Pulmonary aspergilloma - clinical findings and surgical treatment

The management of pulmonary aspergilloma is still a topic of discussion. Demonstrating several cases of pulmonary aspergilloma, their clinical course and their follow-up, we try to contribute some arguments for the preference of an early operation. Between 1992 and 1998, 18 patients underwent thoracotomy for treatment of pulmonary aspergilloma. The most common indication for operation were hemoptysis [6] and indeterminate mass [6]. Lobectomy was the most frequent operation [11]. Underlying diseases were bronchiectasis [10], tuberculosis [3], carcinoma [2], blebs [2], and epitheloid granuloma. Two patients had postoperative complications, another three died later in the clinical course because of liver failure, septicemia, and persisting air leakage and sepsis. We recommend early resection of symptomatic, cavitating aspergilloma in the simple form and even with an inflammatory reaction of the surrounding tissue. Especially low-risk patients profit highly from an early operation. High-risk patients should be operated on only in cases of life-threatening complications.     

Results of surgical treatment for pulmonary aspergilloma with 26 cases in six years: a single center experience

Surgery for pulmonary aspergilloma is reputed to be risky. We analyzed our results of the surgical treatment for pulmonary aspergilloma. Between 2003 and 2009, 26 patients underwent thoracotomy for treatment of pulmonary aspergilloma in our center. Results were evaluated retrospectively. There were 5 female and 21 male patients, with a mean age of 44 ± 11.6 years (28-70). The patients were divided into two groups, group A (simple aspergilloma; n= 8) and group B (complex aspergilloma; n= 18). Major underlying diseases were tuberculosis (61.5%). The most common indication for operation was hemoptysis (57.6%). Of our patients, 23% were complaining of massive hemoptysis or recurrent hemoptysis. Other patients were complaining of mild symptoms and some of them were totally asymptomatic. We performed 15 (57.6%) lobectomies (3 with associated segmentectomies), 8 (30.6%) segmentectomies/wedge resections, 2 (7.6%) pneumonectomies, and 1 (3.8%) cavernoplasty. Postoperative complications occurred in 15 (57.6%) patients. Complications occurred in 72.2% patients of complex aspergilloma, whereas 25% occurred in simple aspergilloma (p= 0.03). Major complications included prolonged air leak, empyema, air space. One patient who underwent lobectomies for complex aspergilloma developed bronchopleural fistula and died of respiratory failure on the 20th postoperative day. Operative mortality was 3.8%. The average postoperative hospital stay was 12.9 days. The mean follow-up period was average 44 months. The actuarial survival at 3 years was 90% and 100% for complex aspergilloma and simple aspergilloma, respectively (p> 0.05). There was two recurrence of disease (8%). But no recurrence of hemoptysis. Low morbidity rate may have been due to the selection of patients with localized pulmonary disease in this study. Surgical resection of asymptomatic or symptomatic pulmonary aspergilloma is effective in preventing recurrence or massive hemoptysis for patients whose condition is fit for pulmonary resection with reasonable mortality, morbidity and survival rates.     

Asymptomatic metalloptysis complicating lobectomy in pulmonary aspergilloma – An unusual complication

Recurrent haemoptysis in pulmonary aspergilloma is an indication for surgical resection of the cavity and removal of the fungus ball, in patients with a sufficient pulmonary function to allow surgery. Use of titanium surgical clips in such cardiothoracic surgical procedures may be the source of unusual complications. We report one such unusual complication of expectoration of a titanium surgical clip through a right lobectomy stump, the procedure having been performed six years previously for a symptomatic aspergilloma. We believe this to be first instance of metalloptysis in a case of pulmonary aspergilloma, following lobectomy.     

