Fungal Empyema Research Articles

Blastomycosis: A Rare Cause of Pleural Effusion, Diagnosed on Cytology

ABSTRACT Among fungal infections, fungal empyema (FE) is rare and has significant mortality. Microscopic examination of the pleural fluid plays an essential role in its diagnosis. Since pleural fluid can be obtained easily as a bedside procedure, yielding significant diagnostic material, other invasive and expensive procedures can be avoided. The fungal elements identified in FE on microscopy can be yeasts, filamentous fungi, and dimorphic fungi. The morphology of spherical, thick-walled yeast cells showing broad-based budding is commonly seen in blastomycosis, coccidioidomycosis, and cryptococcosis. Though microbiological tests remain the gold standard, pleural fluid cytology with various special stains can be used as a rapid, reliable test for diagnosis. This has the advantages of prompt diagnosis, minimum expertise, and cost-effectiveness. We present a case of a 75-year-old male who presented with bilateral pleural effusion, the cytology of which revealed blastomycosis.

Clinical characteristics and decortication outcomes of bacterial, tuberculous and fungal pleural infection.

<sec><title>BACKGROUND</title>Pleural infection leading to empyema is a severe condition marked by accumulated infected fluid in the pleural space. Pneumonia with parapneumonic effusion is its most common precursor. The global incidence of pleural infections has increased significantly, with existing literature mainly focusing on bacterial empyema, leaving a gap in comparative analyses.</sec><sec><title>METHOD</title>A retrospective review was conducted on 561 cases of bacterial, tuberculous, and fungal empyema over a 10-year period. The study compared and analysed overall survival rates, 30-day mortality rates after surgery, and clinical characteristics.</sec><sec><title>RESULTS</title>The three empyema groups displayed distinct clinical characteristics. Fungal empyema had the worst overall survival compared to bacterial and tuberculous empyema, which had similar survival rates based on 30-day and 2-year mortality. Fungal empyema, advanced age, and high Charlson Comorbidity Index (CCI) score were independent predictors of poor prognosis.</sec><sec><title>CONCLUSION</title>Fungal empyema has the highest mortality rate post-decortication surgery. Advanced age and high CCI score are independent predictors of poor prognosis.</sec>.

Community-Acquired Candida albicans Empyema Leading to Tension Physiology: A Case Report.

A tension empyema, in which purulent material accumulates in the chest cavity and leads to cardiopulmonary dysfunction, is a rare complication of empyemas. Moreover, fungal empyemas that grow Candida albicans and cause tension physiology have not yet been previously described. In this report, we present an immunocompetent 30-year-old male who presented to the emergency department with worsening shortness of breath and was found to have a left-sided fungal empyema causing tension physiology. Left chest thoracostomy yielded approximately 4 liters of purulent fluid. Pleural cultures eventually grew C albicans, and after antifungal therapy, surgical decortication of the lung, and a prolonged intensive care unit stay, the patient was discharged home in stable condition. While mortality from C albicans empyemas that cause respiratory compromise is exceedingly high, our case highlights that aggressive management with rapid chest thoracostomy and antifungal therapy can lead to a favorable outcome.

Fungal empyema thoracis, a rare but an emerging entity: a retrospective case series from Pakistan.

Fungal empyema is a rare entity which is associated with high mortality. It is mostly seen in immune-compromised hosts. However, there is limited data available on fungal empyema from developing countries regarding risk factors, treatment, and outcome. This study was conducted to determine the risk factors, clinical features, treatment, and outcome of fungal empyema. A retrospective observational study was performed on proven fungal empyema cases, admitted at Aga Khan University Hospital, Karachi, Pakistan during January 2018 to May 2021. We excluded all those patients with polymicrobial bacterial and fungal empyema or with negative pleural fluid cultures. A preformed questionnaire was filled out for each case. A total of 26 patients were diagnosed with fungal empyema with a mean age of 43.6 ± 20.3 years. Of these, 16 (61.5%) patients were male. Diabetes mellitus was the most frequent comorbidity (n = 11, 42.3%), followed by hypertension (n = 9, 34.6%), malignancy (n = 6, 23.1%), and asthma (n = 1, 3.8%). Ten (38.5%) patients had multiple comorbidities. Candida spp. was isolated in 21 (80.8%) patients and Aspergillus spp. in 7 (26.9%) patients. Fusarium spp. was isolated from one (3.9%) patient. Video-assisted thoracoscopy surgery was done in 14 (53.8%) patients and 12 (46.1%) patients were managed with tube thoracostomy. Twenty-one (80.8%) patients received antifungal agents. Overall, in-hospital mortality was 38.5% (n = 10) and all patients developed respiratory failure. Clinical improvement was seen in 16 (61.5%) patients. Our data suggest that fungal empyema has a poor outcome as almost one-third of our patients died. Early diagnosis and intervention can improve outcome.

