Invited Commentary

Abstract

Surgical resection of advanced persistent mycotic infections of the pleura is challenging, with substantial associated morbidity and mortality. The optimal timing, duration, type, and necessity of adjuvant antifungal pharmacotherapy in this high-risk group of surgical patients remains unknown [1Brik A. Salem A.M. Kamal A.R. et al.Surgical outcome of pulmonary aspergilloma.Eur J Cardiothorac Surg. 2008; 34: 882-885Crossref PubMed Scopus (72) Google Scholar, 2Lee J.G. Lee C.Y. Park I.K. et al.Pulmonary aspergilloma: analysis of prognosis in relation to symptoms and treatment.J Thorac Cardiovasc Surg. 2009; 138: 820-825Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar]. As with other patient groups exhibiting significant pulmonary involvement with fungi such as Coccidioidomycosis, administration of antifungal chemotherapy has been variable and inconsistent [3Jaroszewski D.E. Halabi W.J. Blair J.E. et al.Surgery for pulmonary coccidioidomycosis: a 10-year experience.Ann Thorac Surg. 2009; 88: 1765-1772Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar]. As surgeons, we are left without good scientific data on what is really the optimal therapeutic drug, dosing, and duration of treatment. Sagan and Goździuk [4Sagan D. Goździuk K. Surgery for pulmonary aspergilloma in immunocompetent patients: no benefit from adjuvant antifungal pharmacotherapy.Ann Thorac Surg. 2010; 89: 1603-1611Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar] are to be congratulated for reporting their surgical results in a well-written retrospective review. The duration of follow-up alone reveals the complexity and challenges of this disease. Their assessments and recommendations on antifungal use are derived from the 72 patients they treated for pulmonary aspergilloma (PA) during a 23-year period. Their experience reinforced some of the known significant risk factors for postoperative morbidity, including more complex disease and the need for pneumonectomy. The use of antifungal chemotherapy was extensively reviewed, and they report no significant effects for improved morbidity or survival in patients treated with antifungal and surgical intervention vs an operative alone. The authors provide an excellent discussion on the limitations of their study, including the retrospective design, nonhomogenous treatment options in terms of available antifungal agents throughout the study period, lack of objectively established criteria for selection of patients receiving antifungal pharmacotherapy, and small numbers of patients included. The main weakness of the article is the spectrum of differences in the administration of the antifungal therapy, including variable preoperative and postoperative treatment. Simple mycetomas as well as invasive PA or PA sepsis all received differing neoadjuvant and adjuvant doses for variable lengths of time. Certainly in most cases, there was a tendency towards increased antifungal therapy when patients exhibited more serious or complex disease. This led to the comparison of two groups that had critical differences. A much higher preponderance of the patients in the group that only underwent surgical intervention had simple aspergillomas. The group receiving antifungal therapy with an operation underwent more pneumonectomies and sustained a greater percentage of postoperative complications, including empyemas, bronchopleural fistula, and pneumonia. Given that this group had more complex and substantial disease preoperatively, administration of the antifungal therapy would be a separate factor, and it is likely the group might have benefitted from antifungal pharmacotherapy; however, the preoperative disease incidence diminishes this. In addition, most of the patients in the study received amphotericin B rather than a triazole, which increased substantially the morbidity and mortality of patients in this group. This is most certainly related to the timeline of the patients reviewed. Currently, amphotericin B is usually reserved for severe, nonresolving cases, and the newer generation of less toxic antifungal drugs is more commonly used. An assessment made on the use of triazole drugs is also difficult because fluconazole itself, especially with the low dose they used, would not be expected to be of benefit for PA. The doses used of itraconazole were also below what would be considered therapy for PA [5Campbell J.H. Winter J.H. Richardson M.D. et al.Treatment of pulmonary aspergilloma with itraconazole.Thorax. 1991; 46: 839-841Crossref PubMed Scopus (74) Google Scholar]. The authors made an excellent effort to analyze a challenging problem with all the inherent problems of a retrospective review. Their analysis is not convincing, however, to allow the conclusive statement that adjuvant antifungal pharmacotherapy does not improve the results of surgical treatment for PA. Surgery for Pulmonary Aspergilloma in Immunocompetent Patients: No Benefit From Adjuvant Antifungal PharmacotherapyThe Annals of Thoracic SurgeryVol. 89Issue 5PreviewThe optimal treatment strategy for pulmonary aspergilloma (PA) remains controversial. Among a variety of options, surgical removal of the mycetoma is considered the most effective. However, it ranks among the most challenging procedures and is associated with considerable mortality and morbidity. Previous studies showed that the use of antifungal agents improved outcomes in high-risk surgical patients with mycotic infections. We hypothesized whether combining antifungal pharmacotherapy with surgical resection in patients with PA could yield a strategy more beneficial than surgery alone. Full-Text PDF