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Year : 2017  |  Volume : 13  |  Issue : 1  |  Page : 142-144

Coexistence of hard palate carcinoma with tuberculosis: A rarity

1 Department of Pulmonary Medicine, King George Medical University, Lucknow, Uttar Pradesh, India
2 Department of Pathology, King George Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication16-May-2017

Correspondence Address:
S K Verma
Department of Pulmonary Medicine, King George Medical University, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.174538

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 > Abstract 

Coexistence of tuberculosis (TB) and palatal malignancy is a rare phenomenon and it has never been reported. Here, we present a case of hard palate carcinoma with TB in a 60-year-old male patient who was successfully managed by three pronged approaches by combining antitubercular therapy with chemotherapy and radiotherapy.

Keywords: Carcinoma, hard palate, tuberculosis

How to cite this article:
Verma S K, Srivastava A, Nagaraju K, Mishra AK, Goel M M. Coexistence of hard palate carcinoma with tuberculosis: A rarity. J Can Res Ther 2017;13:142-4

How to cite this URL:
Verma S K, Srivastava A, Nagaraju K, Mishra AK, Goel M M. Coexistence of hard palate carcinoma with tuberculosis: A rarity. J Can Res Ther [serial online] 2017 [cited 2022 Oct 5];13:142-4. Available from: https://www.cancerjournal.net/text.asp?2017/13/1/142/174538

 > Introduction Top

Tuberculosis (TB) of the hard palate is rare and usually secondary to pulmonary TB. Incidence of primary TB of the oral cavity is about 1%.[1] Oral cavity malignancies are more common phenomenon in India with an incidence of about 20/100,000 (30% of all malignancies). On extensive search of the literature, only four cases with coexisting oral malignancy and oral TB have been reported.[2],[3],[4],[5] However, coexisting lesions over the hard palate have never been reported. Here, we present a pioneer case of hard palate carcinoma with TB in a 60-year-old male patient who was successfully managed by three pronged approaches by combining antitubercular therapy (ATT) with chemotherapy and radiotherapy.

 > Case Report Top

A 60-year-old male presented with complaints of difficulty in swallowing solid foods and difficulty in opening mouth completely for 2 months, and loss of appetite and productive cough for 1 month. He was a chronic tobacco chewer and smoked an average of 10 beedis/day for about 25 years. He had previously taken ATT for 6 months for tubercular cervical lymphadenopathy 25 years ago, records of which are not available. There were no complaints of breathlessness, hemoptysis, fever, or chest pain.

On examination, his heart rate was 102/min, respiratory rate was 14/min, and blood pressure was 100/64 mmHg. Oral examination showed the presence of multiple ulcers with the largest measuring about 2 cm × 3 cm. Ulcers had irregular margins with necrotic base near the base of the second and third molar teeth over the hard palate [Figure 1]. Respiratory system examination showed the presence of scattered rhonchi. Rest of the systemic examinations was normal. Investigations showed hemoglobin of 11.4 g, total leukocyte count of 8700/mm, and differential count of 78% polymorphs, 20% lymphocytes, and 2% eosinophils. His renal and liver function tests were normal. Serology for human immunodeficiency virus was negative. Chest X-ray was within normal limits.
Figure 1: The presence of multiple irregular ulcers with necrotic base over the hard palate

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Histopathological examination of a biopsy tissue taken from the ulcer margin showed hypertrophied stratified squamous epithelium with moderate to severe dysplasia along with breach in the basement membrane and subepithelial zone showing few sheets of atypical squamous cells with keratin pearl formation and intraepithelial keratinization. Subepithelial layer also showed chronic granulomatous inflammation comprising epithelioid histiocytes, lymphocytes, and Langhans-type of giant cells in the background of fibrocollagenous tissue and necrosis [Figure 2]. Ziehl–Neelsen stain was positive for acid-fast bacilli. Thus, the diagnosis of concomitant TB with squamous cell carcinoma of the hard palate was made.
Figure 2: The presence of invasive atypical squamous epithelium with keratin pearls and also the presence of Langhans giant cells in an inflammatory background

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In view of the tubercular etiology, the patient was started first on ATT with category II (directly observed treatment, short course) therapy under Revised National TB Control Programme, followed by referral to the Department of Oncosurgery for the treatment of carcinoma of hard palate with chemotherapy and radiation therapy.

