we present a case of a 35-year-old male whodeveloped a multilocular cystic nephroma in the upperpole of the right kidney. The clinicalpresentation, radiological findings, and histopathologic results werereported and the literature was reviewed.

Case Report

Our case a 35 years old male was suffering from lower back pain for 4 years. He did not pay attention to it until he discovered a palpable mass over the right upper quadrant of the abdomen, which was gradually increasing in size. Routine laboratory examinations were all within normal limits. Abdominal ultrasonography showed right renal cystic mass including a cluster of variable-sized cysts separated by hyperechoic tissue at the upper pole of the right kidney (Fig-1). I.V.U was done and the report suggested of mass in right kidney possibly cyst. Both the kidneys were normal functioning (Fig-2) MRI report suggested a right cystic renal mass (stage-II, Fig-3). Right sided  nephrectomy was done. Specimen of kidney with part of right ureter and peri-nephric fat was sent for histopathological examination on March 2010.

 Nephrectomy specimen with part of perinephric fat measured (14x9x6) cm. Cut surface showed multilocular cystic growth measured 9 cm in maximum  diameter involving  whole upper pole and mid portion of the kidney. The largest locule of the cyst measured 3 cm in maximum diameter. The wall of these cysts were thin and the locules contained straw colored watery fluid. Adjacent parenchyma was normal(Fig-4).

Microscopically, the tumor was composed of variable-sized cysts separated by fibrous septa. The cyst wall was partly lined by flattened epithelium and partly by cuboidal epithelium. The stromal septae was made of dense fibrous connective tissue with scattered smooth muscles. No nephron elements were found in the stromal septa. No communication among locules was noted. Kidney tissue surrounding the growth showed no significant change (Fig-5,6,7). A multilocular cystic nephromawas diagnosed on the basis of this  histopathological findings.

No postoperative complication was encountered and the patient was discharged uneventfully 7 days after the surgical procedure. No recurrence was found during 3 years of follow-up.

Discussion

MLCN has at least 20–25 synonyms, which include multilocular cystic renal tumor, benign multilocular cystic nephroma, polycystic nephroblastoma, and so on. Its etiology and histogenesis is debatable, and in the past they were considered to be developmental lesions with malignant potential. According to the World Health Organization (WHO) classification of renal neoplasms, MCN is grouped with the mixed epithelial and stromal tumors (MEST). The term renal epithelial and stromal tumor (REST) can be used to encompass both MCN and MEST.2

Cystic nephroma has a special bimodal age distribution, one in childhood of 2 to 4 years of life, predominantly in boys, and the other in the 40 to 60 years of life. The disease is predominantly found in adult female with an 8-time prevalence compared to male. Similar to other renal tumors, classical signs can include palpable abdominal mass, abdominal pain, and gross hematuria. However, most of cystic nephroma were found incidentally and asymptomatically.4

Usual ultrasonographic findings are multiple hypoechoic spaces separated by thin septa. CT scan, on the other hand, usuallyreveals a multilocular cystic tumor with curvilinear calcifications. Herniation into the renal collecting system with septal enhancement is commonly seen.3 Although in our case the patient done Magnetic Resonance Imaging (MRI) but it is rarely indicated. Imaging features include usually hypointense signal on T1-weighted sequences (although this may vary) and hyperintense signal on T2-weighted sequences. Septa are usually hypointense on all sequences due to fibrous content.2

Unfortunately, it is pretty difficult to differentiate between cystic nephroma, cystic RCC in adults and Wilms tumor in children radiologically even on CT scan.5 Since definitive discrimination is not possible via radiologi­cal means, histopathological diagnosis is required for dif­ferential diagnosis.

