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Ann Thorac Surg 1998;65:927-929
© 1998 The Society of Thoracic Surgeons

Bronchopulmonary Aspergilloma: A Reappraisal

^a Department of Thoracic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

Accepted for publication October 28, 1997.

Address reprint requests to Dr Massard, Department of Thoracic Surgery, Hôpitaux Universitaires de Strasbourg, F-67091 Strasbourg, France

	Abstract

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Background. Classically, most complications observed after operations for aspergilloma occurred in patients with sequelae of tuberculosis. Because the incidence of tuberculosis has declined over the past two decades, aspergilloma is expected to develop with increasing frequency in patients without previous tuberculosis. Therefore, our hypothesis was that operative outcome should have improved during the most recent years in comparison with our previous experience.

Methods. Operative outcome of 12 recently accrued patients was evaluated and compared with a historic control group of 55 patients, previously reported by the same center.

Results. As expected, only 17% of patients of the present series had a history of tuberculosis, compared with 57% in the former series. Postoperatively, there was no mortality. Major morbidity has decreased, although this difference is not statistically significant: bleeding decreased from 44% to 9% of patients; space problems decreased from 47% to 18%; and prolonged hospital stay (>30 days) decreased from 32% to 9%.

Conclusions. Our results support a trend toward improved postoperative outcome of operations for aspergilloma owing to a decreased incidence of aspergilloma growing in tuberculous cavitations.

	Introduction

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In our previous report, the spectrum of indications for operative management of aspergillus-related disease was restricted to megamycetomas developing in parenchymal cavitations, or in residual pleural spaces [1]. Megamycetoma, called "saprophytic" aspergillosis in opposition to invasive and allergic aspergillosis, was hosted by parenchymal cavitations consecutive to pulmonary tuberculosis in up to 80% of patients [1]. The advent of drugs effective on Aspergillus species, such as itraconazole [2], has stimulated debate regarding the utility of surgical procedures in such patients, who are at risk for major postoperative complications. Nonetheless, operation remains the mainstay of treatment for aspergilloma, especially because of the threat of massive hemoptysis [3]. Cure of aspergillus empyema depends on obliteration of any residual pleural space; surgical treatment may promote the healing process by decortication, muscle plombage, or thoracoplasty. The choice of the most appropriate procedure depends on the compliance of the residual lung tissue [4, 5].

In recent years, the spectrum of indications for surgical management has broadened, because surgical intervention has proved itself as a valuable approach for semiinvasive and even invasive pulmonary aspergillosis. Semiinvasive aspergillosis is a well-recognized entity, generating a mycetoma soon after a cavitating aspergillus pneumonia, and is at best subjected to surgical resection [6]. Surgical management for acute invasive aspergillosis is to be discussed in two different settings. An increasing number of publications have demonstrated the feasability and relative safety of surgical management of invasive aspergillosis in immunocompromised patients on an emergency basis during the acute phase of disease; the goal of surgical intervention in these patients is to resect acute cavitations in the vicinity of major pulmonary vessels to prevent fatal hemoptysis [7, 8]. A single report deals with such operations performed in neutropenic patients [9]. Second, resection of mycotic sequestra after invasive aspergillosis may prevent endogenous reinfection during reinduction therapy [6, 10].

In our previous experience, an operation for saprophytic aspergilloma appeared as a high-risk procedure. Operative mortality exceeded 8%. Sixty-six percent of patients suffered from various nonlethal complications, culminating in operative bleeding and pleural space problems. Presence of pleural or parenchymal sequelae significantly heralded postoperative complications [1]. The purpose of the present study was to reevaluate both clinical spectrum and postoperative results of aspergilloma in our most recent experience, since 1991. With the decline of prevalence of tuberculosis observed during the past two decades, we speculated that most aspergillomas that accrued during the latter time period had developed in patients without history of tuberculosis. Therefore, our hypothesis was that postoperative outcome would be improved in comparison with our previous evaluation [1].

	Patients and methods

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Patients
From January 1992 to March 1997, 12 patients were operated on for pulmonary aspergilloma. There were 9 male and 3 female patients with a mean age of 46 years (range, 17 to 66 years). All 12 patients were admitted on an elective basis.

