Treatment

There is no consensus on the treatment of aspergilloma because of a lack of controlled studies. Because life-threatening hemoptysis occurs only in a minority of patients, subjecting all patients with aspergilloma to surgical therapy, which is often associated with significant morbidity and mortality, seems to be inappropriate. Management options for aspergilloma currently include systemic or local administration of antifungal agents, surgical resection, and conservative management with careful follow-up without specific medical or surgical intervention. Often, the best course of action for asymptomatic patients with aspergilloma is carefully repeated clinical evaluation with periodic chest radiographs without surgical intervention. Therapeutic considerations must include the individual patients health status with attention to the potential risks of each treatment. The definitive treatment of aspergilloma is surgical resection. However, in many patients, surgery is contraindicated because of severe underlying pulmonary dysfunction, whereas the operation per se is associated with significant mortality and serious postoperative complications such as hemorrhage, bronchopleural fistula, bacterial superinfection, and empyema. Therefore, it has been suggested that surgical resection of aspergilloma should be restricted to patients with severe, lifethreatening hemoptysis and preserved pulmonary function. Surgical resection should also be considered for patients with poor prognostic features (e.g., chronic immunosuppression, sarcoidosis, and increasing Aspergillusspecific IgG titers). Extrapleural resection has been reported to improve outcome. For patients who are unfit for surgical resection, an alternative approach is cavernostomy, which is performed under local anesthesia; however, cavernostomy is also associated with mortality and mediocre results. This procedure should be considered as a last resort. Intracavitary instillation of an antifungal agent is a promising alternative treatment in patients with severe pulmonary dysfunction who are poor candidates for surgery. CT-guided percutaneous instillation of AMB-D has been shown to be effective for aspergilloma in several cases of massive hemoptysis, with resolution of hemoptysis within 5 d. The response to percutaneous injection of AMB-D is sustained with no recurrences for several months, improvement or even resolution of radiographic abnormalities, and reduction of serumAspergillus antibody titers. Endobronchial instillation of ketoconazole via fiberoptic bronchoscopy has also been successful. Overall, topical therapy with antifungal agents is ideal for patients with a solitary aspergilloma who have severe hemoptysis and contraindications to surgical resection. Bronchial arterial embolization (BAE) has been extensively used in the management of hemoptysis in patients with aspergilloma. However, this approach has proved to be only temporarily effective, and recurrence of hemoptysis usually occurs because of the presence of collateral vessels in the involved area. Hence, BAE seems to be appropriate only as a bridge procedure in patients with massive hemoptysis until surgical resection of the aspergilloma can be performed. Also, radiation therapy has been shown to be effective for aspergilloma, even in patients with massive hemoptysis. This modality has been recommended for cases of recurrence of life-threatening hemoptysis after BAE. Itraconazole is an orally administered antifungal agent with activity against A. fumigatus and high tissue penetration into the lung. The use of itraconazole for aspergilloma has been reported in several noncontrolled studies. Data from these studies showed that the use of itraconazole at doses ranging from 200 to 400 mg/d for 6 to 18 mo resulted in radiographic and symptomatic improvement in almost twothirds of the patients and may have a place for the treatment of aspergilloma. Serum itraconazole levels were not measured in most of these studies, but a recent study of treatment of pulmonary aspergilloma with itraconazole (100 to 200 mg/d) demonstrated sufficient itraconazole levels within the aspergilloma cavities. The major limitation of itraconazole is that it works slowly; thus, use of it would not be

prudent in cases of life-threatening hemoptysis. In addition, recurrence of aspergilloma often follows discontinuation of itraconazole treatment, whereas acquisition of secondary resistance of A. fumigatus isolates to itraconazole has been described in patients with aspergilloma following prolonged treatment.