Combined medical-interventional approaches for the management of complex fungal balls: a case series as a viable alternative in non-surgical patients

• Published in: Therapeutic advances in respiratory disease 2024-01, Vol.18, p.17534666241255203-17534666241255203
• Main Authors: Dumoulin, Elaine, Thornton, Christina S., MacGregor, John H., Tremblay, Alain, Chan, Chrystal, MacEachern, Paul R., Kelly, Margaret M., Somayaji, Ranjani, Parkins, Michael D., Mody, Christopher H.
• Format: Article
• Language: English
• Subjects: Adult; Aged; Antifungal Agents - administration & dosage; Bronchoscopy; Combined Modality Therapy; Cross-Sectional Studies; Female; Humans; Male; Middle Aged; Pulmonary Aspergillosis - drug therapy; Treatment Outcome
• ISSN: 1753-4666; 1753-4666
• DOI: 10.1177/17534666241255203

Intracavitary pulmonary aspergilloma is a persistent and life-threatening infection that carries a mortality rate of up to 15%. It occurs when Aspergillus species gain entry to an existing lung cavity. In the absence of definitive treatment, patients may succumb to severe complications such as massive hemoptysis, cachexia, or secondary infections. Aspergillomas often show limited response to antifungal medications, mainly due to insufficient drug concentrations within the cavities. Surgery is frequently the preferred treatment option, but it poses significant risks, and many individuals are ineligible due to underlying health issues. We present the most extensive non-surgical fungal ball cohort to date, managed using an innovative multimodal strategy that combines antifungal therapy before and after bronchoscopic debulking. This was a cross-sectional observational study. For those who cannot undergo surgery, our medical center has pioneered a multimodal approach to aspergilloma resection. This approach combines bronchoscopic endoscopy with antifungal therapy and has been applied successfully to more than 18 patients that are presented in this series. The median age of the cohort was 58 years (range: 32–73), with an equal sex distribution. The mean percent predicted FEV1 was 65.3%. The mean follow-up duration was 3.6 years (range: 0.5–10 years). The cohort receiving antifungals systematically prior to debridement showed a reduction of the pre-existing cavity (40.38 mm versus 34.02 mm, p = 0.021). Across the 18 patients during the follow-up period, 94% remained recurrence-free (defined by symptoms and radiology). Our study fills a critical knowledge gap regarding the significance of initiating antifungal treatment before bronchoscopic debulking and presents a viable approach in these cases for which there is a current unmet therapeutic need. Plain Language Summary The use of both medical and interventional methods to treat difficult fungal masses: A collection of cases showing efficacy for patients who can’t undergo surgery Intracavitary pulmonary aspergilloma is a serious and potentially deadly infection with a death rate of up to 15%. It happens when certain types of fungi invade existing lung cavities. Without proper treatment, patients may experience severe complications like heavy bleeding from the lungs, weight loss, or other infections. Traditional antifungal medications often don’t work well because they can’t reach high enough concentrations in the