A 74-year-old man sought medical evaluation in May 2004, because of an increasing productive cough. He previously had noted productive cough, but did not become concerned until February 2004, when its frequency and intensity began to increase with no clear triggering episode or factor. He denied any history of hemoptysis, night sweats, pyrexia, or weight loss. Past medical history included pulmonary tuberculosis diagnosed at age 35 and a curative operation in 1995 for oropharyngeal carcinoma requiring reconstruction of the oropharyngeal wall with autologous grafts. Diagnosed with chronic obstructive pulmonary disease at the time of that he quit smoking. He underwent follow-up chest radiography at irregular intervals of 1 to 3 years. In May 2003 the patient was asymptomatic, but a cystic lesion in the right lung showed an increase in wall thickness compared with a previous radiograph obtained in 2000. Computed tomography (CT) of the chest in 2003 (ProSeed; GE Yokogawa Medical Systems, Tokyo) with a conventional protocol without enhancement (10-mm collimation, 10-mm intervals, 120 kVp, 200 mAs, gantry rotation time; 1.0 sec.) showed moderate wall thickening (Fig. 1a). The patient underwent repeated sputum examinations, and then bronchoscopic lung biopsy and bronchial washing targeting the right B6 segment. None of these specimens yielded evidence of cancer or bacterial or fungal pathogens. Further diagnostic procedures were declined. The patient was an office worker with no known history of dust exposure. He had smoked 1.5 packs of cigarettes daily for 42 years until he quit. He denied having undergone any blood transfusions or regular courses of medication.
The patient was 172 cm tall and weighted 55 kg. Vital signs at presentation included body temperature of 36.5  C, blood pressure of 110/78 mmHg, and pulse rate of 72/min with a regular rhythm at resting. Physical examination disclosed a healed surgical scar of the neck and diminished breath sounds in both lungs. Heart sounds included no murmurs. The abdomen was unremarkable. No neurologic findings were present. Finger clubbing was absent. Laboratory data at evaluation in 2004 are summarized in the Table 1. Serologic tests were positive for galactomannan (latex agglutination) and anti-Aspergillus antibody (complement fixation).
Chest CT, acquired by the same protocol as in 2003 without enhancement, disclosed diffuse thickening of the cyst wall (Fig. 1b). Infiltrative opacities were seen in the area proximal to the cystic lesion. Results of sputum cytologic examination were negative. Neither endoscopic trans-bronchial lung biopsy nor CT-guided transthoracic needle aspiration could establish a diagnosis. Surgical removal of the lung lesion initially was declined. When the patient was treated with the antifungal agents itraconazole and micafungin for presumed aspergillosis, the lesion continued to enlarge. The patient then agreed to undergo right lower lobectomy after the 2 months delay.
Macroscopically the resected lesion was solid, but with an outer and inner component (Fig. 2a). Microscopically, the outer portion (labeled "O" in Fig. 2a) showed dense proliferation of atypical cells with focal "pearl" formation, characteristic of squamous cell carcinoma (Fig. 2b). The inner layer (labelled "I" in Fig. 2a) was composed of septate, branching hyphae (Fig. 2c). Branching at acute angles was suggestive of Aspergillus sp. The pathologic tumor stage of the resected lung cancer was T2N0M0. The patient was thus diagnosed as having lung cancer complicated by aspergillosis.