Lung cancer occurrence after an episode of tuberculosis: a systematic review and meta-analysis

Where lung cancer and tuberculosis intersect: recent advances

Lung cancer (LC) and tuberculosis (TB) represent two major global public health issues. Prior evidence has suggested a link between TB infection and an increased risk of LC. As advancements in LC treatment have led to extended survival rates for LC patients, the co-occurrence of TB and LC has grown more prevalent and poses novel clinical challenges. The intricate molecular mechanisms connecting TB and LC are closely intertwined and many issues remain to be addressed. This review focuses on resemblance between the immunosuppression in tumor and granuloma microenvironments, exploring immunometabolism, cell plasticity, inflammatory signaling pathways, microbiomics, and up-to-date information derived from spatial multi-omics between TB and LC. Furthermore, we outline immunization-related molecular mechanisms underlying these two diseases and propose future research directions. By discussing recent advances and potential targets, this review aims to establish a foundation for developing future therapeutic strategies targeting LC with concurrent TB infection.

Antimycobacterial activity of luteolin in resistant Mycobacterium tuberculosis isolates and cytotoxicity on L929 cells

Mycobacterium tuberculosis (M. tuberculosis) bacteria can cause oxidative stress and the production of inflammatory cytokines, creating an environment that enhances tumour formation, progression and metastasis. Epidemiological studies have found a link between lung cancer and tuberculosis (TB), but the cellular mechanism is still unclear. Current treatment involves multiple drugs and a long treatment regimen. The fact that there is a very limited number of anti-tuberculosis (anti-TB) drugs against TB, that no antimicrobial has been developed that can treat TB alone, and therefore, if a pathogen with such limited treatment options develops resistance to existing drugs, treatment success is significantly reduced. As a result, it is very important to develop new and alternative drugs against this important pathogen that can shorten the duration of treatment and increase anti-TB immunity during the treatment phase. In this study, we show that Luteolin (LUT), a plant-based flavonoid, exhibits anti-TB activity with a MIC value of 100 μg/mL when applied alone to control strain and resistant clinical isolates. In addition, a suppressive effect of 6.11 μg/mL LUT on lung cancer cells, as well as a protective and regulatory effect on the function of the antioxidant system, the activity of oxidative metabolism enzymes and inflammation were shown. Therefore, the use of LUT in conventional antibiotic therapy may provide a means to prevent the development of drug resistance and improve disease outcomes.

Clinical and imaging features of co-existent pulmonary tuberculosis and lung cancer: a population-based matching study in China

BACKGROUND

Co-existent pulmonary tuberculosis and lung cancer (PTB-LC) represent a unique disease entity often characterized by missed or delayed diagnosis. This study aimed to investigate the clinical and radiological features of patients diagnosed with PTB-LC.

METHODS

Patients diagnosed with active PTB-LC (APTB-LC), inactive PTB-LC (IAPTB), and LC alone without PTB between 2010 and 2022 at our institute were retrospectively collected and 1:1:1 matched based on gender, age, and time of admission. Symptoms and clinicopathological features were compared among the three groups of patients. Logistic regression was employed for risk factor analysis.

RESULTS

Compared to LC or IAPTB-LC, patients with APTB-LC exhibited higher proportions of weight loss (p < 0.001) and fever (p < 0.001) at the time of diagnosis. Additionally, radiological features such as nodules (p = 0.007), tree-in-bud (p < 0.001), cavitation (p < 0.001), and calcification (p < 0.001) were significantly more prevalent in APTB-LC patients compared to the other groups. Patients with APTB-LC were more susceptible to lymph node involvement (p < 0.001) and distant metastasis (p = 0.006) compared to those with IAPTB-LC or LC alone. Additionally, in comparison to LC alone, patients with IAPTB-LC exhibited more complex symptoms, imaging features, and lymph node metastases. Logistic regression results indicated that factors such as BMI, fever, patchy shadow, cavitation, neck or supraclavicular lymph node metastasis, and liver injury favor the diagnosis of APTB-LC over LC alone. The pre-diagnostic model exhibited robust performance, achieving area under the curve (AUC) values of 0.864 in the training set and 0.830 in the test set.

