Cardiovasc Intervent Radiol (1994) 17:271-275
CardioVascular
Percutaneous Treatment of Pulmonary Hydatid Cysts
Okan Akhan, ~ Mustafa N. 0 z m e n , ~ Alp Dinner, 1 Ayhan G6~men, 2 Fuat Kalyoncu 3
~Department of Radiology, Hacettepe Universitesi, Tip Fakiiltesi, TR-06100 Ankara, Turkey
2Department of Pediatric Chest Diseases, Hacettepe Universitesi, Tip Fakiiltesi, TR-06100 Ankara, Turkey
3Department of Chest Diseases, Hacettepe Universitesi, Tip Fakiiltesi, TR-06100 Ankara, Turkey
Abstract
Purpose: To evaluate the safety and efficacy o f per-
cutaneous drainage o f p u l m o n a r y h y d a t i d cysts.
Methods: E l e v e n p u l m o n a r y h y d a t i d cysts in eight pa-
tients were drained percutaneously after 1 - 2 years o f
treatment with m e b e n d a z o l e (50 mg/kg/day). Percuta-
neous needle aspiration was carried out under ultra-
sound (US) in six patients and c o m p u t e d t o m o g r a p h y
(CT) in two patients. Nine cysts were close to, and two
cysts were distant from the thoracic wall. After aspi-
ration, hypertonic (15%) saline solution was instilled
for up to 35% o f the estimated v o l u m e o f the cyst and
aspirated 5 - 1 0 min later. F o l l o w - u p ranged from 8 to
31 months (mean 16.3 months).
Results: Neither anaphylactic shock nor death occurred
in any o f the eight patients. One patient developed fever,
ipsilateral hydropneumothorax, and contralateral pleural
effusion. One patient suffered from fever, pneumotho-
rax, and abscess and was treated surgically; one devel-
oped fever and dyspnea. The volume reduction during
follow-up was 4 7 % - 9 3 % . The cystic contents turned
into a pseudotumor appearance with a thick irregular
contour on CT and higher Hounsfield units. On US, the
cysts showed a heterogeneous content with internal ech-
oes representing detached and degenerated membranes,
and the fluid content almost completely disappeared.
Conclusion: W e b e l i e v e that percutaneous therapy o f
p u l m o n a r y hydatid disease is an effective alternative to
surgical treatment in patients who have failed m e d i c a l
therapy.
Key words: H y d a t i d cyst, pulmonary, t r e a t m e n t - - P e r -
cutaneous aspiration, needle
H y d a t i d disease, caused b y Eccinoccocus granulosus,
is e n d e m i c in s o m e countries especially the M i d d l e
Correspondence to: Dr. O. Akhan
and Intervenfional
Radiology
9 Springer-Verlag New York Inc. 1994
East, the Mediterranean countries, South A m e r i c a ,
N e w Zealand, and Australia. The most c o m m o n l y in-
v o l v e d organs are liver and lungs [1].
The traditional treatment o f p u l m o n a r y eccinococ-
cal cysts is surgical, as in a b d o m i n a l h y d a t i d disease
[2, 3]. A l t h o u g h l o n g - t e r m medical treatment with me-
b e n d a z o l e or albendazole have been used in the last 15
years, the results are still controversial [ 4 - 8 ] .
In the recent literature, there are several reports on
percutaneous treatment o f a b d o m i n a l h y d a t i d cysts and
unintended percutaneous aspiration o f p u l m o n a r y hy-
datid cysts [ 9 - 1 9 ] . The aim o f this study was to assess
the effectiveness o f the percutaneous treatment o f pul-
m o n a r y h y d a t i d disease as an alternative to surgical
treatment in selected patients in w h o m m e d i c a l treat-
ment had failed.
Material and Methods
From November 1990 to June 1993, eight patients (aged 7-55 years,
three female, five male) with 11 pulmonary hydatid cysts were re-
ferred for percutaneous treatment. Mebendazole (50 mg/kg/day) had
been given as medical treatment in six patients for 1 year and in two
patients for 2 years. One of the patients (patient 8) had undergone
surgery 3 years earlier. One year thereafter, when two recurrent cysts
were diagnosed, she was given mebendazole for 1 year. Medical
treatment was considered ineffective so these patients were referred
for percutaneous treatment. Possible complications and results of sur-
gical and percutaneous treatments were explained in detail to the
patients, and informed consent was obtained. Prior to the percuta-
neous procedure, every patient had a PA chest radiograph, thoracic
ultrasound (US), and computed tomography (CT) for the diagnosis
of hydatid cyst. One of the cysts was in the right lung, and 10 were
left sided. All cysts were type I (pure anechoic cyst with well-defined
borders) according to the classifications of Niron and Ozer or Gharbi
et al. [20, 21]. Nine cysts were close to, and two cysts were distant
from the thoracic wall. One week before and after the percutaneous
procedure, the patients were given mebendazole orally (50 mg/kg/
day) to prevent dissemination from leakage of cyst fluid [22]. Before
the procedure, premedication with diazepam (5 mg) and atropine
(0.25 mg) and a single dose of first-generation cephalosporine (2 g)
were given intravenously. All the patients were monitored by an an-
esthesiologist ready for intervention in case of anaphylaxis.
272 O. Akhan et al.: Percutaneous Treatment of Pulmonary Hydatosis

