Medical and Pediatric Oncology 2:439-440 (1976)
TUBERCULOSIS IN MALIGNANT Martin W. Oster, M.D. Infectious Disease Section, Division of Cancer Treatment, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
INTRODUCTION
Recently (l), a survey at a large cancer center demonstrated an increased risk of developing active tuberculosis (TB) for most cancer patients but remarkably detected no cases of TB among the 2,131 malignant melanoma patients at risk. This assumed greater significance in view of the possibility that animal and human melanoma cells may crossreact immunologically with tubercle bacilli (2,3) and thereby provide immunologic protection against TB infection in patients with malignant melanoma. To evaluate this further, a review of all patients (179) with malignant melanoma cared for at the National Cancer Institute Clinical Center was conducted and revealed only one patient who developed active TB, herein described. CASE REPORT
A 58-year old man developed a malignant melanoma of the right forehead in 1968 and underwent a local excision with radical neck dissection. He had excisions for local recurrences 3 times in the ensuing 4 years and was first referred to the National Cancer Institute in November, 1973, with disseminated cutaneous melanoma, without evidence of visceral involvement. He was treated with various agents, including hydroxyurea, gallium, and a nitrosourea, without any significant clinical responses. In April, 1974, he developed signs of lumbar spinal cord compression and received local spinal radiotherapy with good response. In October, 1974, he developed disseminated malignant melanoma, clinically detected in pericardium, pleura, and gastrointestinal tract. The patient had no history of TB or exposure to TB but on chest roentgenograms since 1973 at the National Cancer Institute had apical calcifications bilaterally consistent with old pulmonary TB, as well as changes of chronic emphysema. In November, 1974, when his malignant melanoma was diffusely disseminated, he developed signs of increasing respiratory dysfunction and was found to have positive sputum cultures for TB. He was
Address reprint requests to Dr. Martin W. Oster, Department of Medicine, Cancer Research Center, Columbia University College of Physicians and Surgeons, 630 West 168 Street, New York, NY 10032.
439
0 1976 Alan R. Liss, Inc., 150 Fifth Avenue, New York, NY 10011
440
Oster
started on isoniazid and rifampin but his pulmonary status deteriorated rapidly with the development of bacterial pneumonia and he died 10 days later. Autopsy findings confirmed dissemination of the melanoma to multiple organs and bilateral pulmonary apical caseous granulomas. COMMENT
This study confirms the rarity of TB infection in patients with malignant melanoma but emphasizes the possibility of reactivation of old TB in patients with disseminated malignant melanoma. Since immunologic competence tends to deteriorate as neoplasms such as melanoma disseminate (3), the putative protective effect of the cross-reactivity of melanoma cells with tubercle bacilli may be lost in advanced melanoma patients. Because the prognosis of disseminated melanoma is so poor, few patients may live long enough to develop active TB despite this loss of immunologic protection. Improved therapy in the future with resultant longer survivals may increase the frequency of active TB complicating disseminated malignant melanoma. REFERENCES 1. Kaplan, M., Armstrong, D., and Rosen, P.: Tuberculosis complicating neoplastic disease. Cancer 33: 850-85 8, 1974. 2. Faraci, R., Barone, J., and Schour, L.: BCG4nduced protection against malignant melanoma: possible immunospecific effect in a murine system. Cancer 35:372-377, 1975. 3. Gutterman, J., Mavligit, G., Reed, R., Richman, S., McBride, C., and Hersh, E.: Immunology and immunotherapy of human malignant melanoma: historic review and perspectives for the future. Seminars in Oncology 2:155-174, 1975.
TUBERCULOSIS IN MALIGNANT Martin W. Oster, M.D. Infectious Disease Section, Division of Cancer Treatment, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
INTRODUCTION
Recently (l), a survey at a large cancer center demonstrated an increased risk of developing active tuberculosis (TB) for most cancer patients but remarkably detected no cases of TB among the 2,131 malignant melanoma patients at risk. This assumed greater significance in view of the possibility that animal and human melanoma cells may crossreact immunologically with tubercle bacilli (2,3) and thereby provide immunologic protection against TB infection in patients with malignant melanoma. To evaluate this further, a review of all patients (179) with malignant melanoma cared for at the National Cancer Institute Clinical Center was conducted and revealed only one patient who developed active TB, herein described. CASE REPORT
A 58-year old man developed a malignant melanoma of the right forehead in 1968 and underwent a local excision with radical neck dissection. He had excisions for local recurrences 3 times in the ensuing 4 years and was first referred to the National Cancer Institute in November, 1973, with disseminated cutaneous melanoma, without evidence of visceral involvement. He was treated with various agents, including hydroxyurea, gallium, and a nitrosourea, without any significant clinical responses. In April, 1974, he developed signs of lumbar spinal cord compression and received local spinal radiotherapy with good response. In October, 1974, he developed disseminated malignant melanoma, clinically detected in pericardium, pleura, and gastrointestinal tract. The patient had no history of TB or exposure to TB but on chest roentgenograms since 1973 at the National Cancer Institute had apical calcifications bilaterally consistent with old pulmonary TB, as well as changes of chronic emphysema. In November, 1974, when his malignant melanoma was diffusely disseminated, he developed signs of increasing respiratory dysfunction and was found to have positive sputum cultures for TB. He was
Address reprint requests to Dr. Martin W. Oster, Department of Medicine, Cancer Research Center, Columbia University College of Physicians and Surgeons, 630 West 168 Street, New York, NY 10032.
439
0 1976 Alan R. Liss, Inc., 150 Fifth Avenue, New York, NY 10011
440
Oster
started on isoniazid and rifampin but his pulmonary status deteriorated rapidly with the development of bacterial pneumonia and he died 10 days later. Autopsy findings confirmed dissemination of the melanoma to multiple organs and bilateral pulmonary apical caseous granulomas. COMMENT
This study confirms the rarity of TB infection in patients with malignant melanoma but emphasizes the possibility of reactivation of old TB in patients with disseminated malignant melanoma. Since immunologic competence tends to deteriorate as neoplasms such as melanoma disseminate (3), the putative protective effect of the cross-reactivity of melanoma cells with tubercle bacilli may be lost in advanced melanoma patients. Because the prognosis of disseminated melanoma is so poor, few patients may live long enough to develop active TB despite this loss of immunologic protection. Improved therapy in the future with resultant longer survivals may increase the frequency of active TB complicating disseminated malignant melanoma. REFERENCES 1. Kaplan, M., Armstrong, D., and Rosen, P.: Tuberculosis complicating neoplastic disease. Cancer 33: 850-85 8, 1974. 2. Faraci, R., Barone, J., and Schour, L.: BCG4nduced protection against malignant melanoma: possible immunospecific effect in a murine system. Cancer 35:372-377, 1975. 3. Gutterman, J., Mavligit, G., Reed, R., Richman, S., McBride, C., and Hersh, E.: Immunology and immunotherapy of human malignant melanoma: historic review and perspectives for the future. Seminars in Oncology 2:155-174, 1975.
