GENERAL THORACIC
Surgical Therapy of Pulmonary Aspergillomas: A
30-Year North American Experience
Ashok Muniappan, MD, Luis F. Tapias, MD, Parag Butala, MD, John C. Wain, MD,
Cameron D. Wright, MD, Dean M. Donahue, MD, Henning A. Gaissert, MD,
Michael Lanuti, MD, and Douglas J. Mathisen, MD
Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
Background. Pulmonary aspergilloma is resected to
control life-threatening complications such as massive
hemoptysis. The role of prophylactic resection in
asymptomatic patients is unclear.
Methods. A retrospective review was conducted of 60
patients treated at a tertiary center from 1980 to 2010.
Results. The mean age in 34 (56.7%) men and 26
(43.3%) women was 51 years. Immunosuppression, most
commonly from chronic steroid use, was present in 17
(28.3%) patients, and preexisting lung disease was
present in 47 (78.3%) patients. Hemoptysis occurred in
33 (55%) patients, whereas 9 (15.0%) patients were
asymptomatic. Aspergilloma was simple in 13 (21.7%)
patients and complex in 47 (78.3%) patients. Surgical
approach was by thoracotomy (n [ 51 [85.0%]), video-
assisted thoracoscopic surgery (n [ 7 [11.7%]), or a cav-
ernostomy (n [ 2 [3.3%]). Sublobar resections (n [ 28
[46.7%]) were most common, followed by lobectomy
(n [ 27 [45%]) and pneumonectomy (n [ 3 [5%]).
P ulmonary infection with Aspergillus exists in invasive
and noninvasive forms. Invasive forms of pulmonary
aspergillosis usually occur in the setting of severe
immunosuppression, such as in human immunodefi-
ciency virus (HIV) infection or hematologic malignancy,
and are often managed medically. In contrast, aspergil-
loma is a cavity or bronchiectatic airway filled with hy-
phae, cellular debris, mucus, fibrin, and blood [1]. Belcher
and Plummer [2] in 1960 classified pulmonary aspergil-
lomas into simple and complex subtypes according to
histologic characteristics and the quality of surrounding
lung. Aspergillomas are strongly associated with a history
of pulmonary tuberculosis, because this disease creates
cavities within which Aspergillus grows. Given the rela-
tively low incidence of tuberculosis and other cavitary
disease in North America, the experience with aspergil-
loma and its surgical management is limited.
Accepted for publication Oct 18, 2013.
Presented at the Poster Session of the Forty-eighth Annual Meeting of The
Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–Feb 1, 2012.
Address correspondence to Dr Muniappan, Massachusetts General Hos-
pital, 55 Fruit St, Blake 1570, Boston, MA 02114; e-mail: amuniappan@
partners.org.
Ó 2014 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Postoperative morbidity occurred in 18 (30%) patients,
with prolonged air leak the most frequent complication
(n [ 9 [15%]). Two (3.3%) patients experienced empyema,
and 4 (6.7%) patients had bronchopleural fistulas (BPFs).
Two patients died within 30 days (3.3%). During a mean
follow-up of 54.1 ± 62.2 months, 3 patients had recurrent
aspergillomas (5.0%). Actuarial 10-year survival was
62.5% for simple and 68.5% for complex aspergillomas
(p [ 0.858). Comorbid conditions (human immunodefi-
ciency virus [HIV] positivity, malignancy) and male sex
were associated with lower survival.
Conclusions. Selective surgical treatment favoring
lesser pulmonary resection results in fungal eradication
and control in most patients. Overall survival is similar
after surgical management of simple and complex
aspergillomas.
(Ann Thorac Surg 2014;97:432–8)
Ó 2014 by The Society of Thoracic Surgeons
Historical reports of significant morbidity and mortality
after surgical management of aspergillomas introduced
controversy about whether asymptomatic patients should
be surgical candidates [3]. Conversely, a high incidence of
life-threatening hemoptysis has been noted in patients
with untreated aspergilloma. Pharmacologic antifungal
therapy is incapable of eradicating aspergilloma, and
treatments such as intracavitary instillation of antifungal
agents have limited efficacy [3].
The aim of this study was to delineate which patients
were selected for surgical management of aspergilloma at
a tertiary referral center in the United States and to re-
view surgical technique, procedure-related morbidity,
and follow-up related to recurrence and patient survival.
Patients and Methods
Patients
The study was approved by the Institutional Review
Board of the Massachusetts General Hospital, who
determined patient consent was not necessary. The study
population included consecutive patients undergoing
surgical treatment for pulmonary aspergilloma at the
Massachusetts General Hospital between January 1980
and December 2010. In general, symptomatic patients
(primarily with hemoptysis) with an aspergilloma
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2013.10.050
Ann Thorac Surg MUNIAPPAN ET AL 433