Table 1. Characteristics and procedural information for 11 percutaneously aspirated echinococcal cysts in eight patients

Preprocedure cyst Complication Cough Postprocedure cyst Volume

Patient during Follow-up reduction
# Type Size (ram) Vol. (cc) Minor Major procedure (months) Type Size (mm) Vol. (cc) rate (%)

1 I 3 0 x 3 0 x 32 14 - - + 31 IV 14 x 16 x 11 1 93
2 I 31 x 30 x 33 15 - - - 23 IV 27 x 27 X 22 8 47
3 I 85 z 63 x 75 198 Fever RP effusion + 20 IV 47 X 26 • 29 17 91
! 54 X 54 X 50 71 LHPT IV 31 x 29 X 25 11 85
4 I 59 X 47 x 50 68 - - - 18 IV 44 x 19 X 20 8 88
I 5 0 X 3 3 x 35 28 IV 52 X 24 X 20 12 57
5 I 97 X 81 X 100 385 Fever Pneumothorax - Operated
Abscess
6 I 37 x 28 X 25 13 - - - 10 IV 28 X 22 X 20 6 54
7 I 100 X 90 X 95 419 Fever - - 8 IV 60 X 40 • 50 59 86
Dyspnea
8 I 40 x 33 X 35 23 - - - 8 IV 30 X 27 • 30 12 48
I 3 7 X 3 2 X 35 20 IV 29 X 25 • 25 9 55

RP: right pleural effusion; LHPT: left hydropneumothorax; Vol.: estimated volume = A x B X C x 0.49 • 10 3 (A, B, C in mm and volume
in cubic cm)
Postprocedural measurements are obtained at the last follow-up time indicated in the table

Percutaneous needle aspiration was carried out under US guid-

ance in six patients and CT guidance in two patients. Under standard
sterile conditions, 2% lidocaine was used for local anesthesia at the
selected puncture point. PAIR (puncture--aspiration of cyst con-
tents--injection of hypertonic saline solution--reaspiration) tech-
nique, described in previous reports [23], was used for the
procedures. An 18-gauge (g) Seldinger needle was used for punctur-
ing the cysts close to the thoracic wall whereas a 22-g Chiba needle
was preferred for the cysts located deeply. After the needle was in
the correct position, hydatid fluid was aspirated as much as possible
and this was followed by instillation of hypertonic saline solution
(15% NaC1) for up to 35% of the estimated cyst volume. The saline
solution was aspirated after 5 - 1 0 rain. After evacuating the cystic
content, the needle was withdrawn.
The follow-up was carded out by clinical and radiological eval-
uation. PA chest radiograms, US, and CT were performed every 3
months for the first year after the procedure and twice annually in
the following years. The follow-up ranged from 8 to 31 months (mean
16.3 months). During the follow-up, changes in size, content, and
wall of the cysts were assessed.

