Asian Cardiovasc Thorac Ann 2006;14:407-411
© 2006 Asia Publishing EXchange Ltd
Analysis of Surgical Treatment for Pulmonary Aspergilloma
Adalet Demir, MD,
Mehmet Z Gunluoglu, MD,
Akif Turna, MD,
Hasan V Kara, MD,
Seyyit I Dincer, MD
Department of Thoracic Surgery, Yedikule Teaching Hospital for Chest Diseases and Thoracic Surgery, Istanbul, Turkey
For reprint information contact: Adalet Demir, MD Tel: 90 212 664 1700 Fax: 90 212 547 2233 Email: dradalet{at}hotmail.com, Yuzyil mah. Kisla Cad. Yesil zengibar sitesi, A-3 Blok, D-9 Bagcilar, Istanbul, Turkey.
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ABSTRACT
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Surgery for pulmonary aspergilloma is reputed to be risky. The results of surgical treatment of pulmonary aspergilloma in 41 patients between 1988 and 2003 were evaluated retrospectively. Hemoptysis occurred in 31 patients (75.6%) and it was massive (> 300 mL in 24 hr) in 3. The underlying lung disease was tuberculosis in 35, bullous lung disease in 2, hydatid cyst in 2, and lung carcinoma in 2 patients. Lobectomy, bilobectomy, wedge resection, and pneumonectomy were performed in 27, 4, 6, and 4 patients respectively. The postoperative complication rate was 24.4%. One patient, who had a right pneumonectomy, died due to respiratory failure; the mortality rate was 2.4%. Recurrent hemoptysis was observed in only one patient. Early surgical treatment of patients with pulmonary aspergilloma resulted in a satisfactory outcome with acceptable morbidity, low mortality, and effective prevention of recurrent hemoptysis. Pneumonectomy has a high morbidity, thus it should be avoided if possible.
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INTRODUCTION
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Aspergilloma generally results from colonization of an existing lung cavity by Aspergillus fumigatus, the most common saprophytic species of aspergillus in human disease, producing a fungus ball or mycetoma.1 Controversy still exists concerning the optimum management of aspergilloma. High morbidity and mortality rates have been reported from surgical series of pulmonary aspergilloma.2–4 Due to the risk of sudden life-threatening hemoptysis and the lack of an effective alternative medical therapy, some have advocated prophylactic resection of all pulmonary aspergillomas.2,3,5 Others recommend surgical treatment only after hemoptysis has occurred.6,7 The purpose of this study was to evaluate the indications and results of surgical treatment of aspergilloma, with specific attention to postoperative complications.
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PATIENTS AND METHODS
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Between 1988 and 2003, 41 patients were operated on for pulmonary aspergilloma. There were 5 females and 36 males, with a mean age of 42 years (ranging from 17 to 70 years). None was immunocompromised. All patients underwent posteroanterior and lateral chest radiography, computed tomography of the chest, and fiberoptic bronchoscopy. Transthoracic fine-needle aspiration biopsy was performed in some patients who could not be diagnosed by other means. Histology of cultured material with periodic acid-Schiff staining or histopathologic evaluation disclosed aspergillus hyphae in all resected specimens.
The degree of hemoptysis was categorized by the amount of blood lost in 24 hr; it was considered massive if the amount exceeded 300 mL. Pleural space problems included prolonged air leaks of more than 7 days. Operative mortality was defined as any death occurring during the first 30 days postoperatively or during the initial hospital stay. Comparisons were made using the chi-squared test. If the p-value was below 0.05, the result was considered significant.
