Thorax 1990;45:846-849

Management of post-tuberculous complexaspergilloma of the lung: role of surgical resection

Sulaiman A Al-Majed, Mahmoud Ashour, Feisal A El-Kassimi, Ismail Joharjy,Abdullah Al-Wazzan, Mohamad S Al-Hajjaj, Rajagopalen Vijay

Department ofMedicineS A Al-MajedF A El-KassimiA Al-WazzanM S Al-HajjajDepartment ofSurgeryM AshourR VijayDepartment ofRadiologyI JoharjyCollege ofMedicine,King Saud University,Riyadh, Saudi ArabiaAddress for reprint requests:Dr Sulaiman A Al-Majed,Medical Department,College of Medicine, KingSaud University, PO Box2925, Riyadh 11461, SaudiArabia.Accepted 14 August 1990

AbstractOf 14 patients with complex asper-gilloma complicating healed tuber-culosis, 12 underwent lobectomy orpneumonectomy for recurrent haemo-ptysis. No deaths occurred, though onepatient needed re-exploration for bleed-ing. There was no postoperative worsen-ing of dyspnoea despite a mean forcedvital capacity (FVC) of 60% predictedfor the patients undergoing surgery andof 20% predicted for two patients withsevere restrictive defects, perhaps owingto the fact that there was little or nofunction in the resected part of the lung,as shown by preoperative isotope ven-tilation-perfusion scanning, and thatpatients were under the age of 50 andgenerally fit. There has been no re-currence of haemoptysis during followup, which has been from 12 to 33 months.Surgical resection, provided that casesare carefully selected, offers the bestchance of cure with low mortality andmorbidity.

Aspergilloma is an opportunist infection ofthe lung complicating necrotic cavitary lesions

WFigure I Radiograph ofan aspergilloma in the left upper lobe showing a classical masswith an air crescent.

such as tuberculosis. The high mortality fromaspergilloma is related to the underlying dis-ease14 and to the frequent occurrence ofhaemoptysis.'-3 Whether surgical or medicalmanagement is better is unresolved.'2Medical treatment occasionally causes thelesions to shrink,413 but is usually unsuccess-ful,1 6 14-16 and surgical resection is associatedwith a high incidence of complications." '7We report our experience with 14 cases of

complex pulmonary aspergilloma complicat-ing healed fibrotic tuberculosis.

Patients and methodsFourteen cases of complex aspergilloma'2complicating healed pulmonary tuberculosiswere seen during 1985-9. All had a roundedmass with an air crescent located in a fibroticlung cavity on the plain chest radiograph orcomputed tomogram. Resected lung in allcases showed branched septate hyphae andinflammatory cells lying free in a chronicfibrotic cavity on histopathological examina-tion. Conservatively treated patients hadaspergillus grown from sputum and positiveprecipitins in the serum.'8 In addition, allpatients had a history of pulmonary tuber-culosis, for which chemotherapy had beengiven, or had Mycobacterium tuberculosis insputum cultures. To be eligible for inclusionall surgical patients had to have a minimum of12 months' postoperative follow up.

ResultsThe 14 patients (table), eight male and sixfemale, were aged from 16 to 50 years. Com-plex aspergillomas occurred in the upper lobesin 13 patients and in the lower lobes in one.Twelve patients reported recurrent moderate(200 ml) to severe (600 ml) haemoptysis. Pre-operative spirometry showed that two patientshad a normal forced vital capacity (FVC)(>80% predicted), seven mild abnormality(60-80% predicted), three moderate abnor-mality (40-60% predicted), and two severeabnormality (<40% predicted). The meanFVC for the patients undergoing surgery was60% predicted (table).

Isotope ventilation-perfusion scans perfor-med in 10 of the 12 patients undergoingsurgery showed absent or greatly reduced per-fusion and ventilation in the affected lobe orlung in all cases. Chest radiography showedan aspergilloma in eight patients; the other sixaspergillomas were seen only by computedtomography.

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Management ofpost-tuberculous complex aspergilloma of the lung: role of surgical resection

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Figure 2 Computed tomogram of the chest showing an aspergilloma.

