Original Article

Asian Cardiovascular & Thoracic Annals

2019, Vol. 27(6) 476–480
Pulmonary aspergilloma: surgical ! The Author(s) 2019
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outcome of 79 patients in a sagepub.com/journals-permissions
DOI: 10.1177/0218492319855492
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Hicham Harmouchi1 , Marouane Lakranbi1,2,

Ibrahim Issoufou1, Yassine Ouadnouni1,2 and
Mohammed Smahi1,2

Abstract
Background: Pulmonary aspergilloma presents in two clinical and radiological forms: simple and complex aspergilloma.
Surgery is the best therapeutic option, most often by anatomic lung resection. Our aim was to report the surgical
outcomes according to our experience.
Methods: A retrospective study was conducted on data of 79 patients operated on for pulmonary aspergilloma over a
period of 10 years. There were 57 (72.15%) men and 22 women (27.84%), with a mean age of 40.45 years.
Results: Tuberculosis, all-form combined, was the predominant pathological antecedent in 57 (72.15%) patients, and
hemoptysis was the most frequent functional sign in 43 (54.43%). The right side was involved in 39 (49.36%) patients.
All patients were operated on via a posterolateral thoracotomy, and an extrapleural plane was necessary in 40 (50.63%).
The surgical procedure was a lobectomy in 38 (48.10%) patients and a pneumonectomy in 14 (17.72%). Transfusion of
red blood cells was carried out in 10 (12.65%) patients, with one (1.26%) requiring a rethoracotomy for postoperative
clotted hemothorax. Two (2.53%) patients presented with empyema after pneumonectomy. The mortality rate was
2.53% (2 patients), and the mean follow-up was 2.5 years.
Conclusion: Surgery for pulmonary aspergilloma is associated with a high rate of morbidity and mortality. This surgery
has been performed in our department with a very acceptable rate of mortality, especially considering that all patients
were operated on by open surgery.

Keywords
Aspergillosis, hemoptysis, lung diseases, fungal, pneumonectomy, thoracotomy, tuberculosis

Introduction and radiological criteria. This differentiation plays a

Pulmonary aspergilloma is a form of aspergillosis char-
acterized by the colonization of a preexisting pulmo-
nary cavity by a fungus, most often Aspergillus
fumigatus.1 Tuberculosis remains the most common
origin of these cavities, but a bubble of emphysema,
bronchiectasis, an evacuated pulmonary abscess,
necrotic malignant cavity, and a pleural space may
also develop aspergillosis. Pulmonary aspergilloma is
an infectious disease that is clinically manifested most
often by hemoptysis which can sometimes be life-
threatening for the patient. The classification of
Belcher and Plummer,2 introduced in 1960 and still in
use, allows differentiation of a simple aspergilloma
from a complex aspergilloma, according to clinical
major role in the surgical management which remains
the basic treatment for pulmonary aspergilloma.
Surgical difficulties in pulmonary aspergilloma are sec-
ondary to chronic inflammatory lesions and the
1
Department of Thoracic Surgery, Centre Hospitalier Universitaire
Hassan II, Fez, Morocco
2
Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdallah
University, Fez, Morocco
Corresponding author:
Hicham Harmouchi, Department of Thoracic Surgery, Centre Hospitalier
Universitaire Hassan II, Fez, Morocco.
Email: harmouchi.hicham@gmail.com
Harmouchi et al. 477