Rare Case of Candida Parapsilosis Empyema Thoracis

BACKGROUND: This case report describes a patient with pleural empyema that grew Candida parapsilosis, an unexpected finding, especially in an immunocompetent individual with no prior surgery or trauma to the area. Candida empyema is a rare infection associated with mortality rates as high as 61.9%. METHODS: A 63-year-old male with a past medical history of pulmonary emboli was in his usual state of health when he developed worsening left-sided chest pain over 3 days, with associated shortness of breath and productive cough that was blood-tinged on occasion. Extensive imaging and a diagnostic thoracentesis confirmed an expanding left-sided parapneumonic effusion that was drained and found to grow Streptococcus anginosis and Candida parapsilosis. During his hospitalization, the patient also demonstrated increased alkaline phosphatase levels without abdominal pain or elevation in AST, ALT, or bilirubin, prompting further diagnostic imaging. Ultrasound of the abdomen showed a large, heterogeneous liver; follow-up CT scan, which was done without contrast due to worsening acute kidney injury, did not rule out liver masses. The patient’s clinical condition began to significantly improve following drainage of the pleural effusion and removal of the chest tube. After his kidney function returned to baseline, the patient was discharged with the remainder of his 18-day courses of amoxicillin-clavulanate and fluconazole, with a contrasted CT of the abdomen scheduled in the outpatient setting. CONCLUSION: This is an unusual case of fungal empyema, a severe manifestation of invasive candidiasis with a poor prognosis. Given the paucity of studies on Candida empyema, there is no definitive treatment for this deadly infection. A 2021 retrospective study of 81 patients with Candida empyema at two academic centers posited that optimal management included pleural drainage and fluconazole treatment. The same study found that 20% of Candida empyema originated from intra-abdominal sources. As for the patient in this case report, there remains the possibility that upcoming outpatient contrasted CT imaging of the abdomen will reveal the source of his infection.

Fungal empyema thoracis

Fungal empyema (FE), which has a death rate of 70%, is still a rare condition. FE is a rare cause of empyema. Its association with chronic pancreatitis in immunocompetent patients is rarely reported. This rare case is reported from the tertiary care hospital in central rural India. We present the case of a 40-year-old male known alcoholic with chronic pancreatitis who presented with dyspnea, fever, and left-sided localized chest pain for 2 months. Pleural fluid cytology revealed periodic acid–Schiff and Giemsa stain-positive fungal hyphae morphologically appear to be Candida albicans. Candida empyema thoracic in an immunocompetent patient with chronic pancreatitis responded well to early treatment with pleurocentesis and intravenous fluconazole.

The outcomes of thoracoscopic decortication between fungal empyema and bacterial empyema

BackgroundFungal empyema is an uncommon disease and is associated with a high mortality rate. Surgical intervention is suggested in stage II and III empyema. However, there were no studies that reported the outcomes of surgery for fungal empyema.MethodsThis study is a retrospective analysis in a single institute. Patients with empyema thoracis who underwent thoracoscopic decortication between January 2012 and December 2021 were included in the study. We separated the patients into a fungal empyema group and a bacterial empyema group according to culture results. We used 1:3 propensity score matching to reduce selection bias.ResultsThere were 1197 empyema patients who received surgery. Of these, 575 patients showed positive culture results and were enrolled. Twenty-eight patients were allocated to the fungal empyema group, and the other 547 patients were placed in the bacterial empyema group. Fungal empyema showed significantly longer intensive care unit stay (16 days vs. 3 days, p = 0.002), longer median ventilator usage duration (20.5 days vs. 3 days, p = 0.002), longer hospital stay duration (40 days vs. 17.5 days, p < 0.001) and a higher 30-day mortality rate (21.4% vs. 5.9%, p < 0.001). Fungal empyema revealed significantly poorer 1-year survival rate than bacterial empyema before matching (p < 0.001) but without significant difference after matching.ConclusionsThe fungal empyema patients had much worse surgical outcomes than the bacterial empyema patients. Advanced age and high Charlson Comorbidity Index score are independent predictors for poor prognosis. Prompt surgical intervention combined with the use of antifungal agents was the treatment choice for fungal empyema.

