A patient with insulin-dependent diabetes mellitus was hospitalized for one month for what was presumed to be an aspiration pneumonia due to poor dentition. After initial clinical recovery hemoptysis developed and increased. Pulmonary function tests were near normal. The computed tomographic scan shown was obtained with supine and right lateral decubitus views. The best management is

A. cavernostomy.
B. intravenous amphotericin.
C. left upper lobectomy.
D. left upper lobectomy with en-bloc chest wall resection.
E. percutaneous abscess drainage. 

Answer C

This patient has a large mobile aspergilloma as demonstrated by the movement of the fungus ball on the two-position computed tomographic scan. Presumably, this developed in the area of an aspiration lung abscess. Diabetes may have been a predisposing factor. Hemoptysis is the most common presenting symptom and occurs in more than 50% of these patients. Hemoptysis may be massive and life-threatening. 

Systemic treatment with anti-fungal agents such as amphotericin is not effective because these agents do not penetrate into the fungus ball. Cavernostomy with obliteration of the cavity with intrathoracic transposition of extrathoracic skeletal muscle may be effective treatment for selected patients with complex aspergilloma and significant underlying pulmonary disease. Daly reported good results in six of six patients who underwent cavernostomy and obliteration of the cavity. 

This patient's underlying lung function and lung parenchyma are good, and he has a simple aspergilloma. Although the initial presentation may sometimes be confused with a necrotizing lung cancer, the movement of the fungus ball on the decubitus view confirms that this is a fungus ball and therefore aggressive en-bloc resection is not necessary. While percutaneous instillation of amphotericin has been reported for inoperable poor-risk patients, percutaneous drainage alone will not resolve this problem. Resection, however, also carries significant risk. Daly reported complications in 33% and deaths in 5% of patients who underwent resection for simple aspergilloma (n=21). In patients with complex aspergilloma (thick-walled cavity with substantial surrounding parenchymal disease), complications occurred in 78% and deaths in 34% of patients (n=32). Massard reported no deaths among 24 operated patients who were asymptomatic before resection, whereas there were four deaths among 26 symptomatic patients.