Introduction: Surgical resection offers the only realistic chance of permanent cure for pulmonary aspergilloma. This prospective study was designed to evaluate our indications and surgical outcome of pulmonary aspergilloma with analysis of postoperative complications. Patients and methods: Between 2001 and 2008, 42 patients underwent surgical treatment for pulmonary aspergilloma at Zagazig University Hospital. The patients were divided into two groups, group A (simple aspergilloma) n = 12 and group B (complex aspergilloma) n = 30. Results: Group A consisted of eight male and four female patients with a mean age of 43 ± 11.3 years. Group B consisted of 20 male and 10 female patients with a mean age of 46 ± 12 years. The most common presentation and indication for surgery was hemoptysis (83.3%) in both groups. The common underlying lung diseases were tuberculosis (40.4%), bronchiectasis (33.3%) and lung abscess (11.9%). The common surgical procedure performed was lobectomy (85.7%), followed by pneumonectomy (6.7%), segmentectomy (8.3%), cavernoplasty (4.7%) and bilobectomy (6.7%). The postoperative mortality was 3.3% in group B only. Postoperative non-fatal complications occurred in 12 patients (28.5%) in both groups. The complications included prolonged air leak (2.3%), bleeding (4.7%), wound infection (2.3%), empyema (7.1%), bronchopleural fistula (2.3%) and one patient developed chylothorax after lobectomy (2.3%). The mean follow-up period was (25.5 ± 17 months). The survival rate at 5 years was 91.6% and 83.3% in group A and group B respectively and there was no recurrence of disease or hemoptysis. Conclusion: Surgical treatment of pulmonary aspergilloma is the most effective treatment; pulmonary resection is the treatment of choice when indicated and in unstable surgical patients, palliative procedures chosen in bad cardiopulmonary function.
Pulmonary aspergilloma generally forms from saprophytic colonization of pre-existing pulmonary cavities of Aspergillus fumigatus, the most common saprophytic species of Aspergillus in human disease, producing a fungus ball or a mycetoma [1,2]. After the formation of the fungus ball, antifungal agents are usually ineffective .
Surgical resection offers the only realistic chance of a permanent cure for aspergilloma [4–6], but surgical indication is still controversial because of the high incidence of postoperative complications [7,8].
Patients with aspergilloma should undergo surgical treatment because there is a risk of sudden life-threatening hemoptysis, and alternative medical treatment is ineffective: patients with bad general condition and those with pulmonary insufficiency related to extending the underlying lung disease are especially at high risk for postoperative complications [7,9–11].
Resection is usually contraindicated in patients with compromised lung function and/or bilateral disease. Alternative palliative procedures such as cavernostomy, bronchial artery embolization or intracavitary amphotericin B instillation are often performed . The purpose of this study is to evaluate our indications and surgical outcome of aspergilloma with an analysis of postoperative complications.
Patients and methods
Between 2001 and 2008, 42 surgical procedures were performed for pulmonary aspergilloma at Zagazig University Hospital. Patients with invasive aspergillosis, allergic bronchopulmonary aspergillosis and active tuberculosis were excluded. There were 28 male and 14 females. Patients had a mean age of (44 ± 11).
All the patients were studied for history, clinical presentation, underlying lung disease, chest radiography, computed tomography, indications for surgery, surgical techniques, postoperative complications and follow-up status for recurrence, hemoptysis and functional class. According to previous reports [7,11], patients were classified as having simple or complex aspergilloma on the basis of medical imaging and operative findings: simple aspergilloma (SA) group A was defined as a thin-walled cavitation occurring in an otherwise healthy lung, whereas complex aspergilloma (CA) group B occurred either in a thick-walled cavitation or in the presence of severe underlying parenchymal and pleural sequels, or both. The diagnosis was suspected on chest radiography and CT chest in all the patients with classical picture of an intracavitary mass surrounded by an air crescent. Histological examination of all resected specimens by periodic acid-Schiff staining.
