2010-06-Articles-AR_06-10_Gill-AR_06-10_Gill

10 ■ APPLIED RADIOLOGY© www.appliedradiology.com June 2010

Acavity has been defined as “agas-filled space within a pul-monary consolidation, a mass,

or a nodule, produced by the expulsionof [the] necrotic part of the lesion via thebronchial tree.”1 In oncology patients,cavitary lesions caused by various eti-ologies are seen, and an accurate diagno-sis often can be challenging because thenonmalignant cavitary lesions oftenmimic malignant cavitary lesions. How-ever, the radiological findings of cavi-tary lesions can be useful in differen-tiating a cavitary malignant lesion fromany other nonmalignant cavitary lesion.This review focuses on the cavitarylesions that are encountered in oncologypatients, including primary broncho-genic carcinoma, pulmonary metastasis,infections and other miscellaneous eti-ologies causing cavitation in oncology

patients. The article will highlight radio-logical findings that aid in diagnosis.

Primary lung cancerCavitation in primary lung cancer is

not rare. Cavitation detected on plainchest radiographs has been reported in2% to 16 % of primary lung cancers,2-7

and it is detected with computedtomography (CT) in 22% of primarylung cancers.8 squamous-cell carci-noma is the most common histologicaltype of lung cancer to cavitate (82% ofcavitary primary lung cancer, Figure 1),followed by adenocarcinoma (Figure 2)and large cell carcinoma.4,9 Multiplecavitary lesions in primary lung cancerare rare, however, multifocal bron-choalveolar cell carcinoma can occa-sionally have multiple cavitary lesions(Figure 3).10,11 Small cell carcinoma isnever known to cavitate.12

Cavitation can be emphasized by acheck-valve mechanism developed as aconsequence of tumor infiltration intothe bronchial tree.13 Although themechanism of cavity formation is oftendifficult to ascertain, cavitation in lungcancer most often results from rapidtumor growth that exceeds the bloodsupply with resultant central necrosis.A recent study showed that 81% oftumors with cavitation were associatedwith over-expression of epidermalgrowth factor receptor (EGFR), and thehigh level of EGFR expression in thesetumors might be associated with rapidgrowth, central necrosis and formationof cavitation.8 The presence of cavita-tion in primary lung cancer has beenassociated with a worse prognosis.14

In general, the radiological featuresof cavitation that suggest malignancyinclude wall thickness, and spiculated

Cavities in the lung in oncologypatients: Imaging overview anddifferential diagnoses

Ritu R. Gill, MD, Shin Matsusoka, MD, PhD, and Hiroto Hatabu, MD, PhD

Dr. Gill is an Associate Radiologist,Department of Radiology, Brigham andWomen's Hospital, Boston, MA, and anInstructor of Radiology, Harvard Med-ical School, Boston, MA; Dr. Matsusokais a Visiting Assistant Professor, Depart-ment of Radiology, St. Marianna Univer-sity School of Medicine, Kawasaki,Kanagawa, Japan; and Dr. Hatabu isClinical Director, MRI Program, andMedical Director, Center for PulmonaryFunctional Imaging, Department ofRadiology, Brigham and Women's Hos-pital, Boston, MA, and Associate Profes-sor of Radiology, Harvard MedicalSchool, Boston, MA.

www.appliedradiology.com APPLIED RADIOLOGY©■ 11June 2010

CAVITIES IN THE LUNG

or irregular inner and outer margins.Previous studies with plain chest radi-ography showed that the measurementof the cavity wall thickness at its thick-est section was most useful in predict-ing whether the cavity was malignant

or benign.15,16 In these studies, 30 of 32cavities (94%) with a maximum wallthickness of ≤4 mm were caused by abenign process. Cavities with a maxi-mum wall thickness of 5 mm to 15 mmwere mixed, with 33 of 55 (60%)

benign and 22 of 55 (40%) malignant.Similarly, 35 of 39 cavities (90%) witha maximum wall thickness >15 mmwere usually malignant.

