Indian Journal of Pathology and Microbiology

: 2021  |  Volume : 64  |  Issue : 2  |  Page : 413--414

Endobronchial carcinoid tumor coexisting with saprophytic Aspergillus

Olga Kaplun1, Aikaterini Papamanoli2, Igor Chernyavskiy3, George Psevdos4,  
1 Division of Infectious Diseases, Cooper University Hospital, Camden, New Jersey, 08103, USA
2 Division of Infectious Diseases, Stony Brook University Hospital, Stony Brook, New York, NY 11794, USA
3 Chief of Pulmonary/Critical Care Medicine, Veterans Affairs Medical Center, Northport, NY 11768, USA
4 Chief of Infectious Diseases, Veterans Affairs Medical Center, Northport, NY 11768; Stony Brook University School of Medicine, Stony Brook, New York, NY 11794, USA

Correspondence Address:
George Psevdos
Chief of Infectious Diseases Northport VAMC, 79 Middleville Road, Northport, NY, 11768

How to cite this article:
Kaplun O, Papamanoli A, Chernyavskiy I, Psevdos G. Endobronchial carcinoid tumor coexisting with saprophytic Aspergillus.Indian J Pathol Microbiol 2021;64:413-414

How to cite this URL:
Kaplun O, Papamanoli A, Chernyavskiy I, Psevdos G. Endobronchial carcinoid tumor coexisting with saprophytic Aspergillus. Indian J Pathol Microbiol [serial online] 2021 [cited 2021 Jun 20 ];64:413-414
Available from:

Full Text

Aspergillus species are numerous and widespread in the environment, but few can cause disease in humans. Pulmonary disease by Aspergillus involves three well-known clinical syndromes, invasive disease, aspergillomas, and allergic bronchopulmonary aspergillosis. Tracheobronchitis is a unique entity characterized by invasion of the tracheobronchial tree by Aspergillus.[1] It is commonly seen in patients who have received lung transplants, acquired immunodeficiency syndrome, and cancer.[1] Lung neuroendocrine carcinoid tumors are an uncommon group of pulmonary malignancies. Saprophytic colonization of endobronchial carcinoid tumors by Aspergillus has rarely been reported.[2] Herein, we report a case of right mainstem endobronchial lesion causing dyspnea in a chronic pipe smoker, diagnosed as neuroendocrine carcinoid with the surprisingly finding of fungal hyphae in the necrotic areas of the tumor.

A 69-year-old gentleman presented to our practice complaining of dyspnea on exertion and intermittent cough occasionally productive of brownish phlegm. He denied fevers, night-sweats, and hemoptysis. He smoked pipe for over 40 years. A physical examination revealed wheezing over the right upper lung lobe. A chest X-ray and a computed tomography imaging showed a 2.7 cm × 1.5 cm ovoid density in the right upper lobe [Figure 1]a and [Figure 1]b. A bronchoscopic evaluation confirmed the presence of an occluding endobronchial lesion in the anterior segment of the upper lung lobe [Figure 2]. Histologic analysis showed a carcinoid tumor with spindle cell features and low mitotic index (less than 3 mitoses per high power fields) [Figure 3]. Immuneperoxidase stains revealed that the tumor is diffusely and strongly positive for synaptophysis and chromogranin. These findings are suggestive on well-differentiated neuroendocrine carcinoma as seen in typical carcinoid. Narrow branching hyphae in the necrotic areas of the tumor were appreciated [Figure 4]. The immunoperoxidase stain for Aspergillus was positive. The serum β-(1-3)-D glucan antigen was undetectable and galactomannan antigen was normal with optical density 0.04, normal range 0–0.49. The patient was treated with stereotactic radiation therapy, for a total dose 5,000 cGy. The patient was started on voriconazole 200 mg twice daily 3 days before the initiation of radiation and for 28 days after completion of radiation therapy. The patient tolerated both treatments and remains tumor free one year after the diagnosis.{Figure 1}{Figure 2}{Figure 3}{Figure 4}

Nilson et al. identified 35 cases of non-carcinoid primary lung carcinomas and two cases of endobronchial carcinoid with coexisting Aspergillus at the time of initial diagnosis.[2] The majority of the cases (24) were aspergillomas, in cavitary lesions; in 4 cases the organisms were found within fibrin and necrotic debris denoting likely colonization. Kim et al. described a case of peripheral lung carcinoid tumor associated with aspergilloma.[3] In Nilson's et al. two cases of endobronchial carcinoid and Aspergillus involvement, the hyphae were seen only in necrotic tissue. Wu et al. reported cases of endobronchial tumor lesions of squamous cell carcinoma and synovial sarcoma that had Aspergillus hyphae in the necrotic areas of the tumors.[4] In the majority of the reported cases above there was no demonstration of submucosal tissue invasion or damage caused by hyphae to support the diagnosis of invasive fungal airway disease, that is, invasive tracheobronchitis. The same is true for our case. Aspergillus likely invades the necrotic tumor areas either through colonization of the respiratory tree via inhalation of spores prior to tumor formation or via endogenous spread invading the tumor.[5] Although we suspected colonization rather than invasive disease, radiation therapy could potentially disrupt the patient's innate immune system which could result to local invasion of Aspergillus. Thus, prophylactic antifungal treatment with voriconazole was given during radiotherapy and no invasive disease ensued.

In conclusion, saprophytic colonization of endobronchial carcinoid tumors by Aspergillus species has been rarely reported. Our patient, a 69-year-old gentleman, chronic pipe smoker, who presented with dyspnea, received stereotactic radiation therapy and concurrent antifungal treatment with voriconazole, to eliminate the risk of intrabronchial dissemination of the fungus during radiation therapy. Treatment was well tolerated, there has been no progression of the disease and the patient has been in good health to date.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Kousha M, Soubani AO. Pulmonary aspergillosis: A clinical review. Eur Respir Rev 2011;20:156-74.
2Nilsson JR, Restrepo CS, Jagirdar J. Two cases of endobronchial carcinoid masked by superimposed aspergillosis: A review of the literature of primary lung cancers associated with Aspergillus. Ann Diagn Pathol 2013;17:131-6.
3Kim KJ, Yu JH, Kim NH, Kim YH, Kim YS, Seo JA. A case of pulmonary carcinoid tumor with a superimposed aspergilloma presenting as a covert ectopic adrenocorticotropic hormone syndrome. Front Endocrinol 2017;8:123.
4Wu T, Li P, Wang M, Wang Q, Shi Y, Su X. Pulmonary solid tumor with coexisting pulmonary aspergillosis: Case reports and literature review. Clin Respir J. 2017;11:3-12.
5Lass-Florl C, Salzer GM, Schid T, Rabl W, Ulmer H. Dierici MP. Pulmonary Aspergillus colonization in humans and its impact on management of critically ill patients. Br J Haematol 1999;104:156-7.