underlying pathology. We report our experience in sur- showed right-side involvement in 39 (49.36%) and
gery for pulmonary aspergilloma. left-side involvement in 40 (50.63%). The most
common radiological image was an air crescent in 25
Patients and methods (31.64%) patients, followed by an excavated lesion in
15 (18.98%). The other radiological aspects are sum-
This study was performed in our department of thoracic marized in Table 1. Bilateral aspergilloma was found in
surgery in the Centre Hospitalier Universitaire Hassan 4 (5.06%) cases. Spirometry was requested in 50
II of Fez. It was a descriptive and monocentric study (63.29%) patients who had an average forced expira-
with retrospective collection of data over a period of 10 tory volume in 1 s of 2.4 L. In the other 29 patients, no
years from January 1, 2009 to December 31, 2018. We spirometry was requested because a wedge resection
collected data on 79 patients who were operated on for was decided in 15, whereas in 14, there was develop-
pulmonary aspergilloma, regardless of the surgical pro- ment of aspergilloma in a destroyed lung and the
cedure. We excluded patients with incomplete medical forced expiratory volume in 1 s would not be appro-
records and those who had aspergilloma but did not priate because the patient was already used to living
undergo surgery because of respiratory or cardiovascu- with a single lung. The etiologies of pulmonary asper-
lar failure. There were 57 (72.15%) men and 22 gilloma are listed in Table 2. All patients underwent
(27.84%) women, with a sex ratio of 2.59. The median elective surgery via a posterolateral thoracotomy pre-
age was 40.45 years, ranging from 21 to 71 years. serving the chest wall muscles, especially the latissimus
The diagnosis was obtained according to radiologi- dorsi muscle. An extrapleural plane was necessary in 40
cal, endoscopic, or pathological criteria. Patient data (50.63%) patients. The surgical procedures are listed in
were obtained from the medical records and the hospi- Table 3; pleuropulmonary decortication was necessary
tal information system. These data were collected on a in a patient who presented with tuberculous empyema
study sheet, including age, sex, pathological history, and pulmonary aspergilloma. All patients benefited
functional signs, aspergillus serology, appearance on from manual techniques for ligation of vessels and
chest radiography, thoracic computed tomography
bronchi. In patients having a lobectomy or pneumo-
findings, and spirometry results (forced expiratory
nectomy, the bronchial stump was covered by pleural
volume in 1 s). Surgical data included the approach,
fat. In the immediate postoperative period, red blood
surgical procedure, length of hospital stay, and postop-
erative follow-up.
Table 1. Characteristics of 79 patients undergoing surgery for
Differentiation between simple aspergilloma and aspergillosis.
complex aspergilloma was based on the criteria of
Belcher and Pulmmer.2 Simple aspergilloma is a thin- Characteristic No. of patients
walled parenchymal cavity without a pleuroparenchy- Median age (years) 40.45
mal abnormality, whereas complex aspergilloma is a Male 57 (72.15%)
thick-walled cavity associated with parenchymal or Female 22 (27.84%)
pleural lesions. Pathological history
Tuberculosis (all-form combined) 57 (72.15%)
Chronic smoking 12 (15.18%)
Results Functional signs
The pathological antecedent was predominately tuber- Hemoptysis 43 (54.43%)
culosis (all-form combined) in 57 (72.15%) patients, Hemoptysis þ purulent sputum 26 (32.91%)
followed by chronic smoking in 12 (15.18%). Two Chest pain 2 (2.53%)
patients had been operated on previously in our depart- Dyspnea 2 (2.53%)
Bronchorrhea 2 (2.53%)
ment, the first for a pulmonary hydatid cyst of the right
Fortuitous discovery 2 (2.53%)
lower lobe, and the other for a cavitary lesion in the left Right side 39 (49.36%)
lower lobe, and another patient had received radiother- Left side 40 (50.63%)
apy for dorsal myxofibrosarcoma. The predominant Radiological signs
functional sign was hemoptysis in 43 (54.43%) patients, Air crescent aspect 25 (31.64%)
which was associated with purulent sputum in 26 Excavated lesion 15 (18.98%)
(32.91%). Chest pain, dyspnea, and bronchorrhea Destroyed lung þ aspergilloma 13 (16.45%)
were present in 2 (2.53%) patients each. The discovery Cavitary lesion 9 (11.39%)
was fortuitous in 2 (2.53%) patients. Serology for Nodular appearance 5 (6.32%)
Aspergillus fumigatus was requested in 30 patients, Lung mass 4 (5.06%)
Bronchiectasis 1 (1.26%)
returning positive in 7 (8.86%). Thoracic computed
Empyema 1 (1.26%)
tomography was performed in all patients and
478 Asian Cardiovascular & Thoracic Annals 27(6)

Table 2. Etiologies of aspergilloma in 79 patients.

