Association of Metastasis and Axillary Lymph Node Tuberculosis in Breast Cancer: Clinical Case and Review of the Literature

The coexistence of tuberculosis with axillary lymph node metastases in breast carcinoma is rare. Axillary lymph node metastasis is the most important fac-tor in the staging of breast carcinoma, and the number of axillary lymph nodes metastasizing changes the stage. Since tuberculosis also produces lymph node enlargement, this can mimic or complicate the staging of a ma-lignant disease. Dual organ pathology can lead to interpretation difficulties and inappropriate treatment of tuberculosis as well as breast carcinoma. Ad-ditionally, fine needle aspiration cytology (FNAC) of such cases can be mis-leading if only one of the diseases is detected. We report two cases of infiltrating carcinoma of the nonspecific type of the breast in two women aged 35 and 55 where tuberculosis was found in the axillary lymph nodes in addition to metastases. As the present case led to the fortuitous discovery of tuberculosis with tumor metastasis, it reinforces the possibility of a coexisting lesion in the minds of pathologists, especially in areas endemic to tuberculosis.


Introduction
The coexistence of breast cancer and tuberculosis is very rare and less reported in the literature [1] [2] [3] [4]. The occurrence of metastasis from mammary carcinoma to a tuberculous axillary lymph node is an even more unusual association, with only a limited number of cases in the literature [5] [6]. The concomitant presence of two diseases in an organ is almost always a diagnostic and therapeutic challenge [6] [7]. Tuberculosis (TB), cannot be ignored even if it is considered a coexisting lesion, especially in endemic areas like Mali. It is the histological examination which made it possible to make the differential diagnosis. We report two rare cases of invasive mammary carcinoma of the nonspecific type with metastatic ipsilateral lymph node associated with lymph node tuberculosis discovered incidentally during histological examination.

Summary of Case 1
A 35-year-old woman presented with a left breast mass in the upper outer quadrant for five months, without a personal medical and surgical history. G3P1A2V1.
On examination, a firm, hard, irregular mass, mobile in relation to the two planes, indole, measuring 4 cm was palpable in the upper outer quadrant of the left breast. A left axillary node was also palpable ranging from 2 cm in diameter.
No mass was detected in the contralateral breast and armpit. There was no cervical or inguinal lymphadenopathy.  -Progesterone receptors (monoclonal, clone 1E2) ROCHE: negative with positive internal control -Anti HER2/neu (monoclonal, clone 4B5, rabbit) ROCHE: negative, score 0 (with positive external control) It is a non-specific infiltrating carcinoma stagepT3N2aMx, triple negative. The patient received an anti-tuberculosis treatment combining Rifampicin (H), Isoniazid (I), Pyrazinamide (Z), Ethambutol (E) over 2 months and on the other hand a combination of Rifampicin and Isoniazid over 4 months (2RHZE/4 RH). Antitumor chemotherapy used a protocol combining 4 AC60 + 3 Taxotere (A = Adriblastine ® , C = Cyclophosphamide). Radiation therapy of 35 gray was performed.

Summary of Case 2
A 55-year-old woman presented with a lump in her left breast in the lower outer quadrant for ten months, with no known medical or surgical history, having had two pregnancies and two abortions.
On examination, a firm, hard, irregular mass, mobile in relation to the two planes, indole, measuring 8 cm was palpable in the lower quadrant of the left breast. A left axillary node was also palpable 1 cm in diameter. No mass was detected in the contralateral breast and armpit. There was no cervical or inguinal lymphadenopathy.
Mammography coupled with breast ultrasound revealed nodular opacity of the lower inner quadrant, the largest of which is 6 mm long, thickening of the skin coating.
The thoraco-abdomino-pelvic scanner revealed a scar lesion in the lower quadrant of the left breast. 8 mm homolateral axillary adenomegaly. 4 mm anterior right upper lobe micronodules. No mediastinal lymphadenopathy, pleuropericardial effusion and large vessels or chambers of the heart. Absence of liver metastasis.
Routine hematologic and biochemical examinations and cardiac ultrasound were within normal limits.
The diagnosis of invasive grade II non-specific type carcinoma with axillary metastasis was made by microbiopsy. And neoadjuvant chemotherapy was done. A left mastectomy was performed with axillary dissection (Figure 3   Kaplan et al. [12], the concomitant presence of TB and malignancy has been reported most often in the follow-Hodgkin lymphoma sarcoma, leukemia and lung cancer. Rarely, it has been reported in colon cancer, uterus, bladder, breast and prostate.

Discussion
There is no evidence that tuberculosis is carcinogenic at any place whatsoever [3] [13] [14]. There are no signs and symptoms pathognomic to distinguish breast tuberculosis of breast cancer, especially if the upper quadrant is reached.
It is necessary to multiply further actions to demonstrate the carcinogenic effect of TB and the appropriate symptoms.
The coexistence of tuberculosis and carcinoma requires concomitant treatment of both diseases and counseling to patients to ensure adherence [14] [15] [16].
Patients underwent TB treatment associated with a chemotherapy regimen. and pyrazinamide (Z). The advantage of this phase is that it is very effective in reducing the bacilli and drug resistance. It takes two or three months. The continuation phase is necessary in the patient's final recovery. It helps to prevent the recurrence of tuberculosis treatment discontinuation. He needed two medications over a period of four months.
The safety and adherence were good. They were regularly assessed using the Direct Observed Therapy Strategy (DOT). This strategy is recommended by WHO and consists of giving the drugs under control or to check at least 3 times a week if they are actually taken. Chemotherapy is used by adjuvant and involves the 3 AC + 3 docetaxel protocol. It is currently recommended to administer it before radiotherapy. Treatment usually lasts six months [8] [12] [15].