Results

The results are summarized in Table 1. Neither ana-

Fig. 1. A CT scan of a 32-year-old woman prior to the procedure
shows a round, left pleural based hyperdense mass (14 HU). B CT
scan 16 months after aspiration shows the same mass (63 HU) with
significant size and volume reduction.
phylactic shock nor death occurred in any of the eight
patients. Dyspnea, as a minor allergic reaction, was
seen in one patient (patient 7). Fever was noted in three
patients (up to 38.5~ and subsided without treatment.
Two patients started coughing and expectorated cyst
contents (fluid and membra~es) after hydatid fluid as-
piration or hypertonic saline injection, as air entered
into the cystic cavity. One patient (patient 3) had one
O. Akhan et al.: Percutaneous Treatment of Pulmonary Hydatosis
Fig. 2. Thoracic US (A) and CT (B) of a 10-year-oldboy show a
round cystic mass (12 HU) on the left side prior to treatment. C Nine
months after the percutaneous aspiration, US shows a small hypo-
echoic lesion with irregular contour and internal echoes representing
small cyst in the right lung and two cysts in the left.
We performed percutaneous treatment of the left cysts
where only one was in contact with the thoracic wall.
After the procedure, pleural effusion occurred on the
right side and hydropneumothorax on the left. The hy-
dropneumothorax was treated by a chest tube (22 Fr)
which was removed 24 h later. No recurrence was en-
countered during a follow-up period of 20 months (Fig.
1). In another patient (patient 5), postprocedure pneu-
mothorax occurred on the ipsilateral side. A chest tube
was inserted for 2 days. While the pneumothorax was
treated, an abscess developed in the cyst cavity. Al-
though percutaneous drainage of the abscess was of-
fered, the patient went to surgery 10 days later. No
viable protoscolices were found in the cavity fluid. Ex-
cept for patient 5, hospitalization was limited to 1 - 2
days.
The size of 10 cysts was reduced considerably. This
reduction was found to be significant on a t-test and
Wilcoxon test (p < 0.05). The volume reduction ranged
between 47% and 93% (mean 70.4%). Four of the 10
cysts contained variable amounts of air up to 18 months
after the procedure. Later, all 10 cysts turned into a
small mass (pseudotumor appearance) with a thick ir-
regular contour on CT and had higher Hounsfield units.
273
degenerated laminated and germinative membranes. D CT shows a
small hyperdense lesion with 85 HU absorption value. Volume re-
duction rate is 88%.
Cysts in contact with pleura had a heterogeneous solid
appearance representing detached and degenerated
membranes, and the fluid component almost com-
pletely disappeared on US (type IV, according to Ghar-
bi's classification) (Fig. 2). The wall thicknesses of the
cysts were increased on follow-up US and CT.
Discussion
Pulmonary hydatid cysts rarely heal by spontaneous
evacuation into the bronchus. However, intrabronchial
rupture, anaphylactic reaction, rupture into the pleural
cavity with hydropneumothorax, rupture into the me-
diastinum with sudden occlusion of bronchus or tra-
chea, infection, lung abscess, and bronchiectases are
serious and possibly fatal complications of pulmonary
hydatid cysts [3].
The traditional therapy for pulmonary hydatid cysts
is surgical, as it is for abdominal hydatid cysts. How-
ever, postoperative complications are seen in 3.5% of
patients and the reported 30-day mortality rate is 1.7%
and 2% in two series [3]. Though large series of sur-
gically treated pulmonary hydatid cysts have been re-
274
ported, there is a lack of extended follow-up data
including recurrence rates.
Medical treatment (mebendazole and albendazole)
is the treatment of choice in pulmonary hydatid disease.
The results of this treatment are also variable [4-8].
Todorov et al. [4] reported that 37 of 56 pulmonary
cysts (66%) disappeared after medical therapy with me-
bendazole, whereas no change was seen in 17 (30%).
With albendazole, they observed disappearance of 20
out of 24 cysts (83%). The success of treatment with
benzemidazole-carbamates depends highly on the lo-
calization of the cysts: In patients treated with
mebendazole, successful results were observed in 21%
of pulmonary, but only 7% of liver echinococcosis. A1-
bendazole was successful in three of four (75%) lung,
and in 21% of liver echinococcosis [6]. Grqmen et al.
[7] reported that 30 children with pulmonary hydatid
cysts were given mebendazole (50 mg/kg/day) with a
mean treatment time of 11.7 months. All but one of the
patients had nearly clear chest radiographs with a small
fibrotic band. Although pulmonary hydatid cysts are
more responsive to medical treatment with mebenda-
zole or albendazole, there are still more pulmonary
cysts that are not affected by medical treatment.
Percutaneous aspiration of a hydatid cyst is gener-
ally not recommended because of the risk of an allergic
reaction, which can be serious, and because of the dan-
ger of spreading the disease by spilling cyst contents.
However, there have been several reports of percuta-
neous therapy of liver hydatid cysts which were not
complicated by allergic reaction or spillage of the cyst
contents [9-13]. In an experimental study on sheep,
dissemination and anaphylactic reactions were not
seen, and percutaneous treatment of abdominal hydatid