GENERAL THORACIC
2014;97:432–8 SURGICAL TREATMENT OF PULMONARY ASPERGILLOMAS

confined to a lobe were offered surgical resection by
thoracotomy or video-assisted thoracoscopic surgery
(VATS), as long as they were expected to have reasonable
postoperative pulmonary function. Occasionally, a bilo-
bectomy and pneumonectomy were performed for more
extensive disease. When pulmonary function was signif-
icantly compromised and symptoms warranted surgical
therapy, cavernostomy was the preferred technique.
Cavernostomy was performed with limited rib resection,
debridement, and muscle myoplasty to fill the cavity.
Asymptomatic patients with known aspergilloma were
surgical candidates as long as they had reasonable
pulmonary function.
Pathology records of lung specimens were queried for
the keywords “aspergilloma” or “Aspergillus.” Patients
with a pathologic description of pulmonary aspergilloma,
characterized as a cavity or bronchiectatic airway
involved with Aspergillus, were included in the analysis.
Patients with primarily pleural disease, such as Aspergillus
infections in postlobectomy or pneumonectomy cavities,
were excluded. Demographics, preoperative and intra-
operative data, and outcome measures were recorded.
Using radiologic and pathologic descriptions, simple
aspergillomas were contained within isolated thin-walled
cavities surrounded by normal lung parenchyma,
whereas complex aspergillomas arose in thick cavities
formed within grossly abnormal lung, as defined by
Belcher and Plummer [2].
Massive hemoptysis was defined as greater than 600 mL
of hemoptysis in 24 hours or hemoptysis resulting in he-
modynamic instability, abnormal gas exchange, or blood
transfusion. Primary end points were surgical morbidity,
mortality occurring within 30 days of operation or during
the same hospital admission, and overall survival. Follow-
up data were acquired by reviewing patient records by
Social Security Death Index query.
Statistical Analysis
Analysis was performed with the statistical software
Stata/SE 10.1 (StataCorp LP, College Station, TX). Fisher’s
exact test was used to compare variables in patients with
simple and those with complex aspergilloma. Survival
analysis was performed using the Kaplan-Meier method.
Risk factor analysis for survival was performed with the
Cox proportional hazards method (variables of interest
with p < 0.10). Comparisons were considered to be sta-
tistically significant when the p value was less than or
equal to 0.05.
Results
Sixty patients underwent operations for pulmonary
aspergillomas during the study period. Preoperative pa-
tient characteristics are shown in Tables 1 and 2. Preop-
erative lung function and underlying lung disorders are
shown in Table 3.
Signs and Symptoms at Presentation
In 9 of 60 (15%) patients who were asymptomatic,
aspergilloma was an incidental finding during chest im-
aging performed for other reasons. Common symptoms
were cough in 47 (78.3%) patients, hemoptysis in 33 (55%)
patients, dyspnea in 20 (33.3%) patients, and weight loss
in 14 (23.3%) patients. Massive hemoptysis occurred in 9
(15%) patients. Although simple aspergillomas were more
commonly asymptomatic than complex (p ¼ 0.002), rates

Table 1. Baseline Characteristics of 60 Patients Undergoing Surgical Treatment of Pulmonary Aspergillomas at Massachusetts
General Hospital (1980–2010)
Results

Variable Simple (n ¼ 13) Complex (n ¼ 47) p Value All (n ¼ 60)

Age (y)
Mean  SD 48.6  16.3 51.5  13.4 0.516 50.9  14.0
Median (range) 48 (22–73) 55 (17–69) 0.622 54.5 (17–73)
Sex, n (%) 0.529
Male 6 (46.2) 28 (59.6) 34 (56.7)
Female 7 (53.8) 19 (40.4) 26 (43.3)
Origin, n (%) 0.092
North America 9 (69.2) 42 (89.4) 51 (85.0)
Immigrant 4 (30.8) 5 (10.6) 9 (15.0)
Europe 1 (7.7) 3 (6.4) 4 (6.7)
Asia 2 (15.4) 1 (2.1) 3 (5.0)
Africa 1 (7.7) 1 (2.1) 2 (3.3)
Tobacco smoking, n (%) 5 (38.5) 28 (59.6) 0.217 33 (55.0)
Pack-year, mean  SD 30.0  12.2 43.8  28.8 0.314 40.8  26.5
Immunosuppression, n (%) 2 (15.4) 15 (31.9) 0.314 17 (28.3)
Chronic steroid use 1 (7.7) 12 (25.5) 0.262 13 (21.7)
HIV infection 0 (0) 4 (8.5) 0.568 4 (6.7)
Transplant recipient 1 (7.7) 1 (2.1) 0.389 2 (3.3)

HIV ¼ human immunodeficiency virus; SD ¼ standard deviation.