The degree of hemoptysis was measured by the amount of blood lost in 24 h. Massive hemoptysis, more than 300 ml/24 h severe 150–300 ml, moderate if less than 150 ml and minimal if sputum was blood stained. Preoperative pulmonary function tests were done in the majority of our cases, and all tests to search active tuberculosis were negative in all patients. Preoperative antifungal agents were not used.
Statistical analysis was done using SPSS version II. Data were expressed as mean ± standard deviation for quantitative variable; number and percentage for qualitative one, Student’s t test and chi squared test χ2, when the expected cell are less than 5, the p value of Fisher’s exact result instead of χ2 was used. A p value less than 0.05 was considered significant. Survival probability as calculated by the Kaplan–Meier method, plotted at monthly intervals with the day of surgery as the starting point.
Hemoptysis was the most common presentation and the most frequent indication for surgery (Table 1 ). Hemoptysis was moderate to minimal in 35 patients (83.3%) in both groups, 2 patients who were in severe attack of hemoptysis in group B (2.3%) underwent emergency operation.
Preoperative pulmonary function tests showed a restrictive pattern in 35 patients (83.3%), obstructive in 2 patients (4.7%) and normal in 3 patients (7.1%), pulmonary function testing was not performed in 2 patients (4.7%) because of emergency situation.
Except for five patients without any underlying lung disease, tuberculosis represented the main underlying disease (40.4%) (Table 2 ). Broncheactesis is the second underlying pathology for aspergilloma (33.3%) in both groups, four cases (33.3%) lung abscess in group A and one patient in group B (3.3%), diagnosis of aspergilloma depends on clinical presentation and demonstrating of the characteristic fungus ball with the air crescent sign (Fig. 1 ). Histological examinations with periodic acid Schiff staining identified aspergillus in all resected specimens (Table 3 ).
Surgical procedure was performed in all 42 patients, 36 patients (85.7%) underwent lobectomy in both groups; 2 pneumonectomy in group B (6.7%), one patients for segmentectomy in group (A) (8.3%), 2 patients (6.7%) underwent bilobectomy in complex Aspergilloma (group B) and cavernostomy was performed in one patient in both groups as a palliative procedure due to severe respiratory insufficiency. Mean intraoperative and postoperative blood loss was 750 ± 620 ml (range 150–2400 ml) in the first day, 35 patients required blood transfusion (83.3%).
One patient suffered hospital mortality (3.3%) in group B (complex aspergilloma) after 7 days from cavernostomy due to respiratory failure.
Postoperative non-fatal complications occurred in 12 patients (28.5%) in both groups (Table 4 ).
In group A, one patient (8.3%) had prolonged air leak after segmentectomy, another patients had a wound infection. In group (B), two patients (6.7%) suffered from bleeding and required re-exploration for bleeding, one after pneumonectomy and another after lobectomy. Three patients (7.1%) developed empyema, two in group B after lobectomy and the two patients suffering from prolonged air leak and empyema, one patient (8.3%) in group A developed empyema after lobectomy, bronchopleural fistula in one patient (3.3%) after pneumonectomy in group (B) and was treated by thoracoplasty.
One patient (3.3%) in group B developed chylothorax after lobectomy and responded to conservative treatment.
The mean follow-up period was 25.5 ± 17 months (range, 3–70); three patients were lost to follow-up in group B (complex aspergilloma), one patient died in group A and two patients in group B in the intervening period due to causes other than pulmonary complications.
The remaining 36 patients (85.7%) continue on follow-up, no recurrences or hemoptysis were reported in either group: 34 (80.9%) patients in functional class I, one patient (2.3%) in functional class II, one patient (2.3%) in functional class III and no radiological abnormalities in all 36 patients.
Five-year survival rate in group A and in group B were 91.6% and 83.3% respectively.