cysts was found safe and effective [14]. Lewall and
McCorkell [18] stated that 4 of their 24 patients
(16.7%) with ruptured hydatid cysts had symptoms or
history of an allergic episode following cyst rupture,
but none had fatal anaphylaxis. It could be concluded
that percutaneous aspiration of a hydatid cyst is not
necessarily followed by an anaphylactic reaction. Un-
fortunately, serological or immunological tests play no
role in predicting an anaphylactic reaction [16, 17].
Transbronchial aspiration of pulmonary hydatid
cysts was reported by 6~er et al. [15] in 1977. Fifteen
of the 17 cysts were superinfected without viable par-
asites, whereas the remaining 2 had intact germinative
membranes. Six of 17 cases expectorated all of the cyst
content immediately after transbronchial aspiration or
a couple of days later. No mention of allergic reaction
was made in this report.
Transthoracic aspiration of a pulmonary hydatid
cyst was first reported in 1982 [16]. In a later report,
three viable, noninfected echinococcal cysts of the lung
were unintentionally punctured by transthoracic aspi-
ration. There was no allergic reaction during or after
o. Akhan et al.: PercutaneousTreatmentof PulmonaryHydatosis
the procedure. Cystobronchial communication was
seen in all three cases. The follow-up of the patients
ranged from 2 months to 3 years. There was no evi-
dence of disease spread during follow-up [17]. Unin-
tentional percutaneous aspiration of a pleural hydatid
cyst was reported by Karawi et al. [19] who performed
repeated aspiration of pleural effusion caused by hy-
datid disease. When they proved the existence of pleu-
ral hydatid disease, surgical treatment was performed.
There was no pleural recurrence during 42 months of
follow-up.
Lewall and McCorkell [ 18] reported that communi-
cation between the cyst and the bronchial tree may
be established by bronchioles incorporated in the
pericyst. Communicating rupture into the lung will
lead to expectoration of fluid and membranes, and
may result in evacuation and cure of the cyst. There
was no evidence that transbiliary or transbronchial
dispersion of scoleces causes dissemination of echin-
ococcal disease.
In our study, we performed percutaneous treatment
of 11 pulmonary hydatid cysts in eight patients. One of
them, with a previous history of surgery, had recurrent
disease, and seven of them, who had been given me-
bendazole for more than 1 year, had no sign of im-
provement. Before aspiration, patients were given
mebendazole (50 mg/kg/day) for 1 week in order
to decrease the possibility of spreading echinococcal
cysts [23].
During the procedure and follow-up, we encoun-
tered neither anaphylactic reaction nor recurrence of
disease. Minor complications, such as fever and dysp-
nea, occurred in three of eight patients. As major
complications, we encountered an ipsilateral hydro-
pneumothorax and a contralateral pleural effusion in
one patient (patient 3) and a pneumothorax on the ip-
silateral side in another (patient 5).
Bacterial infection is the most serious complication
of rupture (spontaneous or iatrogenic) of the hydatid
cysts [18]. In this series, we only gave a single dose of
prophylactic antibiotic (first generation cephalospo-
rine). But as demonstrated in one patient (patient 5), a
single dose could not prevent abscess formation. Al-
though in some cases all the fluid content of the cyst
was aspirated, early after the percutaneous procedure,
serous fluid without microorganisms and hydatids
refilled almost 3 0 % - 4 0 % of the cavity. This fluid
gradually resolves spontaneously during follow-up (un-
published data). In patient 5, the aspirated cyst was one
of the two largest in our series. We think that the larger
the amount of serous fluid reaccumulation the greater
the risk of infection. If we had given the patient anti-
biotics for a longer period, the abscess may have been
avoided.
Four of the 10 cysts contained variable amounts of
air up to 18 months after the procedure. Because intra-
O. Akhan et al.: Percutaneous Treatment of Pulmonary Hydatosis
cavitary pressure, which can be as high as 100 c m H 2 0 ,
is reduced by removing some cyst fluid, air may enter
the cystic cavity from a bronchus of the pericyst, which
was compressed before the procedure. According to
our observation, air may enter the cystic cavity either
during (two patients) or after (two patients) the proce-
dure.
During the follow-up, all 10 cysts showed no sign
of viable scolices on US and CT. It has been shown
that significant size and volume reduction, solidifica-
tion, absence of fluid component, and a thick, irregular
contour are signs of healing [14]. Under these criteria,
we had a remarkable cure rate of 91% (10 of 11 cysts).
To our knowledge, this is the first systematic study
on percutaneous treatment of pulmonary hydatid cysts.
We believe that percutaneous treatment of pulmonary
hydatid cysts is the treatment of choice in cases where
the cyst is resistant to medical treatment. The fear of
serious anaphylactic reactions associated with the per-
cutaneous treatment appears unfounded under the treat-
ment regimen we applied. As this study contains only
a limited number of patients, further investigation is
needed.
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