Another recent study reported theresult of differentiation of malignantfrom benign cavitary nodules using CTfindings.17 In this study, the notch wasfound in 29% of benign cavitary nod-ules and in 54% of malignant cavitarynodules (p < 0.01). An irregular inter-nal wall was found in 26% of benignnodules and in 49% of malignant nod-ules (p < 0.01). In addition, a linearmargin, satellite nodules, bronchialwall thickening, consolidation, andground-glass attenuation were signifi-cantly more frequent in benign cavi-tary lesions than in malignant ones.Although these findings might be help-ful in differentiating cavitary nodulesto some degree, the CT findings ofbenign and malignant cavitary nodulescan overlap.

Unusual findings of primary cavitarylung cancer include thin-wall cavita-tion.9 Although the “air-crescent sign”(a collection of air in a crescent-likeshape that separates the wall of a cavityfrom an inner mass) is most often asso-ciated with an inflammatory process(e.g., mycetoma, a hydatid cyst, or pul-monary tuberculosis18), lung cancer canalso have an air-crescent sign in rarecases.19-20 In such cases, positron emis-sion tomography (PET) images canhelp in the differential diagnosis.19 Con-trarily, mycetoma also can arise from acavitary lesion within lung cancer.21 Infact, mycobacterial or fungal pathogenscan also coexist in malignant cavities(Figure 4).22-24

Pulmonary metastasisMetastatic lung lesions also can cavi-

tate, but this occurs less frequently thanin primary lung cancers. The frequencyof cavitation in metastatic tumordetected by plain radiograph is 4%.2

Cavitary lung metastasis can occur inany histological type, however, squa-mous-cell carcinoma is the most com-mon cause of cavitating metastases,comprising 69% of these instances.25

FIGURE 1. Squamous-cell carcinoma. PA chest radiograph (A) shows a thick-walled, cen-trally located cavitating lesion in the left upper lobe. Axial computed tomography (CT) showsirregular inner margins in the cavity suggesting a malignant neoplasm.

FIGURE 2. Adenocarcinoma. Axial CT scan of the chest shows a spiculated, thick-walled,peripherally located cavitating mass in the right upper lobe.

FIGURE 3. Cavitating bronchoalveolar carcinoma. PA chest radiograph (A) and axial CT scan (B)of the chest show several cavitating masses in both lungs. Both thick- and thin-walled cavities areseen. The differential diagnosis includes cavitating lung metastases and fungal infections.

A B

A B



The mechanism of the cavitation hasnot been completely clarified. In meta-static tumors from squamous carcinoma,cavitation might result from cornifica-tion of the squamous epithelium in thecenter of the lesion with subsequent liq-uefaction and evacuation into airway.26

This process could explain the tendencyof head-and-neck squamous cancermetastases to produce cavities moreoften than other squamous-cell carci-noma sites.

Morphologically, cavitating metas-tases have a thick and irregular wall,but thin-walled cavities can beobserved with metastases from sarco-mas and adenocarcinomas.25 Metasta-tic sarcomas with cavitation also canbe complicated by a pneumothorax(Figure 5). The wall thickness of cavi-tary metastasis may remain constant asthe diameter of the cavity increases.2

Cavitation occurs more often in theupper lobe than in the lower lobe.27

Generally, cavitating pulmonarymetastases present as multiple lesions,but can present as a single cavitarylesion.26 In such cases, accurate diag-nosis with only radiological findings isextremely difficult and the clinical his-tory or histopathological analysis postbiopsy is needed.

Other malignant diseasesCavitary lesions in patients with

lymphoma are infrequent, however,pulmonary lymphoma can cavitate(Figure 6).28 These cavities are usuallymultiple with thick walls and have anupper-lobe predominance.29, 30 How-ever, in lymphoma patients with humanimmunodeficiency virus (HIV) infec-tion, cavitation is not rare, and ≤25% ofpatients can have a cavitary lesiondetected on CT images.31

Nonmalignant cavitary diseasesTuberculous, nontuberculous, bacte-

rial and fungal infections can presentwith cavity formation and ascertainingthe most likely diagnosis is vital in themanagement of the oncology patients,especially the post bone-marrow trans-plant population.