Grossly, cystic nephroma is a well-circumscribed tumor with a smooth surface. The cut surface reveals variable-sized cysts separated by thin septa. The cysts contain mostly clear to yellowish fluid but occasionally dark-colored fluid because of blood clots retention. They may be herniated into the renal collecting system but do not communicate with renal pelvis. That is why only parts of patients have hematuria microscopically or macroscopically. Bilateral cystic nephroma and recurrence after excision was rarely reported. Only several case reports in childhood co-existing with nephroblastoma.6

The criteria for pathologic diagnosis were established by Powell et al. in 19517 and later modified by Boggs and Kimmelstiel in 1959,8 and include the following (1) The lesion must be multilocular (2) The cysts must, for the most part, be lined by epithelium (3) The cysts must not communicate with the pelvis (4) The residual renal tissue should be essentially normal, except for pressure atrophy (5) No fully developed nephrons are present within the septa. Our patient fulfills all 5 criteria.

Development of cystic renal cell carcinoma originating from CN has been also reported, and postoper­ative follow-up is recommended. Local recurrence or me­tastasis is limited to a few cases, and it has been reported that local recurrence especially in patients who underwent partial nephrectomy is a possibility which might be re­lated with incomplete resection.3 Contrarily, Castillo et al.9 presented a series of 29 cases, and couldn’t encounter any postoperative local recurrence or metastasis. Also in our case we didn’t observe any local recurrence or metas­tasis,after 3years of  postoper­ative follow-up.

Traditionally, treatment for any solid renal mass or multilocular cystic lesion was nephrectomy. Nowadays, partial nephrectomy has become the initial standard option for small renal mass.10 If the lesion is localized enough, excision of the lesion or partial nephrectomy can be considered, even for large tumor in children.11

Conclusion

Cystic nephroma is a rare, benign renal tumor, which progresses with a silent course, and demonstrates a bimodal age distribution, and it is difficult to differentiate from cystic RCC. Neither clinical signs nor radiological findings can obtain a pre-operative diagnosis of MLCN. Surgical intervention and histopathologicexamination are necessary for the final diagnosis. Noninvasively radiological follow-up is recommended after complete resection.

 References

  1. Edmunds W. Cystic adenoma of the kidney. Trans PatholSocLond. 1892;43:89–90.
  2. Wilkinson C, Palit V,Bardapure M et al., Adult multilocular cystic nephroma: Report of six cases with clinical, radio-pathologic correlation and review of literature. Urol Ann. 2013; 5(1): 13–17.
  3. Cavıldak İD, Çakıcı MÇ, Karakoyunlu N, Ersoy H. Cystic nephroma: A case report in adult patients. Turk J Urol 2018; 44: 373-6.
  4. Chih-Yin Y, Yi-Chia L, Te-Fu T and Thomas ISH, Cystic nephroma: A case report in adult patients. Turk J Urol 2018; 44(4): 373-6.
  5. Kurian JJ, Ninan PJ. A rare case of bilateral cystic partially differentiated nephroblastoma recurring as bilateral cystic Wilmstumour. BMJ Case Rep,2015; 2:1.
  6. Joshi VV, Beckwith JB. Multilocular cyst of the kidney (cystic nephroma) and cystic, partially differentiated nephroblastoma.Terminology and criteria for diagnosis. Cancer,1989; 64: 466-479.
  7. Powell T, Shackman R, Johnson HD. Multilocular cysts of the kidney. Brit J Urol 1951;23:142-52.
  8. Boggs LK, Kimmelstiel P. Benign multilocular cystic nephroma: report of two cases of so-called multilocular cysts of the kidney. J Urol 1956;76:530-41.
  9. Castillo OA, Boyle ET Jr, Kramer SA. Multilocular cysts of kidney.A study of 29 patients and review of literature. Urology 1991;37:156-62.
  10. Dong B. Multilocular cystic nephroma treated with laparoscopic nephronsparing surgery: A case report. Can UrolAssoc J, 2014; 8: 545-547.
  11. Tanaka Y. Laparoscopic partial nephrectomy for the treatment of large cystic nephroma in children. J Laparoendosc Adv Surg Tech A, 2014; 24: 901-906.
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jhc-2019-jul-v-3-n-2-coexistence-hossain-mi

