Pulmonary resection for nontuberculous mycobacterial pulmonary disease: outcomes and risk factors for recurrence

Treatment of nontuberculous mycobacterial pulmonary disease requires a stepwise and multidisciplinary approach

INTRODUCTION

Nontuberculous mycobacterial pulmonary disease (NTM-PD) occurs in people with inborn or acquired susceptibility factors. Current treatment guideline recommendations include a watchful waiting strategy, antimycobacterial and surgical treatment, with a comprehensive assessment of clinical, microbiological, and radiological factors determining which approach is most suitable.

AREAS COVERED

Treatment outcomes in NTM-PD are unsatisfactory with culture conversion rates varying from 30 to 80% and recurrence rates up to 50%. Possible explanations include our insufficient knowledge and management of host susceptibility factors, poor guideline adherence by physicians, frequent adverse drug reactions demanding premature discontinuation, inadequate drug exposures due to both drug-drug interactions and inter-patient variability in pharmacokinetics, and a lack of pharmacokinetics/pharmacodynamics targets.

EXPERT OPINION

We describe a stepwise approach to NTM-PD treatment, complementing existing guidelines, including recommendations for a multidisciplinary assessment, classification of disease severity, personalized supportive care, antimycobacterial treatment, adjuvant surgery, and host-directed therapies. The recommendations are informed by PubMed literature and the authors' clinical expertise. Recognizing that our experience is shaped within a specialized reference clinic, we acknowledge that some of these recommendations may not be applicable in all settings.

Adjuvant surgical resection for nontuberculous mycobacterial pulmonary disease: Effectiveness and complications

BACKGROUND

Standard antibiotic treatment for nontuberculous mycobacteria pulmonary disease (NTMPD) has unsatisfactory success rates. Pulmonary resection is considered adjunctive therapy for patients with refractory disease or severe complications, but surgical indications and extent of resection remain unclear. We present surgical treatment outcomes for NTMPD and analyzes risk factors for unfavorable outcomes.

METHODS

We conducted a retrospective investigation of medical records for patients diagnosed with NTMPD who underwent surgical treatment at Asan Medical Center between 2007 and 2021. We analyzed clinical data including microbiological and surgical outcomes.

RESULTS

A total of 71 NTMPD patients underwent thoracic surgery. Negative conversion of acid-fast bacillus (AFB) culture following pulmonary resection was observed in 51 (73.9%) patients. In terms of long-term outcomes, negative conversion was sustained in 38 cases (55.1%). Mortality occurred in 7 patients who underwent pulmonary resections for NTMPD. Statistically significant associations with factors for recurrence or non-negative conversion of AFB culture were found in older age (odds ratio [OR] =1.093, 95% confidence interval [CI]: 1.029-1.161, P = 0.004), male sex (OR = 0.251, 95% CI: 0.071-0.892, P = 0.033), and extensive NTMPD lesions involving three lobes or more (OR = 5.362, 95% CI: 1.315-21.857, P = 0.019). Interstitial lung disease (OR = 13.111, 95% CI: 1.554-110.585, P = 0.018) and pneumonectomy (OR = 19.667, 95% CI: 2.017-191.797, P = 0.018) were statistically significant risk factors for postoperative mortality.

CONCLUSION

Pulmonary resection can be an effective adjuvant treatment option for NTMPD patients, with post-operative antibiotic treatment as the primary treatment. Careful patient selection is crucial, considering the associated risk factors and resectability due to complications and recurrence.

Surgical Resection in Nontuberculous Mycobacterial Pulmonary Disease

Rates of nontuberculous mycobacterial pulmonary disease are increasing worldwide, particularly in the United States and other developed countries. While multidrug antimicrobial therapy is the mainstay of treatment, surgical resection has emerged as an important adjunct. In this article, we will review the indications for surgery, preoperative considerations, surgical techniques, and postoperative outcomes.

Outcomes of adjunctive surgery for nontuberculous mycobacterial pulmonary disease

Background

Owing to the unsatisfactory results of antibiotic treatment alone, surgical resection is currently considered as adjunctive therapy in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD). However, reports regarding the outcomes of surgery vary considerably by institution. Here, we investigated the surgical outcomes and risk factors associated with unfavorable outcomes after surgery.

Methods

We analyzed patients with NTM-PD who underwent pulmonary resection at Seoul National University Hospital between January 1, 2006, and December 31, 2020, and assessed the types of surgical procedures, complications, and long-term outcomes. Multivariate logistic regression analysis was used to identify the risk factors associated with treatment refractoriness or recurrence after surgery.

Results

Among 67 patients who underwent surgery during the study period, the most common indication for surgery was persistent culture positivity despite rigorous medical treatment (80.6%), followed by longstanding cavitary lesions or radiographic aggravation (10.4%) and massive hemoptysis (4.5%). Among 53 patients with positive mycobacterial cultures at the time of surgery, 38 (71.7%) achieved initial negative culture conversion, 9 (17.0%) of whom experienced recurrence. Nine (13.4%) patients experienced postoperative complications, which were managed without lasting morbidity and mortality. Female sex (adjusted odds ratio [aOR] 6.63; 95% confidence interval [CI] 1.04–42.4; P = .046), preoperative positive mycobacterial culture (aOR 5.87; 95 %CI 1.04–33.08; P = .045), and residual lesions (aOR 6.86; 95 %CI 1.49–31.56; P = .013) were associated with refractoriness or recurrence.

Conclusions

Pulmonary resection is a reasonable treatment modality for patients with refractory NTM-PD or major complications such as massive hemoptysis. The potential risk factors associated with unfavorable outcomes included female sex, preoperative positive mycobacterial culture, and residual lesions after surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01679-0.