A 66-year-old man with no past history of pulmonary TB or immunocompromised status presented at the National Hospital Organization Shikoku Cancer Center with a chief complaint of a painless mass in his left chest wall. Computed tomography (CT) revealed an 8-cm tumor and peripherally enhancing fluid collection in the chest wall adjacent to the seventh and eighth ribs, without osteolytic change (Fig. 1A). A pulmonary nodule demonstrating a mixed ground glass opacity (GGO) measuring 19 x 15 mm in segment 4 of the left lung (Fig. 1B) was detected incidentary. Blood tests revealed that white blood cell count was within the normal range. Levels of C-reactive protein, carcinoembryonic antigen, and cytokeratin 19 fragments in the serum were 0.82 mg/dl, 2.2 ng/ml, and 1.4 ng/ml, respectively. Results of acid-fast staining from the sputum culture and the aspiration specimen were negative. The aspirated specimen from the chest wall tumor was positive for Mycobacterium tuberculosis (polymerase chain reaction). The tumor was therefore diagnosed as TACW. Pulmonary nodule was clinically diagnosed as lung cancer T1aN0M0 stage IA. Surgery was performed at the regional TB ward of the National Hospital Organization Ehime Medical Center.
Lingulectomy and lymph node dissection (levels 10 and 11) were performed. Video-assisted procedure was performed through a 6-cm access thoracotomy over the mid-axillary line in the fourth intercostal space, 1-cm access ports in the mid-axillary line in the sixth intercostal space and posterior axillary line in the fifth intercostal space. No penetration of the parietal pleura by the abscess was evident. Slight adhesion was found in the pleural cavity but not between the lower lobe and the parietal pleura adjacent to the abscess. For the abscess, debridement without rib resection was performed. Debridement of the necrotic tissue and the abscess wall was performed through another 5-cm incision right over the abscess. Chest wall cavity and the pleural cavity were drained with silicon drains. These were removed on postoperative day 5 and postoperative day 7 respectively. The postoperative course was uneventful. Antituberculous chemotherapy consisting of isoniazid (300 mg), rifampicin (600 mg), ethambutol (750 mg), and pyrazynamide (1.5 g) per day was initiated on postoperative day 14. The patient was discharged on postoperative day 17.
Histologically, GGO consisted of an adenocarcinoma mixed subtype (bronchioloalveolar carcinoma + papillary adenocarcinoma) without lymph node metastasis. Pathologically, the tumor was diagnosed as T1aN0M0 stage IA. Caseation necrosis surrounded by Langhans-type giant cells was seen in the specimen from the chest wall abscess, was compatible with tuberculoid granuloma. M. tuberculosis was identified in an 8-week culture of the pus from the abscess.