Expanding the spectrum of chronic necrotising (semi‐invasive) aspergillosis: a series of eight cases presenting as radiologically solid lung nodules mimicking malignancy

Abstract

Aim: To clinicopathologically characterise a subset of aspergillosis cases characterised by radiologically solid lung nodules. Methods and results: We reviewed our archives for lung biopsies/resections with fungal hyphae on histology. Cases classifiable as a well-established form of aspergillosis were excluded. Unclassifiable cases with radiologically solid lung nodules and histological evidence of fungal hyphae consistent with Aspergillus were analysed in detail. Of 134 lung biopsies/ resections with fungal hyphae, eight presented as a solid lung nodule on imaging and could not be classified as a well-recognised form of aspergillosis. All patients were non-immunocompromised/minimally immunocompromised adult smokers. Imaging showed solid, predominantly solitary, spiculated, subpleural, hypermetabolic upper lobe nodules in emphysematous lungs. Malignancy was suspected clinically in all cases. Histologically, the nodules were necrotising granulomas containing fungal hyphae consistent with Aspergillus. On follow-up, none of the nodules recurred or progressed to invasive disease. Conclusions: Aspergillosis can present as a radiologically solid, spiculated lung nodule suspicious for malignancy. Materials and methodsAfter approval from the Cleveland Clinic Institutional Review Board had been obtained (IRB no. 17-072), 134 lung biopsies and resections containing fungal hyphae from a 19-year period (2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017)(2018) were retrieved from our surgical pathology archives. In each case, the electronic medical record was reviewed

Percutaneous diagnosis of an atypical presentation of pulmonary aspergillosis mimicking lung cancer in a renal transplant patient

“…3 Recently, a paper has reviewed cases of patients with pulmonary aspergillosis presenting with lung nodules or masses (tumor-like CNA) and mimicking lung cancer on imaging. 4 Our patient presented with a solitary, spiculated, FDG-avid lung mass without the typical findings of pulmonary angioinvasive aspergillosis (cavitation, halo sign, and air-crescent sign) or pulmonary bronchoinvasive aspergillosis (centrilobular nodules, peribronchial opacities, bronchial wall thickening. .…”

“…We believe that our case does not fit into any of the classic forms of pulmonary aspergillosis: invasive aspergillosis, aspergilloma, allergic bronchopulmonary aspergillosis (ABPA), and chronic necrotising aspergillosis (CNA) 3 . Recently, a paper has reviewed cases of patients with pulmonary aspergillosis presenting with lung nodules or masses (tumor‐like CNA) and mimicking lung cancer on imaging 4 . Our patient presented with a solitary, spiculated, FDG‐avid lung mass without the typical findings of pulmonary angioinvasive aspergillosis (cavitation, halo sign, and air‐crescent sign) or pulmonary bronchoinvasive aspergillosis (centrilobular nodules, peribronchial opacities, bronchial wall thickening…) 5 .…”

“…We therefore think that our case represents a tumor-like variant of semi-invasive (chronic necrotising) aspergillosis, an entity observed in elderly immunocompetent or nonseverely immunocompromised patients (especially patients with COPD, diabetes, or solid-organ cancers) with nodular lung lesions that mimic lung cancer on imaging and with necrotizing granulomatous inflammation on microscopic examination. 4 This CNA variant does not show cavitary lesions on imaging and usually lacks the typical symptoms of classic CNA (fever, weight loss, sputum production, malaise. .…”

Aspergillus-related lung mass masquerading as a lung tumour

“…The postsurgical invasive aspergillosis following cardiac surgery in immunocompetent individuals has been previously reported [ 8–9 ]. The chronic necrotizing form of Aspergillus lung disease causing nodules that were mimicking lung malignancy has also been described in a case series [ 10 ]. However, this was not reported as Aspergillus -related lung mass masquerading as a primary lung neoplasm.…”

“…Interestingly, the lung nodules identified as part of this case series demonstrated the necrotizing granulomas to be containing fungal hyphae. On follow-up none of the nodules has recurred or progressed [ 10 ].…”