Pulmonary Aspergilloma
Percutaneous Intracavitary Treatment
Marcellej Shapiro, M.D.;* Steven M. Albelda, M.D.;t
Robert L. Mayock, M.D., F.C.C.P;t and Gordon K. McLean, M.D.*
Surgical therapy for massive hemoptysis associated with N-acetylcysteine, and aminocaproic acid. Advantages of
pulmonary aspergilloma carries a high morbidity and this method of treatment for patients with severely corn-
mortality in patients with limited pulmonary reserve. promised pulmonary reserve include: (1) no further loss of
Bronchial artery embolization has proven ineffective in lung function; (2) ease and rapidity of catheter insertion;
treating and in preventing recurrent episodes of hemoptysis (3) prompt response to treatment; (4) relatively short
in this group of patients. Over a four-and-one-half year hospitalization; and (5) ability to repeat the procedure in
period, we have successfully treated six episodes of acute the same or another cavity if necessary. (Chest 1988;
hemoptysis in four patients using a percutaneously placed 94:1225-31)
catheter and intracavitary instillation of amphotericin B,
M assive hemoptysis is the cause ofdeath in 2 to 26 to the bronchial art Any embolization of this
percent of patients with pulmonary aspergil- complex and extensive systemic arterial network re-
loma. Fatal hemorrhage from aspergilloma is the quires a high degree ofskill and complete embolization
second most common cause of death in sarcoidosis.2 may be impossible. 13
Traditionally, surgical resection of the involved pul- Antifungal agents have been used in a variety of
monary tissue has been advocated as the treatment of ways. Intravenous amphotericin B has been shown to
choice, although morbidity and mortality rates may be no more effective than routine pulmonary 15
run as high as 25 percent and 8 percent, respec- Several investigators have instilled antifungal agents
112 The foregoing statistics apply to those patients endobronchially67 or via a transthoracic route into
with adequate pulmonary reserve and unilateral hem- the cavity82 in symptomatic, but relatively stable
orrhage. Surgery is even more hazardous for the many patients with aspergilloma. Only one of these studies,
patients with massive hemoptysis and pulmonary a case report,2 has examined the usefulness of this
aspergilloma who have severe underlying pulmonary technique during an acute episode of hemoptysis.
disease. The extremely high morbidity and mortality Over the past four and one half years, we have
of surgery in this subgroup of patients has prompted successfully treated six episodes of severe hemoptysis,
a search for other forms of therapy. including three episodes of massive hemoptysis (>600
Bronchial artery embolization has proven successful ml/24 hours), in four patients with pulmonary asper-
in controlling massive hemoptysis occurring with tu- gillomas and severe underlying lung disease using a
berculosis, bronchiectasis, and lung carcinoma. Unfor- percutaneously placed catheter and instillation of a
tunately, embolotherapy has not been effective in combination of amphotericin B and N-acetylcysteine
permanently controlling massive hemoptysis associ- (Mucomist). In one instance, instillation of aminoca-
ated with pulmonary aspergilloma, probably because proic acid (Amicar) was also employed. This article
of the presence of a massive collateral 13 describes our technique, method of treatment, and
While aspergillomas can develop in any form of cystic long-term results.
lung disease, the most common underlying conditions
MATERIALS AND METHODS
are sarcoidosis or healed cavitary tuberculosis, often
resulting in lesions in the upper lung fields. Through Four patients with aspergilloma were treated for six episodes of
the associated pleural adhesions, the mycetoma cavity hemoptysis from 1983 to 1987. There were three men and one
woman, with a mean age of 54 years (range 48 to 63 years).
wall often receives a rich extrathoracic blood supply
Underlying lung diseases were sarcoidosis in three and bullous lung
from the axillary and subclavian arteries, in addition disease in one. Patient data are summarized in Table 1. Each patient
had a chest roentgenogram documenting an upperlobe intracavitary
*Department of Radiology, Hospital of the University of Pennsyl-
vania, Philadelphia, and the tCardiovascular-Pulmonary Division
mycetoma from three months to ten years prior to admission. Serum
of the Department of Medicine, Hospital of the University of Aspergillus precipitins were positive in each of the patients; three
Pennsylvania, Philadelphia. of the four patients had sputum or percutaneous aspirates or both
Manuscript received September 18, 1987; revision accepted March from which Aspergillus species were cultured. All patients had
13.