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RESULTS
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Hemoptysis, the most frequent symptom, occurred in 31 patients (75.6%). Three patients (7.3%) had massive hemoptysis. All patients had a forced expiratory volume in the first second of more than 40%. Thirty-one patients were suspected to have aspergilloma preoperatively, as their radiographs demonstrated the characteristic fungus ball with the air crescent sign. Sputum or bronchoscopic aspirate cultures and material from transthoracic fine-needle aspirate cultures were repeatedly positive for Aspergillus fumigatus in 18 (58.1%) and 10 (32.3%) patients, respectively. Another 10 patients were found to have other pulmonary pathologies and were not suspected of having pulmonary aspergilloma radiographically. Of these, a diagnosis of aspergilloma was made preoperatively in 3 patients: via bronchoscopy in 1, and by transthoracic fine-needle aspirate cultures in 2. Seven other patients were diagnosed by tissue culture and histological examinations of the resected material. Aspergilloma was located in the left upper lobe, right upper lobe, and right lower lobe in 21 (51%), 16 (39%), and 4 (10%) patients respectively. Most patients (85.4%) were found to have tuberculosis in addition to aspergilloma (Table 1
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All 34 patients who were found to have aspergilloma in addition to other pulmonary pathologies and 7 who were suspected to have other pathologies without a preoperative diagnosis of aspergilloma were operated on regardless of symptoms. Forty-three surgical procedures were performed on these 41 patients, as shown in Table 2. One patient who underwent lobectomy had additional wedge resection, and one had segmentectomy. An additional segmentectomy was performed in one patient who had a bilobectomy. Two of the patients who underwent pneumonectomy had cavitary lesions in both lower and upper lobes. One patient underwent pneumonectomy for a fungus ball in a destroyed lung (Figure 1), and another had a pneumonectomy due to technical reasons that were attributed to adhesions around the hilar structures. A wedge resection was required in 6 patients with either small peripheral lesions or poor respiratory functional reserve. Two of these patients were thought to have bullous lung disease, one was diagnosed with pulmonary hydatid cyst, and the others had lung cancer preoperatively. Postoperative pathologic examination revealed aspergilloma in these patients (Figure 2).
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Figure 2. Mucosal attachment area of fungal hyphae (hematoxylin and eosin stain, original magnification x 10).
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A further 2 procedures were performed in 2 patients: myoplasty for bronchopleural fistula and empyema in one, and completion of the pneumonectomy for hemoptysis in a patient who had previously undergone lobectomy. We encountered a massive hemorrhage while performing hilar dissection in one patient and we had to carry out a pneumonectomy. There were no other perioperative complications except mild hemorrhage in 21 patients who had massive pleural symphysis. There were 16 postoperative complications in 10 (24.4%) patients (Table 3). Pneumonectomy led to significantly more complications than lobectomy ( p = 0.03). One patient who underwent pneumonectomy developed bronchopleural fistula and died of respiratory failure on the 48th postoperative day. Operative mortality was 2.4%.
Follow-up was complete in the survivors, and ranged from 11 to 192 months (median, 67 months). In the long-term follow-up, one patient (2.4%) had recurrent hemoptysis and underwent completion of the pneumonectomy 10 months after his first operation. Another patient died of respiratory failure 40 months after discharge.
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DISCUSSION
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When aspergillus colonizes a pre-existing cavity, the result is a fungus ball or mycetoma that consists of branched septate hyphae and blood cells. MacPherson8 estimated the prevalence of aspergilloma at 0.01%, based on a 10-year survey of chest radiographs in a population of 60,000 patients. A British cooperative study found that patients with a history of tuberculosis and thick-walled lung cavities of more than 7-years’ duration had a higher risk of aspergilloma.2 From 1959 to 1992, the most common pre-existing condition was tuberculosis. Since then, the prevalence of pulmonary aspergilloma has slightly decreased: 63 patients underwent surgery between 1959 and 1992, whereas only 21 patients were operated on in the last 6 years. This decrease seems to be related to a reduced prevalence of sequelae of pulmonary tuberculosis and the extensive use of new antifungal agents.
Although more than 1,000 species of aspergilli have been identified, very few cause human disease, Aspergillus fumigatus being the most common type.1,6 All kinds of cystic and cavitary parenchymal or pleural disease sequelae may be involved, such as old cavities occurring in the course of sarcoidosis, lung cancers, bacterial abscess, bronchiectasis cavitations, congenital cysts, tuberculosis, pulmonary infarction, bullae, blebs, chronic infection, and ankylosing spondylitis.1–3 Interestingly, we discovered an intracavitary aspergilloma in a patient who had undergone cystectomy and capitonnage for pulmonary hydatid cyst. However, old chronic tuberculosis cavities remain the most frequent underlying disease, and were found in 85.4% of our cases. In another series, aspergillomas occurring in tuberculous lung ranged from 13% to 89% (Table 4). A number of studies observed an increased incidence of asymptomatic cases without any underlying disease.1,15 However, an underlying disease was observed in all our cases.