 434 MUNIAPPAN ET AL Ann Thorac Surg
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SURGICAL TREATMENT OF PULMONARY ASPERGILLOMAS 2014;97:432–8

Table 2. Clinical Presentation of Simple and Complex Aspergilloma Before Surgical Management
Results

Variable n (%) Simple (n ¼ 13) Complex (n ¼ 47) p Value All (n ¼ 60)

Asymptomatic 6 (46.2) 3 (6.4) 0.002 9 (15.0)

Hemoptysis 6 (46.2) 27 (57.4) 0.538 33 (55.0)
Massive hemoptysis 2 (15.4) 7 (14.9) 1.000 9 (15.0)
Preoperative bronchial artery embolization 0 (0) 3 (6.4) 1.000 3 (5.0)
Preoperative diagnosis of aspergilloma 8 (61.5) 29 (61.7) 1.000 37 (61.7)
Main indication for operation
Hemoptysis 4 (30.8) 20 (42.6) 0.534 24 (40.0)
Lung lesion refractory to antibiotic therapy 2 (15.4) 12 (25.5) 0.713 14 (23.3)
Solitary pulmonary nodule 7 (53.8) 6 (12.8) 0.004 13 (21.7)
Destroyed lung associated with symptoms 0 (0) 9 (19.2) 0.184 9 (15.0)

of minor and massive hemoptysis were similar in both
groups (Table 2).
Preoperative Workup and Treatment
Aspergillomas were suspected in 37 (61.7%) patients,
whereas typical computed tomographic findings were
present in 19 (31.7%) patients. Sputum cultures grew
Aspergillus in 16 (26.7%) patients. Computed tomogra-
phy–guided needle biopsy of the lung yielded the diag-
nosis in 8 (13.3%) patients, whereas 5 (8.3%) patients had
positive precipitating antibodies. A structural pulmonary
disorder was identified in 47 (78.3%) patients, tubercu-
losis (31.7%) being most prevalent (Table 3).
Massive hemoptysis was observed in 9 patients and
was treated in 3 (5.0%) patients with bronchial artery
embolization. Preoperative antifungal therapy in 25 pa-
tients consisted of amphotericin in 14 (56.0%) patients,
itraconazole in 5 (20.0%) patients, voriconazole in 5
(20.0%) patients, and posaconazole in 1 (4.0%) patient.
The use of amphotericin decreased during the study
period, and voriconazole became the preferred antifungal
agent in 2002.
Pulmonary aspergillomas were predominantly located
in the upper lobes (44 patients [73.3%]). Three (5.0%)
patients had a primary aspergilloma in the right upper
lobe cavity with simultaneous involvement of a different
lobe (right lower lobe ¼ 1, right middle lobe ¼ 1, and
bilateral upper lobes ¼ 1). Two (3.3%) patients had a
primary left upper lobe lesion with simultaneous left
lower lobe involvement.
The indication for operative treatment (Table 2) was
hemoptysis in 24 (40.0%) patients, persistent pulmonary
lesions refractory to antibiotic therapy in 14 (23.3%) pa-
tients, a solitary pulmonary nodule in 13 (21.7%) patients,
and destroyed lung parenchyma associated with symp-
toms in 9 (15.0%) patients. Aspergillomas were complex
in 47 (78.3%) patients and simple in 13 (21.7%) patients.
Mean aspergilloma size was 3.1  1.8 cm (simple, 2.2  1.4
cm; complex, 3.4  1.9 cm; p ¼ 0.090).
Surgical Treatment
Pulmonary resection was performed in 58 (96.7%)
patients, whereas 2 (3.3%) patients underwent cav-
ernostomy (Table 4). Resection was performed by

Table 3. Baseline Lung Function and Preexisting Disease in 60 Patients With Pulmonary Aspergilloma at Massachusetts General
Hospital (1980–2010)
Results

Variable Simple (n ¼ 13) Complex (n ¼ 47) p Value All (n ¼ 60)

