Cavities in the lung in oncology

patients: Imaging overview and

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

cavity has been defined as a

gas-filled space within a pulmonary consolidation, a mass,
or a nodule, produced by the expulsion
of [the] necrotic part of the lesion via the
bronchial tree.1 In oncology patients,
cavitary lesions caused by various etiologies are seen, and an accurate diagnosis often can be challenging because the
nonmalignant cavitary lesions often
mimic malignant cavitary lesions. However, the radiological findings of cavitary lesions can be useful in differentiating a cavitary malignant lesion from
any other nonmalignant cavitary lesion.
This review focuses on the cavitary
lesions that are encountered in oncology
patients, including primary bronchogenic carcinoma, pulmonary metastasis,
infections and other miscellaneous etiologies causing cavitation in oncology
Dr. Gill is an Associate Radiologist,
Department of Radiology, Brigham and
Women's Hospital, Boston, MA, and an
Instructor of Radiology, Harvard Medical School, Boston, MA; Dr. Matsusoka
is a Visiting Assistant Professor, Department of Radiology, St. Marianna University School of Medicine, Kawasaki,
Kanagawa, Japan; and Dr. Hatabu is
Clinical Director, MRI Program, and
Medical Director, Center for Pulmonary
Functional Imaging, Department of
Radiology, Brigham and Women's Hospital, Boston, MA, and Associate Professor of Radiology, Harvard Medical
School, Boston, MA.

10

APPLIED RADIOLOGY

patients. The article will highlight radiological findings that aid in diagnosis.

Primary lung cancer

Cavitation in primary lung cancer is
not rare. Cavitation detected on plain
chest radiographs has been reported in
2% to 16 % of primary lung cancers,2-7
and it is detected with computed
tomography (CT) in 22% of primary
lung cancers.8 squamous-cell carcinoma is the most common histological
type of lung cancer to cavitate (82% of
cavitary primary lung cancer, Figure 1),
followed by adenocarcinoma (Figure 2)
and large cell carcinoma.4,9 Multiple
cavitary lesions in primary lung cancer
are rare, however, multifocal bronchoalveolar cell carcinoma can occasionally have multiple cavitary lesions
(Figure 3).10,11 Small cell carcinoma is
never known to cavitate.12

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Cavitation can be emphasized by a

check-valve mechanism developed as a
consequence of tumor infiltration into
the bronchial tree.13 Although the
mechanism of cavity formation is often
difficult to ascertain, cavitation in lung
cancer most often results from rapid
tumor growth that exceeds the blood
supply with resultant central necrosis.
A recent study showed that 81% of
tumors with cavitation were associated
with over-expression of epidermal
growth factor receptor (EGFR), and the
high level of EGFR expression in these
tumors might be associated with rapid
growth, central necrosis and formation
of cavitation.8 The presence of cavitation in primary lung cancer has been
associated with a worse prognosis.14
In general, the radiological features
of cavitation that suggest malignancy
include wall thickness, and spiculated

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CAVITIES IN THE LUNG

B

FIGURE 1. Squamous-cell carcinoma. PA chest radiograph (A) shows a thick-walled, centrally located cavitating lesion in the left upper lobe. Axial computed tomography (CT) shows
irregular 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.

benign and 22 of 55 (40%) malignant.

Similarly, 35 of 39 cavities (90%) with
a maximum wall thickness >15 mm
were usually malignant.
Another recent study reported the
result of differentiation of malignant
from benign cavitary nodules using CT
findings.17 In this study, the notch was
found in 29% of benign cavitary nodules and in 54% of malignant cavitary
nodules (p < 0.01). An irregular internal wall was found in 26% of benign
nodules and in 49% of malignant nodules (p < 0.01). In addition, a linear
margin, satellite nodules, bronchial
wall thickening, consolidation, and
ground-glass attenuation were significantly more frequent in benign cavitary lesions than in malignant ones.
Although these findings might be helpful in differentiating cavitary nodules
to some degree, the CT findings of
benign and malignant cavitary nodules
can overlap.
Unusual findings of primary cavitary
lung cancer include thin-wall cavitation.9 Although the air-crescent sign
(a collection of air in a crescent-like
shape that separates the wall of a cavity
from an inner mass) is most often associated with an inflammatory process
(e.g., mycetoma, a hydatid cyst, or pulmonary tuberculosis18), lung cancer can
also have an air-crescent sign in rare
cases.19-20 In such cases, positron emission tomography (PET) images can
help in the differential diagnosis.19 Contrarily, mycetoma also can arise from a
cavitary lesion within lung cancer.21 In
fact, mycobacterial or fungal pathogens
can also coexist in malignant cavities
(Figure 4).22-24