The clinical picture of aspergilloma ranges from incidental radiologic findings to life-threatening hemoptysis.2 The most common symptom is hemoptysis, which may be mild, severe, or even exsanguinating; especially in the intracavitary type. In previous series, the incidence of hemoptysis in patients with aspergilloma ranged from 50% to 83%, and it was severe or recurrent in 10%.14–19 Bleeding generally occurs from bronchial arteries and usually stops spontaneously. Proposed mechanisms for hemoptysis include erosion of the vascular cyst wall by the motion of the mycetoma, elaboration of endotoxin by the fungus, and the patient’s underlying disease.20 Bleeding from large arteries is unlikely to stop spontaneously and could be fatal. Neither the size, complexity of the lesion, a forewarning minor hemoptysis, nor the type of underlying disease can predict which patients will progress to life-threatening hemoptysis.10
As demonstrated in our study and in other series, the diagnosis of aspergilloma is based on various signs.1,3,4,10,19 The presence of radiological opacity with the air crescent sign is of specific importance. The spores of aspergilli are easily inhaled and can be identified in sputum and secretions. Isolated growth of aspergillus from sputum culture is not diagnostic, but repeated positive sputum cultures have more significance. In our study, 18 patients (44%) repeatedly had positive sputum cultures for aspergillus, whereas fine-needle biopsy disclosed it in 12 (29%). Although fine-needle aspiration has been recognized as an important tool for most intrathoracic entities, diagnosis of aspergilloma using this technique has not been described before. However, the definitive diagnosis of aspergilloma is established by demonstrating and culturing the organism from a resected specimen.
Systemic antifungal agents (given orally, intravenously, by inhalation, or direct instillation into the cavity) are effective in superficial infections and in some systemic fungal infections, but have shown no consistent success in alleviating symptoms or treating pulmonary aspergilloma.18 Several studies have shown that antifungal treatment varies considerably from case to case and does not affect the size of the aspergilloma or the mortality rate.18,19 As all patients had clinical and/or radiological pathology other than aspergilloma, we did not administer antifungal therapy to any of our patients. Generally, a clear justification is warranted in complex aspergilloma patients.
The rate of hemoptysis in asymptomatic patients may be as high as 20%.2,3,5 Patients untreated due to high risk for surgery have an increased rate of massive hemoptysis. Karas and colleagues4 had 4 deaths in 10 patients who were not operated on due to high surgical risk. Similarly, 2 patients who refused surgery and were not included in our study had massive hemoptysis and both died. In view of this, patients with a diagnosis of aspergilloma should be treated surgically as soon as possible to avoid a major complication. This experience showing an extremely low morbidity rate has led to our present policy of advocating prophylactic resection whenever a fungus ball is diagnosed, if the patient is a suitable candidate for an operation. The main goal of surgery is to resect cavitations near the pulmonary vessels to prevent fatal hemoptysis while limiting the parenchymal resection as much as possible to avoid impairing lung function.2 There is no general agreement on the management of pulmonary aspergilloma. Lobectomy and segmentectomy are the preferred procedures, but segmentectomy or wedge resection should be reserved for patients with either a small peripheral lesion or poor respiratory function. In agreement with previous series, the most common resection in this study was lobectomy in 65.8%.1,2,16,17 Pneumonectomy was associated with a high morbidity rate and this should be reserved for a few selected patients. Cavernostomy is an alternative surgical procedure for patients who cannot tolerate planned lung resection. As no patient in our series had significantly poor respiratory reserve, cavernostomy was not performed.
Pleural space problems were the most common postoperative incidents in all series.1,15 Borelli and colleagues19 performed additional thoracoplasty after lobectomy to prevent such problems. We do not agree that thoracoplasty is indicated in most patients who undergo lobectomy. Myoplasty was needed in only one of our patients who developed empyema and bronchopleural fistula. Although postoperative bleeding was a common complication in some reports, we encountered this complication in only one patient. Bronchopleural fistula is the most feared complication after pneumonectomy. It may lead to life-threatening complications such as respiratory insufficiency, empyema, and aspiration of purulent material to the healthy lung. Thus bronchopleural fistula must be treated energetically. Some patients can be treated with drainage and irrigation only; however, surgical closure of the fistula and thoracoplasty or myoplasty may be necessary. We encountered this complication in 2 of 4 patients who underwent pneumonectomy; one was treated initially with tube thoracostomy and the fistula was closed by subsequent myoplasty; the other was treated conservatively.
It was concluded from this experience that surgical resection for aspergilloma offers potential benefits with low morbidity and mortality, prevention of massive hemoptysis, eradication of the pyogenic component, and limitation of the symptoms. However, pneumonectomy must be avoided if possible as it leads to increased morbidity.
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ABSTRACT
INTRODUCTION