CONCLUSION

Our results indicate that PTB-LC is a distinct disease characterized by complex clinicopathological features and a more aggressive nature. Based on our findings, we recommend conducting TB-related tests for LC patients who exhibit relevant risk factors or are identified as high-risk cases according to the pre-diagnostic model.

Risk of malignant lymphoma in patients with previous tuberculosis infection: a cohort study

Tuberculosis (TB) is associated with chronic inflammation, which has been implicated in the pathogenesis of various malignancies, including lung cancer. However, the relationship between TB and hematological malignancies like lymphoma remains less understood. This study aimed to investigate risks of incident malignant lymphoma according to previous TB infection in a large prospective cohort of 347,204 individuals. Multiple logistic regression analyses were conducted to predict the probability of malignant lymphoma. Propensity score matching was employed to compare the incidence of lymphoma in individuals with and without previous TB infection. Among the overall population, 3.7% (12,694) reported previous history of TB. There was a significantly increased risk of lymphoma in individuals with a TB history, with an odds ratio of 2.14 (95% confidence interval (CI): 1.35-3.39, p = 0.001) and a hazard ratio of 2.13 (95% CI, 1.13-4.00; p = 0.019) in propensity-matched analyses. These findings underscore TB infection as a potential precursor to lymphoma, probably due to prolonged inflammatory and immune dysregulation. The study highlights the importance of considering a TB history in the risk assessment for lymphoma, emphasizing the need for vigilant clinical monitoring in population with high TB burden.

Risk of TB disease in individuals with cancer

BACKGROUND

Cancer increases the risk of developing TB disease; however, there are limited data on the magnitude of risk by cancer type and timing after diagnosis of cancer in low TB incidence settings.

METHODS

We conducted a nested case-control study of persons in Quebec between 1993 and 2017, including people with TB disease and matched controls. Conditional logistic regression was used to estimate adjusted odds ratios (aORs) of developing TB among people with cancer overall, by sub-type, and by time from cancer to TB diagnosis.

RESULTS

There were 4,283 people with TB disease and 268,420 matched controls. The median age for people with TB disease and controls was respectively 46 years (IQR 30-67) and 36 years (24-47). Prior exposure to cancer was associated with TB disease (aOR 6.3, 95% CI 5.3-7.6). The risk of TB diagnosis was highest within 3 months of cancer diagnosis (aOR 26.6, 95% CI 19.6-36.2), with 60% of diagnoses of TB disease occurring within 6 months of cancer diagnosis.

CONCLUSION

Risk of TB varies over time and by cancer type. Screening and treatment should be considered for potentially preventable TB (diagnosed more than 6 months post-cancer), particularly in those with respiratory, haematologic, and head and neck cancers.

Risk of Lung Cancer and Risk Factors of Lung Cancer in People Infected with Tuberculosis

This study investigated lung cancer risk in people infected with tuberculosis (TB) compared to the general population and evaluated factors associated with lung cancer in TB-infected individuals. Mandatory reported TB infection case data in Gyeonggi Province, South Korea (2010 to 2016) were obtained and linked with medical usage and health screening data from the National Health Information Database. Lung cancer incidence in patients with TB was compared to that in the general population using standardized incidence ratio (SIR), adjusted for age and sex. Lung cancer risk factors in patients with TB were studied using the Cox proportional hazards model. By April 2022, 1.26% (n = 444) of 35,140 patients developed lung cancer after TB diagnosis. Compared to the incidence in the general population, increased lung cancer risk in people with TB was observed (SIR: 2.04, 95% CI: 1.85-2.23). Multivariate analysis showed increased lung cancer in TB-infected individuals, associated with being male (hazard ratio [HR]: 2.24, 95% CI: 1.65-3.04), 1-year increase of age (HR: 1.09, 95% CI: 1.08-1.10), ever smoking (HR: 1.42, 95% CI: 1.02-1.97), and amount of daily smoking with one pack or more (HR: 2.17, 95% CI: 1.63-2.89). Increased lung cancer risk was noted in patients with TB compared to the general population, and sex, age, and smoking were factors associated with lung cancer in patients with TB.