Pulmonary metastasis
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 are
seen. The differential diagnosis includes cavitating lung metastases and fungal infections.

or irregular inner and outer margins.

Previous studies with plain chest radiography showed that the measurement
of the cavity wall thickness at its thickest section was most useful in predicting whether the cavity was malignant

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or benign.15,16 In these studies, 30 of 32

cavities (94%) with a maximum wall
thickness of 4 mm were caused by a
benign process. Cavities with a maximum wall thickness of 5 mm to 15 mm
were mixed, with 33 of 55 (60%)

Metastatic lung lesions also can cavitate, but this occurs less frequently than
in primary lung cancers. The frequency
of cavitation in metastatic tumor
detected by plain radiograph is 4%.2
Cavitary lung metastasis can occur in
any histological type, however, squamous-cell carcinoma is the most common cause of cavitating metastases,
comprising 69% of these instances.25

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APPLIED RADIOLOGY

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CAVITIES IN THE LUNG

The mechanism of the cavitation has
not been completely clarified. In metastatic tumors from squamous carcinoma,
cavitation might result from cornification of the squamous epithelium in the
center of the lesion with subsequent liquefaction and evacuation into airway.26
This process could explain the tendency
of head-and-neck squamous cancer
metastases to produce cavities more
often than other squamous-cell carcinoma sites.
Morphologically, cavitating metastases have a thick and irregular wall,
but thin-walled cavities can be
observed with metastases from sarcomas and adenocarcinomas.25 Metastatic sarcomas with cavitation also can
be complicated by a pneumothorax
(Figure 5). The wall thickness of cavitary metastasis may remain constant as
the diameter of the cavity increases.2
Cavitation occurs more often in the
upper lobe than in the lower lobe.27
Generally, cavitating pulmonary
metastases present as multiple lesions,
but can present as a single cavitary
lesion.26 In such cases, accurate diagnosis with only radiological findings is
extremely difficult and the clinical history or histopathological analysis post
biopsy is needed.

FIGURE 5. Pulmonary metastases from soft-tissue

sarcoma of the thigh. Axial CT of the chest shows
FIGURE 4. Adenocarcinoma and myce- cavitating multiple metastases. Sarcoma metastoma were found to coexist on this axial tases can be complicated by pneumothorax, as a
CT image in a renal transplant patient.
result of tumor necrosis into the pleural space.

FIGURE 6. Hodgkins disease. A thick-wall cavitating mass in the right upper lobe. There is
associated right paratracheal lymphadenopathy.

Other malignant diseases

Cavitary lesions in patients with
lymphoma are infrequent, however,
pulmonary lymphoma can cavitate
(Figure 6).28 These cavities are usually
multiple with thick walls and have an
upper-lobe predominance.29, 30 However, in lymphoma patients with human
immunodeficiency virus (HIV) infection, cavitation is not rare, and 25% of
patients can have a cavitary lesion
detected on CT images.31

Nonmalignant cavitary diseases

Tuberculous, nontuberculous, bacterial and fungal infections can present
with cavity formation and ascertaining
the most likely diagnosis is vital in the
management of the oncology patients,
especially the post bone-marrow transplant population.

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APPLIED RADIOLOGY

FIGURE 7. Metastatic pancreatic cancer on chemotherapy. Axial CT shows a thick-walled

cavity in the left upper lobe with surrounding linear and nodular parenchymal opacities. Tuberculosis should be considered in the differential diagnosis.

