Surgical management of invasive pulmonary aspergillosis in immunocompromised patients

The treatment of haematological malignancies with intensive chemotherapyand bone marrow transplantation results in prolonged periods ofimmunosuppression. This is associated with an increased incidence ofinvasive pulmonary aspergillosis (IPA) with reported mortalities of 67-83%.The mainstay of treatment is medical therapy, surgery being reserved forpatients with haemoptysis. Resection of focal sites of infection has notbeen routinely considered in view of the high morbidity and mortalityreported from the surgery of aspergillomas in past series. After the deathof two neutropenic patients from massive haemoptysis following IPA in 1986,we have resected localised pulmonary aspergillus lesions in 16 patientsfollowing IPA. Five patients had haemoptysis. The most common procedureperformed was a lobectomy. All patients were granulocytopenic and excessivepost-operative bleeding occurred in three patients, one of whom required are-thoracotomy as a result. There was one post- operative death due tocytomegalovirus pneumonia. Surgery was otherwise uneventful. There were norecurrent pulmonary aspergillus infections on follow-up and three patientsproceeded to bone marrow transplantation. The success of surgical resectionencourages an aggressive policy in the management of IPA to preventlife-threatening haemoptysis and to allow patients to proceed with furtherchemotherapy and bone marrow transplantation.