Impact of immune checkpoint inhibitors (ICIs) therapy on interferon-γ release assay (IGRA) and diagnostic value in non-small cell lung cancer (NSCLC) patients

BACKGROUND

Tuberculosis (TB), a highly contagious respiratory disease, presents a significant global health threat, with a notable increase in incidence reported by the WHO in 2022. Particularly, the interplay between TB and non-small cell lung cancer (NSCLC) gains attention, especially considering the rising use of immune checkpoint inhibitors (ICIs) in cancer treatment. This interplay may influence TB diagnostics and reactivation, warranting a closer examination.

METHODS

A retrospective analysis was conducted on clinical data of NSCLC patients with positive T-SPOT results before undergoing anti-tumor treatment at Zhongshan Hospital (Xiamen), Fudan University, from January 1, 2021 to December 31, 2022. We assessed the incidence of tuberculosis reactivation and treatment outcomes among these patients. Moreover, we compared the differences in tuberculosis activity between the ICIs and non-ICIs treatment groups. Additionally, we observed the changes in T-SPOT spot count before and after immunotherapy, analyzing their association with tuberculosis activity and prognosis.

RESULTS

A total of 40 NSCLC patients with positive T-SPOT results before treatment were included in the study, with 26 patients in the ICIs treatment group and 14 patients in the non-ICIs treatment group. The study found no significant differences between the two groups in terms of gender, age, stage, histological type, performance status, driver gene expression, and distant metastasis. With a median follow-up time of 10.0 (6.0-14.5) months, three cases (11.5%) in the ICIs treatment group developed tuberculosis activity, diagnosed at 2, 3, and 12 months after ICIs treatment initiation. Conversely, no tuberculosis activity was observed in the non-ICIs treatment group, and the difference between the two groups was not significant (P = 0.186). Among the 32 patients who received ICIs treatment, spot count dynamics were diverse: four cases (12.5%) showed an increase, 12 cases (37.5%) had no change, and 16 cases (50.0%) had a decrease. During the follow-up, the progression rate (PD) was 50.0%, 75.0%, and 62.5% in the three groups, respectively (P = 0.527). Similarly, the mortality rate was 0%, 25.0%, and 25.0%, respectively (P = 0.106). Interestingly, among the patients with decreased spot counts, three cases (18.75%) were diagnosed with active pulmonary tuberculosis.

CONCLUSIONS

For NSCLC patients with a positive T-SPOT response undergoing ICIs treatment, our study observed indications of active tuberculosis. The varied T-SPOT spot count changes post-ICIs treatment suggest a complex interaction, potentially linking T-SPOT spot count reduction to tuberculosis reactivation risk. These preliminary findings underscore the importance of further research to more accurately assess T-SPOT's diagnostic utility in this context.

Micro-nanoemulsion and nanoparticle-assisted drug delivery against drug-resistant tuberculosis: recent developments

Tuberculosis (TB) is a major global health problem and the second most prevalent infectious killer after COVID-19. It is caused by Mycobacterium tuberculosis (Mtb) and has become increasingly challenging to treat due to drug resistance. The World Health Organization declared TB a global health emergency in 1993. Drug resistance in TB is driven by mutations in the bacterial genome that can be influenced by prolonged drug exposure and poor patient adherence. The development of drug-resistant forms of TB, such as multidrug resistant, extensively drug resistant, and totally drug resistant, poses significant therapeutic challenges. Researchers are exploring new drugs and novel drug delivery systems, such as nanotechnology-based therapies, to combat drug resistance. Nanodrug delivery offers targeted and precise drug delivery, improves treatment efficacy, and reduces adverse effects. Along with nanoscale drug delivery, a new generation of antibiotics with potent therapeutic efficacy, drug repurposing, and new treatment regimens (combinations) that can tackle the problem of drug resistance in a shorter duration could be promising therapies in clinical settings. However, the clinical translation of nanomedicines faces challenges such as safety, large-scale production, regulatory frameworks, and intellectual property issues. In this review, we present the current status, most recent findings, challenges, and limiting barriers to the use of emulsions and nanoparticles against drug-resistant TB.

