Among pulmonary fungal infections, aspergillosis poses a major challenge to thoracic surgeons. Aspergilloma classically arises in preexisting cavitary lesions secondary to previous tuberculosis; more recently, they have also been linked to other underlying lung diseases such as sarcoidosis, bronchiectasis, and emphysema. Because the effect of systemic antifungal agents is usually limited, life-threatening hemoptysis and/or deterioration of a patient’s general condition often necessitates surgical intervention. Surgical strategies for pulmonary aspergillomas range from radical pulmonary resection and semi-radical cavernostomy with or without muscle-flap transposition and thoracoplasty to conservative intracavitary instillation of antifungal agents. To select an optimal strategy, it is important to understand the nature of the patient’s aspergilloma—noninvasive or invasive (chronic necrotizing pulmonary aspergillosis), simple or complex—in association with the underlying pulmonary condition.
Acute invasive pulmonary aspergillosis, which usually arises in immunocompromised patients, may also necessitate surgical resection in selected cases, such as those involving lesions that are contiguous with the chest wall, great vessels, or pericardium.
Lung transplantation is another area in which pulmonary aspergillosis is a significant challenge. Preexisting aspergillomas elevate the risk associated with lung transplantation, mandating careful patient selection, and cautious surgical and medical management. Posttransplant aspergillosis can manifest as invasive bronchial aspergillosis, typically at healing bronchial anastomoses, or as acute invasive pulmonary aspergillosis followed by diffuse pneumonia. Both conditions remain the important causes of graft dysfunction and patient death.
In conclusion, pulmonary aspergillosis in its varied forms remains one of the most challenging conditions encountered in thoracic surgery and lung transplantation. The careful selection of optimal medical and surgical strategies is critically important in overcoming this challenge.
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