Surgical Outcomes and Exploratory Preoperative Risk Stratification for Invasive Pulmonary Fungal Infections in Paediatric Patients: A Single-Center Retrospective Study.

BACKGROUND

Invasive pulmonary fungal infections (IPFIs) in immunocompromised children carry high morbidity and may interrupt life-saving chemotherapy or haematopoietic stem cell transplantation (HSCT). Evidence on perioperative risk stratification for surgical management is limited.

PATIENTS AND

METHODS

We conducted a single-center retrospective cohort study of patients < 16 years with proven/probable IPFI who underwent lung resection from 2017 to 2025, with fungal infection confirmed by pathology. Preoperative clinical variables, laboratory tests and CT features were collected. Outcomes included intraoperative blood transfusion, severe postoperative complications, 90-day mortality and time to resumption of chemotherapy/HSCT. An exploratory preoperative weighted risk score was derived and evaluated.

RESULTS

Thirty-three patients were included (median age 9 years; 75.8% male). Aspergillus was the most common pathogen (72.7%); 57.6% had centrally located lesions and 12.1% had multilobe involvement. Procedures were mainly lobectomy (66.7%) or wedge resection (30.3%), with VATS in 45.5%. Peripheral lesion location was associated with less intraoperative transfusion, while hemoptysis and central lesion predicted delayed resumption of chemotherapy/HSCT; preoperative platelet count < 100 × 109/L, multilobe involvement and central location were significantly associated with severe complications. Integrating these independent findings, a 0-8 point composite risk score was constructed (optimism-adjusted C-index: 0.948). The model effectively stratified outcomes: severe complications occurred in 0% (low), 26.7% (moderate) and 75% (high) (p = 0.004). Among survivors, median time to resume chemotherapy/HSCT was 18 days (low) versus 35 days (moderate) versus 78 days (high) (p < 0.001). All 90-day deaths occurred in the high-risk group (p < 0.001).

CONCLUSIONS

Surgery can support source control and timely oncologic treatment in selected paediatric IPFI. A simple, statistically validated preoperative score may help anticipate surgical risk and recovery time and identify a high-risk subgroup with poor short-term outcomes.