Pulmonary function tests

% predicted FEV1  SD 68.9  17.8 67.3  22.1 0.849 67.6  21.0
Range % predicted FEV1 43–92 28–106
Underlying lung disease, n (%)
None 4 (30.8) 9 (19.2) 0.450 13 (21.7)
Tuberculosis 5 (38.5) 14 (29.8) 0.737 19 (31.7)
COPD 2 (15.4) 14 (29.8) 0.481 16 (26.7)
Bronchiectasis 2 (15.4) 11 (23.4) 0.713 13 (21.7)
History of pneumothorax 1 (7.7) 9 (19.2) 0.436 10 (16.7)
Lung cancer 1 (7.7) 3 (6.4) 1.000 4 (6.7)
Sarcoidosis 0 (0) 5 (10.6) 0.575 5 (8.3)
Multiple conditions 2 (15.4) 17 (36.2) 0.194 19 (31.7)

COPD ¼ chronic obstructive pulmonary disease; FEV1 ¼ forced expiratory volume in 1 second; SD ¼ standard deviation.
Ann Thorac Surg MUNIAPPAN ET AL 435

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2014;97:432–8 SURGICAL TREATMENT OF PULMONARY ASPERGILLOMAS

Table 4. Type of Procedure for Pulmonary Aspergilloma at Massachusetts General Hospital (1980–2010)
Results

Procedure, n (%) Simple (n ¼ 13) Complex (n ¼ 47) p Value All (n ¼ 60)

Lung resection
Lobectomy 6 (46.2) 20 (42.6) 1.000 26 (43.3)
Wedge resection 4 (30.8) 13 (27.7) 1.000 17 (28.3)
Segmentectomy 3 (23.1) 8 (17.0) 0.690 11 (18.3)
Pneumonectomy 0 (0) 3 (6.4) 1.000 3 (5.0)
Bilobectomy 0 (0) 1 (2.1) 1.000 1 (1.7)
Other
Flap 7 (53.9) 20 (42.6) 0.538 27 (45.0)
Debridement/drainage of pleural space 0 (0) 4 (8.5) 0.568 4 (6.7)
Cavernostomy and myoplasty 0 (0) 2 (4.3) 1.000 2 (3.3)
Resection of bullae 0 (0) 2 (4.3) 1.000 2 (3.3)
Chest wall resection 0 (0) 1 (2.1) 1.000 1 (1.7)
Thoracoplasty 0 (0) 1 (2.1) 1.000 1 (1.7)

thoracotomy (n ¼ 50 [86.2%]), VATS (n ¼ 7 [12.1%]), or
clamshell bilateral anterior thoracotomy (n ¼ 1 [1.7%]).
Sublobar resections (n ¼ 28 [46.6%]), either segmentec-
tomy (n ¼ 11 [18.3%]) or wedge resection (n ¼ 17 [28.3%]),
were performed more often than lobectomy (n ¼ 26
[43.3%]). Pneumonectomy (n ¼ 3 [5%]) and bilobectomy
(n ¼ 1 [1.7%]) were less frequent. Concomitant pro-
cedures included resection of bullae (n ¼ 2 [3.3%])
and chest wall (n ¼ 1 [1.7%]) and thoracoplasty (n ¼ 1
[1.7%]). Mean duration of the surgical procedure was 262
 133 minutes (range, 50–660 minutes), whereas mean
estimated blood loss was 413  437 mL (range, 50–2,000
mL). Six (10.0%) patients required intraoperative blood
transfusions (simple, 0 cases; complex, 6 cases (13%);
p ¼ 0.322).
The bronchial stump was buttressed in 27 (46.5%) pa-
tients with muscle (n ¼ 13), pericardial fat (n ¼ 8), parietal
pleura (n ¼ 4), thymus (n ¼ 1), or omentum (n ¼ 1).
Vascularized tissue covered a lobar, intermedius, or main
bronchus in 21 of 30 instances (70.0%). Flaps were used in
6 of 28 (21.4%) sublobar resections. Information on post-
operative antifungal use was available for 54 (90%)
patients, and 39 (72.2%) of them received postoperative
antifungal therapy.
Postoperative Morbidity and Mortality
Postoperative complications occurred in 18 (30%) pa-
tients. The most frequent was air leak longer than 5 days
in 9 (15.0%) patients (Table 5). A central bronchopleural
fistula (BPF) with disruption of the airway closure
developed in 3 (5%) patients, whereas 1 patient had a
peripheral BPF. Empyema without a previous BPF
occurred in 2 (3.3%) patients. In 2 of 3 patients with
central BPFs, tissue flaps covered the bronchial stump.
BPFs occurred only in complex aspergillomas (Table 5).
All BPFs occurred before 1996; no instances of BPF
or empyema have arisen in 34 consecutive patients
since then.
Nine (15.0%) patients required additional surgical in-
terventions during the same admission. Three (5%) pa-
tients required a tracheostomy, 3 (5%) required
pleurodesis for prolonged air leaks, 2 (3.3%) underwent
muscle flap transposition for persistent air leaks, and 1
(1.7%) underwent reoperation for BPF. VATS and chest

