Upper lobe cavity with intracavitary mass: an unexpected diagnosis

Abstract

DESCRIPTIONA 77-year-old man, with diabetes and a smoker, with no other medical history, presented with cough with sputum and chest pain that had started 2 months earlier. He had no fever, no haemoptysis and no constitutional symptoms. He had a diminished murmur on right chest auscultation and reported of ipsilateral pleuritic pain. Routine blood tests were unremarkable. The chest X-ray (figure 1) showed a right upper lobe cavity with air-crescent in the periphery of a mass inside. It was better characterised with CT (figure 2) that showed an upper lobe cavitary mass with intracavitary content and adjacent pleural thickening. The mass showed no cleavage plane with the thoracic wall. Despite being highly suggestive of invasive aspergilosis (aspergiloma), 1 2 the differential diagnosis included other fungal infections, mycobacterial infection and neoplasm.A tissue biopsy was obtained by CT-guided needle aspiration, and the histology revealed squamous-cell carcinoma of the lung. On the CT-staging, an adrenal gland nodule was found in relation with metastasis. The patient was referred to the oncologist for evaluation and adequate treatment approach.Despite the highly suggestive diagnosis by the CT image and the lack of clinical signs and symptoms that frequently accompany a carcinoma of such dimensions, the definite diagnosis revealed the importance of tissue biopsy in such rare presentation. Learning points▸ The lack of constitutional symptoms does not exclude the neoplastic aetiology in differential diagnosis. ▸ Despite the highly suggestive diagnosis by the CT image for aspergiloma, a tissue biopsy should be performed in all patients, if possible, given the fact that the management options are widely different.