Surgical resection was performed in the 12patients with haemoptysis. All operationswere elective except in the case of patient 1,who underwent urgent pneumonectomy formassive uncontrolled bleeding. Nine patientshad a lobectomy and three a pneumonectomy.At operation dense vascular adhesions were

found obliterating the pleural space and

surrounding the atelectatic fibrotic lobe of thelung. Bronchial arteries were enlarged andtortuous. In two patients the aspergilloma was

eroding into the chest wall. Extrapleuralmobilisation was carried out in all cases.Bleeding from the chest wall responded totemporary packing with or without dia-thermy.None of the surgical patients had diabetes,

smoked, or were alcoholic and all could beregarded as generally fit. There was no sur-

gical mortality and complications were low.One patient (case 5) developed transientintraoperative atrial fibrillation and another(case 8) was re-explored for postoperativebleeding. None of the patients undergoingsurgery developed late complications such asempyema, bronchopleural fistula, or recur-

rence of aspergilloma or haemoptysis duringthe follow up period, which ranged from 12 to33 months. None of the patients reportedworsening of dyspnoea after resection-noteven the two patients who had a severe reduc-tion in their FVC (20% and 37% predicted).

DiscussionAspergilloma is an important complication oftuberculosis. In 544 patients with healedcavitary tuberculosis the prevalence of asper-gilloma was 11%, rising to 17% three yearslater.2 Although aspergillomas may undergonatural lysis and spontaneous resolution,2 4most persist, giving rise to haemoptysis in morethan half the patients.'"37'18 The high mor-tality from aspergilloma is frequently related tothe severity of the underlying disease' 3 18 ratherthan to the aspergilloma, and is higher in

Details of the patients

Case Age, FEV, (pred %)No sex Haemoptysis Chest radiograph FVC (pred %) Ventilation-perfusion scan Operation

1 25, F Massive Aspergilloma left upper lobe and 1-5 (48) Substantial reduction left Leftextensive fibrotic collapse left 1-9 (46) upper zone pneumonectomylung

2 50, F Moderate Fibrotic collapse right upper lobe 1 74 (92) Defect right upper zone Right upper2-02 (89) lobectomy

3 16, M Moderate Fibrosis collapse left upper lobe 28 (69) Defect left upper zone Left upperand thick walled aspergilloma 3-7 (73) lobectomy

4 45, M Moderate Fibrotic collapse left upper lobe 2-17 (70) Substantial reduction left Left upperand thick walled aspergilloma 2-97 (76) upper zone lobectomy

5 45, F Moderate Fibrotic collapse right upper lobe 1 90 (48) Marked reduction right upper Right upperand thick walled aspergilloma 3 06 (48) zone lobectomy

6 30, F Moderate Extensive fibrotic collapse left 0-7 (22) Defect left lung Leftlung bronchopleural fistula with 0-83 (20) pneumonectomyhydropneumothorax

7 40, M Severe Fibrotic collapse right upper lobe 3-25 (78) Substantial reduction right Right upper4-24 (78) upperzone lobectomy

8 47, M Severe Fibrotic collapse left lung 1-38 (44) Defect left lung Left upper1-42 (37) lobectomy

9 48, F Moderate Fibrotic collapse right upper lobe 1-64 (69) Substantial reduction right Right upper1-94 (67) upper zone lobectomy

10 50, M Nil Fibrotic collapse left upper lobe 1-9 (62) Not done Noneand thick walled aspergilloma 2-5 (65)

11 30, M Nil Fibrosis left upper lobe and thick 3-71 (82) Not done Nonewalled aspergilloma 4-7 (84)

12 37, M Moderate Fibrosis left upper lobe and thick 2 50 (55) Not done Left upperwalled aspergilloma 3-20 (60) lobectomy