Table 5. Postoperative Complications in Pulmonary Aspergilloma

Results

Variable Simple (n ¼ 13) Complex (n ¼ 47) p Value All (n ¼ 60)

Postoperative complications, n (%) 3 (23.1) 15 (31.9) 0.736 18 (30.0)

Prolonged air leak 1 (7.7) 8 (17.0) 0.668 9 (15.0)
Prolonged ventilation (>48 h) 0 (0) 5 (10.6) 0.575 5 (8.3)
Pneumothorax 1 (7.7) 3 (6.4) 1.000 4 (6.7)
BPF 0 (0) 4 (8.5) 0.568 4 (6.7)
Pneumonia 1 (7.7) 2 (4.3) 0.526 3 (5.0)
Empyema without BPF 0 (0) 2 (4.3) 1.000 2 (3.3)
Ventricular arrhythmia/arrest 0 (0) 2 (4.3) 1.000 2 (3.3)
Reintubation 0 (0) 1 (2.1) 1.000 1 (1.7)
Mortality (30 d), n (%) 0 (0) 2 (4.3) 1.000 2 (3.3)

BPF ¼ bronchopleural fistula.

 436 MUNIAPPAN ET AL
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SURGICAL TREATMENT OF PULMONARY ASPERGILLOMAS
tube placement were performed in 1 patient for pneu-
mothorax, whereas another underwent incision and
drainage of the thoracotomy wound. Two (3.3%) patients
required gastrostomy for nutritional support. One patient
experienced small bowel obstruction after an omental
flap procedure and required laparotomy.
There were 2 (3.3%) operative deaths during the
study period; 1 occurred in a patient who died after
lobectomy for massive hemoptysis and was never
weaned from mechanical ventilation. This patient died
of multiorgan failure. Another death occurred in a
patient with acquired immunodeficiency syndrome
(AIDS) after wedge resection for symptomatic asper-
gilloma was performed; this patient died of progression
of the underlying disease with a persistent air leak.
Both deaths occurred in patients with complex asper-
gillomas. No mortality was observed in patients with
simple aspergillomas.
Long-Term Outcome and Survival
Mean follow-up of patients was 54.1  62.2 months.
Recurrent aspergilloma affected 3 (5%) patients. A cavi-
tary lesion with aspergilloma developed in 1 patient in
the contralateral upper lobe 2 years after upper lobec-
tomy; a second upper lobectomy managed the recur-
rence. The second patient underwent cavernostomy for
aspergilloma and later required upper lobectomy when
he presented with hemoptysis originating in the contra-
lateral lung 3 months later. The last patient had recur-
rence of invasive disease that eventually involved the
spine. This patient underwent T7–8 vertebrectomy and
died of septic complications 6 months after reoperation.
Median survival after surgical intervention was 14.3
years. One-, 3-, 5-, and 10-year observed survival rates
were 89.4%, 81.3%, 79.1%, and 68.7%, respectively. A
multivariate analysis identified male sex, HIV infection,
and history of malignancy as predictors of early death
(Table 6). Whether aspergilloma was simple or complex
did not influence survival (Fig 1). Five- and 10-year
survival rates for simple aspergilloma were 100% and
62.5%, respectively, and for complex aspergilloma, they
were 75.4% and 68.5%, respectively.
Table 6. Risk Factor Analysis for 10-Year Survival After Surgical Treatment of Pulmonary Aspergilloma
Univariate Analysis
Variable HR (95% CI)
Age 1.04 (1.00–1.08)
Male sex 2.45 (0.91–6.63)
HIV positivity 5.24 (1.10–25.00)
Diabetes mellitus 3.88 (1.36–11.08)
Cancer 6.03 (1.78–20.36)
Right-sided lesion 0.43 (0.19–0.98)
Underlying lung disease 0.68 (0.28–1.61)
Pharmacologic immunosuppression 1.58 (0.65–3.86)
Complex vs. simple aspergillomas 1.10 (0.37–3.28)
CI ¼ confidence interval; HR ¼ hazard ratio.
Ann Thorac Surg
2014;97:432–8
Comment
A majority of reports on the surgical management of
pulmonary aspergillomas originate in Asia, Africa, and
Europe. The last major series from North America was
published in 1986 [4]. Although encountered infrequently
in North America, our institution has accumulated
experience in the surgical management of pulmonary
aspergilloma over the past 3 decades, encountering on
average 2 patients each year. This prevalence is similar to
the 53 patients managed during an earlier interval at the
Mayo Clinic.
Structural, in particular cavitary, lung disease pre-
disposes to the formation of aspergillomas. Our review of
recent surgical series [5–19] found tuberculosis to be
present in 13% to 89% of patients, with the lowest pro-
portion reported in the Mayo Clinic experience. In
