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Cavity with ball-in-hole lesion in the lung

Published:February 09, 2016DOI:https://doi.org/10.1016/j.ejim.2016.01.021

      Highlights

      • Either benign or malignant process could contribute to pulmonary cavitary lesion.
      • Radiological features of cavity could not differentiate malignancy or not very well.
      • Fungal infection combined with lung cancer should be kept in mind.

      Keywords

      1. Case presentation

      A 35-year-old male suffered from a cough with sputum for one month. He was relatively healthy in the past and had a smoking history of 0.5 PPD for more than 10 years. There was no fever, no dyspnea, no body weight loss and no special travel history. At the OPD, chest radiograph showed a cavity in the upper area of the right lung of 3.5 cm × 4.5 cm with thin wall lesion. Chest computer tomography showed a thin wall cavitary lesion with irregular inner margin over the right apex area and an intracavitary ball-in-hole appearance mass (Fig. 1). Sputum examination showed no evidence of bacterial or tuberculosis infection. However, hemoptysis developed and he was referred to our hospital for surgical intervention due to deteriorating clinical condition. Physical examination was unremarkable and lab data showed leukocytosis and normal liver and renal function.
      Figure thumbnail gr1
      Fig. 1Chest radiograph (left) and computer tomography (right) showed a thin wall cavitary lesion over the right apex area and an intracavitary ball-in-hole appearance mass.
      What is the diagnosis?

      2. Diagnosis

      He received right upper lobe surgical wedge resection and pathology showed pleomorphic carcinoma mixed with aspergillosis infection. Cavitary lesion in the lung is not uncommon in clinical scenarios. Various etiologies contribute to cavity formation, such as tuberculosis, fungus, hydatid cyst, neoplasm [
      • Abramson S.
      The air crescent sign.
      ,
      • Mochizuki T.
      • Ishii G.
      • Nagai K.
      • Yoshida J.
      • Nishimura M.
      • Mizuno T.
      • et al.
      Pleomorphic carcinoma of the lung: clinicopathologic characteristics of 70 cases.
      ]. However, more pulmonary malignancy occupied the cavity etiology, especially squamous cell lung cancer [
      • Vourtsi A.
      • Gouliamos A.
      • Moulopoulos L.
      • Papacharalampous X.
      • Chatjiioannou A.
      • Kehagias D.
      • et al.
      CT appearance of solitary and multiple cystic and cavitary lung lesions.
      ]. Radiological features such as wall thickness or smooth inner margin were used to differentiate malignancy and non-malignancy but the results were disappointing. Ball-in-hole lesions commonly occur in preexisting, thin wall cavitary lesions and are associated with fungal infections, especial the aspergillosis. Most aspergilloma are asymptomatic and surgical resection is indicated for patients with recurrent hemoptysis. So, the fungus was possibly infected from a tumor with necrotic area. We present this case as fungal infected lung tumor with aggressive behavior similar to pleomorphic carcinoma. This case reminded the clinical physician that a scenario of cavitary cancerous lesion with fungal infection should be kept in mind. Hence, pulmonary cavitary lesion even with common radiological features of an infectious process required further examination in clinical practice.

      Conflicts of interest

      The authors have no actual or potential conflicts of interest.

      References

        • Abramson S.
        The air crescent sign.
        Radiology. 2001; 218: 230-232
        • Mochizuki T.
        • Ishii G.
        • Nagai K.
        • Yoshida J.
        • Nishimura M.
        • Mizuno T.
        • et al.
        Pleomorphic carcinoma of the lung: clinicopathologic characteristics of 70 cases.
        Am J Surg Pathol. 2008 Nov; 32: 1727-1735
        • Vourtsi A.
        • Gouliamos A.
        • Moulopoulos L.
        • Papacharalampous X.
        • Chatjiioannou A.
        • Kehagias D.
        • et al.
        CT appearance of solitary and multiple cystic and cavitary lung lesions.
        Eur Radiol. 2001; 11: 612-622