PDF(Pubmed)
Abstract：
BACKGROUND: Nontuberculous mycobacterium (NTM) refers to all mycobacteria except Mycobacterium tuberculosis and Mycobacterium leprae, also known as environmental Mycobacterium. The patients with lung cancer and NTM are somewhat special; the two diseases are inevitably influenced by each other. It brings difficulties and challenges to the choice of treatment. Recently, cancer immunotherapy has been considered one of the pillars for the treatment of lung cancer. However, the clinical experience in the application of immune checkpoint inhibitors is scarce for lung cancer patients with pulmonary tuberculosis, and lung cancer with NTM is even more rare. Although it ameliorates lung cancer, immunotherapy with immune checkpoint inhibitors presents complications of infectious diseases, including tuberculosis and NTM.
METHODS: A 61-year-old male patient visited a doctor in May 2019. His admitting diagnoses were: (1) Cancer of the left lung with a pathological diagnosis of poorly differentiated non-small cell carcinoma, likely poorly differentiated adenocarcinoma, clinical stage IIIb (T3N3M0); and (2) Mycobacterium fortuitum (M. fortuitum) infection. We chose to proceed with pembrolizumab treatment. After two treatment cycles, a chest computed tomography scan showed a new irregular subpleural mass in the anterior segment of the left upper lobe of the lung, a reduction in the mediastinal enlarged lymph node, and no other obvious changes. Next, an ultrasound-guided biopsy of the new tumor was performed. Pathological examination showed that a large number of carbon particles were deposited in the alveolar tissue with histiocyte reaction and multinucleated giant cell formation. The tuberculosis (TB) specialist suggested that anti-TB therapy be combined with continued antitumor treatment. The patient continued to be treated with pembrolizumab. After 14 cycles, the lesion shrunk by 79%, there was no recurrence of M. fortuitum infection, and there were no intolerable adverse reactions.
CONCLUSIONS: We have observed that in cases of lung cancer complicated with M. fortuitum infection, opportunistic pathogen infection recurrence can be overcome, and immunotherapy is most beneficial when TB doctors and oncologists cooperate to closely observe dynamic changes in M. fortuitum and lung cancer. Treatment should be maintained with low dosage anti-TB drugs after general anti-TB chemotherapy for 1 year; this may prevent opportunistic pathogen infection recurrence during immunotherapy.
METHODS: A 61-year-old male patient visited a doctor in May 2019. His admitting diagnoses were: (1) Cancer of the left lung with a pathological diagnosis of poorly differentiated non-small cell carcinoma, likely poorly differentiated adenocarcinoma, clinical stage IIIb (T3N3M0); and (2) Mycobacterium fortuitum (M. fortuitum) infection. We chose to proceed with pembrolizumab treatment. After two treatment cycles, a chest computed tomography scan showed a new irregular subpleural mass in the anterior segment of the left upper lobe of the lung, a reduction in the mediastinal enlarged lymph node, and no other obvious changes. Next, an ultrasound-guided biopsy of the new tumor was performed. Pathological examination showed that a large number of carbon particles were deposited in the alveolar tissue with histiocyte reaction and multinucleated giant cell formation. The tuberculosis (TB) specialist suggested that anti-TB therapy be combined with continued antitumor treatment. The patient continued to be treated with pembrolizumab. After 14 cycles, the lesion shrunk by 79%, there was no recurrence of M. fortuitum infection, and there were no intolerable adverse reactions.
CONCLUSIONS: We have observed that in cases of lung cancer complicated with M. fortuitum infection, opportunistic pathogen infection recurrence can be overcome, and immunotherapy is most beneficial when TB doctors and oncologists cooperate to closely observe dynamic changes in M. fortuitum and lung cancer. Treatment should be maintained with low dosage anti-TB drugs after general anti-TB chemotherapy for 1 year; this may prevent opportunistic pathogen infection recurrence during immunotherapy.
摘要：
背景：非结核分枝杆菌（NTM）是指除结核分枝杆菌和麻风分枝杆菌以外的所有分枝杆菌，也被称为环境分枝杆菌。肺癌和NTM患者有些特殊；这两种疾病不可避免地相互影响。这给治疗方法的选择带来了困难和挑战。最近,癌症免疫疗法被认为是治疗肺癌的支柱之一。然而,肺癌合并肺结核患者应用免疫检查点抑制剂的临床经验较少,NTM肺癌更为罕见。虽然它能改善肺癌，免疫检查点抑制剂的免疫疗法会出现传染病的并发症，包括结核病和NTM。
方法：一名61岁男性患者于2019年5月就诊。他的入院诊断是：（1）左肺癌，病理诊断为低分化非小细胞癌，可能是低分化腺癌，临床IIIb期(T3N3M0)；和(2)偶发分枝杆菌(M.fortuitum）感染。我们选择继续pembrolizumab治疗。两个治疗周期后，胸部计算机断层扫描显示左上叶前段有一个新的不规则的胸膜下肿块，纵隔淋巴结肿大缩小，没有其他明显的变化。接下来,对新肿瘤进行了超声引导活检.病理检查显示，肺泡组织中沉积了大量的碳颗粒，并伴有组织细胞反应和多核巨细胞形成。结核病（TB）专家建议将抗结核治疗与持续的抗肿瘤治疗相结合。患者继续接受派姆单抗治疗。14次循环后,病变缩小了79%,没有偶然分枝杆菌感染的复发，没有出现不能容忍的不良反应。
结论：我们观察到，在肺癌合并偶然分枝杆菌感染的病例中，机会性病原体感染复发是可以克服的，当结核病医生和肿瘤学家合作密切观察偶发分枝杆菌和肺癌的动态变化时，免疫治疗是最有益的。一般抗结核化疗1年后，应使用低剂量抗结核药物维持治疗；这可以防止免疫治疗期间机会性病原体感染复发。
方法：一名61岁男性患者于2019年5月就诊。他的入院诊断是：（1）左肺癌，病理诊断为低分化非小细胞癌，可能是低分化腺癌，临床IIIb期(T3N3M0)；和(2)偶发分枝杆菌(M.fortuitum）感染。我们选择继续pembrolizumab治疗。两个治疗周期后，胸部计算机断层扫描显示左上叶前段有一个新的不规则的胸膜下肿块，纵隔淋巴结肿大缩小，没有其他明显的变化。接下来,对新肿瘤进行了超声引导活检.病理检查显示，肺泡组织中沉积了大量的碳颗粒，并伴有组织细胞反应和多核巨细胞形成。结核病（TB）专家建议将抗结核治疗与持续的抗肿瘤治疗相结合。患者继续接受派姆单抗治疗。14次循环后,病变缩小了79%,没有偶然分枝杆菌感染的复发，没有出现不能容忍的不良反应。
结论：我们观察到，在肺癌合并偶然分枝杆菌感染的病例中，机会性病原体感染复发是可以克服的，当结核病医生和肿瘤学家合作密切观察偶发分枝杆菌和肺癌的动态变化时，免疫治疗是最有益的。一般抗结核化疗1年后，应使用低剂量抗结核药物维持治疗；这可以防止免疫治疗期间机会性病原体感染复发。
