Asian Cardiovasc Thorac Ann 2004;12:320-323
© 2004 Asia Publishing EXchange Ltd
Surgical Management of Pulmonary Aspergilloma
Ismail C Kurul, MD,
Sedat Demircan, MD,
Ulku Yazici, MD1,
Tamer Altinok, MD1,
Salih Topcu, MD1,
Mehmet Unlü, MD1
Department of Thoracic Surgery, Gazi University Medical Faculty
1 Department of Thoracic Surgery, Atatürk Center for Chest Disease and Thoracic Surgery, Ankara, Turkey
For reprint information contact: Ismail C Kurul, MD Tel: 90 312 202 5638 Fax: 90 312 214 9014 Email: cuneyt{at}gazi.edu.tr Oyak Sitesi Blok 1/20, 06610 Çankaya, Ankara, Turkey.
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ABSTRACT
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Records of 59 patients (41 males and 18 females) who underwent 70 operations for pulmonary aspergilloma in a 23-year period were examined retrospectively. Sixty-three operations were for primary treatment of pulmonary aspergilloma, and 7 were for complications of surgery. Twenty-six postoperative complications occurred in 19 patients. Three lobectomies that resulted in bronchopleural fistula were managed by intercostal muscle-flap closure and partial thoracomyoplasty. Two patients died within the first week of surgery. Surgery is the treatment of choice for most patients with pulmonary aspergilloma. Selective bronchial artery embolization is helpful only in combating hemoptysis, and this has been considered a temporary measure in most reports. Thus, open thoracotomy and anatomical resection are recommended as early as possible after the diagnosis is established.
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INTRODUCTION
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Aspergillus is a genus of saprophytic fungi that is ubiquitous in nature. These species reproduce by formation of conidia and reach the airways through inhalation. Aspergillus infections are classified into three types: allergic aspergillosis, invasive aspergillosis, and colonizing aspergillosis (aspergilloma).1–3 Aspergilloma is the most frequent manifestation of aspergillosis.1,3–10 There are still differing opinions regarding the optimal treatment for pulmonary aspergilloma. However, recent reports advocate surgery as the mainstay of treatment.9,10 Our 23-year experience of surgical management of aspergilloma is described in this report.
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PATIENTS AND METHODS
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From 1977 to 2000, 59 patients underwent a total of 70 operations; 63 for primary treatment of pulmonary aspergilloma, and 7 for complications of surgery. There were 41 males and 18 females, their ages ranged from 22 to 58 years (median age, 39 years). The records of the 59 patients were reviewed retrospectively for preoperative symptoms, underlying lung disease, surgical procedures performed, and postoperative outcome. Patients were also classified as having simple or complex aspergilloma according to the definition of Daly and colleagues3 based on radiographic findings.1,4–6,9 Simple aspergilloma was defined as thin-walled cavities without substantial surrounding parenchymal lung disease. In contrast, complex aspergilloma involved thick-walled cavities, usually greater than 3 mm, with substantial surrounding parenchymal lung disease or associated infiltration.
Surgical treatment was recommended in 13 patients who reported to the chest diseases clinics at the onset of their disease, without any symptoms, but they all refused. They were given systemic medical treatment under the supervision of the chest diseases clinics. However, after a median of 6 months, 7 of them reported again with massive hemoptysis and subsequently underwent surgery. No information on outcome was available for the rest of these patients as they lived outside the city. Eight patients from the chest diseases clinics with hemoptysis were considered unfit for surgery; all underwent medical treatment with embolization or systemic antifungal agents. No data on the outcomes in these patients were available.
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RESULTS
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Hemoptysis was the most common symptom, occurring in 41 (69.5%) patients (Table 1
). Massive hemoptysis (> 600 mL per day) occurred in 16 of these 41 patients. Life-threatening hemoptysis occurred in 5 of 16 patients who underwent an emergency operation. Tuberculosis was the most common underlying disease, being present in 79.7% of the patients (Table 2). The surgical procedures performed are shown in Table 3. Lobectomy was the most frequent procedure for pulmonary aspergilloma. Four patients had bilateral aspergilloma and 4 upper lobectomies were performed. Double-lumen endotracheal tubes were used in almost all patients. According to the radiological appearance and pathological examination, 43 patients (72.9%) had complex aspergilloma and 16 (27.1%) had simple aspergilloma. Twenty-six major postoperative complications occurred in 19 patients, all of whom had complex aspergilloma. Three lobectomies resulted in bronchopleural fistula; they were managed by intercostal muscle-flab closure of the fistula and partial thoracomyoplasty. Pleural space problems and delayed air leakage occurred in 14 patients, with empyema which healed on drainage developing in 10 of them. Early postoperative hemorrhage necessitated re-exploration in 2 patients. Wound infection occurred in 4 patients.
Two patients died within the first week of surgery. Respiratory failure due to gram-negative septicemia and shock developing after the operation were responsible for these deaths. No antifungal agent was given before or after surgery. There were no recurrences in the follow-up period which ranged from 3 to 5 years. In our 23-year experience, a morbidity rate of 32.2% and a mortality rate of 3.4% were achieved.
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DISCUSSION
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The spores of Aspergillus, which have a low pathogenic potential for humans, are ubiquitous in nature and rarely cause infection.1–3,10 Aspergilloma, the saprophytic colonization of a parenchymal cavity by aspergillus, is the most common form of infection. It has been reported in association with a wide variety of chest diseases including tuberculosis, bronchiectasis, sarcoidosis, and bronchogenic carcinoma.1,2,9,10 In most series involving aspergilloma, tuberculosis has been the most common cause of the cavitary lung disease (up to 60%).4 The rate in this series is considerably higher than that reported in other specialized centers, due to the fact that our center is one of the largest referral centers in Turkey.