Aspergillus pleural empyema in a chronic smoker – A case report and review of literature

Aspergillus species are ubiquitous saprophytic fungi that are present in the air, water, soil, and decaying vegetables. Clinical features of Aspergillus infection largely depend on the interplay between the fungi and the host immune status. We present a case of a chronic smoker with shortness of breath who was found to have diffuse bronchiectatic changes and empyema of the right lung. Emphysema was also noticed in the left lung. Rare Aspergillus fumigatus was identified in the pleural fluid, while the acid-fast stain and bacterial cultures were negative. The patient's serum Aspergillus fumigatus IgG antibody and galactomannan antigen were negative; however, the pleural galactomannan antigen was elevated. He was treated with video-assisted thoracoscopic surgery (VATS) and partial decortication of the right lung, along with intravenous voriconazole. Despite aggressive therapeutic measures, he died after a prolonged hospital stay. Aspergillus pleural empyema is rare but can be fatal; however, it is not included in the classification for pulmonary aspergillosis. Clinicians should be vigilant to evaluate for fungal empyema in patients with chronic obstructive pulmonary diseases, even without profound immunosuppression.

Favorable prognosis after pancreatico-pleural fistula and subsequent fungal empyema

Introduction: The diagnosis of pancreatico-pleural fistula is one that requires a high index of clinical suspicion. Furthermore, a subsequent fungal empyema is rare and life-threatening.

Fungal Empyema Thoracis due to Candida species: A diagnosis on fine needle aspiration cytology

Fungal Empyema Thoracis due to Candida species: A diagnosis on fine needle aspiration cytology

ASPERGILLUS FUMIGATUS EMPYEMA IN AN IMMUNOCOMPROMISED PATIENT WITH RHEUMATOID ARTHRITIS

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Fungal empyema is a rare entity (less than 1 percent of all cases) with Candida spp. being the most common etiological agents and only a few cases due to Aspergillus spp (1). CASE PRESENTATION: A 74-year-old male with history of rheumatoid arthritis on maintenance prednisone and methotrexate presented with progressive exertional shortness of breath and productive cough for 3 months. Chest X-ray showed a large left pleural collection with air-fluid level and thick wall. Computed tomography (CT) of the chest showed a large pleural loculation with an air fluid level surrounded by thickened wall, consolidation of the left lower lobe, and scattered tree-in-bud opacities bilaterally. A small right pleural effusion with multiple benign appearing pulmonary nodules was also noted. Video-assisted thoracoscopic surgery (VATS) with decortication was done. Pleural biopsy showed a dense mat of branching, septated fungal hyphae involving necrotic pleura. Pleural fluid cultures grew Aspergillus fumigatus. IV liposomal amphotericin was started, caused hypotension, was changed to IV voriconazole which led to acute liver injury and was eventually treated with micafungin. Repeat cultures from thoracostomy drainage grew Streptococcus viridans and Neisseria flava. They were suspected to have seeded from a bronchopleural fistula and IV piperacillin-tazobactam was given for coverage. The hospital course was complicated by left sided pneumothorax post-VATS requiring reinsertion of chest tube, atrial fibrillation with rapid ventricular rate, dysphagia and right sided pleural effusion requiring diagnostic thoracentesis (exudative fluid with negative culture). Patient requested discontinuation of medical therapy and transition to comfort measures due to his extended hospital stay. He was eventually transferred to hospice. DISCUSSION: Among the Aspergillus empyema cases, A. fumigatus is isolated most often, though other spp., such as A. flavus and A. terreus, have also been implicated (2). Fifty percent of such cases are polymicrobial. Risk factors include immunocompromised state and conditions predisposing to bronchopleural fistula (tuberculosis, sarcoidosis, cavitary pneumonia, thoracic surgery, pneumonectomy and lung transplantation). Diagnosis is made from pleural fluid culture or pleural biopsy stains showing characteristic hyphae. Pleural fluid is generally turbid with high protein, low glucose, increased neutrophils and galactomannan. Treatment is combined surgical (drainage of the pleural cavity, necrotic tissue resection and closure of bronchopleural fistula) and prolonged systemic antifungal therapy with triazoles (first line) or echinocandins (salvage therapy for treatment failure or tolerability concerns) (3). CONCLUSIONS: Aspergillus empyema is a rare but highly morbid entity that should be considered in immunocompromised hosts and requires surgical and prolonged medical management. Reference #1: Ko SC, Chen KY, Hsueh PR, Luh KT, Yang PC. Fungal empyema thoracis: an emerging clinical entity. Chest. 2000;117(6):1672. Reference #2: Albelda SM, Gefter WB, Epstein DM, Miller WT. Bronchopleural fistula complicating invasive pulmonary aspergillosis. Am Rev Respir Dis. 1982 Jul;126(1):163-5 Reference #3: Bonatti H, Lass-Floerl C, Angerer K, Singh N, Lechner M, Stelzmueller I, Singh R, Schmid T, Geltner C. Successful Management of Post pneumonectomy Aspergillus pleural empyema by combined surgical and antifungal treatment with voriconazole and caspofungin. Mycoses. 2010 Sept; 53(5) 448-54 DISCLOSURES: No relevant relationships by Amit Rout, source=Web Response No relevant relationships by Adrian Sarzynski, source=Web Response No relevant relationships by Sahib Singh, source=Web Response