肺曲菌球40例临床分析

目的 探讨肺曲菌球的诊断和治疗方法. 方法 分析2001-2005年武汉市结核病院收治的40例肺曲菌球患者的临床诊治情况. 结果 40例中男24例,女16例,年龄17～61岁,平均37.7岁.40例中支气管扩张症和空洞型肺结核37例,肺囊肿2例,空洞型肺癌1例;咯血33例,反复间断小量咯血(＜20 ml/次)27例,大咯血6例;咳嗽、咳痰5例次;发热、盗汗3例次.40例患者均无基础疾病及长期使用抗生素史.术前、术后曲菌球的诊断符合率为60%(24例),原发病的诊断符合率为40%(16例).手术切除肺叶39例,全肺切除1例.死亡1例.随访1年,仅1例抗曲霉治疗6个月,余均未按要求服药.除2例大咯血患者复发外,余均痊愈. 结论 肺曲菌球多见于支气管扩张症及空洞型肺结核患者.多数患者可出现反复小量咯血.术前曲菌球和原发病诊断较困难.可根据病情采取不同的治疗方法,是否应首选手术或预防性手术有待商榷.出院后的抗曲霉治疗似乎并非必要.     

Cavernostomy and simultaneous removal of fungus ball of pulmonary aspergilloma]

Between 1991 and 2000, 21 patients (16 male and 5 female) underwent 28 cavernostomies for the treatment of pulmonary aspergilloma. The median age was 59.4 years (range 37-85 years). The mean %VC was 59.6 (range 30.4-91.2), and the mean FEV 1.0 was 1.51 ml (range 0.64-2.67 ml). The mean body mass index was 17.6 (range 12.7-23.2). The most common complaint was hemoptysis. The underlying lung disease was tuberculosis in 17 cases, atypical mycobacteriosis in 2, and unclassified in 2. All cases had been diagnosed as complex aspergilloma. The mean surgical duration was 136 minutes (range 85-203 min.) and the mean blood loss during surgery was 242 ml(range 5-810 ml). No death or major complications occurred in the postoperative course. During follow-up, 4 patients died of massive hemoptysis, cancer, respiratory failure or an unknown cause. Relapses of aspergilloma occurred in 9 patients (42.9%). Recavernostomy was performed safely on 5 patients. In conclusion, although the relapse rate of aspergilloma was high after cavernostomy, safe reoperations were performed. Cavernostomy is thus an effective treatment in high-risk patients.     

肺结核合并肺曲菌球病的外科治疗

目的总结肺结核合并肺曲菌球病的诊断和外科治疗经验。方法对经手术治疗的24例肺结核合并肺曲菌球病患者的临床资料进行分析。结果 24例患者术前确诊率为37.5%(9/24)。行肺叶切除术20例,全肺切除术4例,19例同时行肥厚胸膜切除术。全组无手术死亡。术后并发症8例(33.3%),分别为胸腔出血1例,支气管胸膜瘘3例,包裹性液气胸2例,肺不张2例。术后随访22例,患者无肺曲菌球病复发。结论肺结核合并肺曲菌球病术前确诊率低;手术切除病变肺叶及肥厚胸膜是治疗肺结核合并肺曲菌球病的有效方法。     

肺曲菌球手术出血情况分析及术前评估

目的明确合并有肺曲菌球的不同类别肺切除手术的出血情况及并发症相关性,为术前评估及术后并发症预防提供依据。方法对合并有肺曲菌球的各类肺叶切除手术按胸膜腔黏连情况及手术方式与手术出血情况,术后并发症进行分类对比。数据进行统计学处理,明确各类手术相关情况。结果132例中手术出血及并发症与胸腔黏连情况存在显著性差异,而与手术方式无明确相关性。结论对合并有曲菌球的肺手术,在术前评估时应充分考虑病史体征及症状,对黏连情况做出正确判断,选择恰当的手术方案将减少不必要的手术风险和术后并发症的发生。     

