Aspergilloma within cavitary lung cancer: MR imaging findings.
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PURPOSE: To analyze high resolution CT (HRCT) features of a miliary pattern in different diseases. MATERIAL AND METHODS: Eight HRCT studies with a miliary lung pattern were retrospectively reviewed with the diagnoses tuberculosis (n=3), Candida albicans (n=1), sarcoidosis (n=3), and metastatic adenocarcinoma (n=1). RESULTS: In all cases, HRCT showed diffusely disseminated nodules up to 3 mm. In 2 cases of tuberculosis and 1 of sarcoidosis, the lesions predominated in the upper/middle lung zones. In the case of metastatic adenocarcinoma the nodules were more sparse in the lung periphery while in 1 case of sarcoidosis, HRCT revealed a predominance of the lesions in the outer third of the lungs. Cyst-like lesions of 12 mm were observed in 2/3 cases of tuberculosis and in metastatic adenocarcinoma. Notably thickened interlobular septa and interlobar fissures were each seen in 2/3 cases of sarcoidosis. In general, a random relationship of miliary nodules to secondary lobular structures and bronchovascular bundles was observed, despite the co-existence of centrilobular, subpleural and paraseptal nodules. CONCLUSION: HRCT features that potentially contribute in making a differential diagnosis are: a) A peripheral distribution of nodules, an increased number of thickened interlobular septae, and a notable thickening of interlobar fissures, all of which are indicative of sarcoidosis; and b) Multiple cyst-like lesions which should direct attention to tuberculous or metastatic origin. The predominance of miliary nodules in relation to cephalocaudal axis, their margin and size are not helpful features to the differential diagnosis of diseases presenting a miliary pattern.
Aspergillosis was diagnosed in a 69-year-old man presenting with blood-stained sputum, and was treated with an antifungal agent. As radiographic lesions persisted after 3 months, left upper lobectomy was performed. The surgical specimen revealed pulmonary carcinoma associated with an intracavitary aspergillar infection.
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A teenage boy presented with hypercalcemia and a large intrathoracic mass. Results of an extensive evaluation, including normal findings on parathyroid hormone and urinary 3', 5'-cyclic adenosine monophosphate assays, failed to explain his hypercalcemia. During surgery, a large plasma-cell granuloma of the right middle and lower lobes was resected. Within 2 weeks, serum calcium levels returned to normal. Serum calcitriol (1,25-dihydroxyvitamin D3) levels were elevated before surgery and decreased to normal afterward, correlating with the serum calcium level. Homogenates of the plasma-cell granuloma synthesized a compound indistinguishable from calcitriol.
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A 67-year-old man was admitted with the complaint of hemosputum. Chest X-ray films resulted in a diagnosis of pulmonary aspergilloma, and treatment with intravenous amphotericin B was initiated. However, therapy was discontinued due to renal insufficiency, an adverse effect of amphotericin B. The size of the fungus ball and cavity increased despite treatment with oral itraconazole (200 mg/day). Cavernostomy was performed and the fungus ball was removed from the upper lobe of the left lung. Computed tomographic scans disclosed thickening of the remaining wall of the cavity, with destruction of the ribs. The patient experienced worsening respiratory distress and died. Necropsy revealed adenocarcinoma of the left lung.
Routine chest radiographs of a 52-year-old woman displayed abnormal opacities in the right lower lung field. A computed tomographic (CT) scan of the chest disclosed irregular nodular opacities in the peripheral zone of the right S6. Reconstructed three-dimensional images obtained by helical CT displayed the lesions as agglutinated small nodules, with other small nodules near the bronchi appearing as "tree-in-bud" formations. Specimens obtained by transbronchial lung biopsy of the right B6b revealed atypical glandular structures, thus leading to suspected adenocarcinoma of primary lung cancer. A right lower lobectomy was performed; cut-surface specimens of the resected tissues showed multiple lobulate, milky-white nodules near the bronchi. Histopathologic examination found no malignant cells. PAS staining revealed numerous cryptococcal organisms, thus yielding the final diagnosis of primary pulmonary cryptococcosis.
Two apparently solitary granulomas, each containing an adiaconidia, 200 and 300 microm in diameter, were incidentally found in the lung parenchyma on a pleuro-pneumonectomy specimen for malignant mesothelioma, and in the stroma of a pulmonary adenocarcinoma, respectively. These two cases of adiaspiromycosis illustrate well the characteristic morphology of this strictly pulmonary, rare, ubiquitous, and histologically diagnosed mycosis.
75-year old woman admitted to Institute of TB due to the opacity in middle lobe of the right lung is described. The chest X-ray might suggest possibility of the lung cancer. The examination of the patient did not revealed any abnormalities. At the admission the nature of the lesion was not recognised by the accessible methods. Therefore, the thoracotomy was performed, and the aspergilloma was confirmed by intraoperative histopathologic methods. The middle lobe with the lesion was totally resected. The postoperative period was uneventful. The six months follow-up revealed that patient was cured.
A 59-year-old male clerk consulted in general practitioner due to cough and hemoptysis. A mass shadow was pointed out in the left upper lung field on a chest radiograph. Patient was referred to our hospital for further treatment. Any definitive daiagnosis could not be made after examinations including sputum culture, cytology and TBLB. Because a lung cancer was strongly suspected, an exploratory thoracotomy was performed. Actinomyces was detected by pathological study of excised specimen, with no evidence of cancer. ABPC was administered for two months postoperatively. The patient is doing well without recurrence of actinomycosis 2.5 years after the surgery. Pulmonary actinomycosis presenting a mass shadow on a radiograph may mimick a pulmonary tumor, especially a lung cancer. Pulmonary actinomycosis should be considered in a differential diagnosis of pulmonary lesion thought to be malignant.
A 66-year-old man was referred to our hospital because of cough. Chest X-ray films showed complete atelectasis of the left lung. Serum CYFRA was elevated. Bronchoscopic examination disclosed a white polypoid lesion occluding the left main bronchus. A biopsy specimen from the lesion revealed numerous aspergillus hyphae. Oral itraconazole (100 mg) and weekly endobronchial instillation of fluconazole were administered. Three months later, on the 12th bronchoscopic examination, the tumor occluding the left main bronchus was detected after the removal of aspergillus, and the biopsy findings yielded a diagnosis of squamous cell carcinoma. Aspergillosis complicated by lung cancer without cavity formation is very rare, and compounded the difficulty of diagnosing lung cancer in this case.
In spite of improvements in the surgical technique of lung transplantation, early and late complications after surgery are not uncommon. The authors review the clinical aspects and radiological findings of these complications, including reperfusion edema, acute rejection, infections, airway complications, vascular complications, pleural complications, chronic rejection, omentopexy complications, transbronchial biopsy complications, post-transplantation lymphoproliferative disease and recurrence of the primitive disease. Early detection of these complications is important for early appropriate treatment, resulting in the decrease in morbidity and mortality of the transplanted patients.
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