severely compromised pulmonary function, with forced vital capac-
Reprint requests: DrMcLean, Hospital, University of Pennsylvania,
Anglo-Interventional Radiology, 3400 Spruce Street, Philadelphia ity <50 percent and resting PaO2 <80 mm Hg. Each presented
19104 with recurrent, persistent hemoptysis. One patient with bilateral
Hemoptysis
Patient Underlying Mycetoma Vol/24 hr Drainage Total Dose
No. Age/Sex Disease Location Site (Bronch) Catheter Used Amphotericin Results Long-Term Follow-up
la* 49/F Sarcoidosis LUL 600 ml; LUL 12 F Ring-McLean 500 mg Hemoptysis ceased Vide infra
sump by 48 hr; myce-
toma cleared (
seven days
(see case report)
lb 49/F Sarcoidosis RUL 600 ml; 12 F Ring-McLean 800 mg Hemoptysis ceased Only minor hemopty-
RUL- sump within seven sis for 54 months,
posterior days; cavitary then had another
seg. mass/mycetoma episode of massive
decreased in size hemoptysis (vide
over three weeks infra)
( see case report).
ic 54/F Sarcoidosis RUL 500 ml; RUL 12 F Ring-McLean 750 mg Initial treatment
sump with aminoca-
proic acid; mas-
sive hemoptysis
ceased then re-
curred five days
later; additional
amino-caproic
acid then ampho-
tericin B; no fur-
ther bleeding
over two months
( see case report).
2 57/M Sarcoidosis RUL 100 ml; RUL 12 F Ring-McLean 500 mgt Hemoptysis ceased Readmitted on three
sump within 48 hrs; occasions (7/83-11/
mycetoma 85) for exacerbation
cleared within ofasthma (associ-
four weeks ated with allergic
bronchopulmonary
aspergillosis); no
further hemoptysis
or mycetoma over
4.5 years
3 63/M Sarcoidosis LUL 100-200 ml; 8 F Pigtail catheter 500 mg Hemoptysis ceased. At two years, readmit-
(History with 24 hrs; my- ted with recurrent
of cetoma cleared hemoptysis due to
asbestos within two weeks endobronchial
exposure) mass; symptoms re-
solved in one week;
lost to follow-up
4 48/M Bullous lung LUL 50-100 ml; 8.5 F Cope loop 690 mg No hemoptysis fol- No further hemopty-
disease LUL nephrostomy lowing catheter sis at 12 months
catheter placement; myce-
toma decreased
in size over three
weeks
DISCUSSION
FIGURE 3. Twelve-French left percutaneous sump catheter in place;
communication with LUL bronchus following contrast medium Although the treatment of choice for patients with
injection.
symptomatic pulmonary aspergilloma is surgical re-
mg of amphotericin B was instilled over 20 days. Although there section of the involved segments, this therapy suffers
was incomplete resolution of the RUL mycetoma, the patient was
from several drawbacks. The most significant of these
symptomatically improved, with no further hemoptysis. The cathe-
ter was removed, and she was discharged.
is the very high operative morbidity and mortality
Over the next three years, she experienced occasional bouts of which occurs in the setting of reduced pulmonary
coughing with blood-streaked sputum and was hospitalized once for reserve and especially when diffuse underlying disease
bacterial superinfection of the LUL cavity associated with mild, is present. 1-12,22,23 Israel et al2 reviewed their surgical
self-limited hemoptysis.
experience with aspergillomas in patients with sar-
Fifty-four months following initial therapy ofthe RUL mycetoma,
the patient presented again with massive hemoptysis. Emergency
coidosis who had severely compromised pulmonary
bronchoscopy revealed bleeding from the RUL. Intracavitary ther- function, as defined by FVC and maximum breathing
apy was again initiated in the RUL cavity by placing a 12-French capacities below 50 percent and resting PaO2 <80 mm
F1;uRE 4. Chest x-ray film (posteroanterior view, seven days FIGURE 5. Chest x-ray film (posteroanterior view; five years post-
p()stdramage). Contents of LUL cavity have disappeared; RUL drainage). Note bilateral upper lobe cavities. Small mass persists in
mycetoma persists. RUL cavity; LUL cavity remains clear.