Methods
We applied a methodology similar to our previous study [1]. Briefly, charts were reviewed for underlying lung disease, clinical presentation, operative procedure, and outcome. Patients were classified as having simple or complex aspergilloma according to Daly and colleagues [12] on the basis of medical imaging: simple aspergilloma was defined as a thin-walled cavitation occurring in an otherwise healthy lung; the qualification as complex aspergilloma required either a thick-walled cavitation or presence of underlying parenchymal and pleural sequelae, or both. Operative mortality was defined as any death occurring during the first 30-day period or during the initial hospital stay. Bleeding was considered excessive when the sum of intraoperative bleeding plus postoperative drainage in the first 24 hours exceeded 1,500 mL. Pleural space problems included air leaks prolonged beyond 10 days, secondary pneumothorax, and empyema [1].

Clinical data as well as operative outcome were compared with the previously published results [1]; comparisons were made with the ² test. Statistical significance was obtained for any value of p less than 0.05.

	Results

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Underlying disease
Three patients presented with a bronchial aspergilloma without any additional underlying disease (25%). Various diseases were observed in 7 patients (58%): 2 presented with tuberculous cavitations (17%), each had postpneumonic cavitation, bullous emphysema, radiation pneumonitis, pulmonary infarction, and sarcoidosis. Two final patients presented with persisting aspergilloma-like lesions with air-crescent sign several weeks after invasive aspergillosis, which had initially been treated with liposomal amphotericin B.

Symptoms and rationale for operation
On initial presentation, 3 patients were free of symptoms (25%). Five were complaining of hemoptysis, and 4 had chronic cough together with low-grade fever. The classic air-crescent sign was identified in only 5 patients (42%). According to the criteria of Daly and colleagues [11], 5 had complex aspergillomas and 7 had simple aspergillomas. Surprisingly, serodiagnosis was positive in only 3 patients (25%). Including the 2 patients with previous invasive aspergillosis, conservative management with itraconazole as antifungal therapy was attempted in 8 patients; none of these patients had an objective response to treatment. Operation was decided because of symptoms in 8 patients (66%), and because of an indeterminate diagnosis in 2; in 2 patients with hematologic disease, resection of aspergilloma was planned before reinduction chemotherapy.

Surgical procedure and outcome
A single patient was managed by thoracoplasty without parenchymal resection (8%); he presented with disabling pulmonary function that precluded resection. Nine patients underwent a lobectomy through a muscle-sparing posterolateral thoracotomy: there were 4 right upper lobectomies, 4 left upper lobectomies, and 1 left lower lobectomy. Two patients underwent multiple wedge excisions, performed through a posterolateral thoracotomy in 1, and through a median sternotomy in 1.

There were no operative deaths. Mean operative blood loss was 309 ± 181 mL (range, 200 to 800 mL); total perioperative blood loss (24 hours) averaged 825 ± 380 mL (range, 350 to 1,600 mL). Total blood loss exceeded 1,500 mL in a single patient.

Two patients had prolonged air leaks (17%); one of them required secondary tube thoracostomy and pneumoperitoneum to seal his pleural space. Postoperative recovery was uneventful in 10 patients.

Sampling of the mycetoma was sent for titration of the itraconazole content in 3 patients. Two had a chronic saprophytic aspergilloma, containing less than 250 ng/g. A mycotic sequestrum after invasive aspergillosis contained 829 ng/g.

Comparison with previous data
Regarding initial presentation, the prevalence of major sequelae of tuberculosis decreased from 57% in our previous series to 17% in the current series. As a consequence, the prevalence of complex aspergilloma [11] dropped from 80% to 42% (Table 1). Salvage operations with thoracoplasty in poor-risk patients have decreased from 20% to 8%. Regarding parenchymal resections less than pneumonectomy, incidence of bleeding decreased from 44% to 9%; pleural space problems decreased from 47% to 18%; hospital stay prolonged beyond 30 days postoperatively decreased from 32% to 9% (Table 2). However, none of these differences reached the level of statistical significance.

	Comment

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Postoperative complications are preferentially anticipated in patients with debilitated general health status or respiratory function, in the presence of pleural and parenchymal sequelae, and in symptomatic patients [1]. Expectations for a more benign postoperative outcome, founded on the less morbid profile of the present series’ patients, were fulfilled: we observed a dramatic decrease in operative mortality and morbidity, although statistical significance was not reached. During the years, we did not substantially modify either operative technique or postoperative management, except for two details. First, when pleural space problems are anticipated, we prophylactically create a pneumoperitoneum by intraoperative insufflation of 1 to 1.5 L of air through the diaphragm. The most common indications are upper lobectomy extended to the apical segment of the lower lobe and poor compliance of the remaining lobe. Second, we liberally use aprotinin during decortication in an attempt to reduce oozing from the extrapleural surface. However, there is no scientific evidence to date that such measures do prevent postoperative complications. As formerly reported, thoracoplasty remains a viable option for debilitated patients who are unlikely to undergo lobectomy. In our opinion, pneumonectomy should be avoided because of the major risk for empyema [12].