Saprophytic colonization of pre-existing pulmonary cavities predominantly in the upper lobe leads to the formation of a fungus ball, aspergilloma: it is a rounded necrotic mass of matted hyphae, fibrin, and inflammation cells (Fig. 2 ). X-ray chest and CT scanning show a characteristic crescentic radiolucency.
Pulmonary tuberculosis is highly prevalent in developing countries; pulmonary aspergilloma occurs in pre-existing pulmonary cavities and the most common cavitary lesion in all series is tuberculosis representing 32% of patients  and 45% in other reports . In our experience, tuberculosis was the cause of cavitary lung lesions in 40.4% of the cases with significant high tuberculous lesions in complex aspergilloma. The symptoms and signs of aspergilloma range from life-threatening hemoptysis to incidental X-ray finding. Five patients (11.9%) were asymptomatic in our series, which is also shown in the series published by Babatasi et al.  in which (18%) of the patients had no symptoms. The low percentage of our series is due to our center receiving referred patients from different centers, and our chance to discover a symptomatic patient is considered to be low. The natural history of aspergilloma is not well documented. Few long-term follow-up reports have been published, and in many of the reports, it is difficult to distinguish between the course of the underlying disease and that of the aspergilloma [17,18].
Hemoptysis is the most common indication for surgery in our series (85.6%) as reported by previous reports; the incidence of hemoptysis ranged from 50% to 83% and was severe or recurrent in 10% . In our series bronchial artery embolization was not performed because the hemoptysis was moderate to minimal except in two cases that were operated on an emergency basis. The most common surgical procedure performed was lobectomy (85.7%) in our series followed by bilobectomies in two cases of complex aspergilloma, and segmentectomy in two cases of complex aspergilloma. Pneumonectomy and lobectomy were the most difficult surgical procedure because of severe adhesions as reported in a previous study . Postoperative complications depended on underlying lung lesions. Bleeding is one of the complications that depend on the severity of adhesion inside the chest; every effort should be made toward meticulous hemostasis, to avoid extrapleural approach and usually electrocautery for adhesion lysis is used.
Pleural space problems like empyema, prolonged air leak, bronchopleural fistula and chylothorax were considered to be of low incidence in our series because, in contrary to a previous report  of avoiding the extrapleural dissection, effective hemostasis, use of electrocautery in adhesion lysis, judicious use of crushing of the phrenic nerve, good postoperative chest physiotherapy, continuous low suction to keep the lung expanded and postoperative bronchoscopic suction was frequently performed.
Thoracoplasty was performed in one patient with bronchopleural fistula.
Ten patients in group B had complications. Two patients with postoperative bleeding were managed by re-exploration and blood transfusion. Three patients had postoperative empyema, all of them were treated by prolonged chest tube drainage. Two patients with prolonged air leak were treated conservatively by frequent bronchoscopic suction and chest physiotherapy. One patient with wound infection was managed by frequent dressing. Bronchopleural fistula was encountered in one patient treated by thoracoplasty.
One patient developed chylothorax and was treated by conservative measures. Even through postoperative morbidity is up to 33.3% in group B. Furthermore, minor complications occurred in group A, as Kim et al. report that postoperative complications were 32% in complex aspergilloma .
In previous reports, overall mortality rates were 22%  and as high as 34% for complex aspergilloma. But, recent reports show significant reduction in morbidity and mortality . The overall operative mortality rate in our series was 3.3%, occurring only in the complex type. In our report the mortality rates were better than in previous reports and we attribute this to good preoperative preparation, meticulous selection of the patients, our experience in chest surgery and good postoperative management. Recurrence of aspergilloma was not reported and no recurrence of hemoptysis during the follow up period of our patients.
We believe that surgical treatment of pulmonary aspergilloma is the most effective treatment; pulmonary resection is a good option when the general condition of the patients can withstand surgical interference; otherwise in cases with insufficient cardiopulmonary function, palliative procedures may be indicated. In the remaining cases non-operative management is recommended.