肺曲菌球的外科治疗（附182例报告）

目的探讨肺曲菌球的手术适应证及手术治疗效果。方法回顾性分析我院1975年9月至2008年1月经手术治疗的182例肺曲菌球患者资料,分为单纯性肺曲菌球组（SPA,n：42）和复合性肺曲菌球组（CPA,n;140）。行肺叶切除术146例,全肺切除13例,复合切除（肺叶＋肺段或楔形切除）11例,肺段切除7例,楔形切除5例。结果182例患者中治愈178例,治愈率97．8％。无手术死亡,术后发生并发症47例（25．8％）,包括出血5例,持续漏气10例,肺炎11例,肺复张不全8例,支气管胸膜瘘、脓胸3例,心律失常3例,肺脓肿5例,切口感染2例。SPA组术后并发症发生率低于CPA组（P〈0．05）。术后随访173例,随访4个月～5年无复发。结论外科手术为肺曲菌球的首选治疗方法。对于病程短、肺病变局限、胸膜粘连较轻的患者电视胸腔镜具有创伤小、恢复快、术后并发症少的优点是其最佳选择。     

The successful surgery of lung abscess formed from pulmonary aspergilloma in a patient with recurrence of acute promyelocytic leukemia during remission induction therapy

This is a case report of a successful case of surgical treatment of a lung abscess formed from pulmonary aspergilloma in a patient with a recurrence of acute promyelocytic leukemia during remission induction therapy. A 39 year-old woman was admitted to our hospital for remission induction therapy of a recurrence of acute promyelocytic leukemia. We were successful in bringing her to a state of complete remission by a therapy of a intermediate-dose of Ara-C. Pulmonary aspergilloma was formed in the right lung during therapy. We performed transbronchial infusions to Amphotericin B which dissipated the fungus ball. However, a lung abscess was formed. We needed radical therapy, and there were no complications in the following surgical treatment. Recently, along with the tendency for the use of stronger chemotherapy treatment regimes for acute leukemia, there has been an increase of the number of mycosis cases such as the pulmonary aspergilloma case reported here. Accordingly, surgical treatment is becoming more and more a matter of necessity in the clinical course of leukemia patients.     

Role of surgical procedures in the diagnosis and therapy of tuberculosis

Over the last decades the annual number of surgical intervention for treatment of pulmonary tuberculosis has steadily declined. Despite effective antituberculotic medication, there are still indications for thoracic surgery. The aim of the present study was to give an account of the diagnostic and therapeutic role of surgery of pulmonary tuberculosis. Therefore we analysed all operated patients with pulmonary tuberculosis between 1988 and 1999. In 2% of all patients with pulmonary tuberculosis surgical intervention was performed (n = 35). Their main indication was resection for suspected carcinoma, multi-drug resistance or non-compliance to the medical treatment, decortication because of cavern rupture or empyema, hemoptoe and destroyed lung. A additional indication for surgery was pulmonary aspergilloma caused by superinfection of postspecific cavities. Postoperative complications like bleeding (> 1000 ml) or broncho-pleural fistula occurred in 37%, none of the patients died. Surgery is still a valid option für the treatment of pulmonary tuberculosis. Before surgical intervention, a long term antituberculotic chemotherapy is essential. Patients have to be selected individually because of an increased morbidity. In 10% of all operated patients (n = 1132) with preoperative unidentifiable pulmonary mass the infiltrate was specific aetiology.     

Pulmonary aspergilloma, diagnosis and treatment

Pulmonary aspergilloma is a saprophytic form of aspergillosis, and the diagnosis is usually based on radiological findings such as thickened cavitary wall and fungus ball, and on positive serum antibody. Up to 58% of the patients with aspergilloma in Japan have medical history of tuberculosis. Serum anti-Aspergillus antigen is almost always positive in aspergilloma patients but aspergillus antigen is usually negative. Massive hemoptysis can be a fatal complication of aspergilloma, and the most common complication was respiratory failure according to our study. Surgical resection is the only promising intervention to cure the aspergilloma, however, low pulmonary function does not allow operation. Antifungal treatment is chosen for those who are out of operation indication, but the efficacy of antifungal treatment against aspergilloma is controversial. Some patients with aspergilloma show progressive form, and we define such aspergillosis as CNPA, chronic necrotizing aspergillosis, although the original entity of CNPA by Binder et al. is different. We make a diagnosis of CNPA only if all the following entity meets, 1; progressive shadows in radiological findings regardless of the presence of aspergilloma, 2; have some symptoms such as cough, sputum, hemosputum, hemoptysis or fever, 3; proof of Aspergillus attribution by mycological or pathological examination, 4; positive systemic inflammatory reaction, 5; neglect of other etiology of pulmonary diseases. Since CNPA is usually progressive, patients with CNPA should be treated with antifungals.     