The reasons for the rapid effectiveness of this ther- 1 Glimp BA, Bayer AS. Pulmonary aspergilloma: diagnostic and
apy are not entirely clear. The initial rapid response therapeutic considerations. Arch Intern Med 1983; 143:303-08
to amphotericmn B instillation may be related to its 2 Israel HL, Lenchner GS, Atkinson GW. Sarcoidosis and asper-
gilloma: the role of surgery. Chest 1982; 32:430-32
irritative properties and sclerosing ability rather than
3 Garvey J, Crastnopol P, Weisz D, Wisoff C. Surgical treatment
its antifungal action. It is believed that the bleeding ofpulmonary aspergillomas. NY State J Med 1978; 78:1722-25
associated with aspergilloma is due to extensive cap- 4 Garvey J, Crastnopol P, Weisz D, Khan F. The surgical treatment
illary oozing, rather than large vessel disruption. It of pulmonary aspergilloma.s. J Thorac Cardiovasc Surg 1977;
extravascular clots which have formed in vivo and treatment of pulmonary aspergilloma. Ann Surg 1977; 186:13-
16
have incorporated aminocaproic acid may not undergo
10 Aslam PA, Eastridge CE, Hughes FA Jr. Aspergillosis of the
spontaneous lysis.2 lung-an eighteen-year experience. Chest 1971; 59:28-23
The optimal approach to the patient with mycetoma 11 Jewkes J, Kay PH, Paneth M, Citron KM. Pulmonary aspergil-
and pulmonary hemorrhage is unclear. Spontaneous loma: analysis ofprognosis in relation to haemoptysis and survey
lysis of mycetoma has been reported in up to 10 oftreatment. Thorax 1983; 38:572-78
12 Mattox KL, Guinn GA. Emergency resection for massive
percent of patients. However, the incidence of spon-
hemoptysis. Ann Thorac Surg 1974; 17:377-83
taneous lysis or recurrence ofbleeding once an episode 13 Remy J, Arnaud A, Fardou H, Giraud R, Voisin C. Treatment of
of significant hemoptysis has occurred is unknown. hemoptysis by embolization of bronchial arteries. Radiology
With persistent , progressively increasing frequency 1977; 122:33-37
and amount of hemoptysis, intervention must be 14 Uflacker R, Kaemmerer A, Neves C, Picon PD. Management
of massive hemoptysis by bronchial artery embolization. Radi-
considered. In patients with adequate pulmonary
ology 1983; 146:627-34
reserve and hemoptysis associated with an aspergil- 15 Hammerman KJ, Sarosi GA, Tosh FE. Amphotericin B in the
loma, surgical resection remains the definitive therapy. treatment of saprophytic forms of pulmonary aspergillosis. Am
However, in patients with severe, chronic respiratory Rev Respir Dis 1974; 109:57-62
insufficiency and limited pulmonary reserve with 16 Hamamoto T, Watanahe K, Ikemoto H. Endobronchial mico-
nazole for pulmonary aspergilloma. Ann Intern Med 1983;
diffuse or localized underlying lung disease, intracav-
98: 1030
itary therapy with amphotericin B, N-acetylcyste- 17 Ramirez-R J. Pulmonary aspergilloma: endobronchial treatment.
me aminocaproic acid offers an alternative for the N EngI J Med 1964; 271:1281-85
18 Adelson HT, Malcolm JA. Endocavitary treatment of pulmonary
treatment of hemoptysis. The approach offers a num-
mycetomas. Am Rev Respir Dis 1968; 98:87-92
ber of advantages. There is no loss of lung function.
19 Hargis JL, Bone RC, Stewart J, Rector N, Hiller FC. Intracav-
Rapid evacuation of intracavitary blood and fungal itary amphotericin B in the treatment ofsymptomatic pulmonary
debris is possible through the catheter. The technique aspergillomas. Am J Med 1980; 68:389-94
can be performed quickly, and in our experience, was 20 Krakowka P. Traczyk K, Walczak J, Halwey H, EIsner Z, Pawlick
L. Local treatment of aspergilloma of the lung with a paste
associated with minimal morbidity and no mortality.
containing nystatin or amphotericin B. Tubercle (London) 1970;
Hemoptysis was controlled in all episodes, including 51: 184-91
episodes ofintermittent massive hemoptysis occurring 21 Fernandez NA. Intracavitary anlinocaproic acid for massive
pulmonary hemorrhage. Chest 1984; 85:839
shortly after initial catheter placement. Most impor-
22 Tomlinson JR. Sahn SA. Aspergilloma in sarcoid and tubercu-
tantly, this approach offers another therapeutic option losis. Chest 1987; 92:505-08
for a group of patients with an otherwise poor prog- 23 Butz RO. Aspergilloma in sarcoid and tuberculosis (editorial).
