Intracavitary amphotericin B in the treatment of symptomatic pulmonary aspergillomas

doi:10.1016/0002-9343(80)90109-6

The American Journal of Medicine

Volume 68, Issue 3, March 1980, Pages 389-394

https://doi.org/10.1016/0002-9343(80)90109-6 Get rights and content

Abstract

The optimal treatment of pulmonary aspergillomas is not established. Surgical resection is often impossible because of severe, underlying pulmonary impairment, and medical treatment has given negative or inconclusive results. Six patients with symptomatic pulmonary aspergillomas were treated with percutaneous instillation of intracavitary amphotericin B. Four patients who received the full course of therapy showed improvement and stabilization or reversal of progressive roentgenographic changes. Also, follow-up serologic studies of Aspergillus spp. precipitins were obtained in three and were negative. One patient did not tolerate this treatment because of repeated systemic reactions. Another patient did not respond clinically or roentgenographically. Intracavitary amphotericin B therapy should be considered in patients with symptomatic pulmonary aspergilloma, particularly when surgical resection is not feasible.

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Cited by (86)

Non-surgical treatment options for pulmonary aspergilloma
2020, Respiratory Medicine
Aspergilloma, also known as mycetoma or fungus ball, is the most common manifestation of pulmonary involvement by Aspergillus species. The fungal ball typically forms within preexisting cavities of the lungs. Diagnosis requires both radiographic evidence along with serologic or microbiologic evidence of Aspergillus species involvement. While clinical features such as hemoptysis, chest pain, shortness of breath, cough, and fever are helpful in diagnosis, they are non-specific symptoms. Surgery is currently the mainstay of treatment for aspergilloma but is associated with considerable mortality and morbidity. Alternative options exist for patients who are poor surgical candidates and for those who prefer a less invasive treatment modality. Systemic treatment with amphotericin B is ineffective and is not recommended as a monotherapy, but systemic azoles is effective in approximately 50–80% of patients. Potential alternatives to surgery include intracavitary instillation or endobronchial administration of antifungal medication, as well as direct transbronchial aspergilloma removal. Bronchial artery embolization and radiotherapy are options to manage hemoptysis until definite eradication of the aspergilloma. More rigorous studies are needed to better establish non-surgical treatment paradigm for inoperable patients.
Does antifungal therapy influence postoperative morbidity or long-term survival after surgical resection for pulmonary aspergilloma?
2014, Revue de Pneumologie Clinique
Le traitement chirurgical des aspergillomes pulmonaires permet de contrôler les symptômes, de prévenir les complications et d’améliorer la survie. Dans les formes accessibles à la chirurgie, l’impact d’un traitement antifongique demeure controversé. L’objectif de cette étude est d’analyser l’impact d’un traitement antifongique sur la morbidité postopératoire et la survie globale des patients opérés pour un aspergillome pulmonaire.
De janvier 1989 à décembre 2010, 113 patients ont été opérés pour un aspergillome pulmonaire. Parmi eux, 64 patients ont reçu un traitement antifongique dans la période périopératoire et ont été inclus dans le groupe 1, 49 patients n’ont pas reçu de traitement antifongique et ont été inclus dans le groupe 2.
Le taux de complications postopératoires était de 31,2 % dans le groupe 1 et de 20,4 % dans le groupe 2 (p = 0,30). En analyse univariée, l’immunodépression (p < 0,001), les antécédents de cancers (p = 0,050), les expectorations purulentes préopératoires (p = 0,024) et la pneumonectomie (p < 0,001) étaient significativement associés aux complications postopératoires. Le taux de survie globale à 5 ans et à 10 ans était respectivement de 78,3 % et de 57,8 % pour le groupe 1 vs 85,9 % et 65,7 % pour le groupe 2 (p = 0,23). En analyse multivariée, l’âge supérieur à 50 ans, l’immunodépression et la pneumonectomie étaient des facteurs de mauvais pronostic (χ² = 6,59, df = 5, p < 0,001).
La résection chirurgicale des aspergillomes pulmonaires est associée à une morbidité postopératoire et à une survie à long terme acceptables. Le traitement antifongique périopératoire n’influence en aucun cas la morbidité postopératoire ou la survie à long terme.
Surgical resection of pulmonary aspergilloma is associated with symptoms control, complications prevention, and improved survival, given that the disease is localized and the patient fit enough to undergo surgery. In these operable forms, the impact of perioperative antifungal therapy remains controversial. The purpose of this study was to analyze the impact of antifungal therapy on postoperative morbidity and overall survival in patients with operable pulmonary aspergilloma.