Case Report

Coexistence of Primary Tuberculosis and Metastatic Ductal Carcinoma in Axillary Lymphnode: Report of a Rare Case

* Hossain MI,1 Sadaf A,2 Sultana N,3 Khan AS4

 

  1. * Mohammad Ismail Hossain. Lecturer, Department of Pathology, Chattogram Medical College, Chattogram, Bangladesh.ismail. tushar@gmail.com
  2. Anika Sadaf, MD (Pathology) Phase B Student. Department of Pathology, Chattogram Medical College, Chattogram, Bangladesh.
  3. Nahid Sultana, Senior Consultant, Obstetrics & Gynaecology, Chandpur 250 bed General Hospital, Chandpur, Bangladesh.
  4. Professor Dr. AKM Shahabuddin Khan, Ex Professor, Department of Pathology, Cumilla Medical College, Cumilla, Bangladesh. Chief Consultant, Cytosite (Histopathology Laboratory), Chandanpura, Chattogram.

 *For correspondence

 Abstract

Concomitant breast cancer metastasis and tubercular lymphadenitis in axillary lymph node is an extremely rare occurrence. Co-existence of two pathologies in one organ always poses a diagnostic and therapeutic challenge. Here, we report a case of 47-years old female presented with lump in the right breast. Fine-needle aspiration cytology (FNAC) from breast and axillary lymph node revealed ductal carcinoma with axillary metastasis. The patient underwent total mastectomy with axillary lymph node dissection and microscopy showed concomitant presence of metastatic tumor and tubercular lymphadenitis in axillary nodes. Majority of previously reported cases were breast cancer with axillary lymphadenopathy having tubercular foci, while our patient had a metastatic carcinoma and tubercular granulomatous foci in the same lymph node with the absence of tubercular foci elsewhere. The case is being reported for its rarity. It also indicates that FNAC can fail to detect mixed lesions unless multiple punctures from many sites are performed.

 [Journal of Histopathology and Cytopathology, 2019 Jul; 3 (2):162-166]

 Key Words: Ductal carcinoma, Tuberculosis, Metastasis, Axillary lymph node, Coexistence

 Introduction

The synchronous occurrence of tuberculosis and carcinoma is unusual. Coexistence of tuberculosis and metastatic carcinoma in axillary lymph nodes, without pulmonary or mammary tuberculosis is even rarer.1 It is always adiagnostic and therapeutic challenge that simultaneous presence of two diseases in one organ. Though carcinoma of the breast and tuberculosis (TB) both are common in developing countries, their coexistence is uncommon.2 Warthinfirst described two cases of coexistence of TB and carcinoma of mammary glands in axillary node in 1899.3 Kaplan et al. examined the frequency of the coexistence between different cancer types and TB in a retrospective study and reported that the prevalence of TB was 19 per 10,000 cases of breast cancers.4 Here we report a rare case of metastatic duct cell carcinoma of breast in axillary lymph nodes harboring tubercular lymphadenitis that was incidentally discovered during the histological examination, wherein no evidence of tuberculosis was found elsewhere.

 Case Report

A 46-years old multiparous woman presented at out-patient department of Chattogram Medical College Hospital with the history of painlesslump in her right breast for about last one and halfmonths. On examination, a fixed and hard nodule measuring 3 cm in diameter was palpable in the lower outer quadrant of right breast.The overlying skin, areola and nipple were apparently normal. Multiple right axillary nodes, ranging from 0.5 to 2 cm in diameter were also palpable with mild tenderness. No palpable lump was detected in contralateral breast & axillaand no cervicalor inguinal lymphadenopathy. There was no past history/family history of tuberculosis, malignancy or any other chronicmedical illness.She was taking combined oral pills for contraception for about 20 years.

