Patient GM is a 55 year old male, a chronic smoker (50pk yrs) with a history of coughing diagnosed under CT and PET scans as having nodules in the left upper and lower lobes of his lungs, consistent with possible malignancy.
A wide wedge excision of the left lower lobe was carried out and the tissue subjected to microscopic and macroscopic examination:
Macroscopic examination:- The nodule was described as an ill-defined firm yellow to pale nodule with a necrotic centre.
Microscopic examination:- the lesion comprises a large area of necrotic material surrounded by granulomatous inflammation with scattered multinucleate giant cells. Focally at the periphery there is a metaplastic squamous epithelium suggesting involvement of a bronchus. In the centre of the necrotic material there are numerous fungal hyphae and conidial heads with features in keeping with Aspergillus. In the surrounding lung parenchyma and visceral pleura there is fibrosis and chronic inflammation. Adjacent vessels show intimal thickening by fibrosis and chronic inflammatory cells (including focal granulomatous inflammation). ZN is negative. No evidence of neoplasia.
A. fumigatus precipitins were negative but the patient precipitins were positive for A. nidulans. A diagnosis of invasive aspergillosis was determined.
This patient was given a CT/PET fusion scan as the nodule was judged not to be suitable for biopsy. The half body PET scan was performed from the base of the skull to the upper thighs 68 mins post injections of 376MBq 18F FDG.
Findings:- the 2.6 x 2.6cm pleurallly based mass in the left lower lobe shows non-homogenous intermediate FDG uptake. A few subcentimetre nodules are seen in both lungs which only have very low FDG uptake.
There is diffuse intermediate uptake throughout the length of the oesophagous which can be variation to normal or reflect oesophagitis.
The FDG uptake in the right arm is thought to be related to the point of injection.
The uptake in the larynx is prominent but is thought to be within physiological variation. The FDG uptake in the abdomen and pelvis is within normal limits.