Mycobacterium tuberculosisinfection

Cavitation is common in post primarytuberculosis and is usually located in theapical and posterior segments of theupper lobes and superior segments of thelower lobes.32,33 The prevalence of cavi-ties on plain chest radiographs varies in30% to 50% of patients. Cavities canvary widely in size and have beenreported to have both thick and thin

walls.34-36 Multiple cavities are often pre-sent and frequently occur in areas of con-solidation.34,37 The presence of cavitationis associated with a greater degree ofinfectiousness, likely due to higherorganism burden.38 The number andmaximum size of cavities can correlatewith the numbers of acid-fast bacilli(AFB) in sputum.39 Although the mor-phological findings of cavitation inpatients with post primary tuberculosis

FIGURE 4. Adenocarcinoma and myce-toma were found to coexist on this axialCT image in a renal transplant patient.

FIGURE 5. Pulmonary metastases from soft-tissuesarcoma of the thigh. Axial CT of the chest showscavitating multiple metastases. Sarcoma metas-tases can be complicated by pneumothorax, as aresult of tumor necrosis into the pleural space.

FIGURE 6. Hodgkinʼs disease. A thick-wall cavitating mass in the right upper lobe. There isassociated right paratracheal lymphadenopathy.

FIGURE 7. Metastatic pancreatic cancer on chemotherapy. Axial CT shows a thick-walledcavity in the left upper lobe with surrounding linear and nodular parenchymal opacities. Tuber-culosis should be considered in the differential diagnosis.

A B

A B



are hardly distinguishable from malig-nant cavitary lesions (Figure 7), the pres-ence of adjacent tree-in-bud lesions,40 orsatellite nodules may help in differentiat-ing tuberculosis from malignancy. Theefficacy of dynamic CT and magnetic res-onance imaging (MRI) has been reportedto differentiate between malignant tumorand tuberculoma,41.42 but it has not beenclarified whether the presence of cavita-tion affects that efficacy or not.

Factors that depend on the host play animportant role in the prevalence of cavita-tion of tuberculosis. In patients withacquired immunodeficiency syndrome,cavitation is less frequent,43,44 whereascavitation is highly prevalent among dia-betic patients with tuberculosis,45 and

multiple small, irregular cavities alsohave been reported on CT scans.46

Nontuberculous mycobacterialinfection

Nontuberculous mycobacteria includ-ing Mycobacterium kansasii andMycobacterium avium-intracellularecomplex can cause pulmonary infectionsthat are associated with cavities. As forMycobacterium avium-intracellularecomplex, 65% of patients have cavitation(Figure 8), and the presence of cavity onCT is associated with positive sputumculture.47 The cavities are relativelysmall and thin walled.48,49 Sometimes itis difficult to differentiate from cavitarymetastasis. However, other typical CT

findings, including nodules with associ-ated bronchiectasis particularly in thelingula and right middle lobe, may helpin the diagnosis.47,50

In patients with Mycobacteriumkansasii, the frequency of cavitation ishigh (87% to 96%) and cavitation isvisible even on plain radiographs. Cav-itary lesions may be single or multiplewith thin walls, predominantly in theupper lobes.51,52

Fungal infectionsThe radiological presentations of pul-

monary fungal infections vary depend-ing on the patient’s immune conditions.In the immunocompetent patient, fungalinfections are uncommon, however,

FIGURE 8. A patient with non-Hodgkinʼs lymphoma with Mycobacterium avium intracellulare infection. Axial CT (A and B) shows a cavitatinglesion with tree-in-bud nodules. Centrilobular nodules are often seen with infections caused by atypical mycobacteria.

