Survival following lung resection in immunocompromised patients with pulmonary invasive fungal infection.
OBJECTIVE
Pulmonary invasive fungal infections (IFIs) are associated with high mortality in patients being treated for haematological malignancy. There is limited understanding of the role for surgical lung resection and outcomes in this patient population.


METHODS
This is a retrospective cohort of 50 immunocompromised patients who underwent lung resection for IFI. Patient charts were reviewed for details on primary malignancy and treatment course, presentation and work-up of IFI, reasons for surgery, type of resection and outcomes including postoperative complications, mortality, disease relapse and survival. Analysis was also performed on two subgroups based on year of surgery from 1990-2000 and 2001-2014.


RESULTS
The median age was 39 years (range: 5-64 years). Forty-seven patients (94%) had haematological malignancies and 38 (76%) underwent haematopoietic stem cell transplantation (HSCT). Surgical indications included haemoptysis, antifungal therapy failure and need for eradication before HSCT. The most common pathogen was Aspergillus in 34 patients (74%). Wedge resections were performed in 32 patients (64%), lobectomy in 9 (18%), segmentectomy in 2 (4%) and some combination of the 3 in 7 (14%) for locally extensive, multifocal disease. There were 9 (18%) minor and 14 (28%) major postoperative complications. Postoperative mortality at 30 days was 12% (n = 6). Acute respiratory distress syndrome was the most common cause of postoperative death. Overall 5-year survival was 19%. Patients who had surgery in the early period had a median survival of 24 months compared with 5 months for those who had surgery before 2001 (P = 0.046). At the time of death, 15 patients (30%) had probable or proven recurrent IFI. Causes of death were predominantly related to refractory malignancy, fungal lung disease or complications of graft versus host disease (GVHD). Patients who had positive preoperative bronchoscopy cultures had a trend towards worse survival compared with those with negative cultures (hazard ratio: 1.80, P = 0.087).


CONCLUSIONS
Surgical resection of IFI in immunocompromised patients is associated with high perioperative mortality. Long-term survival is limited by recurrent malignancy, persistent fungal infection and GVHD but has improved in recent years. Selection for surgical resection is difficult in this patient population, but should be carefully considered in those who are symptomatic, or have failed antifungal treatment.
Department of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA, USA gwu@coh.org.
Geena X
GX
Wu
Department of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA, USA.
Marine
M
Khojabekyan
Department of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA, USA.
Jami
J
Wang
Department of Infectious Diseases, City of Hope National Medical Center, Duarte, CA, USA.
Bernard R
BR
Tegtmeier
Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA.
Margaret R
MR
O'Donnell
Department of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA, USA.
Jae Y
JY
Kim
Department of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA, USA.
Frederic W
FW
Grannis
Department of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA, USA.
Dan J
DJ
Raz
D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D005260:Female; D019337:Hematologic Neoplasms / Q000150:complications / Q000276:immunology / Q000628:therapy; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D016867:Immunocompromised Host; D008172:Lung Diseases, Fungal / Q000150:complications / Q000276:immunology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009894:Opportunistic Infections / Q000150:complications / Q000276:immunology / Q000601:surgery*; D011013:Pneumonectomy / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications; D011379:Prognosis; D012189:Retrospective Studies; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult
Fungal infection; Haematological malignancy; Immunocompromised; Surgery