D24-23 Minimally Invasive Treatment of Cavitary Pulmonary Aspergilloma: A Novel Combined Bronchoscopic Approach

Abstract Introduction Pulmonary aspergilloma within a pre-existing cavity represents a chronic and therapeutically challenging condition, with reported mortality rates reaching up to 15%. First-line therapy for cavitary pulmonary aspergilloma (CPA) consists of systemic antifungal agents. However, combined therapy with antifungals and endoscopic debridement has demonstrated high efficacy and safety when performed appropriately in selected patients. Intracavitary voriconazole have shown benefit in reducing the recurrence of hemoptysis, cough, and the size of the aspergilloma. The use of cone-beam computed tomography (CBCT) enables real-time three-dimensional imaging, improving navigation accuracy and allowing for tool-in-lesion confirmation during extraction. Case A 24-year-old male with chronic pulmonary aspergillosis and poor adherence to systemic antifungal therapy presented with recurrent hemoptysis over the past 13 years, recently increasing in frequency and severity. Computed tomography (CT) of the chest revealed a stable 3.1 cm x 3.1 cm cavitary lesion in the left upper lobe (LUL), consistent with aspergilloma. A therapeutic strategy was undertaken, consisting of embolization of the left bronchial artery and systemic voriconazole (300 mg twice daily), followed by definitive bronchoscopic removal. Flexible bronchoscopy with complete airway inspection to the subsegmental level revealed the aspergilloma in the superior lingular segment of the left upper lobe (LUL). CBCT enabled real-time, three-dimensional imaging and precise intraprocedural localization of the mycetoma. Full clearance of the cavity was achieved using forceps, 2.4mm erbe cryoprobes and suction. Two months follow-up laboratory tests, including serum IgE for aspergillus, C-reactive protein, and broncho alveolar lavage culture for aspergillus, were negative. Given the large diameter of the cavitary lesion, poor adherence to systemic antifungal therapy, and multiple previous episodes of hemoptysis, the patient was considered an appropriate candidate for bronchoscopic instillation of voriconazole. Four sessions of intracavitary instillation of voriconazole were performed at weekly intervals. Each instillation consisted of 400 mg of voriconazole diluted in 16 mL of saline, followed by immediate occlusion of the segment with a 5 Fr Fogarty balloon for 20 minutes. During the final session, an endobronchial valve was placed within the residual cavity to facilitate its collapse, enhance healing, and prevent recolonization. The four bronchoscopic procedures were completed without complications, and the patient has not experienced any further episodes of hemoptysis. Conclusion: and clinical importance This case highlights the effectiveness of a comprehensive, minimally invasive approach combining bronchoscopic cryoextraction, intracavitary voriconazole instillation, and endobronchial valve placement for the management of CPA in a non-surgical candidate with poor adherence to systemic antifungal therapy. This abstract is funded by: none