Resection of invasive pulmonary aspergillosis in immunocompromised patients

Background: Immunocompromised patients are prone to develop invasive pulmon ary aspergillosis (IPA). Relapse and high mortality rates are seen in those patients who receive subsequent immunotoxic therapy. Standard antifungal r egimens often fail to completely eradicate IPA, which then warrants an aggr essive 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 tomograp hic scan in all patients. A preoperative diagnosis of aspergillosis was mad e in three patients, and mucormycosis in one patient, by bronchoalveolar la vage. Before surgery, seven patients received chemotherapy, one patient und erwent bone marrow transplantation, and five patients received a combinatio n of chemotherapy and bone marrow transplantation. Symptoms included cough (54%), fever (54%), hemoptysis (30%), and shortness of breath (8%). Three p atients (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 al so underwent nephrectomy for invasive aspergillosis and one patient underwe nt craniotomy to resect an aspergillus brain mass. Surgical pathology revea led IPA in 13 (76%), invasive mucormycosis in 2 (15%), aspergilloma in 1, a nd diffuse alveolar hemorrhage in 1. Postoperative complications included t he following: operative bleeding requiring transfusion, three patients; pro longed air leak, two patients: death because of hepatic/renal failure, one patient; and death because of overwhelming multisystem aspergillosis, one p atient. Seven (54%) patients underwent further immunotoxic treatment with n o aspergillosis recurrence. After a mean follow-up of 13 months, five (38%) patients are alive and seven (54%) have died without evidence of aspergill osis and/or mucormycosis. Conclusions: Surgical resection, in combination with antifungal agents, is a safe and effective form of therapy for invasive mycoses. It prevents recu rrence and allows for subsequent cytotoxic therapies.