 > Discussion Top

Oral lesions of TB, though uncommon, are seen both in the primary as well as the secondary stages of the disease. In secondary TB, the oral manifestations are accompanied by lesions in the lung, lymph nodes, or any other organ system of the body. This can be detected by the usual clinical history and systemic examination. Among the oral lesions, tongue is the usual site for tubercular infection, upper lip, and soft palate being the least affected. Other sites can be salivary glands, tonsils, uvula and mandibular ridge.[6] They may be painful or painless and may resemble a malignant ulceration. In our case, there were multiple painless ulcers over the hard palate. Biopsy generally reveals nonspecific inflammation, caseating granulomas and foreign body giant cells. The differential diagnosis of the lesions of oral TB includes trauma, actinomycosis, syphilis, carcinoma, Wegener's granulomatous and aphthous ulceration.

TB cutis orificialis is a rare manifestation of mucocutaneous TB that is caused by auto-inoculation of mycobacteria in patients with advanced TB. The presenting features include (i) Ulcer on the tonsil or oropharyngeal wall; (ii) granuloma of the nasopharynx; and (iii) neck abscess. Infection in the oral cavity is usually acquired through infected sputum coughed out either by a patient with open pulmonary TB or by hematogenous spread. Secondary oral TB can occur in all age groups but most common in middle- and older-age groups. The most common occurring lesion is an ulcer, characterized by irregular edges with minimal induration, as was the finding in our case. The base of an ulcer may be granular or covered with pseudomembrane. Sometimes oral TB ulcer can be seen as superficial ulcers, patches, indurated soft-tissue lesions, or even lesions within the jaw that may be in the form of TB osteomyelitis. Presence of an intact squamous epithelium of the oral mucosa possibly makes TB bacilli penetration difficult and provides protection against the infection. The systemic factors that favor the chances of oral TB infection included lowered host resistance and increased virulence of the organisms.[6] In our case, the breach in the mucosa of the hard palate due to a malignant ulcer could probably have been responsible for the penetration of the tubercle bacilli.

On the other hand, prevalence of oral malignancies involving the hard palate is more common compared to TB.[7] Squamous cell carcinoma (SCC) is the most common malignant neoplasm affecting the hard palate (50%). Other malignancies include minor salivary gland cancers, sarcomas, and melanomas. A strong etiology has been associated with tobacco chewing and alcohol consumption, more specifically with reverse smoking. Ill-fitting dentures, poor oral hygiene, mechanical irritation, and mouthwash are other factors associated SCC of the hard palate. They usually present as a painless ulcer with a necrotic base as seen in our case. Local extension, lymph node, and perineural involvement is usually seen. Coexistence of TB with malignancy has been well-reported in the past.[8] Usually, in other situations, the presence of active TB in a malignant lesion is attributed to the chronic inflammatory state associated with TB or a chance finding. However, in our patient, we suspect that the cause for coexistent finding of malignancy and TB is a breach of intact mucosal epithelium due to the malignancy per se and chronic tobacco chewing causing a secondary tubercular infection.

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Conflicts of interest

There are no conflicts of interest.

 > References Top

Dixit R, Sharma S, Nuwal P. Tuberculosis of oral cavity. Indian J Tuberc 2008;55:51-3.  Back to cited text no. 1
Landa LE, Kathju S, Nepomuceno-Perez MC, Gordon C, Sotereanos GC. Tuberculous granuloma and adenoid cystic carcinoma presenting as a single buccal space mass. J Craniofac Surg 2002;13:533-7.  Back to cited text no. 2
Bishara J, Calderon S, Okon E, Shevach I, Maimon S, Pitlik S. Coexisting extrapulmonary tuberculosis and malignancy. Am J Med 1998;105:443-6.  Back to cited text no. 3
Gal G, Kaplan I, Calderon S, Carlson ER. Large perimandibular swelling. J Oral Maxillofac Surg 1997;55:1134-43.  Back to cited text no. 4
Bagga P, Dewan A, Agarwal P, Garg C, Datta NR. Oral tuberculosis following successful treatment of oral malignancy. J Cancer Res Ther 2012;8:650-1.  Back to cited text no. 5
Ebenezer J, Samuel R, Mathew GC, Koshy S, Chacko RK, Jesudason MV. Primary oral tuberculosis: Report of two cases. Indian J Dent Res 2006;17:41-4.  Back to cited text no. 6
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de Souza DL, Pérez MM, Curado MP. Predicted incidence of oral cavity, oropharyngeal, laryngeal, and hypopharyngeal cancer in Spain and implications for cancer control. Cancer Epidemiol 2011;35:510-4.  Back to cited text no. 7
Falagas ME, Kouranos VD, Athanassa Z, Kopterides P. Tuberculosis and malignancy. QJM 2010;103:461-87.  Back to cited text no. 8


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