Surgical Treatment of Pulmonary Aspergilloma HOOSHANG SOLTANZADEH, M.D., ADAM R. WYCHULIS, M.D., FARROKH SADR, M.D., PAUL J. BOLANOWSKI, M.D., WILLIAM E. NEVILLE, M.D.

From the Departments of Surgery and Thoracic Surgery, New Jersey College of Medicine, Newark, New Jersey

Fourteen patients with aspergilloma (fungus ball) were reviewed. Hemoptysis was the major symptom (93%). Chest roentgenograms disclosed a "fungus ball" in every patient, and the mycelia of Aspergillus fumigatus were recovered from all resected specimens. One of three patients treated by pneumonectomy died post-operatively. A lobectomy was performed in ten patients, and segmental resection in one without mortality or significant morbidity. There has been no evidence of recurrence in a follow up of six months to ten years. On the basis of this experience and a review of the literature, excision of a solitary "fungus ball" is recommended when the diagnosis is made. Non-surgical therapy should be reserved for patients whose general medical status or pulmonary reserve prohibit resection.

the past. Of four additional patients with concommitant disease, there was one with diabetes mellitus and tuberculosis, one with diabetes, one with sarcoidosis and one with epidermoid carcinoma. Radiographic features typical of a "fungus ball" were noted in all 14 cases. The lesion was located in the left upper lobe (Fig. 1) in seven patients, in the right upper lobe (Fig. 2a) in 5 and in the right upper and middle lobes in one. The fungus ball associated with carcinoma was found in the right lower lobe. Sputum cultures were positive for aspergillosis in four of the six cases in which they were available. Cultures of the resected specimens were positive for Aspergillus Fumigatus in all instances. Precipitin and complement fixation were positive in one of two cases in which these determinations were made. All patients underwent surgical treatment consisting of pneumonectomy in 3, lobectomy in 10, and segmental resection in one. One patient died in congestive heart failure seven days after pneumonectomy, and one patient had persistent air leak following lobectomy which responded to prolonged thoracotomy tube drainage. There has been no evidence of recurrence in the 13 surviving patients followed from six months to ten years (Fig. 2b).

T HE FUNGUS Aspergillus Fumigatus was discovered

by Mitcheli22 in 1729 but the role of aspergilli in human pulmonary pathology was described by Virchow27 in 1856. Slayter23 was the first to report a case of pulmonary Aspergillosis in 1847, while Gerstyl10 is credited with the first surgical resection for pulmonary Aspergillosis in 1948. In recent years, there have been divergent opinions regarding the best form of treatment for Aspergilloma.2'3'18'24'29 For this reason, we decided to review the combined experience at the New Jersey Medical School at Newark and affiliated hospitals. Fourteen cases of Aspergilloma were encountered during the years 1966 through 1974. Case Material During the past 10 years, 14 patients have been seen with pulmonary aspergilloma. Eleven patients were Negro while the remainder were caucasian. Ages ranged from 35 years to 69 years, with the majority in the fifth, sixth and seventh decades. The male to female ratio was six to one. Hemoptysis was the predominant symptom in 13 cases (93%) being massive in three. A chronic productive cough was present in seven patients, Two patients complained of chest pain and weight loss was noted by two. Ten individuals were treated for tuberculosis in

Discussion Infection with aspergillus is uncommon. It has a low pathogenicity for man unless resistance is overcome by an overwhelming innoculum of fungus or a debilitating illness. Aspergillus Fumigatus is the most common species responsible for Aspergillosis in man. There are other forms such as A. nidulan, A. niger and A. flavus that can cause disease similar to that produced by A. Fumigatus.9'1728 The respiratory tract is involved in about 90% of cases, half of which are superinfections of pre-existing pulmonary tuberculosis.29 This organism also complicates other frequently

Reprint requests: Dr. Adam R. Wychulis, Saint Michael's Medical Center, 306 High Street, Newark, New Jersey 07102. Submitted for publication: August 9, 1976. 13