Etiology No. of patients

Tuberculosis 57 (72.15%)
Nondocumented origin 13 (16.45%)
Postoperative residual cavity 2 (2.53%)
Ruptured hydatid cyst of lung 3 (3.79%)
Bronchiectasis 1 (1.26%)
Bronchogenic cyst 1 (1.26%)
Emphysema bubble 1 (1.26%)
Cavity after radiotherapy 1 (1.26%)

Table 3. Surgical and postoperative outcomes.

Variable No. of patients Figure 1. Thoracic computed tomography in parenchymal

window, showing a simple aspergilloma in the left lower lobe in
Approach 79 (100%)
the form of lung mass.
Extrapleural plane 40 (50.63%)
Surgical procedure
Lobectomy 38 (48.10%)
Pneumonectomy 14 (17.72%)
Segmentectomy 11 (13.92%)
Wedge resection 15 (18.98%)
Decortication 1 (1.26%)
Postoperative outcomes
Red blood cells transfusion 10 (12.65%)
Hemothorax 1 (1.26%)
Prolonged air leak 3 (3.79%)
Empyema after pneumonectomy 2 (2.53%)
Recurrence of hemoptysis 2 (2.53%)
Death 2 (2.53%)

cell transfusion was required in 10 (12.65%) patients,

and one presented with postoperative clotted hemo-
thorax requiring a rethoracotomy for evacuation of
blood clots. Prolonged air leak was recorded in 3
(3.79%) patients, with good resolution. The mortality
rate was 2.53% (2 patients); the first died due to car-
diopulmonary arrest on the day after surgery, and the
other without a specific cause after one month. During
a mean follow-up of 2.5 years, empyema after pneumo-
nectomy occurred in 2 (2.53%) patients, one benefited
from thoracostomy followed by thoracomyoplasty,
and the other had only thoracostomy with ongoing
follow-up. Recurrence of hemoptysis was noted in 2
(2.53%) patients, one of whom had bilateral aspergil-
loma requiring further surgery, and the other had a
complex aspergilloma treated by wedge resection due
to difficulty in apical separation, and underwent embo-
lization with a good result.
Discussion
In Morocco, tuberculosis remains a health problem
and is still endemic despite the efforts of the Ministry
Figure 2. Thoracic computed tomography in parenchymal
window, showing a complex aspergilloma in the right upper lobe
(air crescent appearance).
of Health.3 This endemicity is responsible for cases of
parenchymal sequelae such as bronchiectasis and
aspergilloma. Development of pulmonary aspergilloma
requires a pulmonary or rarely, a pleural cavity, which
communicates with the bronchial tree in a patient
whose immune defenses are deficient.4 This chronic
development is associated with hypervascularization
that is manifested by hemoptysis, ranging from
simple hemoptoic sputum to massive hemoptysis that
is life-threatening. Hemoptysis was the most reported
functional sign in various series,5,6 in agreement with
our findings.
The surgical decision in our department is based on
the patient’s symptomatology and results of thoracic
computed tomography that allows differentiation
between a simple (Figure 1) and complex aspergilloma
(Figure 2) according to the radiological criteria
described by Belcher and Plummer.2 Bronchial
Harmouchi et al.
fibroscopy has the advantage of specifying the origin of
the bleeding, especially in bilateral forms of aspergil-
loma, and the etiological character, especially in chron-
ic smokers. Bronchoscopy can potentially be used to
perform a hemostatic procedure, take biopsies, and
look for tuberculosis in the fibro-aspiration fluid,
because this disease is the most common underly-
ing pathology.
The best therapeutic option for pulmonary aspergil-
loma remains surgery which allows resection of the
mycetoma, thus the underlying cavity. The standard
approach is a thoracotomy because pulmonary asper-
gilloma, especially developing after tuberculosis, is
characterized by retractile lesions with a thick and
tight sclerosing symphysis, resulting in an encrusted
pleural shell in the wall.7 Also, there is retraction of
the pulmonary vessels with loss of anatomical land-
marks, associated with lymph nodes adhering to the
vessels and sometimes calcified.7 These features explain