contrast, we noted tuberculosis in approximately 30% of
our patients. Tuberculosis-related pathologic conditions
therefore continue to exist in North American hospitals
despite a continuing decline in the national incidence of
tuberculosis.
The controversy surrounding surgical therapy for
asymptomatic aspergilloma concerns potential morbidity.
However, surgical results in the absence of symptoms are
good when appropriately selected patients undergo
technically well-executed procedures [6, 16, 20]. Most
contemporary series report mortality rates less than 6%
and morbidity in the range of 20% to 40%, with even
better outcomes in asymptomatic patients [20]. Our
experience compares favorably with recent reports and
represents an advance from the earlier North American
experience reported by Daly and associates [4].
We and others [6] found life-threatening hemoptysis
similar in both symptomatic and previously asymptom-
atic patients. Aspergilloma size and underlying lung
disease are not helpful in predicting bleeding [21]. Med-
ical therapy, including systemic or intracavitary instilla-
tion of antifungal agents, is typically noncurative [22],
and there are only anecdotal reports of partial success
[23, 24]. Moreover, the rationale for intervening at a stage
of disease when the aspergilloma is more limited is
sound because sublobar resections are less morbid.
Multivariate Analysis
p Value HR (95% CI) p Value
0.046 1.04 (0.99–1.09) 0.123
0.077 3.88 (1.19–12.63) 0.025
0.038 15.81 (2.53–98.83) 0.003
0.011 3.32 (0.85–13.04) 0.085
0.004 16.70 (3.23–86.40) 0.001
0.044 0.47 (0.17–1.29) 0.144
0.379 – –
0.312 – –
0.858 – –
Ann Thorac Surg
2014;97:432–8
Fig 1. Survival curves for patients undergoing surgical management
of simple (solid line) and complex (dashed line) aspergillomas
(p ¼ 0.827).
Untreated aspergillomas may progress to invasion, thus
complicating definitive surgical therapy [25].
In patients with very poor lung function or those
requiring a resection more extensive than lobectomy, the
enthusiasm for surgical resection of aspergilloma is
tempered by the known high morbidity and mortality. A
significant proportion of our patients (45%) underwent
sublobar resection, either as wedge resection or seg-
mentectomy. The desire to avoid lobectomy may be
appropriate but must be balanced with the risk of
recurrence if the aspergilloma is incompletely removed.
Lesser resections are associated with improved post-
operative function and fewer complications such as em-
pyema and BPF. Although most surgical series note that
pneumonectomies for aspergillomas are associated with
poorer outcomes and significant risk of mortality [6, 8], we
recognize that Endo and associates [12] performed
pneumonectomy in 35% of their patients without opera-
tive mortality. Although pneumonectomy for aspergil-
loma may be safely performed in well-selected patients at
experienced centers, it should be avoided in general. In
contrast, in patients with very poor lung function, we and
others have found cavernostomy to be a safe option to
control aspergilloma [26, 27].
All 6 patients in whom empyema developed, 4 of whom
had BPF, underwent operation before 1996. We believe
that improved antifungal pharmacotherapy may have
reduced infectious complications in our more recent
experience. Although Sagan and Gozdziuk [28] in a recent
article suggested that adjuvant antifungal pharmaco-
therapy was unnecessary, voriconazole, the most effective
agent directed against Aspergillus and unrelated to
amphotericin, was not used in their patients. Amphoter-
icin therapy may be complicated by nephrotoxicity, and
fluconazole is ineffective against Aspergillus. The exact
role of voriconazole in reducing postoperative infectious
MUNIAPPAN ET AL 437
GENERAL THORACIC
SURGICAL TREATMENT OF PULMONARY ASPERGILLOMAS
complications is unknown. In patients with structural
lung disease, we prefer a course of postoperative vor-
iconazole to control pleural contamination and support
bronchial stump healing.
Ample evidence suggests that surgical therapy for
complex aspergillomas is associated not only with greater
operative morbidity and mortality but also with reduced
survival. We noted slightly better survival after resection
