SURGICAL THERAPY FOR PULMONARY ASPERGILLOSIS IN IMMUNOCOMPROMISED PATIENTS

Background. Medical management for invasive pulmonary aspergillosis (I PA) is often unsatisfactory. Antifungal therapy may be unable to eradi cate IPA in the immunocompromised or neutropenic patient. Methods. We retrospectively reviewed the surgical management of IPA in 13 immunoco mpromised patients at our institution. Twelve patients underwent perio perative bone marrow transplantation (4 autologous, 8 allogenic). All 13 patients received antifungal therapy. Eleven patients were neutrope nic at the time of operation. Results. The mean interval from diagnosi s of aspergillosis to operation was 42 days (range, 3 to 135 days). Ei ghteen operations were performed on the 13 patients. Seven patients ha d resections from multiple pulmonary sites, whereas 6 had a single les ion resected. The average lesion resected was 3.7 cm in greatest diame ter (range, 1 to 9 cm). After a mean follow-up of 21 months (range, 0 to 9 years), 3 patients (23%) are alive with no evidence of aspergillo sis, 6 patients (46%) died without evidence of aspergillosis, and 4 pa tients (31%) died secondary to aspergillus infection. All 4 patients w ho died of aspergillus infection received an allogenic bone marrow tra nsplantation. Two patients with direct extrapulmonic extension of IPA at time of operation died of recurrent aspergillus infections. Three o f 4 patients who died of aspergillus infection had an absolute neutrop hil count less than 1,300 cells/mu L at time of operation. The mean ab solute neutrophil count of the patients who cleared the aspergillus in fection was 5,538 cells/mu L. The mean survival of allogenic bone marr ow transplant recipients was 5.2 months, and for recipients of autogra fts was 51.4 months. Conclusions. In this series, surgical resection o f IPA cleared the aspergillus infection in 69% of the patients. Neutro penia, extrapulmonic extension of IPA, and allogenic bone marrow trans plantation may predict a worse prognosis. Surgical resection of IPA in immunocompromised patients is an effective form of therapy in a prope rly selected patient population. (C) 1998 by The Society of Thoracic S urgeons.