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Crafton and Douglas6 divided respiratory tract infection with Aspergillus into four varieties on the basis of anatomic location and clinical manifestations. The first three include infection with allergic manifestations, infection associated with pulmonary necrosis, and disseminated Aspergillosis. The fourth mode of infection encountered is the Aspergilloma of "fungus ball" which forms the basis of this report. The typical Aspergilloma is a mass of mycelia within a pulmonary cavity (Fig. 3) that is partially lined by modified bronchial epithelium. There is usually little or no surrounding inflammatory reaction.1' Progressively, the mass increases in size and may finally almost completely fill the cavity.6 Hemoptysis of varying degrees is the leading symptom, occurring in 60-75% of the patients with Aspergilloma. 1,15,22,24,29 Other symptoms in decreasing order of incidence are cough, weight loss, fatigue, chest pain, fever and dyspnea. In our series, the incidence of hemoptysis was 93%, cough 65%, and weight loss 14%. Deve8 was the first to describe the radiographic appearance of an intracavitary Aspergilloma in 1938, but

FIG. 1. Sixty-nine year old male with Apergilloma of left upper lobe of lung.

recognized pulmonary diseases such as bronchiectasis, sarcoidosis, and bronchogenic carcinoma." Less frequently encountered predisposing factors include pneumonia, bronchial cyst, lung abscess, pneumoconiosis, and histoplasmosis.6 The association of Marie-Strumpell disease with aspergillosis has been reported by Krohn et al'4 who encountered this combination in three of five patients with ankylosing spondylitis. The British Tuberculosis Association4 collected a total of 544 patients with previous pulmonary tuberculosis who had persistent cavities of 2.5 cm. in size and negative sputum cultures for one year. Chest x-rays revealed Aspergilloma in 11% and highly suggestive findings in another 4%. Aspergillomas were found most commonly in patients with large, thick-walled cavities for seven to eleven years. In another reported series of 18 patients with Aspergilloma and underlying tuberculosis, eight had positive sputum cultures for acid fast bacillus.24 Thus, active tuberculosis does not preclude the development of Aspergilloma. In our series, there was one case of Aspergilloma associated with active tuberculosis.

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FIG. 2a. Tomogram reveals Aspergilloma of right upper lobe of lung in 47 year old male.

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FIG. 3. Pathologic specimen obtained from 35 year old female with sarcoidosis and Aspergilloma. Left upper lobectomy was performed because of massive hemoptysis.

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classic features of a "fungus ball" were more completely outlined by Monod in 1952.'3 It is usually a rounded mass surrounded on its superior margin by a clear, crescent-shaped area (Fig. 4). The density of a mycetoma will shift its location within the cavity as the position of the patient is changed.16 Although it has been suggested that Aspergilloma is essentially a benign disease, it is well known that hemoptysis occurs frequently and may even be life threatening. Furthermore, the disseminated form of the disease can develop in a patient harboring the Aspergillus if a debilitating illness occurs.29 We tend to agree with Solit and associates24 who advocate removal of "fungus ball" in all patients who are suitable candidates for operation. If the risk of surgery is prohibitive, other therapeutic measures may be utilized. Amphotericin B has been commonly used in spite of unpredictable results and toxic reactions.1 20 Kilman et al5 have used the drug in four complicated cases and were unable to determine whether the Amphotericin B altered the course of infection in any of the patients.5 Aslam et a8 and Ramirez2' obtained satisfactory results in several cases by endobronchial instillation of I or 2% Sodium Iodide and Amphotericin B. Natamycin has been used

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consisted of pre-operative aerosol inhalation of Natamycin followed by evacuation of the fungus ball under local anesthesia through a limited thoracotomy incision. The cavity is then irrigated for several weeks with Natamycin.l In our opinion, medical treatment should be reserved for only those patients who are not surgical candidates. References 1. Aslam, P. A. Aspergillosis of the Lung An Eight Year Experience. Chest, 59:28, 1971. 2. Baum, G. L. Textbook of Pulmonary Diseases. Boston, Little, Brown and Company, 1965. 3. Beeson, P. and McDermott, W.: Textbook of Medicine. Philadelphia, W. B. Saunders Company, 1967. 4. British Tuberculosis Association: Aspergillosis in Persistent Lung Cavities After Tuberculosis. Tubercle, 48:1, 1968.