Is video-assisted thoracic surgery a versatile treatment for both simple and complex pulmonary aspergilloma?

Background

Pulmonary aspergilloma (PA) is a common fugal infectious disease mostly occurred in developing countries. This study aims to evaluate the outcomes of video-assisted thoracic surgery (VATS) treatment for simple pulmonary aspergilloma (SPA) and complex pulmonary aspergilloma (CPA).

Methods

From October 2009 to March 2013, 16 patients were treated by VATS for PA in our department. The patients were divided into SPA group and CPA group. Records were retrospectively reviewed and data were collected and compared.

Results

Patients had a median age of 52.8 years [95% confidence interval (CI): 47.8-57.9 years]. The most common symptom was hemoptysis (68.7%) in our patients. The underlying lung diseases were tuberculosis (31.1%), bronchiectasis (12.5%) and pneumatocele (6.2%). All patients received successful lesion resection by VATS, none was converted to thoracotomy. No significant difference was found in terms of sex and age. Patients with CPA tent to have larger lesion (P=0.001) and more intraoperative findings (P=0.003), they also needed longer operative time (P=0.016) and more blood loss (P=0.003). In addition, CPA patients had more volume of drainage after surgery (P=0.005), longer duration of drainage ((P=0.007) and length of stay in hospital (P=0.004). No difference was found in postoperative complications between the two groups.

Conclusions

SPA patients are the best candidates for VATS, but comprehensive measure should be taken for the overall benefit of CPA patients before conducting VATS.     

Place of surgery in pulmonary aspergillosis and other pulmonary mycotic infections

Surgery is part of the therapeutic strategy of aspergillosis and mucormycosis. The aspergilloma is defined as a rounded mass, developing in a cavity by the proliferation of spores of Aspergillus. The most common complication was haemoptysis reported in 50-95% of cases. The pleuropulmonary lesions predisposing are: tuberculosis, residual pleural space, emphysema and lung destroyed by fibrosis or radiotherapy or bronchiectasis. The indications for surgery depend on symptoms, respiratory function, the parenchyma and the type of aspergilloma (simple or complex). In a patient with an intrapulmonary aspergilloma, lung resection preceded by embolization is recommended based on respiratory function. For intrapleural aspergilloma, thoracoplasty is recommended according to the patient's general condition. The invasive pulmonary aspergillosis (IPA) is characterized by an invasion of lung tissue and blood vessels by hyphae in immunocompromised patients. The death rate of patients who have an API after treatment for leukemia or lymphoma was 30 to 40%, after bone marrow transplantation 60%, after solid organ transplantation from 50 to 60% and after any other cause of immunocompromising from 70 to 85%. The main cause of these deaths is massive hemoptysis. Surgery (lobectomy) is indicated for the prevention of hemoptysis when the mass is in contact with the pulmonary artery or one of its branches, and if it increases in size with the disappearance of border security between the mass and the vessel wall. The patient will be operated in an emergency before the white blood cells do not exceed the threshold of 1000 cells/μl. A persistent residual mass after antifungal treatment may justify a lung resection (lobectomy or wedge) before a new aggressive therapy. Mucormycosis affects patients following immunocompromising states--haematologic malignancy, diabetes mellitus, transplantation, burns and malnutrition. The treatment of pulmonary mucormycosis combines surgical and medical approach.     

