Ann Thorac Surg 2010;89:291-292. doi:10.1016/j.athoracsur.2009.06.084
© 2010 The Society of Thoracic Surgeons
Case Reports
Video-Assisted Thoracoscopic Lobectomy for Pulmonary Aspergilloma After Life-Threatening Hemoptysis in a Patient With Lupus
Kathryn L. Parker, BSa,
Michael D. Zervos, MDa,
Farbod Darvishian, MDb,
Costas S. Bizekis, MDa,*
a Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, New York
b Department of Pathology, New York University Langone Medical Center, New York, New York
Accepted for publication June 16, 2009.
* Address correspondence to Dr Bizekis, 530 First Ave, Skirball 9 9V, New York, NY 10016 (Email: costas.bizekis{at}nyumc.org).
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Abstract
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Open thoracotomy procedures serve as the mainstay for surgical resection of pulmonary aspergilloma. These procedures are considered among the most challenging for thoracic surgeons, and postoperative morbidity and mortality rates are high. Here, we present patient who underwent video-assisted thoracoscopic lobectomy for aspergilloma. Based on the success of the operation, we suggest that video-assisted thoracoscopic surgical resection be considered as an option for pulmonary aspergilloma.
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Introduction
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Aspergillus is a ubiquitous saprophytic fungus usually found in damp areas or on decaying plants [1]. Each day, humans inhale an average of 15 to 30 of these spores without disease developing. In some people, however, especially in immunocompromised individuals, severe and life-threatening infections result. Aspergilloma is the most common type of infection caused by Aspergillus and consists of a round fungus ball that colonizes in preexisting lung cavities, such as those caused by tuberculosis. The most common presenting symptom is hemoptysis, and current literature recommends surgical intervention because antifungal therapy is unreliable. We report a case of aspergilloma discovered in a patient with massive hemoptysis that was successfully resected through a video-assisted thoracoscopic surgical (VATS) lobectomy.
In January 2009, a 57-year-old woman was hospitalized for life-threatening hemoptysis out of a previously placed tracheostomy. Her medical history included systemic lupus erythematosus (SLE) complicated with Pneumocystis carinii pneumonia (PCP) and subsequent respiratory failure. She was receiving long-term immunosuppression therapy with mycophenolate and prednisone.
After an emergency bronchoscopy was performed to remove a 6.5 x 2.5 x 1 cm clot embedded in both her right and left mainstem bronchi, a computed tomography (CT) scan revealed a very large, 7 cm right upper lobe fungus ball cavity (Fig 1). A bronchial artery embolization was performed to prevent future hemoptysis (Fig 2), and treatment with voriconazole was started.
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Fig 1. A transverse computed tomography scan shows the large aspergilloma fungus ball in the right upper lobe.
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Fig 2. Contrast angiograms (A) before and (B) after bronchial artery embolization. (A) A large bronchial artery supplies the large fungus ball (mycetoma). (B) The same mycetoma is shown after the procedure.
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After a brief period of stabilization, she underwent surgical resection. Initially, an exploratory VATS using two lower thorascopic ports was performed. Adhesions between the upper lobe and the chest wall were identified and taken down endoscopically with a harmonic scalpel. An anterior access incision was then created in the fifth intercostal space. Owing to the size and location of the mass, a lobectomy would be necessary for resection. The hilum was carefully dissected, and the vessels and bronchus to the right upper lobe were individually ligated with endoscopic stapling devices to free the lobe. No surgical complications were noted, and the patient made an uneventful recovery.
Macroscopic examination of the surgical specimen revealed a cavitary, brown-red mass containing soft and friable material. Microscopically, this material consisted of concentric aggregates of hyphae that were rimmed by an incomplete fibrous capsule and focal abscess formation. On high magnification, the hyphal elements of the fungus ball were uniform, septated at regular intervals, and branching at 45° angles. These features were consistent with aspergilloma. A Gomori methenamine silver (GMS) stain highlighted the fungal structures and supported the diagnosis (Fig 3).
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Fig 3. Photomicrograph of the lesion shows a thin, septate hyphae with acute angle branching in a background of necrotic tissue (Gomori methenamine silver stain, original magnification x200).
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Comment
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Surgical resection of pulmonary aspergilloma presents a challenge for thoracic surgeons due to associated pleural adhesions, indurated hilar structures, and diseased lung parenchyma [2]. Mortality rates of up to 44% have been reported, and postoperative complications are common. Surgical intervention is currently recommended in all operable patients with aspergilloma, however, because hemoptysis occurs in 50% to 80% of untreated patients and is life threatening in 30% [3]. Furthermore, bronchial artery embolization is considered only a temporary measure to stop blood loss because collateral circulation may trigger future episodes of hemoptysis.
Open thoracotomy has served as the main surgical technique, with lobectomy as the most common procedure [3]. These surgeries are invasive, however, and require an extended postoperative hospital stay. Furthermore, they are not recommended in patients with low pulmonary function reserves [4].
Surgical groups in Japan recently reported successful aspergilloma resections using VATS lobectomies in 3 patients [5–7] and VATS wedge resections in 2 others [8]. The VATS technique has many advantages over an open thoracotomy: it is less invasive, involves fewer postoperative complications, and requires a shorter postsurgical recovery. It also offers excellent visualization when taking down adhesions in the apex of the chest. Because respiratory failure is the most common cause of death after pulmonary aspergilloma resection, VATS procedures also may be preferable because of their enhanced ability to preserve postoperative respiratory function [8]. Consequently, patients with low pulmonary function reserves may better tolerate these procedures.
We report a successful VATS lobectomy for pulmonary aspergilloma. From this experience, we recommend an exploratory VATS be done before surgical resections of these fungus balls to aid in taking down adhesions and to determine if a VATS resection is possible.
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References
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- Lee SH, Lee BJ, Jung DY, et al. Clinical manifestations and treatment outcomes of pulmonary aspergilloma Korean J Intern Med 2004;19:38-42.[Medline]
- Itano H, Andou A, Date H, Shimizu N. Non-small cell lung cancer coexisting with pulmonary aspergilloma Jpn J Thorac Cardiovasc Surg 2005;53:513-516.[Medline]
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- Nakajima J, Takamoto S, Tanaka M, Takeuchi E, Murakawa T. Thoracoscopic resection of the pulmonary aspergilloma Chest 2000;118:1490-1492.[Abstract/Free Full Text]
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Abstract
Introduction