The clinical course of pulmonary aspergilloma varies widely. Sometimes it remains stable over long periods.5 The majority of those with intracavitary mycetoma present with hemoptysis. It has been reported that 50%–80% of patients with aspergilloma have hemoptysis which is life-threatening in up to 30% of cases.1,3–5 Hemoptysis occurred in 41 of our patients; we believe that the high incidence of hemoptysis was related to the high incidence of tuberculosis. Another reason believed to be responsible for this observation was the delay in operation; the refusal of 13 patients to undergo surgery at the onset of the disease when they were still asymptomatic, resulted in exacerbation of the disease. Our records confirm that 7 out of these 13 patients reported again to our center and were operated on but there were no data on the other 6 patients who might have reported to other hospitals. We can therefore infer from these findings that despite systemic medical treatment, at least 50% of these patients are likely to develop massive hemoptysis later in their lives.
The diagnosis of aspergilloma is usually made by the characteristic appearance of a fungus ball on a chest radiograph or chest computed tomography. The most characteristic radiological changes are a solid mass with an associated crescent of air (Figure 1). These masses may move freely within the cavity upon changes in the position of the patient (Figure 2). Antifungal agents, such as amphotericin B or itraconazole, have no success in treating or palliating the clinical symptoms of this disease as they hardly penetrate to the lung cavities.2,4,6,7,9,10 Some investigators have attempted to instill antifungal agents into the aspergilloma cavity. The instillation is often performed by repeated transthoracic placement of a needle into the cavity, with variable success.1,2,6,7,9,10 Although treatment with selective bronchial artery embolization may be helpful in the cessation of hemoptysis, this was considered a temporary measure, and it may be unsuccessful in the presence of massive collateral circulation.10 Moreover, it is not possible to eradicate aspergilloma in this manner.6,8,10 Open thoracotomy and anatomical resection has become widely accepted as the main treatment for pulmonary aspergilloma in patients who are suitable candidates for an operation. These procedures control symptoms, and especially prevent hemoptysis and prolong life.5,7,9,10 The most common procedure performed was lobectomy. This prevents the pleural dissemination that usually occurs with limited resections such as wedge or segmental resections and cavectomies.1,6,9,10 Pneumonectomy can only be performed in cases with good lung function and with widespread destruction of one lung due to the underlying disease.10 This is equivalent to "destroyed lung" which usually occurs as a sequela of tuberculosis. Another alternative approach described in the literature is cavernostomy, which has been applied in patients unfit for resective surgery.3–7,9,10 Nevertheless, despite the good long-term results reported, some consider this technique unsatisfactory due to atrophy of the muscle pedicle.4,5 Our center has had no experience of this method. Surgery can also be employed in cases of bilateral aspergilloma, which requires sequential operations. The patient in Figure 1 underwent sequential surgery with a consecutive lobectomy. From this study it was concluded that surgery is the treatment of choice for most patients with pulmonary aspergilloma. Nevertheless, treatment of pulmonary aspergilloma must be individualized for each patient, with the thoracic surgeon weighing the risks and benefits of surgery based on the complexity of the lesion. From our observations, at least 50% of patients with aspergilloma who have no symptoms upon presentation and who refuse operation will probably experience hemoptysis later in their lives. Therefore, we recommend surgical resection as early as possible once the diagnosis has been established.
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Figure 1. (A) Radiograph and (B) computed tomogram showing typical aspergillomas in bilateral upper lobe cavities.
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Figure 2. Radiograph of the same patient in the lateral decubitus position, showing the freely movable aspergilloma.
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REFERENCES
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- Battaglini JW, Murray GF, Keagy BA, Starek PJK, Wilcox BR. Surgical management of symptomatic pulmonary aspergilloma.Ann Thorac Surg
1985;39:512–6.[Abstract]
- Glimp RA, Bayer AS. Pulmonary aspergilloma. Arch Intern Med
1983;143:303–8.[Abstract/Free Full Text]
- Daly RC, Pairolero PC, Piehler JM, Trastek VF, Payne WS, Bernatz PE. Pulmonary aspergilloma. Results of surgical treatment. J Thorac Cardiovasc Surg
1986;92:981–8.[Abstract]
- Babatasi G, Massetti M, Chapelier A, Fadel E, Macchiarini P, Khayat A, et al. Surgical treatment of pulmonary aspergilloma: current outcome. J Thorac Cardiovasc Surg
2000;119:906–12.[Abstract/Free Full Text]
- El Oakley R, Petrou M, Goldstraw P. Indications and outcome of surgery for pulmonary aspergilloma. Thorax
1997;52:813–5.[Abstract]
- Chen JC, Chang YL, Luh SP, Lee JM, Lee YC. Surgical treatment for pulmonary aspergilloma: a 28-year experience. Thorax
1997;52:810–3.[Abstract]
- Massard G, Roeslin N, Wihlm JM, Dumont P, Witz JP, Morand G. Pleuropulmonary aspergilloma: clinical spectrum and results of surgical treatment. Ann Thorac Surg
1992;54:1159–64.[Abstract]
- Jewkes J, Kay PH, Paneth M, Citron K. Pulmonary aspergilloma: analysis of prognosis in relation to haemoptysis and survey of treatment. Thorax
1983;38:572–8.[Abstract/Free Full Text]
- Chatzimichalis A, Massard G, Kessler R, Barsotti P, Claudon B, Ojard-Chillet J, et al. Bronchopulmonary aspergilloma: a reappraisal. Ann Thorac Surg
1998;65:927–9.[Abstract/Free Full Text]
- Regnard J, Icard P, Nicolosi M, Spagiarri L, Magdeleinat P, Jauffret B, et al. Aspergilloma: a series of 89 surgical cases. Ann Thorac Surg
2000;69:898–903.[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