13 45, M Mild Fibrotic collapse left upper lobe 1-80 (58) Multiple matched perfusion Left upperand thick walled aspergilloma 2-69 (67) substantial in the apical part lobectomy

of the left lung14 48, F Moderate Fibrosis and collapse 1-64 (69) Not done Right upper

consolidation of apico-posterior 1-94 (67) lobectomysegment of right upper lobe

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Al-Majed, Ashour, El-Kassimi, Joharjy, Al-Wazzan, Al-Hajjaj, Vijay

patients with a diffuse lung disease such assarcoidosis than in a localised disease such astuberculosis.3 Haemoptysis, however, is im-portant also as up to 28% of patients with non-malignant aspergilloma die as a direct result ofmassive haemoptysis.'9 The management ofaspergilloma with a history of bleedingtherefore acquires a special importance.There is agreement that surgical resection

should be performed in patients with haemo-ptysis and adequate pulmonary reserve,' 8 andavoided in the presence of poor reserve.Opinion is divided on whether symptomlesspatients should have routine surgical resec-tion' 11 1 or be treated medically.'4 There isno evidence that surgical resection improvesprognosis except in patients with massivehaemoptysis 18 and resection is complicated bya high rate of serious postoperative com-plications, 7 11 17 19 20 22 such as empyema, prolon-ged air leak, bronchopleural fistula, respiratoryinsufficiency, haemorrhage, and a residualintrapulmonary space. Surgical mortality isbelow 10% in simple aspergilloma," 20 butincreases to 34% in complex aspergilloma.'7Alternative procedures have been attempted inpatients considered unsuitable for surgicalresection but none is fully satisfactory. Treat-ment with intravenous amphotericin or 5-flucytosine is usually ineffective.'1318 Althoughbronchial artery embolisation arrests bleedingin most cases, haemoptysis invariablyrecurs,23 24 possibly owing to the presence of arich "parasite" blood supply from the chestwall to the aspergilloma.23 Endobronchial orintracavitary instillation of various antifungalagents have given encouraging results.' 419 withdisappearance of the mycetoma, but the longterm outcome is unknown. More importantly,intracavitary instillations have resulted inserious and often fatal bleeding. Intracavitaryinstillation of N-acetylcysteine and amino-caproic acid with amphotericin B was success-ful in arresting bleeding during acute episodesof haemoptysis, but bleeding recurred in fourof the six cases.25 Radiotherapy might tem-porarily arrest massive haemoptysis withoutchanging the size of the aspergilloma.26

In our series there was no recurrence ofbleeding over a follow up period of 12-33months. We encountered no serious complica-tions or deaths despite the fact that all thepatients treated surgically had complex asper-gillomas and five had severe or moderatereduction in spirometric measurements. Noneof the patients reported worsening of dyspnoeaafter resection. We consider that several factorsmight have contributed to this favourable out-come. All our patients had unilateral disease, inwhich resection might be associated with a lowincidence of respiratory insufficiency, thoughprevious studies document some postoperativedeaths and morbidity in post-tuberculousaspergillomas. In one study of eight cases ofsurgical resection for post-tuberculosis asper-gilloma, one patient required postoperativetracheostomy and respiratory support andanother had a prolonged air leak." Among ninecases of aspergilloma complicating activetuberculosis surgery resulted in two deaths

from bleeding and three patients developed anempyema.27 The difference in outcome may berelated to the selection of cases for surgery.Another possible factor is that resection in ourpatients was limited to a poorly perfused lobeor lung, as indicated by a preoperative ven-tilation-perfusion radionuclide scan, and atten-tion was paid to preservation ofthe functioninglung. Lastly, all of our patients were relativelyyoung and generally fit, with no history ofsmoking, alcoholism, or systemic disease suchas diabetes.Our series suggests that surgical resection

can be performed, with relatively low risk, forpost-tuberculous aspergilloma complicated byhaemoptysis. Selection of relatively young, fitpatients and preoperative ventilation-per-fusion radionuclide scanning could play a partin reducing the operative risk.

We would like to thank Mrs Mimi S Gurrea-Villamil forsecretarial assistance with this paper.

1 Jewkes J, Kay PH, Paneth M, Citron MK. Pulmonaryaspergilloma: analysis of prognosis in relation to haemo-ptysis and survey of treatment. Thorax 1983;38:572-8.

2 Research Committee of the British Thoracic andTuberculosis Association. Aspergillomas and residualtuberculous cavity. The result of a resurvey. Tubercle1970;51:227-45.