nosis. Chest 1987; 92:392
24 Kaplan J, Johns CJ. Mycetomas in pulmonary sarcoidosis: non-
ACKNOWLEDGMENTS: We would like to thank Dr. Howard
surgical management. Johns Hopkins Med J 1979; 145: 157-61
Eisen (Hospital of the University of Pennsylvania) for his assistance
in this study and Mr. Henry Way for his skillful preparation of the 25 Hammerman KJ, Christianson CS, Huntingdon I, Hurst GA, et
manuscript. al. Spontaneous lysis of aspergillomata. Chest 1973; 64:697-99
The reasons for the rapid effectiveness of this ther- 1 Glimp BA, Bayer AS. Pulmonary aspergilloma: diagnostic and
apy are not entirely clear. The initial rapid response therapeutic considerations. Arch Intern Med 1983; 143:303-08
to amphotericmn B instillation may be related to its 2 Israel HL, Lenchner GS, Atkinson GW. Sarcoidosis and asper-
gilloma: the role of surgery. Chest 1982; 32:430-32
irritative properties and sclerosing ability rather than
3 Garvey J, Crastnopol P, Weisz D, Wisoff C. Surgical treatment
its antifungal action. It is believed that the bleeding ofpulmonary aspergillomas. NY State J Med 1978; 78:1722-25
associated with aspergilloma is due to extensive cap- 4 Garvey J, Crastnopol P, Weisz D, Khan F. The surgical treatment
illary oozing, rather than large vessel disruption. It of pulmonary aspergilloma.s. J Thorac Cardiovasc Surg 1977;
extravascular clots which have formed in vivo and treatment of pulmonary aspergilloma. Ann Surg 1977; 186:13-
16
have incorporated aminocaproic acid may not undergo
10 Aslam PA, Eastridge CE, Hughes FA Jr. Aspergillosis of the
spontaneous lysis.2 lung-an eighteen-year experience. Chest 1971; 59:28-23
The optimal approach to the patient with mycetoma 11 Jewkes J, Kay PH, Paneth M, Citron KM. Pulmonary aspergil-
and pulmonary hemorrhage is unclear. Spontaneous loma: analysis ofprognosis in relation to haemoptysis and survey
lysis of mycetoma has been reported in up to 10 oftreatment. Thorax 1983; 38:572-78
12 Mattox KL, Guinn GA. Emergency resection for massive
percent of patients. However, the incidence of spon-
hemoptysis. Ann Thorac Surg 1974; 17:377-83
taneous lysis or recurrence ofbleeding once an episode 13 Remy J, Arnaud A, Fardou H, Giraud R, Voisin C. Treatment of
of significant hemoptysis has occurred is unknown. hemoptysis by embolization of bronchial arteries. Radiology
With persistent , progressively increasing frequency 1977; 122:33-37
and amount of hemoptysis, intervention must be 14 Uflacker R, Kaemmerer A, Neves C, Picon PD. Management
of massive hemoptysis by bronchial artery embolization. Radi-
considered. In patients with adequate pulmonary
ology 1983; 146:627-34
reserve and hemoptysis associated with an aspergil- 15 Hammerman KJ, Sarosi GA, Tosh FE. Amphotericin B in the
loma, surgical resection remains the definitive therapy. treatment of saprophytic forms of pulmonary aspergillosis. Am
However, in patients with severe, chronic respiratory Rev Respir Dis 1974; 109:57-62
insufficiency and limited pulmonary reserve with 16 Hamamoto T, Watanahe K, Ikemoto H. Endobronchial mico-
nazole for pulmonary aspergilloma. Ann Intern Med 1983;
diffuse or localized underlying lung disease, intracav-
98: 1030
itary therapy with amphotericin B, N-acetylcyste- 17 Ramirez-R J. Pulmonary aspergilloma: endobronchial treatment.
me aminocaproic acid offers an alternative for the N EngI J Med 1964; 271:1281-85
18 Adelson HT, Malcolm JA. Endocavitary treatment of pulmonary
treatment of hemoptysis. The approach offers a num-
mycetomas. Am Rev Respir Dis 1968; 98:87-92
ber of advantages. There is no loss of lung function.
19 Hargis JL, Bone RC, Stewart J, Rector N, Hiller FC. Intracav-
Rapid evacuation of intracavitary blood and fungal itary amphotericin B in the treatment ofsymptomatic pulmonary
debris is possible through the catheter. The technique aspergillomas. Am J Med 1980; 68:389-94
can be performed quickly, and in our experience, was 20 Krakowka P. Traczyk K, Walczak J, Halwey H, EIsner Z, Pawlick
L. Local treatment of aspergilloma of the lung with a paste
associated with minimal morbidity and no mortality.
containing nystatin or amphotericin B. Tubercle (London) 1970;
Hemoptysis was controlled in all episodes, including 51: 184-91
episodes ofintermittent massive hemoptysis occurring 21 Fernandez NA. Intracavitary anlinocaproic acid for massive
pulmonary hemorrhage. Chest 1984; 85:839
shortly after initial catheter placement. Most impor-
22 Tomlinson JR. Sahn SA. Aspergilloma in sarcoid and tubercu-
tantly, this approach offers another therapeutic option losis. Chest 1987; 92:505-08
for a group of patients with an otherwise poor prog- 23 Butz RO. Aspergilloma in sarcoid and tuberculosis (editorial).
nosis. Chest 1987; 92:392
24 Kaplan J, Johns CJ. Mycetomas in pulmonary sarcoidosis: non-
ACKNOWLEDGMENTS: We would like to thank Dr. Howard
surgical management. Johns Hopkins Med J 1979; 145: 157-61
Eisen (Hospital of the University of Pennsylvania) for his assistance
in this study and Mr. Henry Way for his skillful preparation of the 25 Hammerman KJ, Christianson CS, Huntingdon I, Hurst GA, et
manuscript. al. Spontaneous lysis of aspergillomata. Chest 1973; 64:697-99