ASPERGILLUS EMPYEMA IN A LUNG TRANSPLANT PATIENT

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Fungal empyema thoracis is an uncommon entity with reported mortality rates as high as 73% [1]. Here we report a case of aspergillus empyema with associated cutaneous lesion in a lung transplant patient. CASE PRESENTATION: A 70 year old man who had undergone left lung transplant 5 years prior for chronic hypersensitivity pneumonitis, on immune suppressive therapy with tacrolimus, mycophenolate and prednisone presented with 3 months of weight loss, generalized weakness and confusion. He noted a stable chronic cough productive of clear phlegm, without dyspnea, hemoptysis, fever or night sweats. Approximately 3 months prior to presentation, while undergoing treatment for squamous cell carcinoma of the scalp, he had an anterior chest wall mass excised, histopathology notable for severe acute inflammation and narrow septate hyphal elements. Serum and bronchoalveolar lavage fluid galactomannan levels at that time were not detected, and treatment with systemic antifungals was deferred. On hospitalization, he was well-appearing with normal oxyhemoglobin saturation on room air. Limited bedside ultrasound examination demonstrated a large multi-loculated pleural effusion. Computed tomography imaging revealed severe traction bronchiectasis and fibrosis of native right lung and a large right sided pleural effusion. Diagnostic thoracentesis yielded a hazy yellow exudate with a pH 6.99, LDH of 1462 U/L, total protein 2.2 g/dL, and glucose 256 mg/dL. Fluid culture revealed 2+ Aspergillus fumigatus, consistent with a diagnosis of aspergillus fumigatus. He underwent treatment with oral isavuconazole and intrapleural tPA/dornase alpha via a pleural pigtail catheter. Unfortunately, the effusion persisted; surgical options were reviewed with patient, who elected to defer surgery and discharge home with hospice. DISCUSSION: Aspergillus empyema thoracis is an uncommon disease which mostly occurs in patients with established empyema or bronchiectectatic cavities and a bronchopleural or pleurocutaneous fistula [2]. In our case, early manifestations of invasive aspergillosis were subtle, and diagnosis elusive until the disease was advanced. CONCLUSIONS: Fungal empyema thoracis is an important differential consideration for pleural effusion in patients with chronic immune suppression, solid organ or hematologic malignancy. Mortality for this condition is high, particularly if not recognized and treated appropriately. Reference #1: Ko, SC et al. Fungal empyema thoracis: an emerging clinical entity. Chest, 2000; 117(6):1672-8. Reference #2: Zhang, W. et al. Pleural aspergillosis complicated by recurrent pneumothorax: a case report. J Med Case Rep, 2010. 4: p 180. DISCLOSURES: No relevant relationships by Nicholas Braus, source=Web Response No relevant relationships by Timothy Rowe, source=Web Response

Fungal empyema thoracis in cancer patients.

