Adjuvant antifungal therapy after pulmonary surgery for aspergilloma: Is it useful?

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether adjuvant antifungal therapy is useful after pulmonary surgery for aspergilloma. One hundred and sixteen papers were identified using the search described below, of which 5 papers presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. No paper was greater than level-three evidence. One study compared the outcomes of 72 patients treated for pulmonary aspergilloma (PA) during a 23-year period. Despite no difference being found in outcomes, more complications were seen in the surgery-alone group. Another study included 14 patients treated with amphotericin B alone or with flucytocine. They found no benefit in the treatment of PA by systemic antifungal therapy. One retrospective study reported complete eradication of PA in patients treated with preoperative and postoperative oral itraconazole. One large cohort study reported their outcomes in 256 patients with PA, divided into two groups: Group A (simple aspergilloma, n = 96) and Group B (complex aspergilloma, n = 160) after aggressive surgical treatment and antifungal therapy. They found no difference in the postoperative morbidity between two groups (P = 0.27). A postoperative fungal relapse was found in 2 patients. One retrospective study reported the outcomes and mortality in 61 cases with PA. Thirty-five (60%) patients were treated with antifungal agents, and 15 (25%) patients were treated surgically. Many cases did not respond to antifungal therapy. Nineteen (31%) patients died. We did not find evidence to support the role of adjuvant antifungal therapy following definitive surgical removal of the fungus ball in immunocompetent patients; however, randomized control studies in multiple centres, with new antifungal therapy, are necessary to confirm these preliminary results. © 2014 The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.