Increased Lung Cancer Risk and Associated Risk Factors in Tuberculosis Survivors: A Korean Population-Based Study

BACKGROUND

Few studies have comprehensively evaluated the risk of lung cancer in tuberculosis survivors with consideration of smoking status and chronic obstructive pulmonary disease (COPD). Furthermore, little is known about lung cancer risk factors in tuberculosis survivors.

METHODS

This population-based cohort study enrolled tuberculosis survivors (n = 75 467) between 2010 and 2017 and 1:1 age- and sex-matched controls. Subjects were followed up for 1 year from the date of tuberculosis diagnosis to the date of the incident lung cancer, death, or December 2018, whichever came first. The risk of lung cancer was evaluated according to smoking and COPD status. We also evaluated the risk factors for lung cancer and developed an individualized lung cancer prediction model for tuberculosis survivors.

RESULTS

During a median follow-up duration of 4.8 years, the incident lung cancer risk was 1.72-fold higher in tuberculosis survivors than in the controls. Among tuberculosis survivors, those who were current smokers with ≥20 pack-years showed the highest risk of lung cancer (adjusted hazard ratio, 6.78) compared with never-smoker, non-tuberculosis-infected controls. tuberculosis survivors with COPD had a higher risk (2.43) than non-COPD, non-tuberculosis-infected controls. Risk factors for lung cancer in tuberculosis survivors were pulmonary tuberculosis, age >60 years, smoking, and the presence of COPD or asthma. The individualized lung cancer risk model showed good discrimination (concordance statistic = 0.827).

CONCLUSIONS

Previous tuberculosis infection is an independent risk factor regardless of smoking status or amount and COPD. Closer monitoring of tuberculosis survivors, especially heavy smokers or those with COPD, is needed for early lung cancer diagnosis.

The diagnosis interval influences risk factors of mortality in patients with co-existent active tuberculosis and lung cancer: a retrospective study

BACKGROUND

Previous studies reported that tuberculosis (TB) is associated with an increased risk of lung cancer or the survival and mortality of lung cancer. However, the impact of coexisting TB on the survival of lung cancer patients was controversial. We aimed to identify risk factors on the survival rate of patients with co-existent active TB and lung cancer.

METHODS

One hundred seventy-three patients diagnosed with active TB and lung cancer from January 2016 to August 2021 in Shanghai pulmonary hospital were selected and divided into two groups (≤ 6 months, > 6 months) according to the diagnosis interval between active TB and lung cancer (the order of diagnosis is not considered). The clinical characteristics and survival were analyzed. Univariate and multivariate logistic regression analyses were used to identify the risk factors for overall survival (OS).

RESULTS

One hundred seventy-three patients were diagnosed with lung cancer and active TB. The study population exhibited a median age of 64 years, with a majority of 81.5% being male, 58.0% of patients had a history of smoking. Among those involved, 93.6% had pulmonary TB, 91.9% were diagnosed with non-small cell lung cancer (NSCLC), 76.9% were Eastern Cooperative Oncology Group (ECOG) 0-2 and 12.7% were ECOG 3-4. We observed better survival in the > 6 months group compared with the ≤ 6 months group (hazard ratio [HR] 0.456, 95% confidence interval [CI]:0.234-0.889, P = 0.017). The 1-, 3-, and 5- year OS rates were 94.2%, 80.3%, and 77.6%, respectively, in the > 6 months group and 88.3%, 63.8%, and 58.5%, respectively, in the ≤ 6 months group. Surgery (HR 0.193, [95% CI, 0.038-0.097]; P = 0.046) and ECOG Performance Status (HR 12.866, [95% CI, 2.730-60.638]; P = 0.001) were independent prognostic factors in the > 6 months group.

CONCLUSIONS

Patients diagnosed with lung cancer and active TB for more than half a year have a significantly better prognosis than those diagnosed within half a year. ECOG Performance Status and surgery might possibly affect the outcomes of patients with co-existent active TB and lung cancer.

