대한흉부영상의학회 Korean Society of Thoracic Radiology

Discussion

Diagnosis With Brief Discussion

Diagnosis

Invasive Cavitating Aspergillosis in a Patient with Cancer

Radiologic Findings

Chest radiographs show multiple, cavitating nodules in the both lungs. The size ranges from 2.0 to 5.0 cm. They are predominent in periphery, lower and slightly right lung. Most of them are well-demarcated, but right perihilar lesion has surrounding parenchymal consolidation. There is a lobulated mass density in right upper medial chest. Differential diagnoses were cavitating metastatic ca. such as primary or metastatic squamous cell ca. (lung, cervix, head and neck ca, esophagus, etc), inflammation (invasive aspergillosis, invasive mucormycosis, nocardiosis, cryptococcosis), Wegener’s granulomatosis, septic or aspetic emboli.
Chest CT scans show diffuse, peribronchial consolidation in the medial aspects of right upper and lower lung fields. Necrotic material is noted in the dependent portion of the largest cavity of the right lower lobe. The wall of the cavities are slightly ragged or spiculated with surrounding halos in some nodules. Capsules of the nodules are enhanced as rim pattern.
Tissues were obtained by CT-guided, core needle biopsy. Aspergillus fumigatus was cultured. Pathologic specimen show fungal organisms (aspergillus) and coagulation necrosis (probably, infectious origin) without the evidence of tumor cells.

Brief Review

Cavitating aspergillosis infection has been documented in immunosuppressed patient with cancer (1, 2). Underlying malignancies included leukemia, lymphoma, and metastatic carcinoma (lung ca, breast ca, colon ca). Patients received the following immunosuppressed therapy: chemotherapy alone, chemotherapy plus corticosteroids, corticosteroid alone, and steroids plus localized radiation (one of eleven patients).
Lung cavitation occurs in 4% to 16% of patients with invasive aspergillosis. Invasive pulmonary aspergillosis is defined histologically by parenchymal and blood vessel invasion by fungal hyphae with ensuing thrombosis, infarction, and acute inflammation. Cavities occur most frequently by separation of the infarcted lung from adjacent viable lung, resulting in as intracavitary sequestrum of necrotic lung tissue. The roentgenologic correlation of this sequence of events is the “air-crescent” sign. The proposed pathogenesis of cavity formation invokes proteolytic destruction of lung parenchyma by enzymes released from neutrophils at the periphery of the infarct. The mechanism is supported by the study of Albelda et al. (3), who documented that cavitation appeared coincident with recovery from granulocytopenia. Fungal invasion, acute inflammation, and necrosis of blood vessels adjacent to developing cavities can result in arterial fistulae and massive hemoptysis. Massive fatal hemoptysis is clearly associated with lung cavitation in invasive aspergillosis (2). There was a relatively good correlation between the clincal duration of pulmonary disease and the histologic maturity of cavities. As cavities age they progress through a stage of granulation tissue to dense mural fibrosis. This process is accompanied by organizing pneumonia in the adjacent lung. One of histologic pattern of cavitary aspergillosis was that of a suppurative, granulomatous pneumonia with abscess formation, similar to lesions seen in chronic bacterial or fungal infections, such as actinomycosis or cryptococcosis. Suppurative, granulomatous aspergillosis has been described in patients with chronic granulomatous disease of childhood. Suppurative aspergillus pneumonia also has been reported rarely in patients with antecedent viral or bacterial infection or general debilitation or as a localized or disseminated form of invasive aspergillosis. Of particular interest was the ability of CT-guided TBNA to assist in diagnosing invasive aspergillosis in small peripheral inflammatory lesions in severely immunocompromised patients (4).

References

1. Pai U, Blinkhorn Jr RJ, Tomashefski Jr JF. Invasive cavitary pulmonary aspergillosis in patients with cancer: A clinicopathologic study. Human pathology 1994; 25(3): 293-303
2. Borkin MH, Arena FP, Brown AE, Armstrong DA. Invasive aspergillosis with massive fatal hemoptysis in patients with neoplastic disease. Chest 1980; 8(6): 835-839
3. Albelda SM, Talbot GH, GersonSL, et al. Pulmonary cavitation and massive hemoptysis in invasive pulmonary aspergillosis. Influence of bone marrow recovery in patients with acute leukemia. Am Rev Respir Dis 1985; 131:115-120
4. White CS, Weiner EA, Patel P, Britt EJ. Transbronchial needle aspiration. Guidance with CT fluoroscopy. Chest 2000; 118:1630-1638

Keywords

Lung, Infection, immune related, Invasive Cavitating Aspergillosis in a Patient with Cancer