Fungal empyema thoracis (FET) is a rare life-threatening infection. We sought to describe the clinical characteristics of FET in a large academic cancer center. We conducted a retrospective chart review of all cancer patients who had a fungal isolate from the pleural fluid culture between 1/2005 and 8/2013. A total of 106 fungal isolates were identified in 97 patients. Yeasts accounted for 62% of the isolates whereas 38% were identified as molds. The most frequent pathogens were Candida spp. (58%) and Aspergillus spp. (12%). All patients with Aspergillus and 83% with Candida met criteria for proven fungal disease. Compared to the Aspergillus group, Candida FET was associated with recent abdominal or thoracic surgical procedures (44% vs. 0%, p=0.01). Overall, 6-week mortality was high, with no significant differences between Candida and Aspergillus (31% vs. 45%, respectively [p=0.48]). Only 1 out of 11 patients with uncommon molds died at 6 weeks, despite only 2 of them received appropriate antifungal therapy. Development of FET carries a high mortality in cancer patients. A history of a recent surgical procedure is a risk factor for FET due to Candida. Isolation of uncommon molds is likely to represent a contamination of the pleural fluid.

Case Report—Aspergillus Empyema Necessitans Post Double-lung Transplant

Empyema necessitans (also called empyema necessitatis) is a sequelae of empyema/parapneumonic effusion where infection progresses beyond the pleural space into the soft tissues of the chest wall. Typical pathogens includeMycobacterium tuberculosis,Streptococcus pneumoniae, andStaphylococcus aureus. Fungal empyema necessitans is uncommon, with the majority of cases secondary to Candida species. We report a rare and fatal case of empyema necessitans presenting in a patient with cystic fibrosis more than 10 years following double-lung transplant.

On a Fatal Case of Candida krusei Pleural Empyema in a Pregnant Woman with Spontaneous Esophagus Perforation

Candida empyema thoracis can be a consequence of operation, gastropleural fistula, and esophageal perforation. Case report and review of the literature. A fatal case of a 45-year-old pregnant woman with Candida krusei empyema thoracis secondary to spontaneous esophagus perforation associated with candida esophagitis is reported. The case is contextualized among similar cases found through a PubMed search. A suspect of esophagus rupture should arise in the presence of a fungal empyema. Candida esophagitis should be always considered as a possible cause or con-cause of esophagus rupture. An empirical systemic antimycotic therapy should always be considered in an ideal multidisciplinary approach to the management of patients with esophagus rupture.

Retrograde Esophageal Stent Placement Via a Gastrostomy Site as a Treatment for Boerhaaveʼs Syndrome

We present a case of a 40 year old male active duty soldier who came to a troop medical clinic complaining of emesis and chest pain. He was found to have a pneumothorax and left pleural effusion. An esophagram showed free communication of the esophagus with the left pleural cavity consistent with Boerhaave's Syndrome. He underwent left thoracotomy with decontamination, thoracostomy tube placements, and exploratory laporatomy with draining gastrostomy and feeding jejunostomy tube placement. Later, a loop esophagostomy was placed in his neck for diversion of his salivary stream. During a repeat left thoracotomy for decortication of a fungal empyema, the esophageal rupture was identified and repair attempted. A subsequent esophagram showed persistent contrast extravasation at the distal esophagus. After dilation of the gastrostomy site to allow introduction of the delivery system, a 9cm/16mm Polyflex stent (Boston Scientific) was placed over the distal esophagus via a retrograde approach under fluoroscopic guidance. The stent migrated into the stomach within minutes and was removed. Another attempt was successfully made 3 days later with a larger 15cm/25mm stent, confirmed by an immediate gastrograffin contrast study. Following the procedure, the patient recovered quickly. A chest film 8 days later showed the stent to be in unchanged position. He was discharged after thoracostomy tube removal. He returned several weeks later much improved. Repeat esophagram showed no extravasation, but the stent had migrated into the stomach. He is now scheduled for re-anastamosis of the esophagus, with possible intestinal interposition or gastric pull-through approach, in the next few weeks. The stent will be removed at that time. This case represents an unorthodox retrograde approach to stent placement not commonly seen in the literature. While surgical correction remains the gold standard, stent placement has enjoyed increasing popularity though the number of reported cases is still relatively small, especially so with respect to a retrograde approach. As seen in our case, finding the correct size stent may be a commonly encountered problem. In general, Polyflex stents are more economical and more pliable than metallic stents. The pliable nature of this stent may minimize complications previously seen upon stent removal.