A rare case report: co-occurrence of two types of lung cancer with hamartoma and pulmonary tuberculosis

With the widespread use of low-dose chest Computed Tomography (CT), lung nodules are being increasingly detected. Common pulmonary conditions such as lung adenocarcinoma, lung squamous cell carcinoma, and tuberculosis are typically diagnosable through imaging examinations. Nevertheless, when multiple types of lung cancer are combined with other benign tumors, how can an accurate diagnosis be made? In this report, we present a rare case of a patient with the simultaneous occurrence of lung adenocarcinoma, lung squamous cell carcinoma, pulmonary tuberculosis, and pulmonary hamartoma, which has not been previously reported. This patient underwent surgical intervention in the Department of Thoracic Surgery at the Second Hospital of Jilin University and has now fully recovered and been discharged. The patient's preoperative positron emission tomography-CT(PET-CT)results did not align with the postoperative pathological diagnosis. The imaging findings were atypical, and the pathological diagnosis was exceptionally rare. We share this case report to contribute to the accumulation of clinical experience.

Coexistence of pulmonary tuberculosis and small cell lung carcinoma: A significant problem in tuberculosis-endemic country?

Pulmonary tuberculosis and lung cancer are public health problems, causing significant morbidity and mortality worldwide. The coexistence of the two diseases has rarely been reported while their causative association has been noticed leading to diagnosis delayed and prognosis worsening. In this case report, we present the case of a patient with coexistence of pulmonary tuberculosis and small cell lung carcinoma. A 54-year-old male was presented with the complained of lower left chest pain for six months, which was getting worse four days before admission to the hospital. The patient also complained of cough and decreased appetite and weight loss. Initial chest X-ray revealed an infiltrate and cavity in the upper right lung and inhomogeneous consolidation in the left paracardial. After the patient was diagnosed with pulmonary tuberculosis and was given anti-tuberculosis drugs for two months, the cavity and consolidation decreased with no clinically significant improvement. We performed a bronchoscopy with suspicion of lung cancer and a forcep biopsy in which small cell carcinoma was confirmed. The patient received two cycles of chemotherapy and anti-tuberculosis was continued for four months. During the observation in the fourth month, there was a reduction in the tumor size. This case highlights that similarity of clinical symptoms between pulmonary tuberculosis and lung cancer often lead to misdiagnosis of both. Therefore, in the absence of complete clinical and radiological improvement in pulmonary tuberculosis patients, the coexistence of lung cancer should be considered. This also highlights that early diagnosis is critical for the favorable outcome.

Residual respiratory disability after successful treatment of pulmonary tuberculosis: a systematic review and meta-analysis

Background

Pulmonary tuberculosis (PTB) can result in long-term health consequences, even after successful treatment. We conducted a systematic review and meta-analysis to estimate the occurrence of respiratory impairment, other disability states, and respiratory complications following successful PTB treatment.

Methods

We identified studies from January 1, 1960, to December 6, 2022, describing populations of all ages that successfully completed treatment for active PTB and had been assessed for at least one of the following outcomes: occurrence of respiratory impairment, other disability states, or respiratory complications following PTB treatment. Studies were excluded if they reported on participants with self-reported TB, extra-pulmonary TB, inactive TB, latent TB, or if participants had been selected on the basis of having more advanced disease. Study characteristics and outcome-related data were abstracted. Meta-analysis was performed using a random effects model. We adapted the Newcastle Ottawa Scale to evaluate the methodological quality of the included studies. Heterogeneity was assessed using the I² statistic and prediction intervals. Publication bias was assessed using Doi plots and LFK indices. This study is registered with PROSPERO (CRD42021276327).