Mycobacterium tuberculosis
infection
Cavitation is common in post primary
tuberculosis and is usually located in the
apical and posterior segments of the
upper lobes and superior segments of the
lower lobes.32,33 The prevalence of cavities on plain chest radiographs varies in
30% to 50% of patients. Cavities can
vary widely in size and have been
reported to have both thick and thin

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walls.34-36 Multiple cavities are often present and frequently occur in areas of consolidation.34,37 The presence of cavitation
is associated with a greater degree of
infectiousness, likely due to higher
organism burden.38 The number and
maximum size of cavities can correlate
with the numbers of acid-fast bacilli
(AFB) in sputum.39 Although the morphological findings of cavitation in
patients with post primary tuberculosis

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CAVITIES IN THE LUNG

B

FIGURE 8. A patient with non-Hodgkins lymphoma with Mycobacterium avium intracellulare infection. Axial CT (A and B) shows a cavitating
lesion 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 in
the bronchopleural cavity in the left apex. PA radiograph (A) shows post radiation changes
and the mycetoma in the left apex. Axial CT (B) confirms the mycetoma in the left apical cavity.

are hardly distinguishable from malignant cavitary lesions (Figure 7), the presence of adjacent tree-in-bud lesions,40 or
satellite nodules may help in differentiating tuberculosis from malignancy. The
efficacy of dynamic CT and magnetic resonance imaging (MRI) has been reported
to differentiate between malignant tumor
and tuberculoma,41.42 but it has not been
clarified whether the presence of cavitation affects that efficacy or not.
Factors that depend on the host play an
important role in the prevalence of cavitation of tuberculosis. In patients with
acquired immunodeficiency syndrome,
cavitation is less frequent,43,44 whereas
cavitation is highly prevalent among diabetic patients with tuberculosis,45 and

June 2010

multiple small, irregular cavities also

have been reported on CT scans.46

Nontuberculous mycobacterial
infection
Nontuberculous mycobacteria including Mycobacterium kansasii and
Mycobacterium avium-intracellulare
complex can cause pulmonary infections
that are associated with cavities. As for
Mycobacterium avium-intracellulare
complex, 65% of patients have cavitation
(Figure 8), and the presence of cavity on
CT is associated with positive sputum
culture.47 The cavities are relatively
small and thin walled.48,49 Sometimes it
is difficult to differentiate from cavitary
metastasis. However, other typical CT

FIGURE 10. Hodgkins lymphoma post bone

marrow transplant, presenting with fever and
seizures. The patient was diagnosed with
Cryptococcus infection. Axial CT shows a
peripheral cavitary lesion, which was biopsyproven to be Cryptococcus.

findings, including nodules with associated bronchiectasis particularly in the

lingula and right middle lobe, may help
in the diagnosis.47,50
In patients with Mycobacterium
kansasii, the frequency of cavitation is
high (87% to 96%) and cavitation is
visible even on plain radiographs. Cavitary lesions may be single or multiple
with thin walls, predominantly in the
upper lobes.51,52

Fungal infections
The radiological presentations of pulmonary fungal infections vary depending on the patients immune conditions.
In the immunocompetent patient, fungal
infections are uncommon, however,

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APPLIED RADIOLOGY

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CAVITIES IN THE LUNG

B

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

FIGURE 12. Patient with pancreatic cancer with an infected central venous
catheter presenting with septic emboli. Axial CT image shows cavitating nodules in both right and left lower lobes. The lower lobe predominance, peripheral
location of the nodules and a pulmonary vessel leading to the nodule in this
clinical setting are suggestive of septic emboli. Hematogenous metastases
also have similar distribution and may demonstrate the feeding vessel sign.

cavitation in fungal infection is not rare

and can mimic malignant cavity. Thus,
occasionally differentiating a fungal
cavity from malignant cavity is difficult.
An aspergilloma represents growth
of aspergillus within a pre-existing
lung cavity. The typical radiographic
finding is a rounded soft tissue within a
previously existing cavitary lesion
such as tuberculosis cavity (Figure 9).
The appearance of the soft tissue can
be similar to malignant lesion. It has
been reported that the enhancement of
the intramural soft tissue on CT
implies malignancy, while the findings
of adjacent bronchiectasis, a dependent