3 Tomlinson JR, Sahn SA. Aspergilloma in sarcoidosis andtuberculosis. Chest 1987;92:505-8.

4 Varkey B, Rose HD. Pulmonary aspergilloma-a rationalapproach to treatment. Am J Med 1976;61:626-31.

5 Reddy PA. Comparison of treated and untreated pulmonaryaspergilloma. Am Rev Respir Dis 1970;101:928-34.

6 Glimp RA, Bayer AS. Pulmonary aspergilloma: diagnosticand therapeutic considerations. Arch Intern Med 1983;143:303-8.

7 Kilman JW, Ahn C, Andrews NC, Klassen K. Surgery forpulmonary aspergillosis. J Thorac Cardiovasc Surg 1969;57:642-7.

8 AsIam PA, Eastridge CE, Hughes FA. Aspergillosis of thelung-an eighteen year experience. Chest 1971;59:28-32.

9 Faulkner SL, Vernon R, Brown PP, Fisher RD, BenderHW. Hemoptysis and pulmonary aspergillomas: operativeversus nonoperative treatment. Ann Thorac Surg 1978;25:389-92.

10 Garvey J, Crastnopol P, Weisz D, Khan F. The surgicaltreatment ofpulmonary aspergillosis. J Thorac CardiovascSurg 1977;74:542-7.

11 Solit RW, McKoewn JJ, Smullens S, Fraimow W. Thesurgical implication of intracavitary mycetomas (fungusballs). J Thorac Cardiovasc Surg 1971;62:411-22.

12 Belcher JR, Plummer NS. Surgery in broncho-pulmonaryaspergillosis. Br J Dis Chest 1960;54:335-41.

13 Karas A, Hankins JR, Attar S, Miller JE, McLaughlin JS.Pulmonary Aspergillosis: An analysis of 41 patients. AnnThorac Surg 1976;22:1-7.

14 Ikemoto H. Treatment of pulmonary aspergilloma withamphotericin B. Arch Intern Med 1965;115:598-601.

15 Hargis JL, Bone RC, Stewart J, et al. Intracavitaryamphotericin B in the treatment of symptomaticpulmonary aspergilloms. Am JMed 1980;68:389-94.

16 Rafferty P, Biggs BA, Crompton G, Grant IW. Whathappens to patients with pulmonary aspergilloma?Analysis of 23 cases. Thorax 1983;38:579-83.

17 Daly RC, Pairolero PC, PiehlerJM, Trastek VF, PayneWS,Bernatz PE. Pulmonary aspergilloma-Results ofsurgicaltreatment. J Thorac Cardiovasc Surg 1986;92:981-8.

18 Johnson JS. Pulmonary aspergillosis. Semin Respir Med1987;9:187-99.

19 Eastridge CE, Young JM, Cole F, Gourley R, Pate JW.Pulmonary aspergillosis. Ann Thorac Surg 1972;13:397-403.

20 Garvey J, Crastnopol P, Weisz D, Khan F. The surgicaltreatmnent of pulmonary aspergillomas. J ThoracCardiovasc Surg 1977;74:542-7.

21 Soltanzadeh H, Wychulis AR, Sadr F, Bolanowski PJ,Nenille WE. Surgical treatment of pulmonary

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Management ofpost-tuberculous complex aspergilloma of the lung: role of surgical resection

aspergilloma. Ann Surg 1977;186:13-6.22 Battaglini JW, Murray GF, Keagy PA, Starek PJK, Wilcox

BR. Surgical management of symptomatic pulmonaryaspergilloma. Ann Thorac Surg 1985;39:512-6.

23 Remy J, Amaud A, Fardou H, Giraud R, Voisin C.Treatment of hemoptysis by embolization of bronchialarteries. Radiology 1977;122:33-7.

24 Uflacker R, Kaemmerer A, Neves C, Picon DP.Management of massive hemoptysis by bronchial arteryembolization. Radiology 1983;146:627-34.

25 ShapiroMJ,Albelda SM,Mayock RL, McLean GK. Severehenxptysis associated with pulmonary aspergilloma-percutaneous intracavitary treatment. Chest 1988;94:1225-31.

26 Shneerson JM, Emerson PA, Phillips RH. Radiotherapy formassive haemoptysis from an aspergilloma. Thorax1980;35:953-4.

27 Adeyemo AD, Odelowo EO, Makanjuola DI. Managementof pulmonary aspergilloma in the presence of activetuberculosis. Thorax 1984;39:862-7.

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