Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 55, Num. 3, 2009, pp. 234-236

Journal of Postgraduate Medicine, Vol. 55, No. 3, July-September, 2009, pp. 234-236

Letter

Granulomas in association with neoplasm: A reaction or a different primary process?

Chhabra S, Mohan H¹ , Bal A²

Departments of Immunopathology and ² Histopathology, PGIMER;
¹ Department of Pathology, GMCH - 32, Chandigarh, India

Correspondence Address: Dr. Seema Chhabra, Department of Immunopathology, PGIMER
drseemachhabra@gmail.com

Code Number: jp09075

PMID: 19884761

DOI: 10.4103/0022-3859.57398

Sir,

The presence of granulomatous response within the stroma of tumors and coexistence of granulomas and metastatic tumor within lymph nodes are rare phenomena. ^[1],[2] A summary of analysis of 11 cases of neoplasms with coexisting granulomas is presented here. All cases diagnosed as benign or malignant neoplasm with coexistent granulomas within the tumor stroma or the draining lymph nodes were retrieved from the records. Patients' clinical details, gross findings of the specimens received, and hematoxylin and eosin (H and E) stained sections were reviewed. Wherever required, special stains were done. The relevant findings are depicted in [Table - 1].

Caseating epithelioid cell granulomas were seen in tumor stroma and contiguous lymph nodes in association with adenocarcinoma colon [Figure - 1]a, Hodgkin's lymphoma [Figure - 1]b, bronchial carcinoid, mucinous cystadenoma ovary [Figure - 1]c and ampullary carcinoma. Zeihl Neelson (ZN) stain for acid-fast bacilli (AFB) was positive in only 3/7 cases. Based on the presence of caseating granulomas, the diagnosis of granulomatous inflammation consistent with tuberculosis coexistent with neoplasm was rendered. Three cases showed non-caseating sarcoid-like granulomas in stroma of follicular adenoma, metastatic deposits of medullary carcinoma thyroid and metastatic adeocarcinoma in lymph node from unknown primary [Figure - 1]d. ZN stain for AFB was negative in these cases. These cases were reported as neoplasms with granulomatous reaction. In one case, both caseating and non-caseating granulomas were seen in one lymph node associated with infiltrating carcinoma breast. The findings are summarized in [Table - 1].

Granulomas within the stroma of tumors have been reported in various neoplasms. However, the presence of coexisting metastatic tumor deposits and a non-caseating granulomatous reaction in lymph nodes has been described only with nasopharyngeal carcinoma, seminoma and malignant melanoma. ^[3] In this study, two cases of thyroid neoplasms had non-caseating granulomas. This association has not been reported so far. Their presence may be a response to material like mucin or an immunological reaction. Stromal granulomatous reaction represents a T-cell mediated immunological response to cell surface antigens. Granulomatous reaction in draining lymph nodes without metastatic deposits can be attributed to a response to a soluble tumor-related antigen reaching the lymph nodes. ^[1] It is not clear whether granulomas in tumors have any prognostic significance. However, before labeling this reaction as an immunological response to tumor antigens, it is important to exclude other causes of granulomatous inflammation, especially tuberculosis.

The synchronous occurrence of tuberculosis and carcinoma is unusual and this association often confuses the clinician. ^[4],[5] Close association of two pathological lesions always incites a debate about their etiological relationship. Coexistence of tuberculosis and carcinoma may be a simple co-incidence because of the high prevalence of tuberculosis in India or one disease process might lead to the other. Tuberculosis is known to reactivate in the setting of any immunosuppression, and malignancy is one of the causes of immunosuppression. Finally, it is important to assess whether granulomatous reaction is related to the neoplasm or is a different primary process requiring treatment.

References

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