Findings

61 studies with 41,014 participants with PTB were included. In 42 studies reporting post-treatment lung function measurements, 59.1% (I² = 98.3%) of participants with PTB had abnormal spirometry compared to 5.4% (I² = 97.4%) of controls. Specifically, 17.8% (I² = 96.6%) had obstruction, 21.3% (I² = 95.4%) restriction, and 12.7% (I² = 93.2%) a mixed pattern. Among 13 studies with 3179 participants with PTB, 72.6% (I² = 92.8%) of participants with PTB had a Medical Research Council dyspnoea score of 1-2 and 24.7% (I² = 92.2%) a score of 3-5. Mean 6-min walk distance in 13 studies was 440.5 m (I² = 99.0%) in all participants (78.9% predicted, I² = 98.9%) and 403.0 m (I² = 95.1%) among MDR-TB participants in 3 studies (70.5% predicted, I² = 97.6%). Four studies reported data on incidence of lung cancer, with an incidence rate ratio of 4.0 (95% CI 2.1-7.6) and incidence rate difference of 2.7 per 1000 person-years (95% CI 1.2-4.2) when compared to controls. Quality assessment indicated overall low-quality evidence in this field, heterogeneity was high for pooled estimates of nearly all outcomes of interest, and publication bias was considered likely for almost all outcomes.

Interpretation

The occurrence of post-PTB respiratory impairment, other disability states, and respiratory complications is high, adding to the potential benefits of disease prevention, and highlighting the need for optimised management after successful treatment.

Funding

Canadian Institutes of Health Research Foundation Grant.

Cancers attributable to infectious agents in Italy

OBJECTIVES

To provide an evidence-based, comprehensive assessment of the current burden of infection-related cancers in Italy.

METHODS

We calculated the proportion of cancers attributable to infectious agents (Helicobacter pylori [Hp]; hepatitis B virus [HBV] and hepatitis C virus [HCV]; human papillomavirus [HPV]; human herpesvirus-8 [HHV8]; Epstein-Barr virus [EBV]; and human immunodeficiency virus [HIV]) to estimate the burden of infection-related cancer incidence (2020) and mortality (2017). Data on the prevalence of infections were derived from cross-sectional surveys of the Italian population, and relative risks from meta-analyses and large-scale studies. Attributable fractions were calculated based on the counterfactual scenario of a lack of infection.

RESULTS

We estimated that 7.6% of total cancer deaths in 2017 were attributable to infections, with a higher proportion in men (8.1%) than in women (6.9%). The corresponding figures for incident cases were 6.5%, 6.9% and 6.1%. Hp was the first cause of infection-related cancer deaths (3.3% of the total), followed by HCV (1.8%), HIV (1.1%), HBV (0.9%), HPV, EBV and HHV8 (each ≤0.7%). Regarding incidence, 2.4% of the new cancer cases were due to Hp, 1.3% due to HCV, 1.2% due to HIV, 1.0% due to HPV, 0.6% due to HBV and <0.5% due to EBV and HHV8.

CONCLUSIONS

Our estimate of 7.6% of cancer deaths and 6.9% of incident cases that were attributable to infections in Italy is higher than those estimated in other developed countries. Hp is the major cause of infection-related cancer in Italy. Prevention, screening and treatment policies are needed to control these cancers, which are largely avoidable.

Incidence and Risk of Lung Cancer in Tuberculosis Patients, and Vice Versa: A Literature Review of the Last Decade

Background

The incidence and risk of both lung cancer (LC) and tuberculosis (TB) are increasing rapidly. These two diseases frequently exist together and can influence the incidence and risk of each other. The aim of the current review was to summarize the incidence and risk of LC in TB patients, and vice versa, short out research gap, and contemplate future research perspectives. Methodology. PubMed and Scopus databases, and Google Scholar search engine were searched for epidemiological studies that investigated the incidence and risk of TB and LC, published since January 2011 to April 2022, and written in English. We used the searching keyword "tuberculosis" combined with "lung cancer" and associated medical subject heading (MeSH) to retrieve eligible research articles. We retrieved information's regarding the diagnosis of TB and LC, confounders, the associations of TB and LC, and incidence and risks of each other.

Results

We found higher incidence rate and risks (1.64 to 6 times higher) of LC in TB patients in comparison to non-TB participants. However, the incidence rate and risks of TB in LC patients were comparatively low. Male patients were exhibited higher risks than female. The medical comorbidities, smoking habits, and age can also influence the associations and risks of LC in TB patients or vice versa.

Conclusion

Our summarized studies might suggest that existing active TB may increase the incidence and risk of LC. However, large prospective cohort study is warranted to explore the real scenario worldwide.