The ultrasonographyrevealed a nodule of 46x39x32 mm in the lower outer quadrant of the right breast, associated with a group of axillary lymph nodes the largest one measuring 22×15 mm.

Routine hematological & biochemical tests were within normal limit except a hemoglobin level of 9.2 g/dl with raised ESR and chest X-ray showed unremarkable change. Fine needleaspiration cytology (FNAC) from right breast lump revealed highly cellular smears showing atypical ductal cells in clusters and dispersed singly. The cells had moderately pleomorphic nuclei, coarsely granular chromatin and 1–2 prominent nucleoli. FNAC from the largest axillary node revealed tumor metastasis. A diagnosis of ductal carcinoma with axillary metastasis was given on cytology. A right modified radical mastectomy performedandthe specimens were sent to Cytosite (A private cyto-histopathological laboratory) for histopathological diagnosis. Specimen showed a firm to hard, whitish about 40×35 mm nodular lump in the breast. On axillary dissection, eight lymph nodes were isolated larger one measured 20 mm in diameter. Cut surface ofmost of the nodes were adherent and gray-white in colour (Figure 1).

The histological examination revealed a tumor composed of neoplastic ductal cells arranged in cords, nests and tubules invading into the stroma. These cells had moderate amount of cytoplasm with moderate nuclear pleomorphism and 1-2 prominent nucleoli. Mitotic count was less than ten/10 high power fields. Surgical resection margins were free of tumor, where the base was tumor-free. Lymphovascular tumor emboli were also evident with no perineural involvement.

Out of eight nodes three showed tumor metastases and two of the lymph nodes showed epithelioid cell granulomas with Langhans type giant cells and central caseaous necrosis (Figure 3, 4, 5).

Immunohistochemical (IHC) examination revealed overexpression of estrogen & progesterone receptor and negativity for Her-2/neu in the breast lesion. With these findings, diagnosis of “invasive ductal carcinoma, grade II (Nottingham modification of Bloom Richardson grade) with concomitant regional nodal metastasis done and caseating granuloma” found, so “AJCC staging II”was made. Since preoperatively tuberculosis was not suspected and no other clinical feature of TB was found, mantoux test, culture, serology or polymerase chain reaction were not performed. Due to unavailability modified Ziehl–Nielsen staining on axillary tissue and CD68 immunostain for epithelioidhistiocytes not done.

 Discussion

TB remains a major public health problem worldwide. According to the Global Tuberculosis Report 2018, it affected 10 million people in 2017 and is responsible for 1.2–1.4 million deaths globally in HIV-negative patients. It is caused by Mycobacterium tuberculosis and most often affects the lungs. About 23% of the world’s population (1.7 billion people) has latent tuberculosis, with a risk of reactivation of 5–15%.5 Tubercular lymphadenitis is the most common form of extra pulmonary tuberculosis. But isolated axillary tubercular lymphadenitis without any evidence of clinical disease in any other organ is extremely uncommon in adults. Axillary tubercular lymphadenitis can be accounted for by either retrograde spread from the mediastinal nodes or hematogenous spread from a subclinical focus.

An alternative explanation for the co-occurrence of TB and metastasis could be activation of a silent Mycobacterium tuberculosis infection due to immunocompromised state in cancer patients.6 Tubercle bacillus can exist in a state of microbial latency within the macrophage of the granulomas for the lifetime. Factors that disturb host immunity can allow the tubercle bacillus to cause endogenous reinfection.7

In general, TB is diagnosed by clinical history, erythrocyte sedimentation rate, chest X-ray, Ziehl–Nielsen staining, polymerase chain reaction (PCR)based detection of acid fast bacilli (AFB) and others. But a significant proportion of cases of extra-pulmonary TB may be negative for chest X-rays or regular stains for AFB.8