why a thoracotomy is performed several times in the
extrapleural plane to ensure easy pleuropulmonary
release and avoid opening the aspergillar lesions in
the pleural cavity. Sometimes, a costal resection is man-
datory to place the costal retractor because of intercos-
tal narrowing. Conservation of the latissimus dorsi
muscle during thoracotomy is useful in order to achieve
thoracomyoplasty after a persistent pleural pocket.
Minimally invasive surgical techniques are mainly
video-assisted thoracoscopic surgery that can be per-
formed for simple, peripheral, and small aspergilloma.8
In a study published in 2014, Chen and colleagues9
showed that video-assisted thoracoscopic surgery is a
safe alternative to open surgery in selected cases such as
young patients or high-risk patients with localized
aspergilloma without pulmonary or pleural scaring,
and without adherent lymph nodes around the vessels.
However, anatomical lung resection remains the stan-
dard surgical procedure for pulmonary aspergilloma.
In our series, it was performed in 79.74% of cases com-
pared to 18.98% benefiting from wedge resection.
Marghli and colleagues8 carried out wedge resection
for any peripheral lesion and those less than 4 cm,
and an anatomical lung resection for complex and cen-
tral aspergilloma or lesions greater than 4 cm.
In our practice, all patients undergoing lobectomy
or pneumonectomy are hospitalized in the intensive
care unit for 24 to 48 hours postoperatively. They
receive daily respiratory physiotherapy after effective
multimodal analgesia, or noninvasive ventilation (in
the intensive care unit) to avoid bronchial congestion
and atelectasis. In patients who have had a pneumo-
nectomy, we do not place a chest tube. They have clin-
ical monitoring (measurement of temperature,
assessment of dyspnea) and radiological monitoring
every 48 hours. If a patient presents with severe
479
dyspnea after pneumonectomy, a puncture of the pneu-
monectomy cavity is performed under strict asep-
sis rules.
Bleeding complications remain common after sur-
gery for pulmonary aspergilloma, especially complex
aspergilloma. Prolonged air leakage is responsible for
a longer hospital stay and most often requires mobili-
zation of the chest tube placed in the intraoperative
period, or addition of a second chest tube. The compli-
cation that is challenging for thoracic surgeons is the
occurrence of empyema after anatomical lung resec-
tion. The rate of empyema after pneumonectomy
ranges from 2% to 16%, and after lobectomy it is
2%.10–12 The first abnormality to look for in the pres-
ence of empyema after anatomical lung resection is a
bronchopleural fistula. Technically, to avoid broncho-
pleural fistula, suture closure was first recommended by
Sweet13 in 1945, thus avoiding excessive dissection to
prevent devitalization, burying the bronchial stump
beneath the mediastinal tissues.13–15 The reported rate
of mortality after pulmonary aspergilloma surgery
varies from 5% to 10%.16,17 The rate is increased in
the group with complex aspergilloma compared to
those with simple aspergilloma.
The limitations of this study are the retrospective
design, as well as being a study that is not comparative
because all patients underwent a thoracotomy (we
could not compare thoracotomy with video-assisted
thoracoscopic surgery), and we did not compare
wedge resection with anatomical lung resection.
However, we concluded that pulmonary aspergilloma
is still widespread because of the endemicity of tuber-
culosis in our context. Anatomic lung resection is per-
formed for complex aspergilloma, most often by
thoracotomy, and segmentectomy or wedge resection
is used for simple aspergilloma. In our center, surgery
for pulmonary aspergilloma is associated with a very
acceptable rate of mortality.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Hicham Harmouchi https://orcid.org/0000-0002-
5174-1277
480
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