Resection of invasive pulmonary aspergillosis in immunocompromised patients

Background: Immunocompromised patients are prone to develop invasive pulmonary aspergillosis (IPA). Relapse and high mortality rates are seen in those patients who receive subsequent immunotoxic therapy. Standard antifungal regimens often fail to completely eradicate IPA, which then warrants an aggressive surgical approach. Methods: We performed a retrospective chart review of 13 immunocompromised patients who were considered to have IPA and who underwent surgery between 1988 and 1998. Results: Twelve patients had a hematological malignancy and one patient had breast cancer. The diagnosis of IPA was based on a chest computed tomographic scan in all patients. A preoperative diagnosis of aspergillosis was made in three patients, and mucormycosis in one patient, by bronchoalveolar lavage. Before surgery, seven patients received chemotherapy, one patient underwent bone marrow transplantation, and five patients received a combination of chemotherapy and bone marrow transplantation. Symptoms included cough (54%), fever (54%), hemoptysis (30%), and shortness of breath (8%). Three patients (23%) were asymptomatic. The mean preoperative absolute neutrophil count was 4881 cells/mu l. Seventeen thoracic operations were performed, i.e., 12 wedge resections, 4 lobectomies, and 1 pneumonectomy. One patient also underwent nephrectomy for invasive aspergillosis and one patient underwent craniotomy to resect an aspergillus brain mass. Surgical pathology revealed IPA in 13 (76%), invasive mucormycosis in 2 (15%), aspergilloma in 1, and diffuse alveolar hemorrhage in 1. Postoperative complications included the following: operative bleeding requiring transfusion, three patients; prolonged air leak, two patients: death because of hepatic/renal failure, one patient; and death because of overwhelming multisystem aspergillosis, one patient. Seven (54%) patients underwent further immunotoxic treatment with no aspergillosis recurrence. After a mean follow-up of 13 months, five (38%) patients are alive and seven (54%) have died without evidence of aspergillosis and/or mucormycosis. Conclusions: Surgical resection, in combination with antifungal agents, is a safe and effective form of therapy for invasive mycoses. It prevents recurrence and allows for subsequent cytotoxic therapies.