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APPLIED RADIOLOGY

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

location and positional mobility suggest aspergilloma.53

The radiological findings of cryptococcosis also depend on the immune
status of the patient. The most common
findings in immunocompetent patients
are focal infiltration and nodules. Cavitation can be detected in 14% to 42%
within consolidation and nodules in
immunocompetent patients (Figure 10).
There are no specific findings that can
differentiate cavitary cryptococcosis
from malignant cavitary lesion. On the
other hand, cavitation is significantly
less common in severely immunocompromised patients, particularly in HIV

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patients, than in immunocompetent

ones.54-56 However, in mild to moderately immunocompromised patients
such as diabetes, liver cirrhosis, and
corticosteroid therapy, cavitation is
observed more frequently (62.5% of
patients).54
Cavities with thick or thin walls are
seen in patients with pulmonary blastomycosis, histoplasmosis, coccidioidomycosis, and mucormycosis.57-60 These
cavitary lesions can be solitary or multiple. Unfortunately, there are no specific
findings that can differentiate between
these cavitary fungal nodules and
malignant cavities.

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CAVITIES IN THE LUNG

FIGURE 14. Necrobiotic cavitary nodules in a

patient with colon cancer and rheumatoid
arthritis. Coronal CT image shows a cavitary
lesion in the right lower lobe. The diagnosis
was made on open surgical biopsy. A small
right basilar pneumothorax is incidentally
seen.

FIGURE 15. Patient with renal cell cancer,

presenting with hemoptysis. Axial CT image
shows a consolidative opacity in the left
upper lobe with cavitation. Biopsy was negative for malignant cells, serological markers
helped confirm the diagnosis of Wegeners
granulomatosis.

Bacterial infections
Cavitation can be seen with community-acquired bacterial pneumonia,
particularly Klebsiella pneumoniae
pneumonia (Figure 11) and Staphylococcus aureus pneumonia. However,
most cases of community-acquired
bacterial infection present sympto-

16

FIGURE 16. A patient with asymptomatic

Hodgkin's disease, in remission, who had a
screening CT study. Coronal CT image shows
multiple thin-walled cavities with sparing of the
costophrenic sulci (arrow). Open lung biopsy
confirmed the diagnosis of eosinophilic granulomatosis.

APPLIED RADIOLOGY

matic inflammatory changes such as

productive cough and high-grade
fever. In addition, rapid change of illdefined consolidation on plain chest
radiography suggests bacterial pneumonia rather than malignancy.
Pulmonary actinomycosis usually
results from aspiration of infected

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FIGURE 17. Maximum intensity projection (MIP) axial

images in a 45-year-old
woman with renal cell cancer
show chronic thrombus
involving the superior segmental branch of the right
lower lobe pulmonary artery.
LAVA post-contrast axial
image (B) shows the cavitary
infarct. Coronal magnetic resonance angiogram (MRA, C)
shows a paucity of vasculature on the right. V/Q scan (D)
shows the perfusion defect in
the superior segment.

material containing actinomyces.61

Cavitation in actinomycosis is a common finding on CT in 62% to 75%.62,63
Pulmonary actinomycosis is relatively
asymptomatic and progresses gradually
with nonproductive cough or low-grade
fever. In addition, chest-wall invasion,
transfissural extension, and hilar or

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CAVITIES IN THE LUNG

A

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

bronchoalveolar cell carcinoma can

have cavitations. Thus, it is often difficult to differentiate from bacterial pneumonia (Figure 13). In old times, the
angiogram sign, in which branching
pulmonary vessels could be visualized
normally within areas of consolidation
on contrast-enhanced CT, was reported
as a specific sign of the pneumonic type
of bronchoalveolar cell carcinoma,70
however, it also can be seen in pneumonia .71 A recent study showed that consolidation on CT may suggest infectious
pneumonia rather than the pneumonic
type of bronchoalveolar cell carcinoma
when bronchial wall thickening, proximal to the lesion, and pleural thickening,
associated with the lesion, is evident.72

Noninfectious inflammatory diseases

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

FIGURE 20. Nocardia under the status of

bone marrow transplant for non-Hodgkins
lymphoma with fever. Axial CT scan shows a
mass-like opacity with a small cavity within it
in the left lower lobe. The differential diagnosis includes invasive aspergillosis and
nocardia. Specimens obtained following
biopsy demonstrated nocardia.