Surgery for pulmonary aspergilloma and pleural aspergillosis

Pulmonary aspergilloma and pleural aspergillosis are a potentially lifethreatening disease resulting from the colonization of lung or pleural cavities by the ubiquitous fungus Aspergillus fumigatus. Twenty four patients with pulmonary aspergilloma and five with pleural aspergillosis underwent major thoracic procedures at our hospital between 1976 and 1986. Fourteen of the patients had haemoptysis, in 9 it was recurrent, and in 5 life-threatening. Tuberculosis, pneumonia, and sarcoidosis were the most common preexisting lung lesions. Surgical procedures included 7 pleuropneumonectomies, 18 lobectomies and 4 wedge resections. The postoperative mortality rate was approximately 7% (2 pat.). Based on the pathological examination 4 patients had unexpectedly a bronchial carcinoma in addition to the aspergilloma. Bronchopleural fistula with persistent air space was a serious complication only for patients after pleuropneumonectomy. 23 patients including those with complex aspergilloma and pleural infection had no postoperative complications; in none of the 27 operative survivors were there any recurrent symptoms over a follow-up between one and ten years. Good-risk patients with documented aspergilloma, even asymptomatic, should be resected, because of the danger of exsanginating haemorrhage. For patients with pleural aspergillosis only the aggressive resection can provide effective long term palliation.     

Results of surgical treatment of 107 patients with complications of pulmonary tuberculosis

Abstract The objective of this study was to evaluate the results of surgical intervention performed on 107 patients with pulmonary tuberculosis complications. Between September 1988 and December 1995, 107 patients underwent a total of 126 operations for major complications of pulmonary tuberculosis. One hundred and twenty-six operations consisted of lobectomies only or plus other lung resections performed in 55 cases, pneumonectomies in 20 cases, segmentectomies in 18 cases, wedge resections in two cases, tracheobronchoplasties in four cases, decortications in two cases, cavernostomies with concomitant muscle transpositions in seven cases, thoracoplasties reserved for the previously failed operations or to be a supplement for pulmonary resections in 18 cases. The operative mortality rate was of 1.8%, and the major complication rate was of 16.8%. Twenty-eight (26.1%) patients with tuberculosis bacilli in sputum before operation have converted except one diabetic patient. In conclusion, surgery is indicated in pulmonary tuberculosis complications that are life-threatening or unresponsive to chemotherapy. Pulmonary resection is the procedure of choice for most cases that require surgery.     

Spontaneous lysis of pulmonary aspergillosis: "Aspergillus destroyed by Actinomyces"

A 79 years old patient developed a large pulmonary aspergilloma in the cavities of his right upper lobe after postinfarctional pneumonia with local abscess formation. The clinical follow-up was characterized by recurrent hemoptysis resulting in marked anemia as well as by a continuous growth of the mycetoma. Suddenly a purulent gangrene of the whole upper lobe occurred infected by actinomyces israelii and staphylococcus but not aspergillus as it could be demonstrated in specimens from repeated transthoracic needle aspirations. After percutaneously inserted chest-tube drainage during 30 days the upper lobe cavity cleared up and the previously impressive aspergilloma had disappeared completely, however, the serum precipitins from aspergillus fumigatus still remained positive. After a course of several months without further pulmonary complications the patient finally died from a ruptured aortic aneurysm. It is suggested, that the spontaneous lysis of the aspergilloma was due to a deprivation of it' nutritive basis by the infected pulmonary tissue. A similar mechanism may also account for a sometimes successful treatment of pulmonary aspergilloma after injection of an amphotericin containing paste as a novel therapeutic strategy which is recommended in the case of patient's inoperable conditions.     

Large cell neuroendocrine carcinoma of the lung incidentally found at surgery for pulmonary aspergillosis]

We report a 56-year-old man with pulmonary large cell neuroendocrine carcinoma (LCNEC) incidentally found at the surgery for pulmonary aspergillosis. In 1991, an abnormal chest radiographic shadow was found on a mass screening. A diagnosis of pulmonary aspergillosis was made by bronchoscopic examination. The patient was then followed up without treatment. He had hemoptysis in 2005, and was referred to our hospital. Chest CT scan revealed a cavitary lesion with an air crescent sign and an irregularly shaped nodule in the right apex. Wedge resection of these lesions was performed under video-assisted thoracoscopic surgery. Pathological examination revealed not only aspergilloma, but also an LCNEC 11 x 7 mm in size, which was located close to the aspergilloma. Microscopically, nests of tumor cells were distributed peribronchially. Right upper lobectomy and mediastinal lymph node dissection was performed, and the pathological stage was IIIA (T1N2M0). The patient received four cycles of adjuvant chemotherapy with carboplatin and paclitaxel. No recurrence has been observed since surgery. This is the first report describing co-existence of pulmonary aspergilloma and LCNEC.     

