Are peripheral pulmonary cavity lesions caused by coccidioidomycosis normally resected?

Management of Peripheral Pulmonary Cavity Lesions in Coccidioidomycosis

Most peripheral pulmonary cavity lesions caused by coccidioidomycosis are NOT routinely resected, as many follow a benign course and spontaneously resolve without intervention. 1

Asymptomatic Cavitary Disease: Observation is Standard

The majority of coccidioidal cavities do not require surgical intervention or antifungal therapy. 1 The Clinical Infectious Diseases guidelines explicitly state that many cavities are benign in their course and do not warrant treatment, even when viable fungus is present and cultures yield Coccidioides species. 1

Initial Management Approach

• Observe asymptomatic cavities with serial imaging rather than immediate resection. 1
• Many cavities disappear spontaneously over time, eliminating the need for any intervention. 1
• Indefinite follow-up without intervention is appropriate for most patients. 1

Selective Indications for Surgical Resection

Resection should be considered only in specific high-risk scenarios, not as routine management. 1

Delayed Elective Resection (1-2+ years)

Consider resection for asymptomatic cavities when: 1

• The cavity persists unchanged for more than 2 years on serial imaging
• Progressive enlargement is documented on follow-up radiographs
• The cavity is immediately adjacent to the pleura (increased rupture risk)

Symptomatic Disease Requiring Intervention

Resection becomes indicated when complications develop: 1

• Recurrent or significant hemoptysis (most common surgical indication)
• Local discomfort refractory to medical management
• Superinfection with bacteria or other fungi not responding to antimicrobials
• Chronic or intermittent symptoms despite prolonged azole therapy

Emergency Surgical Indications

Cavity rupture into the pleural space (pyopneumothorax) requires urgent surgical intervention. 1

• In young, otherwise healthy patients, lobectomy with decortication is the preferred management. 1
• Wedge resection is recommended when the pleural space is not massively contaminated. 1
• Approximately one-third present as simple pneumothorax, with the remainder showing hydropneumothorax or frank empyema. 1

Medical Management Takes Priority

Initial treatment with oral azole antifungals is recommended before considering surgery for symptomatic cavitary disease. 1

First-Line Medical Approach

• Oral azole therapy (fluconazole or itraconazole 400 mg daily) should be attempted for symptomatic cavities. 1
• Continue therapy for at least 1 year if the patient improves. 1
• Surgical resection is reserved as an alternative for refractory lesions that remain well-localized despite adequate medical therapy. 1

Clinical Evidence from Surgical Series

Only 2-6% of patients with pulmonary coccidioidomycosis require surgical intervention. 2, 3 In a 10-year surgical series, only 86 of 1,496 patients (6%) underwent operations, with 40% of these performed for persistent symptoms or disease progression despite adequate antifungal therapy. 2 A more recent series showed only 58 of 2,166 patients (2.7%) required surgery. 3

Surgical Outcomes and Complications

• Morbidity is significantly higher for cavitary lesions with complications (41%) versus nodular disease (12%). 2
• Prolonged air leaks or bronchopleural fistulas are the most common postoperative complications (occurring in 13-22% of patients). 2, 3
• Video-assisted thoracoscopic surgery (VATS) can be used for most procedures (95% in recent series), though conversion to thoracotomy may be necessary due to inflammation. 1, 3

Critical Pitfalls to Avoid

Do not routinely resect stable, asymptomatic coccidioidal cavities. 1 The absence of controlled trials demonstrating benefit from antifungal therapy for asymptomatic cavities underscores the benign natural history of most lesions. 1

Do not proceed directly to surgery without attempting medical management for symptomatic cavitary disease. 1 Oral azole therapy should be the initial approach, with surgery reserved for treatment failures or specific complications like hemoptysis.

Recognize that peripheral location alone is not an indication for resection—only when the cavity is immediately adjacent to the pleura AND meets other high-risk criteria (persistence >2 years or progressive enlargement) should resection be considered. 1