Cavitation
Sudhakar Pipavath, MD
DIFFERENTIAL DIAGNOSIS
Common
Tuberculosis (TB)
Lung Cancer
Wegener Granulomatosis
Septic Emboli
Pneumatocele
Lung Abscess
Less Common
Cavitary Lung Metastasis
Fungal Infections
Angioinvasive Aspergillosis
Blastomycosis
Coccidioidomycosis
Paracoccidioidomycosis
Pneumocystis Pneumonia
Rare but Important
Recurrent Respiratory Papillomatosis
Intralobar Sequestration with Superinfection
Hydatid Cyst (Echinococcus)
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
Features of cavity to consider in differential diagnosis
Wall thickness of cavity can be thick or thin
Thick wall usually indicates neoplastic disease
Thin walls favor benignity
Nodularity of internal wall is associated with neoplastic etiology
Solitary cavities: Primary lung cancer, lung abscess (except when part of septic emboli), intralobar sequestration, and tuberculosis
Multiple cavities: Wegener granulomatosis, septic emboli, metastasis, fungal infection, and recurrent respiratory papillomatosis
Associated airway wall (tracheal) thickening: Wegener granulomatosis, sarcoidosis, and recurrent respiratory papillomatosis
Location of abnormalities: Left lower lobe for intralobar sequestration, lower and peripheral lungs are favored by septic emboli, and posterior upper lobes are favorite site for TB
Helpful Clues for Common Diagnoses
Tuberculosis (TB)
Imaging clues
Thick- or thin-walled cavity in posterior upper lobe
Associated findings, such as consolidation or nodules in airway distribution (tree in bud pattern)
Typically in posterior upper lobes
Clinical clues
Patients present with cough, low-grade fever, night sweats
Purified protein derivative (PPD) skin test shows induration above 10 mm, except in anergic conditions, (e.g., HIV infection)
Lung Cancer
Solitary mass with central necrosis
Thick-walled cavity with nodularity of inner wall
Cavitation is typically seen in lung cancers of squamous cell histopathology
Wegener Granulomatosis
Imaging clues
Combination of nodules, nodules with cavitation, and airway wall thickening is characteristic
In most cases, not all features are present at same time
Pulmonary hemorrhage presenting as diffuse airspace disease, sometimes with sparing of peripheral lung
Clinical clues
Antineutrophil cytoplasmic antibodies (c-ANCA) test carries high sensitivity (90%) and specificity (70%)
Renal and sinus involvement is seen in majority
Septic Emboli
Imaging clues
Multiple peripheral lung nodules or nodules with cavitation that appear and evolve rapidly
Lower and peripheral lungs are typically involved
Clinical clues
Pneumatocele
Thin-walled air-filled cavity that may result from either prior trauma or necrotizing lung infection
Can completely resolve or persist indefinitely
Lung Abscess
Imaging clues
Lung consolidation with nonenhancing center indicating necrosis
Cavitation and air-fluid level (suggestive of communication with airway) with surrounding lung consolidation
Usually solitary, except when associated with septic embolism, where there are usually multiple abscesses
Clinical clues
Aspiration, poor dental hygiene, esophageal dysmotility, low level of consciousness are some predisposing factors
Mixed anaerobic infection, Staphylococcus aureus, and Pseudomonas aeruginosa are some commonly involved organisms
Helpful Clues for Less Common Diagnoses
Cavitary Lung Metastasis
Thick or thin walled, may have internal nodularity, and are often multiple
Head and neck cancers, transitional cell carcinoma of urinary bladder, high-grade sarcomas
Fungal Infections
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