The clinical features of breast carcinoma may reveal nodules and ulcerations,appearance of lymphadenopathies lead us to suspect a metastatic tumor. It is the histological examination that enabled making the differential diagnosis.9 Ina few cases diagnosis have been made through preoperative investigations like cytology or core biopsy. PET-CT as we know is the imaging of choice in certain cancers like lung cancer, its role in breast cancer is limited.8

Breast cancer patientsalso may suffer reactivation of TB during their treatment. It not only disturb the treatment protocol but also the clinical and radiologic findings confuse the follow up process since a malignant and a tubercular lesion may be indistinguishable.7 Axillary lymph node metastasis is the most important factor in the staging of ductal carcinoma and the number of metastatic axillary nodes alter the stage. As tuberculosis also produces nodal enlargement, this can mimic or complicate the staging of malignant disease.6 Therefore, pathologists and lab technicians should also be aware and vigilant in ruling out possible differentials such as metastasis, tuberculosis, fat necrosis, actinomycosis, suture granuloma accordingly.10

 Conclusion

Simultaneous presence of axillary tubercular lymphadenitis and metastatic carcinoma is a significant but rare event that can confuse and complicate the diagnosis, grading, staging and most importantly, the treatment of the disease. It is important for the physician in endemic countries like ours to consider the possibility of a granulomatous disease masquerading as axillary metastasis in order to correctly address both diseases.

 

 References

  1. Pandey M, Abraham EK, Chandramohan K and Rajan B. Tuberculosis and metastatic carcinoma coexistence in axillary lymph node: A case report. World Journal of Surgical Oncology; 2003;1(3):1-3.
  2. Tulasia NR, Rajub PC, Damodaranb V and Radhikab TS. A spectrum of co-existent tuberculosis and carcinoma in the breast and axillary lymph nodes: Report of five cases.The Breast; 2006;15:437–439.
  3. Caroppo D, Russo D, Merollam F, Ilardi G, Caro MD, Lorenzo PD, Varricchio S, Mascolo M and Staibano S. A rare case of coexistence of metastasis from head and neck squamous cell carcinoma and tuberculosis within a neck lymph node. Diagnostic Pathology; 2015;10(197):1-3.
  4. Kaplan MH, Armstrong D, Rosen P. Tuberculosis complicating neoplastic disease:A review of 201 Cases. Cancer 1974;;33:850-858
  5. Almeida S, Valentim M, Neto C, Cerol M, Boticário M, Santos MI, Gameiro A. Extrapulmonary Tuberculosis Presenting as a Suspected Case of Metastatic Breast Cancer. European Journal of Case Reports in Internal Medicine 2019. DOI:10.12890/2019_001062
  6. Pujani M, Khan S, Hassan MJ, Jetley S and Raina PK. Coexistence of metastatic breast carcinoma and primary tuberculosis in axillary lymph nodes: A report of a rare case; Breast Disease. 2015;35:195–198.
  7. Baslaim MM, Al-Ghamdi MA, Al-Numani TS, Ashour AS and Al-Amoudi SA. Tuberculosis in 7 breast cancer cases: Diagnostic and therapeutic challenges. J Mycobac Dis; 2013;3(3):1-4.
  8. Mukhopadhyay T, Nandi M, Bhattacharya S, and Khan EM. Contralateral contiguous tuberculous lymphadenitis in a case of right breast carcinoma – Diagnostic dilemma. J Can Res Ther.2015;11:102-6.
  9. Ouedraogo AS, Bambara HA, Ademayali FAH, Ramde WN, Sawadogo RJ, Savadogo I, Ouattara S, Barry1 H, Lamien AS, Lompo OM. Anatomo-clinical case: coexistence of tuberculosis with axillary lymph node metastasis in breast carcinoma. Open Journal of Pathology; 2018;8:132-138.
  10. Lee CH. and Sharif SJ. Primary breast tuberculosis (TB) in a patient with known invasive breast carcinoma: A case report. Med J Malaysia.2016;71(3):149-151.