The clinical records of 113 patients who underwent thoracic surgery for aspergilloma in our institution from January 1989 to December 2010 were retrospectively reviewed. Of these, 64 patients received antifungal therapy in the perioperative period and were included in group 1, and 49 patients did not receive antifungal therapy and were included in group 2.
Postoperative complication rates were 31.2% in group 1 and 20.4% in group 2 (P = 0.30). Univariable analysis showed that immunocompromised status (P < 0.001), past history of cancer (P = 0.50), preoperative purulent sputum (P = 0.024), and pneumonectomy (P < 0.001) were significantly associated with postoperative complications, but that antifungal therapy was not. Five- and 10-year overall survival rates were respectively 78.3% and 57.8% in group 1 vs. 85.9% and 65.7% in group 2 (P = 0.23). Multivariate analysis revealed that age higher than 50, immunocompromised status and pneumonectomy were significantly associated with adverse long-term survival (χ² = 6.59, df = 5, P < 0.001), but that antifungal therapy was not.
Antifungal therapy has no significant impact on postoperative morbidity or long-term survival following surgical resection of pulmonary aspergilloma. Such procedure is associated with acceptable postoperative morbidity and long-term survival.
A modern series of percutaneous intracavitary instillation of amphotericin B for the treatment of severe hemoptysis from pulmonary aspergilloma
2013, Chest
Pulmonary aspergillomas may cause life-threatening hemoptysis. The treatment of this condition is problematic because poor pulmonary function often precludes definitive surgical resection.
We retrospectively reviewed all patients hospitalized at our institution for hemoptysis associated with an aspergilloma over an 8-year period and who underwent percutaneous intracavitary instillation of amphotericin B (ICAB). ICAB consisted of catheter placement into the aspergilloma cavity with subsequent instillation of 50 mg amphotericin B in 20 mL 5% dextrose solution daily for 10 days.
ICAB was attempted for 23 distinct episodes of severe hemoptysis in 20 individual patients. Catheter placement was successful in 21 of the 23 episodes (91%), and of these, ICAB instillation was successfully completed in 20 episodes (95%). In these 20 episodes, hemoptysis ceased by hospital discharge in 17 of 20 patients (85%) and in all 18 who survived until a follow-up visit 1-month after treatment. Pneumothorax occurred in six of 23 (26%) catheter placement attempts without long-term complications. Recurrence of serious hemoptysis occurred after six of 18 episodes for which follow-up was available. Potential risk factors associated with severe, recurrent hemoptysis were a size increase or reappearance of the aspergilloma on a chest CT scan (P = .001), bleeding diathesis (P = .08), and lack of bronchial artery embolization during index hospitalization (P = .07).
Our data suggest that ICAB is an effective short-term treatment to control severe hemoptysis caused by pulmonary aspergilloma. The long-term benefit of this procedure is unknown. We identified several potential risk factors for recurrent hemoptysis after ICAB that could be examined prospectively in future trials.
Noninvasive Pulmonary Aspergillus Infections
2009, Clinics in Chest Medicine
Massive Hemoptysis
2008, Critical Care Medicine: Principles of Diagnosis and Management in the Adult
Cavitating invasive pulmonary aspergillosis visualized and diagnosed by ultrathin bronchoscopy
2006, Chest
Citation Excerpt :
Moreover, a biopsy with direct visualization using miniforceps may decrease the risks of bleeding. Visualization of intracavitary lesions during bronchoscopy in patients with pulmonary aspergillosis, mostly aspergilloma, which is characterized by mycelial growth in a preexisting lung cavity and usually has a good prognosis without any treatments, has been rarely reported.192021 However, there may be only a limited number of cases in which the diameter of the bronchus leading to the cavity is relatively large.
A definitive diagnosis of invasive pulmonary aspergillosis (IPA), which usually occurs in immunocompromised patients, is often difficult. We report two cases of cavitating IPA in a peripheral pulmonary region in patients who were receiving corticosteroids, in whom the cavity was successfully visualized and sampled during ultrathin bronchoscopy. Ultrathin bronchoscopy provides a new option for definitive diagnosis of cavitating IPA.

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^∗: Fellowship supported by Arkansas Lung Association.

¹: From the Pulmonary Division, University of Arkansas College of Medicine, Little Rock, Arkansas.

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Clinical studyIntracavitary amphotericin B in the treatment of symptomatic pulmonary aspergillomas

Abstract

Chest

Ann Thor Surg

J Thor CV Surg

Chest

Chest

Am J Med

Tubercle

Clinical study
Intracavitary amphotericin B in the treatment of symptomatic pulmonary aspergillomas