Attila Csekeo

Surgery for pulmonary aspergillosis.

OBJECTIVE Surgery of pulmonary aspergillosis followed by higher incidence of post-operative complications. This was the purpose to evaluate our material. METHODS Between January 1983 and December 1995, the operation was carried out on a total of 84 patients for pulmonary aspergillosis. The patients were comprised of 71 males and 13 females, with a mean age of 49 years (range, 24-71). Previous lung disorders were observed in about half of the cases (most frequently tuberculosis), while in the other half aspergillosis was developed on the basis of (sub)-acute infections. Haemoptysis was present in 48% of patients. The diagnosis was suspected in 47 cases by chest X-ray. Aspergilloma was diagnosed in 50 patients pre-operatively (excluding 12 typical aspergillomas for cavernostomies), with the other pre-operative diagnoses being tuberculosis, lung cancer, pyoscelrosis, etc. RESULTS In 71 cases pulmonary resection was carried out (52 lobectomies, 13 wedge resections and six pulmonectomies). A total of 12 cavities were opened by cavernostomy and one lung biopsy was performed for disseminated lung disease. The post-operative mortality rate was 9.5%. The most common complications were bleeding, empyema, bronchial fistula and wound infection. In 23 patients with developed prolonged air leak and/or residual air space, complications were observed more frequently in patients with greater cavitation near the chest wall. CONCLUSIONS In most cases of pulmonary aspergilloma surgical intervention remains the only effective therapy. The operation has a lower risk factor in asymptomatic patients and in patients without pleural or chest wall involvement. In some cases, cavernostomy may be the only remaining surgical choice.

Sarcoidosis lymphoma syndrome - the value of PET-CT in the diagnosis

We report a 52-year-old patient who developed B-cell non-Hodgkin’s lymphoma subsequent to sarcoidosis. Sarcoidosis was diagnosed 16 years ago and remained asymptomatic for 14 years after steroid treatment. She presented with new symptoms of arthralgia, photosensitivity, butterfly erythema, autoimmune antibodies (ANA, chromatin positivity) associated with progression of the known left upper lobe lesion on the chest X-ray suggesting primary autoimmune disease (systemic lupus erythematosus). As steroid treatment was not effective, we started bolus cyclophosphamide therapy after which progression was seen on the chest X-ray. Computed tomography (CT)-guided needle biopsy confirmed malignancy of indefinable origin. Despite of the well-known fluorodeoxyglucose (FDG) avidity in active sarcoidosis, a FDG-positron emission tomography (PET) scan was performed to stage the primary tumour. Intensive FDG uptake was detected in the affected lung segment, with moderate uptake in mediastinal lymph nodes. The patient underwent left upper lobectomy. The histology showed pulmonary mucosa-associated lymphoma (bronchus-associated lymphoid tissue (BALT) lymphoma) in the lung tissue, while only sarcoidosis was present in the mediastinal lymph nodes. Bone marrow biopsy was negative.The association between sarcoidosis and lymphoma is known as sarcoidosis lymphoma syndrome, which is a rare disease. PET-CT was helpful in the differentiation of sarcoidosis and malignancy in this patient. It is important to be aware of the risk of lymphoma in sarcoidosis and FDG-PET, used for adequate purpose, can help the diagnosis.