of simple aspergilloma at 5 years but survival similar
to that of complex aspergilloma at 10 years. A large
series from Korea also found that overall survival was
similar in simple and complex aspergillomas [14]. The
small numbers of patients with simple aspergilloma
render detailed comparisons to complex aspergilloma
impossible.
In summary, we have shown that surgical therapy for
pulmonary aspergillomas in a North American popula-
tion is associated with excellent control of this disease and
acceptable morbidity and mortality. Limited resection in
selected patients does not pose a greater risk of recur-
rence. Cavernostomy is preferred in patients with very
poor lung function. Despite effective surgical control
of fungal disease, preexisting conditions such as lung
disease or immunosuppressed states may determine
long-term outcome.
References
1. Riscili BP, Wood KL. Noninvasive pulmonary Aspergillus
infections. Clin Chest Med 2009;30:315–35.
2. Belcher JR, Plummer NS. Surgery in broncho-pulmonary
aspergillosis. Br J Dis Chest 1960;54:335–41.
3. Kauffman CA. Quandary about treatment of aspergillomas
persists. Lancet 1996;347:1640.
4. Daly RC, Pairolero PC, Piehler JM, Trastek VF, Payne WS,
Bernatz PE. Pulmonary aspergilloma—results of surgical
treatment. J Thorac Cardiovasc Surg 1986;92:981–8.
5. Ahmad T, Ahmed SW, Hussain N, Rais K. Clinical profile
and postoperative outcome in patients with simple and
complex aspergilloma of lung. J Coll Physicians Surg Pak
2010;20:190–3.
6. Lee JG, Lee CY, Park IK, et al. Pulmonary aspergilloma:
analysis of prognosis in relation to symptoms and treatment.
J Thorac Cardiovasc Surg 2009;138:820–5.
7. Brik A, Salem AM, Kamal AR, et al. Surgical outcome of
pulmonary aspergilloma. Eur J Cardiothorac Surg 2008;34:
882–5.
8. Caidi M, Kabiri H, Al Aziz S, El Maslout A, Benosman A.
Surgical treatment of pulmonary aspergilloma—278 cases.
Presse Med 2006;35:1819–24.
9. Okubo K, Kobayashi M, Morikawa H, Hayatsu E, Ueno Y.
Favorable acute and long-term outcomes after the resection
of pulmonary aspergillomas. Thorac Cardiovasc Surg
2007;55:108–11.
10. Pratap H, Dewan RK, Singh L, Gill S, Vaddadi S. Surgical
treatment of pulmonary aspergilloma: a series of 72 cases.
Indian J Chest Dis Allied Sci 2007;49:23–7.
11. Demir A, Gunluoglu MZ, Turna A, Kara HV, Dincer SI.
Analysis of surgical treatment for pulmonary aspergilloma.
Asian Cardiovasc Thorac Ann 2006;14:407–11.
12. Endo S, Otani S, Tezuka Y, et al. Predictors of postoperative
complications after radical resection for pulmonary asper-
gillosis. Surg Today 2006;36:499–503.
13. Akbari JG, Varma PK, Neema PK, Menon MU,
Neelakandhan KS. Clinical profile and surgical outcome for
pulmonary aspergilloma: a single center experience. Ann
Thorac Surg 2005;80:1067–72.
 438 MUNIAPPAN ET AL
GENERAL THORACIC
SURGICAL TREATMENT OF PULMONARY ASPERGILLOMAS
14. Kim YT, Kang MC, Sung SW, Kim JH. Good long-term
outcomes after surgical treatment of simple and complex
pulmonary aspergilloma. Ann Thorac Surg 2005;79:294–8.
15. Kurul IC, Demircan S, Yazici U, Altinok T, Topcu S, Unlu M.
Surgical management of pulmonary aspergilloma. Asian
Cardiovasc Thorac Ann 2004;12:320–3.
16. Park CK, Jheon S. Results of surgical treatment for
pulmonary aspergilloma. Eur J Cardiothorac Surg 2002;21:
918–23.
17. Al-Kattan K, Ashour M, Hajjar W, El Din MS, Fouda M, Al
Bakry A. Surgery for pulmonary aspergilloma in post-
tuberculous vs. immuno-compromised patients. Eur J
Cardiothorac Surg 2001;20:728–32.
18. Babatasi G, Massetti M, Chapelier A, et al. Surgical treatment
of pulmonary aspergilloma: current outcome. J Thorac
Cardiovasc Surg 2000;119:906–12.
19. Regnard JF, Icard P, Nicolosi M, et al. Aspergilloma: a series
of 89 surgical cases. Ann Thorac Surg 2000;69:898–903.
20. Lejay A, Falcoz PE, Santelmo N, et al. Surgery for aspergil-
loma: time trend towards improved results? Interact
Cardiovasc Thorac Surg 2011;13:392–5.
21. Jewkes J, Kay PH, Paneth M, Citron KM. Pulmonary
aspergilloma: analysis of prognosis in relation to
haemoptysis and survey of treatment. Thorax 1983;38:
572–8.
ABTS Requirements for the 10-Year Milestone
for Maintenance of Certification
Diplomates of the American Board of Thoracic Surgery