无免疫功能缺陷者肺曲霉感染15例临床分析

目的 探讨无免疫功能缺陷患者肺曲霉感染的诊断及治疗.方法 回顾性分析1997年1月至2006年12月在北京军区总医院胸外科住院的15例肺曲霉感染患者的病历资料.结果 15例患者中男12例,女3例,年龄43～62岁,平均46.8岁.12例有肺部病变;2例肺内肿块影,CT显示有晕征;1 例左主支气管腔内可见曲霉.15例均无免疫功能缺陷.肺癌空洞伴曲菌球的术前、术后诊断符合率为100%.术前经细菌学诊断者仅3例,诊断为肺癌2例.手术治疗13例,其中12例恢复良好,无并发症;1例胸膜残腔感染经开窗引流和抗曲霉治疗,感染未能控制.1例仅行抗肿瘤治疗,1例猝死.结论 CT表现的晕征及组织学检查对疑有肺曲霉感染者的诊断有重要意义.基础性肺病变伴曲菌球和肿块表现的肺曲霉感染应积极手术治疗.     

Pulmonary aspergilloma: A rational approach to treatment

A prospective study of 15 patients with pulmonary aspergilloma was undertaken over an 11 year period. Serious underlying diseases, particularly chronic obstructive pulmonary disease and alcoholic cirrhosis, were present in 12 of them. Eight of 15 patients whose clinical and roentgenographic course was followed for an average of 50 months, received no specific therapy. There were four deaths in this group, none attributable to aspergilloma. The aspergilloma had lysed spontaneously in two, decreased in size in one and was unchanged in one. In the four surviving patients who had no treatment, the aspergilloma lysed spontaneously in one, remained unchanged in two and increased in size in one. Of the seven patients who were treated medically or surgically, three died. Among the seven deaths (untreated and treated patients combined), six were clearly related to underlying disease. The prognosis of aspergilloma is related primarily to the nature and severity of the underlying diseased). Contrary to the conclusions of previous reports, the experience in our series of patients suggests that routine surgical excision of aspergilloma is not indicated.     

Tuberculosis sequelae: clinical aspects

We studied the pulmonary diseases which had developed as consequent deformities after healing of tuberculosis, which we called tuberculosis sequelae. Results are described as follows. 1. The frequency of tuberculosis sequelae was about 6% in the patients with pulmonary diseases admitted to our hospital. 2. 93 cases of them consisted of 4 groups, which were 39 of repeated bacterial infection of lower respiratory tract, 23 of pulmonary aspergilloma, 13 of atypical mycobacteriosis and 28 of chronic respiratory failure. 3. Patients with tuberculosis sequelae were distributed more in the younger age group than others with resembled pulmonary diseases. The men to women ratio was about 2:1. Patients with pulmonary aspergilloma were younger than those with atypical mycobacteriosis. 4. Death rate in tuberculosis sequelae was about 5% per year. 46% of patients with atypical mycobacteriosis and 44% with chronic respiratory failure died within 4 years. 5. In chest X-ray findings, fibrosis and shrinkage of the lung, compensatory pulmonary emphysema, deformity or dilatation of bronchi, bulla formation and residual tuberculous cavities were recognized in 40 to 65% of the cases. Severe pleural thickness or past thoracoplasty were frequently recognized in the patients with chronic respiratory failure. All the patients with pulmonary aspergilloma had one or more residual cavities. 6. The frequency of systemic complications was not more than in the control population matched by age. Comparatively, serum IgG and IgA were elevated and PHA-induced lymphocyte activation was not lowered in the patients with pulmonary aspergilloma and atypical mycobacteriosis. From these results, the main factor in the development of tuberculosis sequelae seemed to be local defects of the chest.