The introduction of itraconazole into the therapeutic armamentarium raised great expectations, which have been frustrated by disappointing clinical results. In the case of a classic saprophytic aspergilloma, intracavitary diffusion is hampered by fibrosis, and unexpectedly low concentrations of itraconazole are obtained within the mycetoma; therefore, long-term results on the mycetoma are not satisfactory [2]. In contrast, mycotic lung sequestra in the setting of invasive aspergillosis may concentrate itraconazole to a high level. Histologically, mycotic lung sequestra are formed by fungal material mixed up with necrotic pulmonary parenchyma, which may explain the different pattern of drug diffusion. Nevertheless, persistent mycotic lung sequestra are a permanent threat for reinfection during reinduction chemotherapy, and should therefore be resected if tolerable. Both patients of the present series who were subjected to resection of mycotic lung sequestra subsequently underwent successful autologous bone marrow grafting.

Because to date there is no effective alternative, surgical management remains the mainstay of treatment for aspergilloma. With the decline of tuberculosis, operations are less challenging, and postoperative outcome is improved. We entirely suscribe to our previous conclusions that surgical risk is minimal in asymptomatic patients without major sequelae; in symptomatic patients, surgical intervention is necessary to avoid spontaneous deterioration of the patient [1]. Recent literature opens up the way to surgical management for invasive aspergillosis [6–10]; the surgical goals in these patients are both to oppose vascular erosion in the acute setting and to prevent endogenous reinfection during reinduction therapy.

	Acknowledgments

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Doctor Chatzimichalis was a clinical fellow at our institution. His current address is the Department of Thoracic Surgery at Evangelismos Hospital, Athens, Greece.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

1. Massard G., Roeslin N., Wihlm J.M., Dumont P., Witz J.P., Morand G. Pleuro-pulmonary aspergilloma: clinical spectrum and results of surgical treatment. Ann Thorac Surg 1992;54:1159-1164.[Abstract]
2. Campbell J.H., Winter J.H., Richardson H.D., Shandlaud G.S., Banham S.N. Treatment of pulmonary aspergilloma with itraconazole. Thorax 1991;46:839-841.[Abstract/Free Full Text]
3. Jewkes J., Kay P.H., Paneth M., Citron K.M. Pulmonary aspergilloma: analysis of prognosis in relation to hemoptysis and survey of treatment. Thorax 1983;38:572-578.[Abstract/Free Full Text]
4. Shirakusa T., Ueda H., Suito T., et al. Surgical treatment of pulmonary aspergilloma and aspergillus empyema. Ann Thorac Surg 1989;48:779-782.[Abstract]
5. Massard G., Rougé C., Wihlm J.M., et al. Decortication is a valuable option for late empyema after collapsotherapy. Ann Thorac Surg 1995;60:888-895.[Abstract/Free Full Text]
6. Kibbler C.C., Milkins S.R., Bhamra A., Spiteri M.A., Noone P., Prentice H.G. Apparent pulmonary mycetoma following invasive aspergillosis in neutropenic patients. Thorax 1988;43:108-112.[Abstract/Free Full Text]
7. Young V.K., Maghur H.A., Luke D.A., McGovern E.M. Operation of cavitating invasive pulmonary aspergillosis in immunocompromised patients. Ann Thorac Surg 1992;53:621-624.[Abstract]
8. Robinson L.A., Reed E.C., Galbraith T.A., et al. Pulmonary resection for invasive aspergillus infections in immuno-compromised patients. J Thorac Cardiovasc Surg 1995;109:1182-1197.
9. Bernard A., Loire J., Caillot D., et al. Résections pulmonaires en urgence pour aspergillose invasive chez des patients neutropéniques. Ann Chir 1995;49:849-853.[Medline]
10. Massard G., Lioure B., Wihlm J.M., Morand G. Resection of mycotic lung sequestra after invasive aspergillosis. Ann Thorac Surg 1993;55:561-568.
11. Daly R.C., Pairolero P.C., Piehler J.M., Trastek V.F., Payne W.S., Bernatz P.E. Pulmonary aspergilloma. Results of surgical treatment. J Thorac Cardiovasc Surg 1986;92:981-988.[Abstract]
12. Massard G., Dabbagh A., Wihlm J.M., et al. Pneumonectomy for chronic infection is a high risk procedure. Ann Thorac Surg 1996;62:1033-1038.[Abstract/Free Full Text]

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