Fungal Empyema Thoracis

To analyze the clinical spectra, pathogenesis, treatment, outcome, and prognostic factors of fungal empyema thoracis. The medical records of patients with positive fungal cultures from pleural effusions were retrospectively analyzed. A university-based tertiary care hospital in Taipei, Taiwan. From January 1990 through December 1997, patients diagnosed with fungal empyema were included in this study. The criteria for diagnosis of fungal empyema thoracis were as follows: (1) isolation of a fungal species from the pleural effusion; (2) significant signs of infection, such as fever (body temperature > 38.3 degrees C) and leukocytosis (white blood cell > 10,000/microL); and (3) isolation of the same mold species from pleural effusion on more than one occasion, or from pleural effusion and other specimens such as blood, sputum, or surgical wounds that showed evidence of tissue invasion. Sixty-seven patients with fungal empyema thoracis were included. Their mean age was 54 years (range, 2 weeks to 93 years), and 64% (43 patients) were men. Fifty-seven patients (85%) had various underlying diseases, and 18 (27%) had more than one immunocompromising condition. A total of 73 fungal isolates were recovered from pleural effusion; the most commonly encountered were Candida species (47 isolates, 64%), Torulopsis glabrata (13 isolates, 18%), and Aspergillus species (9 isolates, 12%). Candida albicans (28 isolates) was the most common Candida species, followed by Candida tropicalis (13 isolates). Six patients (9%) had two fungal strains isolated, and 16 (24%) had concomitant bacterial empyema thoracis. Eighteen patients (27%) had concurrent fungemia. Most (56 patients, 84%) cases of fungal empyema thoracis were nosocomial, and many case (43 patients, 64%) were acquired in ICUs. Abdominal disease (20 patients, 30%), especially previous abdominal surgery and GI perforation (12% and 10%, respectively), was the most common cause of fungal empyema thoracis, followed by bronchopulmonary infection (15 patients, 22%) and chest surgery (12 patients, 18%). Forty-nine patients (73%) received systemic antifungal therapy, and 38 (57%) underwent closed drainage therapy. Eleven patients (16%) underwent pleural irrigation with normal saline solution, povidone-iodine solution, or antifungal agents. Six patients (9%) finally received decortication. All patients receiving surgery or pleural irrigation with antifungal agents survived. Despite the aforementioned management, the crude mortality was high (73%). Multivariate analysis showed a significantly increased risk of death in immunocompromised patients (relative risk, 1.58; p < 0.005) and those with respiratory failure (relative risk, 2.31; p < 0.001). Systemic antifungal therapy was associated with a significantly lower risk of death (relative risk, 0.69; p < 0.05). These data imply an increasing incidence of fungal empyema thoracis in recent years and the necessity for aggressive treatment of patients with this disease.

Completion pneumonectomy and thoracoplasty for bronchopleural fistula and fungal empyema

Achieving sterilization of the postpneumonectomy space and bronchial healing may be difficult when active granulomatous infection of the pleural space and lung parenchyma is present at the time of operation. Three patients with chronic bronchopleural fistula, fungal empyema, and fungal cavities of the remaining ipsilateral lobe were managed with one-stage completion pneumonectomy and modified eight-rib thoracoplasty. Two patients had infection with Aspergillus fumigatis and 1 patient had Coccidioides immitis. Two patients had received mediastinal radiation after prior upper lobectomy for carcinoma of the lung. Two patients were having massive hemoptysis at the time of pneumonectomy. Eight-rib thoracoplasty with suturing of the intercostal muscles to the bronchial stump was performed on all patients. In 2 patients a mass closure of hilar vessels and bronchus was used because of inability to individually close the vessels and bronchus due to ligneous scarring of the hilum. Antibiotic and antifungal irrigations into the operative area were used postoperatively. Chest tubes were left in place 6 to 8 weeks. All wounds healed primarily. Patients were alive without recurrent local infection or tumor at follow-up 3 to 13 years postoperatively.