The patient whose x-ray and CT scan images are shown has severe chronic obstructive lung disease and a cavitary lesion.  The measured FEV1 is 0.6 liters.  The patient has been experiencing persistent daily hemoptysis and there have been two episodes of massive hemoptysis.  The best definitive management of this problem is 

A.  amphotericin intravenously. 

B.  cavernostomy and muscle flap. 

C.  intracavitary amphotericin. 

D.  right upper lobectomy.  

E.  tube thoracostomy.

Answer B

The development of an aspergilloma in a cavitary lesion of the lung is commonly associated with hemoptysis.  Cavities have been classified as simple or complex based on the condition of the surrounding lung.  A simple cavity has little destroyed lung associated with it whereas complex cavities are associated with extensive destruction of surrounding lung.  Treatment options are limited in patients with marginal pulmonary function.  Amphotericin is helpful in invasive fungal infection, but it is not efficacious in treating cavitary lesions such as aspergillomas.  It has no benefit in treating hemoptysis, especially massive hemoptysis.  Cavernostomy and transposition of extrathoracic muscle has been shown to be effective treatment and is associated with fewer complications and lower mortality rates than pulmonary resection for complex aspergillomas.  The Mayo Clinic reported complications following thoracotomy in 78% of 32 patients with complex aspergilloma compared to 33% in 21 patients with simple aspergilloma.  Operative mortality was 34% for complex cavities and 5% for simple aspergilloma.  Intracavitary amphotericin has been tried with limited success in treating aspergillomas.  Because of limited success and complications, it has almost been abandoned.  It has no role in the management of massive hemoptysis secondary to aspergilloma.  Tube thoracostomy or  cavernostomy alone is not definitive treatment and the rates of rebleeding are high.