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Pulmonary resection for invasive Aspergillus infections in immunocompromised patients
L A Robinson1, E C Reed, T A Galbraith
1Section of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, USA.
Abstract:
Standard antifungal medical therapy of invasive pulmonary aspergillosis that occurs in immunocompromised patients with hematologic diseases with neutropenia or in liver transplant recipients results in less than a 5% survival. In view of these dismal mortality rates, we adopted an aggressive approach with resection of the involved area of lung along with systemic antifungal therapy when localized invasive pulmonary aspergillosis developed in these patients. Between January 1987 and December 1993, 14 patients with hematologic diseases and 2 liver transplant recipients underwent resection of acute localized pulmonary masses suggestive of invasive pulmonary aspergillosis a median of 7.5 days (range 1 to 45 days) after the diagnosis was clinically suggested and confirmed by chest computed tomographic scans. Operative procedures done included two pneumonectomies, one bilobectomy with limited thoracoplasty, nine lobectomies, and five wedge resections (one patient with hematologic disease had two procedures). All patients were treated before and after the operation with antifungal agents. Nine (64%) of 14 patients with hematologic disease and 2 (100%) of 2 liver transplant recipients survived the hospitalization with no evidence of recurrent Aspergillus infection after a median 8 months of follow-up (range 3 to 82 months). The five hospital deaths (all patients with hematologic diseases) occurred a median of 20 days after operation from diffuse alveolar hemorrhage in three, graft-versus-host disease in one, and multiple organ system failure with presumed disseminated Aspergillus infection in one. Four of the five deaths were in patients with allogeneic bone marrow transplants. Two of the three patients requiring resection of multiple foci of infection died, as did the only patient who was preoperatively ventilator dependent. In immunocompromised patients with hematologic diseases or liver transplantation with invasive pulmonary aspergillosis, early pulmonary resection should be strongly considered when the characteristic clinical and radiographic pictures appear.
Insights
Aggressive surgical resection combined with antifungal therapy significantly improves survival for immunocompromised patients with invasive pulmonary aspergillosis. This approach offers hope for patients with hematologic diseases or liver transplants facing grim prognoses.
Area of Science:
- Medical Mycology
- Thoracic Surgery
- Transplant Surgery
- Hematology Oncology
Background:
- Invasive pulmonary aspergillosis (IPA) in immunocompromised patients, particularly those with hematologic diseases and neutropenia or liver transplant recipients, has a very low survival rate (<5%) with standard antifungal therapy alone.
- The dismal outcomes necessitate exploring more aggressive treatment strategies to improve patient survival and manage this severe fungal infection.
Purpose of the Study:
- To evaluate the efficacy of an aggressive treatment approach combining surgical resection of the involved lung area with systemic antifungal therapy for localized invasive pulmonary aspergillosis.
- To assess the survival rates and recurrence of Aspergillus infection in immunocompromised patients undergoing this combined treatment strategy.
Main Methods:
- A retrospective analysis of 14 patients with hematologic diseases and 2 liver transplant recipients diagnosed with localized invasive pulmonary aspergillosis between January 1987 and December 1993.
- Patients underwent resection of pulmonary masses suggestive of IPA, with operative procedures including pneumonectomies, bilobectomies, lobectomies, and wedge resections.
- All patients received systemic antifungal agents before and after surgical intervention.
Main Results:
- Nine out of 14 patients (64%) with hematologic diseases and both liver transplant recipients (100%) survived hospitalization without evidence of recurrent Aspergillus infection.
- Median follow-up was 8 months (range 3-82 months), with no recurrence observed.
- Five hospital deaths occurred, all in patients with hematologic diseases, primarily due to diffuse alveolar hemorrhage, graft-versus-host disease, or presumed disseminated Aspergillus infection.
Conclusions:
- Early pulmonary resection, when combined with systemic antifungal therapy, should be strongly considered for immunocompromised patients with hematologic diseases or liver transplants presenting with characteristic clinical and radiographic signs of invasive pulmonary aspergillosis.
- This aggressive multimodal approach significantly improves survival outcomes compared to standard antifungal therapy alone in this high-risk patient population.