FIGURE 9. Bronchogenic carcinoma of the left upper lobe post radiation with a mycetoma inthe bronchopleural cavity in the left apex. PA radiograph (A) shows post radiation changesand the mycetoma in the left apex. Axial CT (B) confirms the mycetoma in the left apical cavity.

A B

A B

FIGURE 10. Hodgkinʼs lymphoma post bonemarrow transplant, presenting with fever andseizures. The patient was diagnosed withCryptococcus infection. Axial CT shows aperipheral cavitary lesion, which was biopsy-proven to be Cryptococcus.



cavitation in fungal infection is not rareand can mimic malignant cavity. Thus,occasionally differentiating a fungalcavity from malignant cavity is difficult.

An aspergilloma represents growthof aspergillus within a pre-existinglung cavity. The typical radiographicfinding is a rounded soft tissue within apreviously existing cavitary lesionsuch as tuberculosis cavity (Figure 9).The appearance of the soft tissue canbe similar to malignant lesion. It hasbeen reported that the enhancement ofthe intramural soft tissue on CTimplies malignancy, while the findingsof adjacent bronchiectasis, a dependent

location and positional mobility sug-gest aspergilloma.53

The radiological findings of crypto-coccosis also depend on the immunestatus of the patient. The most commonfindings in immunocompetent patientsare focal infiltration and nodules. Cavi-tation can be detected in 14% to 42%within consolidation and nodules inimmunocompetent patients (Figure 10).There are no specific findings that candifferentiate cavitary cryptococcosisfrom malignant cavitary lesion. On theother hand, cavitation is significantlyless common in severely immunocom-promised patients, particularly in HIV

patients, than in immunocompetentones.54-56 However, in mild to moder-ately immunocompromised patientssuch as diabetes, liver cirrhosis, andcorticosteroid therapy, cavitation isobserved more frequently (62.5% ofpatients).54

Cavities with thick or thin walls areseen in patients with pulmonary blasto-mycosis, histoplasmosis, coccidioido-mycosis, and mucormycosis.57-60 Thesecavitary lesions can be solitary or multi-ple. Unfortunately, there are no specificfindings that can differentiate betweenthese cavitary fungal nodules andmalignant cavities.

FIGURE 11. Patient with leukemia presenting with fever and chills. Chest PA radiograph (A) and axial CT (B) of the thorax show a well-definedcavity with an air-fluid level suggestive of a lung abscess, bronchial lavage cultures were positive for Klebsiella.

A B

FIGURE 12. Patient with pancreatic cancer with an infected central venouscatheter presenting with septic emboli. Axial CT image shows cavitating nod-ules in both right and left lower lobes. The lower lobe predominance, peripherallocation of the nodules and a pulmonary vessel leading to the nodule in thisclinical setting are suggestive of septic emboli. Hematogenous metastasesalso have similar distribution and may demonstrate the “feeding vessel sign.”

FIGURE 13. Adenocarcinoma with bronchoalveolar-cell fea-tures diagnosed in a patient presenting with bronchorrehea.Axial CT image shows a dominant left upper lobe mass withsurrounding ground-glass opacification and irregular cavity.Multifocal ground-glass opacities are seen in the right lung sec-ondary to transbronchial spread of disease.


Bacterial infectionsCavitation can be seen with commu-

nity-acquired bacterial pneumonia,particularly Klebsiella pneumoniaepneumonia (Figure 11) and Staphylo-coccus aureus pneumonia. However,most cases of community-acquiredbacterial infection present sympto-

matic inflammatory changes such asproductive cough and high-gradefever. In addition, rapid change of ill-defined consolidation on plain chestradiography suggests bacterial pneu-monia rather than malignancy.

Pulmonary actinomycosis usuallyresults from aspiration of infected

material containing actinomyces.61

Cavitation in actinomycosis is a com-mon finding on CT in 62% to 75%.62,63

Pulmonary actinomycosis is relativelyasymptomatic and progresses graduallywith nonproductive cough or low-gradefever. In addition, chest-wall invasion,transfissural extension, and hilar or


FIGURE 14. Necrobiotic cavitary nodules in apatient with colon cancer and rheumatoidarthritis. Coronal CT image shows a cavitarylesion in the right lower lobe. The diagnosiswas made on open surgical biopsy. A smallright basilar pneumothorax is incidentallyseen.

