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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Passera E, Rizzi A, Robustellini M, Rossi G, Della Pona C, Massera F, et al. Pulmonary aspergilloma: clinical aspects and surgical treatment outcome. Thorac Surg Clin. 2012;22(3):345–61.CrossRefPubMedGoogle Scholar
Barnes PD, Marr KA. Aspergillosis: spectrum of disease, diagnosis, and treatment. Infect Dis Clin North Am. 2006;20(3):545–61.CrossRefPubMedGoogle Scholar
Nam HS, Jeon K, Um SW, Suh GY, Chung MP, Kim H, et al. Clinical characteristics and treatment outcomes of chronic necrotizing pulmonary aspergillosis: a review of 43 cases. Int J Infect Dis. 2010;14(6):e479–82.CrossRefPubMedGoogle Scholar
Greene RE, Schlamm HT, Oestmann JW, Stark P, Durand C, Lortholary O, et al. Imaging findings in acute invasive pulmonary aspergillosis: clinical significance of the halo sign. Clin Infect Dis. 2007;44(3):373–9.CrossRefPubMedPubMedCentralGoogle Scholar
Belcher JR, Plummer NS. Surgery in bronchopulmonary aspergillosis. Br J Dis Chest. 1960;54:335–41.CrossRefGoogle Scholar
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(5):906–12.CrossRefPubMedPubMedCentralGoogle Scholar
Regnard JF, Icard P, Nicolosi M, Spagiarri L, Magdeleinat P, Jauffret B, et al. Aspergilloma: a series of 89 surgical cases. Ann Thorac Surg. 2000;69(3):898–903.CrossRefPubMedGoogle Scholar
Kurihara M, Kataoka H, Ishikawa A, Endo R. Latest treatments for spontaneous pneumothorax. Gen Thorac Cardiovasc Surg. 2010;58(3):113–9.CrossRefPubMedGoogle Scholar
Grima R, Krassas A, Bagan P, Badia A, Le Pimpec Barthes F, et al. Treatment of complicated pulmonary aspergillomas with cavernostomy and muscle flap: interest of concomitant limited thoracoplasty. Eur J Cardiothorac Surg. 2009;36(5):910–3.CrossRefPubMedGoogle Scholar
Ono N, Sato K, Yokomise H, Tamura K. Surgical management of pulmonary aspergilloma. Role of single-stage cavernostomy with muscle transposition. Jpn J Thorac Cardiovasc Surg. 2000;48(1):56–9.CrossRefPubMedGoogle Scholar
Iuchi K, Tanaka H, Shirahasi K, Okura E, Katsura H, Matsumura A, et al. Cavernostomy and simultaneous removal of fungus ball of pulmonary aspergilloma. Nihon Kokyuki Gakkai Zasshi. 2001;39(12):903–9. [In Japanese].PubMedGoogle Scholar
Kravitz JN, Berry MW, Schabel SI, Judson MA. A modern series of percutaneous intracavitary instillation of amphotericin B for the treatment of severe hemoptysis from pulmonary aspergilloma. Chest. 2013;143(5):1414–21.CrossRefPubMedGoogle Scholar
Giron J, Poey C, Fajadet P, Sans N, Fourcade D, Senac JP, et al. CT-guided percutaneous treatment of inoperable pulmonary aspergillomas: a study of 40 cases. Eur J Radiol. 1998;28(3):235–42.CrossRefPubMedGoogle Scholar
Walsh TJ, Anaissie EJ, Denning DW, Herbrecht R, Kontoyiannis DP, Marr KA, et al. Treatment of aspergillosis: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2008;46(3):327–60.CrossRefPubMedGoogle Scholar
Orens JB, Estenne M, Arcasoy S, Conte JV, Corris P, Egan JJ, et al. International guidelines for the selection of lung transplant candidates: 2006 update—a consensus report from the Pulmonary Scientific Council of the International Society for Heart and Lung Transplantation. J Heart Lung Transplant. 2006;25(7):745–55.CrossRefPubMedGoogle Scholar
Hadjiliadis D, Sporn TA, Perfect JR, Tapson VF, Davis RD, Palmer SM. Outcome of lung transplantation in patients with mycetomas. Chest. 2002;121(1):128–34.CrossRefPubMedGoogle Scholar
Vadnerkar A, Clancy CJ, Celik U, Yousem SA, Mitsani D, Toyoda Y, et al. Impact of mold infections in explanted lungs on outcomes of lung transplantation. Transplantation. 2010;89(2):253–60.CrossRefPubMedPubMedCentralGoogle Scholar
Solé A, Salavert M. Fungal infections after lung transplantation. Transplant Rev (Orlando). 2008;22(2):89–104.CrossRefGoogle Scholar
Hadjiliadis D, Howell DN, Davis RD, Lawrence CM, Rea JB, Tapson VF, et al. Anastomotic infections in lung transplant recipients. Ann Transplant. 2000;5(3):13–9.PubMedGoogle Scholar
Husain S, Paterson DL, Studer S, Pilewski J, Crespo M, Zaldonis D, et al. Voriconazole prophylaxis in lung transplant recipients. Am J Transplant. 2006;6(12):3008–16.CrossRefPubMedGoogle Scholar
Neoh CF, Snell G, Levvey B, Morrissey CO, Stewart K, Kong DC. Antifungal prophylaxis in lung transplantation. Int J Antimicrob Agents. 2014;44(3):194–202.CrossRefPubMedGoogle Scholar
Bhaskaran A, Mumtaz K, Husain S. Anti-Aspergillus prophylaxis in lung transplantation: a systematic review and meta-analysis. Curr Infect Dis Rep. 2013;15(6):514–25.CrossRefPubMedGoogle Scholar
Gupta DK, Sharma S. Chronic pleuro-pulmonary and chest wall infection. In: Parikh DH, Crabb DCG, Auldist AW, Rothenberg SS, editors. Paediatric thoracic surgery. London: Springer; 2009. p. 179–90.CrossRefGoogle Scholar