Complex bronchopulmonary foregut malformation: extralobar pulmonary sequestration associated with a duplication cyst of mixed bronchogenic and oesophageal type

We report a 13-year-old girl with an unusual, complex bronchopulmonary foregut malformation. The malformation included extralobar pulmonary sequestration and a duplication cyst of mixed bronchogenic and oesophageal type. Preoperative CT and MRI demonstrated the cystic and solid portions of the mass and indicated an aberrant vascular supply, suggesting the possibility of bronchopulmonary foregut malformation and several other differential diagnoses. A direct communication between the cyst and the bronchus of the sequestrated lung was found on pathological examination. This unusual combination of an extralobar pulmonary sequestration and a foregut cyst points to a common embryological pathogenesis.

Pulmonary sequestration-like anomaly presenting as a spontaneously resolving mass

A premature baby boy presented at birth with respiratory distress. A right lower lobe opacity was found on chest X-ray. Pulmonary sequestration was the diagnosis suggested by ultrasound. The size of the mass decreased on subsequent examinations. 4 months later X-rays and sonography failed to demonstrate any remaining mass. This case illustrates another example of involutive pathology and suggests that not all pulmonary sequestration-like anomalies should be operated on.

Extralobar pulmonary sequestration in the posterior mediastinum

Extralobar pulmonary sequestration was incidentally detected in a 65-year-old man. Preoperatively, the lesion presented as a posterior mediastinal mass. At operation the mass was found to be attached to the paravertebral region at the level of the seventh thoracic vertebra by a feeding artery originating from the descending aorta. Only two cases of extralobar pulmonary sequestration in the posterior mediastinum have been previously reported.

Non-mosaic trisomy 20 presenting at 21 weeks' gestation as a thoraco-abdominal mass

Non-mosaic trisomy 20 is rare in fetuses surviving beyond the first trimester. We report a case of a fetus with non-mosaic trisomy 20 in amniotic fluid cultures obtained during the prenatal evaluation of an unusual thoraco-abdominal mass which was found at autopsy to be pulmonary sequestration. Gross inspection and autopsy of the fetus revealed multiple anomalies.

Pulmonary sequestration: three dimensional dynamic contrast-enhanced MR angiography and MRI

In order to evaluate the diagnostic value of three-dimensional contrast-enhanced MR angiography and MRI for pulmonary sequestration, 5 patients with pulmonary sequestration underwent 3D fast imaging by steady state precession (FISP) with a contrast medium and breath holding following chest radiography, CT and MR scans. The reconstructed MR angiography was performed using maximum intensity projection (MIP) and multiplanar reconstruction (MPR) techniques. It was found that the chest radiography showed pulmonary sequestration as a persistent area of opacity in the posterior basal segment of the left lower lobe, which was close to mediastinum in 2 cases and close to diaphragma in 3 cases. CT revealed a soft issue mass beyond descending aorta and lobar emphysema around the pulmonary sequestration. And the supplying vessel was documented in 2 cases on enhanced CT. MRI demonstrated a hyperintensity mass with respect to normal lung parenchyma on T1WI and T2WI, and the origin of the supplying vessel in 3 cases. The reconstructed CE MRA using MIP or MRP techniques clearly showed the supplying vessel and its course, branches as well as draining vessels. It was concluded that 3D CE MRA of demonstrating the supplying and draining vessels to pulmonary sequestration, together with plain MRI, can provide a diagnosis and aid in surgical planning without the need for DSA.

Intralobar bronchopulmonary sequestration evaluated by contrast-enhanced three-dimensional MR angiography

Bronchopulmonary sequestration (PS) is characterized by non-functioning lung tissue fed from one or several aberrant systemic arteries. The condition is diagnosed by visualizing the feeding arteries using non-invasive CT, MRI, colour Doppler sonography or conventional angiography. We present a 5-year-old boy in whom intralobar sequestration was diagnosed using contrast-enhanced 3D MR angiography, which visualised fine blood vessels in the thoraco-abdominal region without arterial puncture. This technique is useful for diagnosing PS.