mediastinal lymphadenopathy can be

occasionally observed.64 Segmental
consolidations that contain low-attenuation areas with peripheral enhancement and adjacent pleural thickening
suggest pulmonary actinomycosis.62

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Septic embolism usually presents

with severe symptoms including highgrade fever and dyspnea, however,
asymptomatic cases also have been
reported.65 Cavitary nodule located in
the lung periphery is frequent and can
be detected in 85% of instances on CT.66
The appearance can be confused with
cavitary malignant lesion such as multiple pulmonary metastases (Figure 12).
Classically, a feeding vessel sign, in
which a distinct vessel is seen leading to
the center of a pulmonary nodule, has
been reported as a typical finding of
septic emboli.67 however, the feeding
vessel sign also can occur in pulmonary
metastasis.68 In addition, a recent study
showed that most of these vessels
coursed around the nodule and some
were pulmonary veins.69
Meanwhile, the pneumonic type of
bronchoalveolar cell carcinoma shows
lobar consolidation, and both bacterial
pneumonia and the pneumonic type of

In rheumatoid patients, nodular lung

disease in the form of necrobiotic
(rheumatoid) nodules can be encountered. Patients with pulmonary necrobiotic nodules are typically men with
clinical and radiographic evidence of
rheumatoid arthritis, including subcutaneous nodules, high rheumatoid factor,
and pulmonary interstitial pneumonia.
Usually, pulmonary rheumatoid nodules are multiple, involving the lower
lobes of the lungs, and can cavitate
(Figure 14). Recently, an association
between rheumatoid disease and several types of malignancy has been confirmed,73 and necrobiotic nodules may
be indistinguishable radiologically
from malignant lesions. Therefore, it
has been recommended that all pulmonary nodules in rheumatoid patients
be biopsied.74
Wegeners granulomatosis can present as multiple masses or a single mass
with cavitation.75.76 Cavitation of the
nodules occurs in approximately 50%
of cases. The cavities usually have
irregular, thick walls (Figure 15).77
Cavitary nodules represent active
inflammatory lesions,78 and with treatment the nodules or cavities may
resolve completely or result in a scar.77
There are several reports of Wegeners
granulomatosis being misdiagnosed as
primary lung cancer and metastasis.79.80

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CAVITIES IN THE LUNG

A

FIGURE 21. Stage IV nonsmall-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, representing good response.

FIGURE 22. Stage IIIA nonsmall-cell cancer 6 weeks post radiotherapy presented with
hemoptysis and chest pain. Axial CT (A) shows multiple septations and cavitation in the radiated lung, and a right hilar mass. Post pigtail catheter placement image (B) shows drainage of
the necrotic debris.

FIGURE 23. Stage IIIA nonsmall-cell cancer post resection and radiation therapy has
now developed a bronchopleural fistula.
Coronal miniMIP image shows the bronchus
leading to the cavity in the left apex.

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

Radiologically, it may be difficult to differentiate between malignant lesion and

Wegeners granulomatosis. However, in
patients with Wegeners granulomatosis,
proteinase 3anti-neutrophil cytoplasmic
antibodies (PR3-ANCA) are positive in
>90% of cases.81

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APPLIED RADIOLOGY

Eosinophilic granulomatosis (EG)

can incidentally be found with malignancy and has been found to coexist
with lymphoma.82 EG can present as
nodules and small cavitary lesions generally <10 mm and mediastinal
adenopathy in 30% of patients; the

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hallmark of the disease is sparing of

costophrenic sulci (Figure 16).

Miscellaneous diseases
with cavitation
Pulmonary infarction occurs in nearly
one third of patients with pulmonary

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CAVITIES IN THE LUNG

embolism, and cavitation can be
detected in 32% of patients with pulmonary infarction on CT scans.83 Cavitation in infarction is located in the lung
periphery, and there is evidence of pulmonary embolus, right heart strain and
pleuritic chest pain, but no specific radiographic findings related to the cavity.84
Oncology patients are at increased risk
for pulmonary emboli,85 however, the
frequency of pulmonary infarction and
cavitation has not been reported in this
group (Figure 17).

