PMC8789659_01
Chest CT in years 2016-2020: (a) 2016 - 3 months after chemoradiotherapy: solid tumor in the upper lobe of the right lung, emphysema in the apical parts of both lungs; (b) 2018 - cavity with the thick wall has formed at the site of the tumor in the right lung; (c) 2020 - progression of an irregular cavity in the upper part of the right lung with thick walls (concomitant mass on the posterior wall), surrounded by solid consolidation, dilated bronchus, and emphysema; (d) 2020 - positron emission tomography combined with computed tomography: unclear character of hypermetabolic masses in the right lung, more likely inflammatory, SUVmax = 2.5.
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F1
Three and a half years earlier, the patient underwent radiochemotherapy for locally advanced non-small-cell lung cancer of the right upper lobe (adenocarcinoma, the clinical stage of the tumor was T3N2Mo CS IIIA /T:tumor, N:lymph node, M:metastasis/, Figure 1a). A cavitary lesion developed at the site of the tumor of the right lung 2 years after the end of lung cancer treatment (Figure 1b). Chest CT scans showed an irregular cavity in the upper part of the right lung with thick walls and accompanying mass of the posterior wall, surrounded by solid consolidation, dilated surrounding bronchus, and emphysema (Figure 1c). Imaging diagnostics was extended to PET-CT, which revealed the unclear nature of the hypermetabolic masses in the right lung, more likely inflammation (Figure 1d).
Bronchoscopy: (a) main trachea - purulent bronchitis, more severe in the right main bronchus; the bronchial mucosa is dull, red, with dilated vessels; (b) thick, purulent mucus in the right main bronchus; (c) fungal hyphae (yellow arrows) in the bronchial wash (original magnification x 100).
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F2
During bronchoscopy, purulent bronchitis was confirmed (Figures 2a,b). In the cytological examination of the bronchial wash, fungal hyphae were detected for the first time during the entire diagnostic process (Figure 2c).
Controlled chest computed tomography during first-line treatment in 2020: (a) at the beginning of the therapy - irregular cavity size 102 x 59 mm in apical parts of the right lung, surrounded by solid consolidations widely adhere to the parietal pleura, connecting to the right hilum; (b) after 2 months - cavity with thick walls size 71 x 49 mm, concomitant mass on the posterior wall-size 29 x 10 mm; (c) after 4 months - cavity with thick walls size 69 x 47 mm, concomitant mass on the posterior wall-size 14 x 5 mm; (d) after 6 months - image stabilization.
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F3
Every 8 weeks, the patient was re-evaluated clinically by physical examination and radiologically on the basis of chest CT (Figures 3a-d) and x-rays (Figures 4a-d).
Controlled chest x-ray during first-line treatment in 2020: (a) at the beginning of the therapy - thick-walled cavity with internal consolidations in apical parts of the right lung; (b) after 2 months - cavity consolidation; (c) after 4 months - further cavity consolidation; (d) after 6 months - image stabilization.
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F4
Every 8 weeks, the patient was re-evaluated clinically by physical examination and radiologically on the basis of chest CT (Figures 3a-d) and x-rays (Figures 4a-d).
Controlled chest CT during second-line treatment in 2021: (a) at the beginning of the therapy - cavity with thick walls size 69 x 47 mm, concomitant mass on the posterior wall-size 22 x 9 mm, quantitative progression of the surrounding consolidations compared to the previous image; (b) after 3 months - cavity size 70 x 66 mm, the mass inside larger and more irregular (progression); (c) after 4 months - circumscribed opacity with an air-fluid level size 95 x 75 mm in the place of the previously described cavity (further progression, abscess); (d) after 5 months - cavity with thick wall much smaller, the mass inside size 28 x 20 mm, no fluid was visualized (regression).
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F5
Chest imaging confirmed CPA progression (Figures 5a, 6a). After 3 months, antifungal medication was switched to orally administered voriconazole (200 mg twice daily) due to radiographic progression (Figures 5b, 6b). The cavity in the upper right lobe was larger, with a level of thickened, heterogeneous fluid and air in the upper part (Figures 5c, 6c). Control imaging showed partial regression (Figures 5d, 6d).
Controlled chest x-ray during second-line treatment in 2021: (a) at the beginning of the therapy - a thick-walled cavity in apical parts of the right lung, progression internal consolidations and surrounding opacities; (b) after 3 months - cavity consolidation, regression of surrounding opacities; (c) after 4 months - cystic lesion with an air-fluid level (arrow) (progression, abscess); (d) after 5 months - regression of an air-fluid level (arrow).
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F6
Chest imaging confirmed CPA progression (Figures 5a, 6a). After 3 months, antifungal medication was switched to orally administered voriconazole (200 mg twice daily) due to radiographic progression (Figures 5b, 6b). The cavity in the upper right lobe was larger, with a level of thickened, heterogeneous fluid and air in the upper part (Figures 5c, 6c). Control imaging showed partial regression (Figures 5d, 6d).
A timeline with all relevant data from this clinical case.
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F7
A timeline with all relevant data from this clinical case is available in Figure 7.