[Intralobar sequestration of the lung in an adult (type 1 of pryce). Treatment by coil embolization]

A 34 year old patient presented with recurrent hemoptysis. A chest radiograph was normal. Helical CT angiogram of the chest with tridimensional reconstructions demonstrated an intralobar pulmonary vascular sequestration Pryce I-type of the right lower lobe. The angiography confirmed the diagnosis showing a large feeding artery arising from the coeliac trunk. An embolization of the feeding artery using metallic coils was performed. Transient pulmonary infarction occurred immediately after treatment. At two years follow-up, the patient remains asymptomatic. Percutaneous embolization of this rare pulmonary vascular malformation is an alternative to surgical treatment.

Extralobar pulmonary sequestration with venous drainage to the portal vein: a case report

Venous drainage to the portal vein in pulmonary sequestration is rare. A 7-month-old girl was referred to our hospital following surgery for ventricular septal defect because of a left upper abdominal mass with a large feeding artery from the abdominal aorta and venous drainage to the portal vein. She had had frequent pulmonary infections and was growth retarded. MRI demonstrated that the mass was above the left diaphragm, suggesting extralobar sequestration. An extralobar sequestered lung was resected at thoracotomy. Diagnostic problems and clinical features are presented.

[Intralobar pulmonary sequestration]

For the period of 21 years the intralobar pulmonary sequestration was revealed in 6 patients aging from 11 to 47 years old. In all the observations of the intralobar sequestration the only affection of lower pulmonary lobes was noted. In 4 patients the symptomless course of the disease was present, while in 2 it was manifested by the recurrent pneumonia. The correct diagnosis before the operation was established in one patient only. All the patients were operated on, in 2 two aberrant vessels to the sequestrated pulmonary region were revealed and in all the patients--bronchogenic cyst in the affected region.

The unpredictable character of congenital cystic lung lesions

BACKGROUND

The spectrum of congenital cystic disease of the lung ranges from hydrops and neonatal respiratory distress to asymptomatic lesions. Surgical management is dictated by the presence of symptoms, recurrent infection, and the potential risk of malignant transformation.

METHODS

Since 1995, all consecutive patients with congenital cystic lung lesions underwent follow-up for symptoms, treatment, and correlation of presumptive with pathological diagnosis.

RESULTS

Twelve cystic lung lesions were identified. Seven were diagnosed with mediastinal shift in utero; in 6 of 7, the shift subsequently resolved. Overall, 6 of 7 lesions that were followed up serially decreased in size. Two patients were symptomatic in utero; 1 underwent thoracoamniotic shunting, 1 pleurocentesis for impending hydrops. Postnatally, these 2, and 2 other newborns required urgent surgery. Five of 8 asymptomatic patients had elective resection by 16 months, and 4 await operation. In 6 of the 9 surgical cases (67%), there was a discrepancy between preoperative and pathological diagnosis. There were 4 hybrid congenital cystic adenomatoid malformation (CCAM)/sequestrations.

CONCLUSIONS

At least 6 of 7 congenital cystic lung lesions decreased in size regardless of gestational age or presence of mediastinal shift. Antenatal intervention is therefore rarely indicated. Hybrid morphology may necessitate resection of stable, asymptomatic lesions to prevent the theoretical concern for associated malignancies as well as other complications of CCAM.

Imaging of surgical diseases of the newborn chest. Intrapleural mass lesions

Prenatal detection of intrapleural mass lesions is commonplace. Diagnostic treatment plans often are formulated before birth. The radiologist's involvement in dealing with congenital lobar emphysema, congenital cystic adenomatoid malformation, extralobar pulmonary sequestration, and congenital diaphragmatic hernia has changed. The need for immediate postnatal diagnosis has been de-emphasized, but the demand for precision and efficiency in preoperative cross-sectional imaging, monitoring progress and complications of treatment, and assistance with nutritional support has increased.