FIGURE 15. Patient with renal cell cancer,presenting with hemoptysis. Axial CT imageshows a consolidative opacity in the leftupper lobe with cavitation. Biopsy was nega-tive for malignant cells, serological markershelped confirm the diagnosis of Wegenerʼsgranulomatosis.

FIGURE 16. A patient with asymptomaticHodgkin's disease, in remission, who had ascreening CT study. Coronal CT image showsmultiple thin-walled cavities with sparing of thecostophrenic sulci (arrow). Open lung biopsyconfirmed the diagnosis of eosinophilic granu-lomatosis.

FIGURE 17. Maximum inten-sity projection (MIP) axialimages in a 45-year-oldwoman with renal cell cancershow chronic thrombusinvolving the superior seg-mental branch of the rightlower lobe pulmonary artery.LAVA post-contrast axialimage (B) shows the cavitaryinfarct. Coronal magnetic res-onance angiogram (MRA, C)shows a paucity of vascula-ture on the right. V/Q scan (D)shows the perfusion defect inthe superior segment.

BA

DC


mediastinal lymphadenopathy can beoccasionally observed.64 Segmentalconsolidations that contain low-attenu-ation areas with peripheral enhance-ment and adjacent pleural thickeningsuggest pulmonary actinomycosis.62

Septic embolism usually presentswith severe symptoms including high-grade fever and dyspnea, however,asymptomatic cases also have beenreported.65 Cavitary nodule located inthe lung periphery is frequent and canbe detected in 85% of instances on CT.66

The appearance can be confused withcavitary malignant lesion such as multi-ple pulmonary metastases (Figure 12).Classically, “a feeding vessel sign,” inwhich a distinct vessel is seen leading tothe center of a pulmonary nodule, hasbeen reported as a typical finding ofseptic emboli.67 however, the feedingvessel sign also can occur in pulmonarymetastasis.68 In addition, a recent studyshowed that most of these vesselscoursed around the nodule and somewere pulmonary veins.69

Meanwhile, the pneumonic type ofbronchoalveolar cell carcinoma showslobar consolidation, and both bacterialpneumonia and the pneumonic type of

bronchoalveolar cell carcinoma canhave cavitations. Thus, it is often diffi-cult to differentiate from bacterial pneu-monia (Figure 13). In old times, the“angiogram sign,” in which branchingpulmonary vessels could be visualizednormally within areas of consolidationon contrast-enhanced CT, was reportedas a specific sign of the pneumonic typeof bronchoalveolar cell carcinoma,70

however, it also can be seen in pneumo-nia .71 A recent study showed that con-solidation on CT may suggest infectiouspneumonia rather than the pneumonictype of bronchoalveolar cell carcinomawhen bronchial wall thickening, proxi-mal to the lesion, and pleural thickening,associated with the lesion, is evident.72

Noninfectious inflammatory diseasesIn rheumatoid patients, nodular lung

disease in the form of necrobiotic(“rheumatoid”) nodules can be encoun-tered. Patients with pulmonary necrobi-otic nodules are typically men withclinical and radiographic evidence ofrheumatoid arthritis, including subcuta-neous nodules, high rheumatoid factor,and pulmonary interstitial pneumonia.Usually, pulmonary rheumatoid nod-ules are multiple, involving the lowerlobes of the lungs, and can cavitate(Figure 14). Recently, an associationbetween rheumatoid disease and sev-eral types of malignancy has been con-firmed,73 and necrobiotic nodules maybe indistinguishable radiologicallyfrom malignant lesions. Therefore, ithas been recommended that all pul-monary nodules in rheumatoid patientsbe biopsied.74

