Lung Resection for Invasive Pulmonary Aspergillosis in Neutropenic Patients with Hematologic Malignancies: Long Term Results in Thirty Two Cases.

Invasive pulmonary aspergillosis (IPA) is a major cause of morbidity and mortality in neutropenic patients. Despite adequate medical treatments, such as amphotericin B or voriconazole, the prognosis of IPA remains poor. Nevertheless, recent studies suggest that the outcome of IPA is improving due to early diagnosis (CT scan, antigenemia), use of new antifungal agents (Azols and Echinocandins), and possibly in some cases to early surgical resection. We here report a retrospective one center study of 32 cases of IPA treated by surgical treatment from 1988 to 2005.

Between 1988 and December 2005, thirty-seven consecutive patients underwent lung resection for suspected IPA. They were 22 men and 15 women, with a median age of 49.2 years (15 – 74). The underlying diseases were AML, ALL, aggressive lymphoma and myeloma in 26, 7, 2 and 2 cases, respectively. Surgery was planned after hematologic recovery from the last course of chemotherapy during which IPA was diagnosed, either possible in 18 cases, probable in 18 cases or proven in 1 case (Ascioglu, CID 2002). Surgery consisted in 1 pneumectomy, 6 bilobectomies, 18 lobectomies, 8 wedge resections and 4 lobectomies with wedge resections. No perioperative deaths occurred and the median duration of post surgical hospitalisation was 13 days. Six patients presented surgery related complications: three patients required prolonged pleural drainage, one had a section of the phrenic nerve, one presented a major bleeding and last patient had a pneumopathy. The diagnosis of definite IPA was confirmed in 32 cases. Immediately after surgery, 26 of the 32 patients were able to receive subsequent intensive chemotherapy courses, including 15 stem cell transplant (SCT), either auto (5) or allogenic (10). In all cases, patients subsequently received parenteral antifungal therapy. During these new intensive chemotherapy courses, recurrent aspergillosis was observed in only 2 cases, inducing 1 death from brain localization. Overall, with a median follow-up of 8.3 years (1–18), 40.5% of the patients are alive and the main cause of mortality was relapse, but not IPA.

In conclusion, early surgical resection together with antifungal therapy allows definite diagnosis of IPA, prevents from IPA recurrence and early death due to hemotysis, with very few peri-operative complications. All the more, it allows subsequent high-dose chemotherapy to treat the underlying hematologic disease. Surgery might be a treatment of choice to a define group of patient.