Pulmonary hydatid disease mimicking sequestration: differentiation on magnetic resonance imaging

A case of hydatid disease of the lung proven by thoracotomy and histopathological evaluation is described. It was clinically and radiologically suggestive of a complicated pulmonary sequestration or non-resolving consolidation.

Congenital parenchymatous malformations of the lung

Congenital lung malformations, primary and secondary, contribute to an important portion of pediatric thoracic surgery. One purpose of this report is to outline the close relation in terms of embryology and clinical presentation of congenital parenchymatous pulmonary malformations. In a retrospective study we also aim to evaluate our experience with the diagnosis and surgical management of congenital parenchymatous bronchopulmonary malformations and to compare our data with the literature. From January 1979 to December 1996 a series of 48 patients, 30 males (62.5%) and 18 females (37.5%), were operated on for congenital bronchopulmonary malformations. Pulmonary sequestration, bronchogenic cysts, congenital lobar emphysema, and congenital cystic adenomatoid malformation were seen in 16, 13, 5, and 14 patients, respectively. The first clinical symptoms occurred at a mean age of 8.8 years (1 day to 62 years), and the mean age at the time of surgical intervention was 9.3 years (1 day to 62 years). The maximum time between first symptoms and surgical treatment was 27 years. A lobectomy was performed in 22 cases; in the other patients more lung-preserving surgery such as enucleation or sequestrectomy was performed. Only one postoperative death occurred following lobectomy for pulmonary sequestration, and it was due to pulmonary hypoplasia and pulmonary hypertension. Eleven other patients presented with postsurgical complications: pneumothorax (n = 5), pleural effusion (n = 3), prolonged air leak (n = 2), portal vein thrombosis (n = 1), and hemorrhage requiring reintervention (n = 1). We conclude that any thoracic cystic lesion expanding on chest radiography should be an indication for surgical resection, even if asymptomatic, because of the risk of pulmonary compression, infection, or malignant degeneration. In the few cases of a fetal intrathoracic mass, prenatal diagnosis and intrauterine intervention may be indicated, and these indications are also discussed.

Management of antenatally diagnosed pulmonary sequestration associated with congenital cystic adenomatoid malformation

BACKGROUND

Sequestration with associated cystic adenomatoid malformation is rare. A study was undertaken to determine whether pulmonary sequestration associated with congenital cystic adenomatoid malformation has a more favourable natural history than that of sequestration without associated cystic adenomatoid malformation.

METHODS

An outline of the postnatal work up leading to the management of extralobar or intralobar pulmonary sequestration with congenital cystic adenomatoid malformation diagnosed antenatally as pulmonary malformation is presented and the indications for surgical intervention are discussed.

RESULTS

In five infants in whom an antenatal ultrasound scan had detected a congenital lung malformation at 18-19 weeks gestation a final diagnosis of extralobar or intralobar pulmonary sequestration with congenital cystic adenomatoid malformation was made postnatally. Postnatal ultrasound and computerised axial tomographic scans confirmed the diagnosis of sequestration by delineating anomalous vascular supply. Cystic changes were also observed in the basal area of the sequestration in all patients. Four children remained asymptomatic and one infant presented at 10 months of age with pneumonia. The mean age at surgical resection was 6.8 months (range 2-10). Histopathological examination confirmed intralobar pulmonary sequestration with associated Stocker type 2 congenital cystic adenomatoid malformation in two patients and extralobar pulmonary sequestration with associated Stocker type 2 congenital cystic adenomatoid malformation in three patients. The mean period of follow up was four years (range 1-8). The children remain well and are developing normally.

CONCLUSIONS

The importance of seeking an anomalous blood supply in children with congenital lung lesions is emphasised. Pulmonary sequestration and congenital cystic adenomatoid malformation probably share a common embryogenesis despite diverse morphology. The natural history of antenatally diagnosed lung masses is variable. Early postnatal surgical resection of pulmonary sequestration with cystic adenomatoid malformation is recommended. Surgical excision should be conservative, sparing the normal lung parenchyma.