Wegener’s granulomatosis can pre-sent as multiple masses or a single masswith cavitation.75.76 Cavitation of thenodules occurs in approximately 50%of cases. The cavities usually haveirregular, thick walls (Figure 15).77

Cavitary nodules represent activeinflammatory lesions,78 and with treat-ment the nodules or cavities mayresolve completely or result in a scar.77

There are several reports of Wegener’sgranulomatosis being misdiagnosed asprimary lung cancer and metastasis.79.80


FIGURE 18. Non-Hodgkinʼs lymphoma, status post non-myeloablative stem cell transplant.Dense consolidation (A) with surrounding hazy ground-glass attenuation, representing a “halosign,” resulting from hemorrhage. Peripheral cavitation (B) with the “air-crescent sign,” whichoccurs post treatment with antifungal medication and coincides with recovery of neutrophil count.

FIGURE 19. Pneumocystis jiroveci pneumonia in a patient with leukemia and bone marrowtransplant. Axial CT scan shows extensive ground-glass and air-space opacification in bothlungs. The ground-glass opacification and symmetric distribution of the opacities are sugges-tive of Pneumocystis jiroveci pneumonia. Cavitation is an unusual feature of this infection.

BA

BA

FIGURE 20. Nocardia under the status ofbone marrow transplant for non-Hodgkinʼslymphoma with fever. Axial CT scan shows amass-like opacity with a small cavity within itin the left lower lobe. The differential diagno-sis includes invasive aspergillosis andnocardia. Specimens obtained followingbiopsy demonstrated nocardia.


Radiologically, it may be difficult to dif-ferentiate between malignant lesion andWegener’s granulomatosis. However, inpatients with Wegener’s granulomatosis,proteinase 3–anti-neutrophil cytoplasmicantibodies (PR3-ANCA) are positive in>90% of cases.81

Eosinophilic granulomatosis (EG)can incidentally be found with malig-nancy and has been found to coexistwith lymphoma.82 EG can present asnodules and small cavitary lesions gen-erally <10 mm and mediastinaladenopathy in ≤30% of patients; the

hallmark of the disease is sparing ofcostophrenic sulci (Figure 16).

Miscellaneous diseases with cavitation

Pulmonary infarction occurs in nearlyone third of patients with pulmonary


FIGURE 21. Stage IV non–small-cell carcinoma patient was started on Bevacizumab (Avastin, Genentech, San Francisco, CA). Axial CT (A)shows a solid left apical mass. After 2 cycles (B) the mass has partially cavitated. After 6 cycles (C), the mass is completely cavitated, repre-senting good response.

FIGURE 22. Stage IIIA non–small-cell cancer 6 weeks post radiotherapy presented withhemoptysis and chest pain. Axial CT (A) shows multiple septations and cavitation in the radi-ated lung, and a right hilar mass. Post pigtail catheter placement image (B) shows drainage ofthe necrotic debris.

FIGURE 23. Stage IIIA non–small-cell can-cer post resection and radiation therapy hasnow developed a bronchopleural fistula.Coronal miniMIP image shows the bronchusleading to the cavity in the left apex.

BA C

BA

FIGURE 24. Non–small-cell lung cancer. CT was obtained during ablation (A) and 18 months after radiofrequency ablation (RFA, B) there is acentral, thin-walled cavity. Cavitation is natural sequelae of RFA. Nodularity or abnormal enhancement on follow-up imaging suggests recurrence.

BA C


embolism, and cavitation can bedetected in ≤32% of patients with pul-monary infarction on CT scans.83 Cavi-tation in infarction is located in the lungperiphery, and there is evidence of pul-monary embolus, right heart strain andpleuritic chest pain, but no specific radi-ographic findings related to the cavity.84

Oncology patients are at increased riskfor pulmonary emboli,85 however, thefrequency of pulmonary infarction andcavitation has not been reported in thisgroup (Figure 17).