(ABTS) who plan to participate in the 10-Year Milestone
for the Maintenance of Certification (MOC) process as
Certified-Active must hold an unrestricted medical li-
cense in the locale of their practice and privileges in a
hospital accredited by the JCAHO (or other organization
recognized by the ABTS). In addition, a valid ABTS
certificate is an absolute requirement for entrance into
the MOC process. If your certificate has expired, the
only pathway for renewal of a certificate is to take and
pass the Part I (written) and the Part II (oral) certifying
examinations.
The CME requirements are 150 Category I credits over
a five-year period. At least half of these CME hours need
to be in the broad area of thoracic surgery. Category II
credits are not accepted. Interested individuals should
refer to the Board’s website (www.abts.org) for a complete
description of acceptable CME credits.
Diplomates will be required to take and pass a secured
exam after their application has been approved. Taking
SESATS in lieu of the secured exam is not an option. The
secured exam is administered over a two-week period in
September of every year at Pearson Vue Testing Centers,
which are located nationwide. Diplomates will have the
opportunity to select the day and location of their exam.
For the dates of the next MOC exam, visit the Board’s web
site at www.abts.org.
Ó 2014 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Ann Thorac Surg
2014;97:432–8
22. Walsh TJ, Anaissie EJ, Denning DW, et al. Treatment of
aspergillosis: clinical practice guidelines of the Infectious
Diseases Society of America. Clin Infect Dis 2008;46:327–60.
23. Rumbak M, Kohler G, Eastrige C, Winer-Muram H,
Gavant M. Topical treatment of life threatening haemoptysis
from aspergillomas. Thorax 1996;51:253–5.
24. Yamada H, Kohno S, Koga H, Maesaki S, Kaku M. Topical
treatment of pulmonary aspergilloma by antifungals. Rela-
tionship between duration of the disease and efficacy of
therapy. Chest 1993;103:1421–5.
25. Rafferty P, Biggs BA, Crompton GK, Grant IW. What hap-
pens to patients with pulmonary aspergilloma? Analysis of
23 cases. Thorax 1983;38:579–83.
26. Grima R, Krassas A, Bagan P, Badia A, Le Pimpec Barthes F,
Riquet M. Treatment of complicated pulmonary aspergillo-
mas with cavernostomy and muscle flap: interest of
concomitant limited thoracoplasty. Eur J Cardiothorac Surg
2009;36:910–3.
27. Sagawa M, Sakuma T, Isobe T, et al. Cavernoscopic removal
of a fungus ball for pulmonary complex aspergilloma. Ann
Thorac Surg 2004;78:1846–8.
28. Sagan D, Gozdziuk K. Surgery for pulmonary aspergilloma
in immunocompetent patients: no benefit from adjuvant
antifungal pharmacotherapy. Ann Thorac Surg 2010;89:
1603–11.
Starting on July 1, 2014, the ABTS will require its Dip-
lomates to participate in an outcomes database as fulfill-
ment of Part IV (Performance in Practice) for the 10-year
Milestone of Maintenance of Certification (MOC). For a
list of approved outcomes databases or for more infor-
mation on how to have a database approved by the Board,
visit the Board’s website at www.abts.org. Participation in
the Professional Portfolio will no longer be accepted as
fulfillment of MOC Part IV after July 1, 2014.
Diplomates may apply for MOC in the year their cer-
tificate expires or, if they wish to do so, they may apply up
to two years before it expires. However, the new certificate
will be dated 10 years from the date of expiration of their
original certificate or most recent MOC certificate. In other
words, going through the MOC process early does not
alter the 10-year validation. Diplomates certified prior to
1976 (the year that time-limited certificates were initiated)
are also required to participate in MOC if they wish to
maintain valid certificates.
The deadline for submitting an application for 10-year
Milestone of MOC is March 15 of every year. Information
outlining the rules, requirements, and dates for MOC in
thoracic surgery is available on the Board’s website at
www.abts.org. For additional information, please contact
the American Board of Thoracic Surgery, 633 N St. Clair
St, Ste 2320, Chicago, IL 60611; telephone (312) 202-5900;
fax (312) 202-5960; e-mail: info@abts.org.
Ann Thorac Surg 2014;97:438  0003-4975/$36.00