Abstract:

Objective: To explore the effectiveness and safety of concurrent anti-tuberculosis chemotherapy and intensity-modulated radiotherapy (IMRT) in patients with active pulmonary tuberculosis and different types of thoracic malignancies. Methods: Clinical data, laboratory examination and imaging results of 28 patients with comorbidities in Xi’an Chest Hospital from May 20, 2022 to February 20, 2023 were collected, and the diagnosis method, medication basis and effectiveness evaluation of pulmonary tuberculosis were retrospectively analyzed. At the same time, the target area and dose of radiotherapy, the limit of organs at risk, the remission of tumor related symptoms and the control of tumor were analyzed. The effectiveness and adverse reactions of anti-tuberculosis and anti-tumor treatment were analyzed descriptively. Results: Eastern Cooperative Oncology Group (ECOG)≥2, body mass index (BMI)<18.5, stage Ⅳ, tuberculous lesion and tumor irradiation area overlap happened in 20, 11, 26 and 15 cases, respectively. Chest tumors included 18 cases of lung cancer, 5 cases of esophageal cancer, and 5 other cases (2 cases of thymoma and 3 cases of pleural mesothelioma). Among the 28 patients, 23 had taken drug susceptibility test based on etiological test result of pulmonary tuberculosis, and the other 5 were clinically diagnosed as active pulmonary tuberculosis, all of them received standard anti-tuberculosis therapy. By the end of follow-up, 8 cases were cured for tuberculosis, 10 cases completed treatment, 1 case failed, 7 cases died of tumor progression, 2 cases continued anti-tuberculosis treatment; 18 cases (64.3%) were successfully treated (cured+treatment completed). Image-guided IMRT was used in thoracic tumor radiotherapy, and the improvement of tumor-related symptoms after radiotherapy was all >80% (83.3%-100.0%). Radiotherapy best response evaluation result (2-3 months) was as follows: complete response in 0 case, partial response in 16 cases, stable in 8 cases, progress in 4 cases, disease control (complete response+partial response+stable) in 24 cases (85.7%). Adverse reactions: hematological toxicity: ≥grade 3 leukopenia, lymphocytopenia and anemia were observed in 2, 6 and 1 cases respectively. Non-hematologic toxicity: ≥grade 3 radiation esophagitis, radiation pneumonia, ALT and AST elevation happened in 1 patient for each. There were 2 patients with central lung cancer with airway obstruction and caseous pneumonia, of which 1 patient also had tuberculous lymph node bronchial fistula, and 1 patient was pathologically confirmed to have tuberculosis and cancer coexisted in the same bronchus. Symptoms of these 2 cases worsened after receiving 20 Gy and 14 Gy radiation respectively, after that their radiotherapy were terminated. Conclusion: Image-guided IMRT is safe and effective with acceptable side effects in active pulmonary tuberculosis and thoracic malignancy patients treated with standard anti-tuberculosis drugs. Patients with tuberculous caseous pneumonia, central lung cancer with open tuberculous lymph node bronchial fistula, co-existed cancer and endobronchial tuberculosis induced significant atmospheric tract obstruction which is not effectively relieved should be cautious for receiving IMRT.

Key words: Tuberculosis, pulmonary, Lung neoplasms, Intensity-modulated radiation therapy, Treatment outcome