Anomalous systemic arterial supply to normal basal segments of the left lower lobe

BACKGROUND

Anomalous arterial supply to the normal basal segments of the lower lobe without sequestration is a rare congenital abnormality, and whether it belongs to the broad spectrum of sequestration disorders remains controversial.

METHODS

The cases of all 4 patients who were treated surgically by us were reviewed together with 8 previously reported cases.

RESULTS

The anomalous artery originated from the descending thoracic aorta, distributed to the basal segments of the left lower lobe, and drained to a normal inferior pulmonary vein in each case. The anomalous artery was thick and elastic walled. From the review of all 12 cases, male gender, left side, descending thoracic aorta as the aberrant arterial origin, absence of pulmonary blood flow to the basal segments, and normal pulmonary venous drainage were predominant. Despite some differences, the findings seemed closely related to intralobar sequestration. Surgical treatments were lung resection, anastomosis, and ligation of the anomalous artery.

CONCLUSIONS

This anomaly is probably one type of sequestration complex. Both aortic and pulmonary arterial angiographic studies are needed to plan the definitive surgical procedure.

Preoperative diagnosis of extralobar pulmonary sequestration with unusual vasculature: a case report

Pulmonary sequestrations are uncommon congenital malformations of the lung. Vascular supply to pulmonary sequestrations is variable, with many unusual combinations. Adequate preoperative evaluation is hence advisable to avoid intraoperative complications. Magnetic resonance imaging (MRI) allows accurate diagnosis of extralobar pulmonary sequestration (ELPS), including definition of vascular supply. This may obviate the need for more invasive investigations that were suggested in the past. Presented here is a case of ELPS with its vascular attachments to the intercostal vessels.

Congenital chest lesions: diagnosis and characterization with prenatal MR imaging

PURPOSE

To evaluate prenatal magnetic resonance (MR) imaging for diagnosis of fetal chest masses and to determine if MR imaging provides information in addition to that of ultrasonography (US).

MATERIALS AND METHODS

Eighteen pregnant women were referred for MR imaging of possible fetal chest tumors seen at US (16 congenital cystic adenomatoid malformation [CCAM], two bronchopulmonary sequestration [BPS]). The presence, position, size, and characteristics of masses were determined and correlated with postnatal results.

RESULTS

The MR imaging diagnoses were three cases of congenital diaphragmatic hernia, nine of CCAM, two of BPS, and one each of foregut cyst, lung atresia, tracheal atresia, and bronchial stenosis. MR imaging results were in agreement with US results in nine fetuses and in disagreement in nine. MR imaging diagnoses were confirmed at surgery or autopsy in 17 fetuses. MR imaging results led to an error in diagnosis in one fetus with BPS.

CONCLUSION

Fetal chest masses had characteristic MR imaging appearances. MR imaging was accurate for distinguishing congenital diaphragmatic hernia from CCAM and was useful for less common diagnoses and determination of the origin of very large chest tumors. Prenatal diagnosis was changed in some patients owing to MR results and affected treatment and counseling of parents. MR imaging is a valuable adjunct to US for prenatal diagnosis of fetal chest masses.

Pulmonary sequestration diagnosed by contrast enhanced three-dimensional MR angiography

Pulmonary sequestration is a congenital bronchopulmonary foregut malformation in which a segment of lung parenchyma is not connected to the tracheobronchial tree. This abnormal segment receives a blood supply from the systemic circulation. Multiple imaging modalities have been used to demonstrate the vascular anatomy of the sequestration. Different magnetic resonance angiography (MRA) techniques have been employed in the identification of these anomalous vessels. We report a case of pulmonary sequestration diagnosed by MRI with the use of contrast enhanced three-dimensional MRA.

[Intralobular pulmonary sequestration: apropos a case]

The authors report their experience with a patient suffering from an intralobar bronchopulmonary sequestration (IBS). The lesion was misdiagnosed as metapneumonic lung abscess. IBS is a rare, diagnostically binding lung congenital malformation. So far, TC and MR angiography achieve pathognomonic findings with low invasivity. The best treatment of IBS could be surgical resection.