Cavitary Lung Lesions Diagnosis and Management

Initial Imaging

A chest CT scan is the recommended first diagnostic test to characterize the cavitary lesion, showing associated hilar or mediastinal lymphadenopathy and other abnormalities suitable for biopsy, according to the British Thoracic Society 1, 2
CT allows assessment of cavity wall thickness, internal contents, surrounding infiltrates, and pleural involvement, which help narrow the differential diagnosis, as suggested by the European Respiratory Society 3, 4
Findings suggestive of malignancy include thick-walled cavities, irregular margins, and associated mass lesions, as indicated by the American College of Chest Physicians 1, 5
Findings suggestive of infection include air-fluid levels, surrounding consolidation, and multiple cavities, according to the Infectious Diseases Society of America 3, 6

Patients with cavitary lesions should be discussed with a respiratory physician and radiologist at minimum, preferably in a multidisciplinary meeting, as recommended by the British Thoracic Society 1, 2
Clinical and radiographic information should be reviewed to consider the likely diagnosis and best approach to obtaining a definitive diagnosis, according to the American College of Radiology 1
The likelihood of malignancy increases with lesion size, patient age, smoking history, and history of hemoptysis, as suggested by the American College of Chest Physicians 2

Bronchoscopy with BAL is recommended as the first invasive diagnostic procedure for cavitary lesions, according to the Infectious Diseases Society of America 7
BAL samples should be sent for cytologic assessment, Gram staining and bacterial culture, fungal staining and culture, acid-fast bacilli staining and mycobacterial culture, and galactomannan testing, as recommended by the American Thoracic Society 7

PTNB is indicated when bronchoscopy is negative or unlikely to yield a diagnosis, the lesion is peripheral and accessible, or a tissue diagnosis is required for management decisions, according to the British Thoracic Society 1, 2

Aspergillus IgG or precipitins testing is recommended if fungal infection is suspected, as suggested by the European Respiratory Society 8, 6

Infections, including fungal (Aspergillus species) and mycobacterial (tuberculosis, non-tuberculous mycobacteria), are common causes of cavitary lesions, according to the European Respiratory Society 8, 3, 6, 1
Autoimmune conditions, such as granulomatosis with polyangiitis, can also cause cavitary lesions, as indicated by the European Respiratory Society 4

Cavitating lesions are usually caused by tumors or abscesses; clinical presentation often helps distinguish between these diagnoses, according to the British Thoracic Society 2
Chronic cavitary lesions present for >3 months require evaluation for chronic pulmonary aspergillosis, especially with positive Aspergillus serology, as recommended by the European Respiratory Society 8, 3, 6