Surgery for pulmonary aspergilloma in immunocompetent patients: no benefit from adjuvant antifungal pharmacotherapy.

BACKGROUND: The 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.

METHODS: Medical records of 72 patients with PA treated surgically at our department between January 1984 and December 2007, were retrospectively reviewed for clinical variables including adjuvant antifungal pharmacotherapy and the outcomes of treatment.

RESULTS: Ten-year cumulative survival was 74.8% in patients with adjuvant antifungals and 78.9% after surgery alone (p = 0.11). Multivariable analysis by logistic regression model (chi(2) = 11.41; degrees of freedom = 5; p = 0.043) identified pneumonectomy as a significant risk factor for postoperative morbidity (odds ratio = 6.499; 95% confidence interval 1.388 to 30.423; p = 0.018). Multivariable analysis using the Cox proportional hazard model (chi(2) = 26.3; degrees of freedom = 7; p = 0.00045) revealed that female gender, forced expiratory volume in 1 second greater than 75%, and simple aspergilloma were independent favorable prognostic factors (hazard ratio = 10.86, p = 0.013; hazard ratio = 13.45, p = 0.004; and hazard ratio = 11.97, p = 0.028, respectively). Neither univariable nor multivariable analysis indicated that antifungals significantly affected morbidity or survival.

CONCLUSIONS: Adjuvant antifungal pharmacotherapy appears not to improve the results of surgical treatment for PA, and may cause severe adverse effects. We believe that whenever definitive surgical removal of the mycetoma is feasible, antifungals may not be beneficial.