Ann. Surg. * July 1977

5. Blackwell, J. B.: Bronchopulmonary Aspergillosis. Aust. Ann. Med., 13:49, 1964. 6. Crofton, J. and Douglas, A.: Respiratory Diseases. Blackwell Scientific Publications. Oxford, 17:287, 1969. 7. Campbell, M. J., and Clayton, Y. M.: Bronchopulmonary Aspergillosis. Am. Rev. Respir. Dis., 89:186, 1965. 8. Deve, F.: Une Nouvelle Forme Anatomoradiologicque de Mycose Pulmonaire Primitive. Le Megamycatom Intra Bronchiectasique. Arch. Med. Chir. Appar. Repir, 13:337, 1938. 9. Fineglad, S. M., Will, D. L., and Murray, J. F.: Aspergillosis: A review and report of 12 cases. Am. J. Med., 27:463, 1959. 10. Gerstyl, B., Werdman, W. H., and Newman, A. V.: Pulmonary Aspergillosis. Report of 2 Cases. Ann. Intern Med., 28:662, 1948. 11. Braude, I. A.: Other deep mycoses. In Wintrobe, M. M., Thorn, G. W., Adams, R. D., Braunwald, E., Isselbacher, K. J., and Petersdorf, R. G. (eds.): Harrison's Principles of Internal Medicine, Seventh edition, New York, McGraw-Hill Book Co. 1974, p. 906. 12. Henderson, A. H., and Pearson, J. E. D.: Treatment of Bronchopulmonary Aspergillosis with Observation of the use of Natamycin. Thorax, 23:519, 1968. 13. Irwin, A.: Radiology of the Aspergilloma. Clin. Radiol., 18:432, 1967. 14. Krohn, J.: Aspergillosis of the Lung in Ankylosing Spondylitis. Scand. J. Respir. Dis. [Suppi], 63:131, 1968. 15. Kilman, J. W., Ahn, C., Andrews, N. C., and Klassen, K.: Surgery for Pulmonary Aspergillosis. J. Thorac. Cardiovasc. Surg., 57:642, 196916. Monod, O., Pesle, G. D., and Laberquerie, M.: Laspergilloma bronchi chetasiant, J. Fr. Med. Chiv. Thorac., 6:229, 1952. 17. Naji, A. F.: Bronchopulmonary Aspergillosis. Arch. Pathol. (Chicago), 68:282, 1959. 18. Riddle, R. W.: Fungus Diseases of Britain. Br. Med. J., 2:783, 1956. 19. Reddy, P. A., Christianson, C. S., Brasher, C. A., Larsh, H., and Sutaria, M.: Comparison of Treated and Untreated Pulmonary Aspergilloma. Am. Rev. Respir. Dis., 101:928, 1970. 20. Rifkind, D., Marchioro, T. L., Schenck, S. A., et al.: Systemic Fungal Infections Complicating Renal Transplantation and Immunosuppression Therapy. Am. J. Med., 43:28, 1969. 21. Ramirez, R. J.-Bronchopulmonary Aspergilloma: Endobronchial treatment. N. Engl. J. Med., 271:1281, 1964. 22. Strutz, G. M., Ros§i- P. N. and Ehrenhoft, J. L.: Pulmonary Aspergillosis. J. Thorac. Cardiovasc. Surg., 64:6, 1972. 23. Sluyter, F. T.: De Vgtabilus organisms animalis parasitis ac de movo Epiphyto in pRtgreasi versicolore obvio. Diss. Guang. Berlin, 14, 1847. 24. Solit, R. W., McKeown, J. J., Jr., Smullens, S., and Frainow, W.: The Surgical Implication of Intracavitary Mycetomas. J. Thorac. Cardiovasc. Surg., 62:411, 1971. 25. Saliba, A., Pagnini, L. and Beatty, 0. A.: Intracavitary Fungus Balls in Pulmonary Aspergillosis. Br. J. Dis. Chest, 55:65, 1961. 26. Saab, S. and Almond, C.: Surgical Aspects of Pulmonary Aspergillosis. J. Thorac. Cardiovasc. Surg., 68:455, 1974. 27. Virchow, R.: Beitrage Fur Leure Von Den Bein Menchen Vostrommenden Pflanzlicken Parasiten. Virchow Arch. (Path. Anat.), 9:557, 1856. 28. Villar, T. G., Pimentel, C., and Costa, M. N.: The Tumor-like Forms of Aspergillosis of the Lung Thorax, 17:22, 1962. 29. Zatzkin, H. R., Johnson, L. and Abrahams, I.: Pulmonary Intracavitary Aspergilloma Fungus Ball. Report of 3 Cases. J. Thorac. Cardiovasc. Surg., 61:619, 1971.