Cavitary lesions associated

with oncotherapy
Oncology patients who undergo
chemotherapy and/or radiotherapy
often have a malfunctioning immune
system. Under immunosuppression,
morphological appearances of pulmonary infectious diseases are different
from that in immunocompetent patients.
Invasive pulmonary aspergillosis
afflicts severely immunocompromised
patients, especially those with hematological malignancies or bone marrow
transplant recipients. Cavitation generally emerges later in the course of the
disease and is often noted during recovery from neutropenia it is generally
considered a treatment response to antifungal therapy.86.87 The air crescent sign
is often considered characteristic of
retraction of infected lung in invasive
aspergillosis (Figure 18).88 However,
this sign can be seen in other conditions
such as tuberculosis, Wegeners granulomatosis and lung cancer. In addition, it
has been reported that the presence of a
halo sign, defined as a nodule surrounded by ground-glass attenuation, is
reasonably sensitive and specific for
invasive aspergillosis in high-risk
patients.89 At pathologic examination,
the nodules represent foci of infarction,
and the halo of ground-glass attenuation
results from alveolar hemorrhage.90
However, this CT appearance has been
observed in patients with lung metastases from angiosarcoma, choriocarcinoma and osteosarcoma.91
Pneumocystis jiroveci pneumonia is
a common opportunistic infection in

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HIV-infected patients but can also

occur in patients with hematologic and
solid malignancies. Contrary to the
patient with HIV infection, cavitation
is extremely rare in oncology patients
(Figure 19). Diffuse bilateral groundglass attenuation is the most common
finding in cancer patients.92
Pulmonary nocardiosis is an important
cause of opportunistic infection in immunosuppressed patients, and the incidence of this infection is increasing.
Solitary or multiple nodules with cavitation are detected in 80% of cases (Figure 20).93 Cavitation may be more
frequently observed among patients with
advanced HIV than among other hosts.94

Post therapy with novel

chemotherapy agents
Novel chemotherapeutic agents, such
as anti-angiogenic drugs, have been associated with cavitation in lung tumors.
Bevacizumab (Avastin, Genentech,
San Francisco, CA) is a humanized monoclonal antibody against vascular
endothelial growth factor (VEGF).
Bevacizumab has been associated with
cavitation in primary and metastatic lung
cancer. Cavitation is secondary to central
necrosis due to VEGF inhibition and signifies therapeutic response. Spontaneous
pneumothorax has been reported when a
responding cavitary lesion communicates with the pleura (Figure 21).95

Post radiation therapy

Radiation therapy is an important
technique in treating cancer. Radiation-induced injury in the lung is
dependent on radiation dose, fractionation of dose, portal size and concurrent
or prior administration of chemotherapy.96 In the early stages, radiation
pneumonitis may present as groundglass opacification confined to the radiation port. Cavitation may be seen 6 to
12 weeks post radiation, secondary
to necrosis and expulsion of necrotic
components. Delayed complications
can include spontaneous pneumothorax, secondary to rupture of bleb or
ectatic bronchus to the pleura, and
development of bronchopleural fistula,

secondary to superimposed infection on

a previously radiated lung parenchyma
(Figures 22 and 23).97

Post radiofrequency ablation

Radiofrequency ablation (RFA) has
been advocated as a safe and minimally
invasive procedure for patients with lung
tumors. Cavitation has been described as
evolution of post ablation changes in
treated lesions after RFA therapy (Figure 24).94 Cavitation usually occurs
within the tumor between 1 to 3 months
following RFA and evolves over time.94
The frequency of cavitation is reported to
be significantly higher in patients with
lung cancer as the primary lesion, for
lesions located within 1 cm of the chest
wall, and for pulmonary emphysema.94

Conclusion
Differentiation between malignant
cavitary lesion and nonmalignant
lesions in oncology patients can be challenging. Radiological findings can
sometimes help in narrowing differential diagnosis; however, a comprehensive approach including symptoms and
other clinical data is often required to
obtain accurate diagnosis.

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