Cavitary lesions associated with oncotherapy

Oncology patients who undergochemotherapy and/or radiotherapyoften have a malfunctioning immunesystem. Under immunosuppression,morphological appearances of pul-monary infectious diseases are differentfrom that in immunocompetent patients.

Invasive pulmonary aspergillosisafflicts severely immunocompromisedpatients, especially those with hemato-logical malignancies or bone marrowtransplant recipients. Cavitation gener-ally emerges later in the course of thedisease and is often noted during recov-ery from neutropenia – it is generallyconsidered a treatment response to anti-fungal therapy.86.87 The air crescent signis often considered characteristic ofretraction of infected lung in invasiveaspergillosis (Figure 18).88 However,this sign can be seen in other conditionssuch as tuberculosis, Wegener’s granu-lomatosis and lung cancer. In addition, ithas been reported that the presence of a“halo sign,” defined as a nodule sur-rounded by ground-glass attenuation, isreasonably sensitive and specific forinvasive aspergillosis in high-riskpatients.89 At pathologic examination,the nodules represent foci of infarction,and the halo of ground-glass attenuationresults from alveolar hemorrhage.90

However, this CT appearance has beenobserved in patients with lung metas-tases from angiosarcoma, choriocarci-noma and osteosarcoma.91

Pneumocystis jiroveci pneumonia isa common opportunistic infection in

HIV-infected patients but can alsooccur in patients with hematologic andsolid malignancies. Contrary to thepatient with HIV infection, cavitationis extremely rare in oncology patients(Figure 19). Diffuse bilateral ground-glass attenuation is the most commonfinding in cancer patients.92

Pulmonary nocardiosis is an importantcause of opportunistic infection in im-munosuppressed patients, and the inci-dence of this infection is increasing.Solitary or multiple nodules with cavita-tion are detected in ≤80% of cases (Fig-ure 20).93 Cavitation may be morefrequently observed among patients withadvanced HIV than among other hosts.94

Post therapy with novelchemotherapy agents

Novel chemotherapeutic agents, suchas anti-angiogenic drugs, have been as-sociated with cavitation in lung tumors.Bevacizumab (Avastin, Genentech, San Francisco, CA) is a humanized mon-oclonal antibody against vascular endothelial growth factor (VEGF).Bevacizumab has been associated withcavitation in primary and metastatic lungcancer. Cavitation is secondary to centralnecrosis due to VEGF inhibition and sig-nifies therapeutic response. Spontaneouspneumothorax has been reported when aresponding cavitary lesion communi-cates with the pleura (Figure 21).95

Post radiation therapyRadiation therapy is an important

technique in treating cancer. Radia-tion-induced injury in the lung isdependent on radiation dose, fractiona-tion of dose, portal size and concurrentor prior administration of chemother-apy.96 In the early stages, radiationpneumonitis may present as ground-glass opacification confined to the radi-ation port. Cavitation may be seen 6 to12 weeks post radiation, secondary to necrosis and expulsion of necroticcomponents. Delayed complicationscan include spontaneous pneumotho-rax, secondary to rupture of bleb orectatic bronchus to the pleura, anddevelopment of bronchopleural fistula,

secondary to superimposed infection ona previously radiated lung parenchyma(Figures 22 and 23).97

Post radiofrequency ablationRadiofrequency ablation (RFA) has

been advocated as a safe and minimallyinvasive procedure for patients with lungtumors. Cavitation has been described asevolution of post ablation changes intreated lesions after RFA therapy (Fig-ure 24).94 Cavitation usually occurswithin the tumor between 1 to 3 monthsfollowing RFA and evolves over time.94

The frequency of cavitation is reported tobe significantly higher in patients withlung cancer as the primary lesion, forlesions located within 1 cm of the chestwall, and for pulmonary emphysema.94

ConclusionDifferentiation between malignant

cavitary lesion and nonmalignantlesions in oncology patients can be chal-lenging. Radiological findings cansometimes help in narrowing differen-tial diagnosis; however, a comprehen-sive approach including symptoms andother clinical data is often required toobtain accurate diagnosis.

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