Going With the Flow: An Aid in Detecting and Differentiating Bronchopulmonary Sequestrations and Hybrid Lesions

Prenatal diagnostic accuracy and epidemiology of congenital lung malformations: A retrospective review of cases in a tertiary referral center in northern Finland in 2010-2020

INTRODUCTION

Our objective was to investigate the accuracy of prenatal diagnoses of congenital lung malformations (CLM) compared to postnatal diagnoses in a population in northern Finland and to estimate the birth prevalence of CLMs in the same population.

MATERIAL AND METHODS

A retrospective review of all CLM cases in a tertiary referral center, Oulu University Hospital, Finland, in 2010-2020. Data were collected from medical records. The final postnatal diagnosis was recorded as the pathologic-anatomic diagnosis, if available, and otherwise as the postnatal radiologic diagnosis.

RESULTS

Our case series comprises 37 CLM cases. The prenatal detection rate of CLMs was 100%. The prenatal diagnosis was congenital pulmonary airway malformation (CPAM) in 34/37 cases (92%). The accuracy of prenatal CLM diagnoses was 60% compared to postnatal radiologic diagnoses and 51% compared to final postnatal diagnoses. Relative frequencies of different diagnoses in postnatally confirmed CLM cases were CPAM 47% (16/34 cases), bronchopulmonary sequestration (BPS) 15% (5/34), hybrid CPAM/BPS 15% (5/34), congenital lobar overinflation (CLO) 15% (5/34), bronchial atresia 6% (2/34), and bronchogenic cyst 3% (1/34). Postnatally confirmed cases of CPAM were more likely to have a higher CPAM-volume ratio at diagnosis (p = 0.002), a higher maximum CPAM-volume ratio during pregnancy (p < 0.001), macrocystic appearance on ultrasonography (p = 0.026), and mediastinal shift (p < 0.001) compared with the rest of the cases in this study. The prevalence of all CLMs combined was 3.71 cases per 10 000 live births. The prevalences of CPAM, BPS, hybrid CPAM/BPS, and CLO were 1.69, 0.56, 0.56, and 0.56 cases per 10 000 live births, respectively.

CONCLUSIONS

We found that all CLMs were detected prenatally, but almost half of the prenatal diagnoses were inaccurate compared to postnatal diagnoses. Most lesions were diagnosed prenatally as CPAM, but postnatally many of them turned out to be BPS, hybrid CPAM/BPS, or CLO. Postnatally confirmed CPAM cases were more likely to have a high CPAM-volume ratio, mediastinal shift, and macrocystic appearance on prenatal ultrasonography compared with other CLMs. The prevalence of CLMs is still relatively poorly documented, but we provide new estimates in Finland.

The Diagnostics and Management of Bronchopulmonary Sequestration: An International Survey among Specialized Caregivers

BACKGROUND

 Our objective was to explore the treatment preferences for bronchopulmonary sequestration (BPS) among an international group of specialized caregivers.

METHODS

 Sixty-three participants from 17 countries completed an online survey concerning the diagnostics, treatment, and follow-up. Recruitment took place among members of the Collaborative Neonatal Network for the first European Congenital Pulmonary Airway Malformation Trial Consortium and through the Association for European Pediatric and Congenital Cardiology working group database.

RESULTS

 Most of the 63 participants were pediatric surgeons (52%), followed by pediatric pulmonologists (22%), and pediatric cardiologists (19%). The majority (65%) treated more than five cases per year and 52% standardly discussed treatment in a multidisciplinary team. Half of the participants (52%) based the management on the presence of symptoms, versus 32% on the intralobar or extralobar lesion localization. Centers with both surgical and interventional cardiac/radiological facilities (85%) preferred resection to embolization in symptomatic cases (62 vs. 15%). In asymptomatic cases too, resection was preferred over embolization (38 vs. 9%); 32% preferred noninterventional treatment, while 11% varied in preference. These treatment preferences were significantly different between surgeons and nonsurgeons (p < 0.05). Little agreement was observed in the preferred timing of intervention as also for the duration of follow-up.

CONCLUSIONS

 This survey demonstrates a variation in management strategies of BPS, reflecting different specialist expertise. Most centers treat only a handful of cases per year and follow-up is not standardized. Therefore, management discussion within a multidisciplinary team is recommended. Recording patient data in an international registry for the comparison of management strategies and outcomes could support the development of future guidelines.

LEVEL OF EVIDENCE

Level IV.

Cystic masses of the pediatric lung: update on congenital pulmonary airway malformation and its differential diagnosis

Localized cystic lung lesions in pediatric patients encompass a spectrum of benign and rare malignant conditions that are quite distinct from cystic lung disease arising in adulthood. The majority have historically fallen under the diagnostic category of "congenital pulmonary airway malformation," a term that has been used to denote a diverse group of diseases ranging in etiology from ectopia to bronchial atresia to mosaic oncogenic mutation or neoplasia. This article reviews the clinical characteristics, gross and histologic features, and pathogenetic underpinnings of congenital pulmonary airway malformation as well as lesions that enter its histologic differential diagnosis. In light of ongoing advances in the field, previously proposed pathology-based classification schemes are critically appraised, and a new diagnostic framework is considered.

A case of bronchopulmonary sequestration combined with congenital pulmonary airway malformation prenatally diagnosed as having two aberrant arteries originating from the celiac artery

We report a case of BPS combined with CPAM prenatally diagnosed as having two aberrant arteries from the celiac artery by fetal 3D-US. Although the pattern of arterial feeding vessels was extremely rare in our case, the vasculature images obtained using fetal 3D-US were comparable to those obtained using postnatal CT angiography.

Imaging of fetal tumors and other dysplastic lesions: A review with emphasis on MR imaging

Fetal tumors and other dysplastic masses are relatively rare. They are usually the result of failure of differentiation and maturation during embryonic or fetal life; dysplastic lesions may be the consequence of an obstruction sequence. In this review, we present the most commonly encountered tumors and masses seen during fetal life. Imaging characteristics, tumoral organ of origin, and its effect on the surrounding organs and overall fetal hemodynamics are descriptors that must be relayed to the fetal surgeon and maternal fetal medicine expert, in order to institute most accurate parental counseling and appropriate perinatal treatment plan.

Fetal ultrasound and magnetic resonance imaging: a primer on how to interpret prenatal lung lesions

Fetal lung lesions include common lesions such as congenital pulmonary airway malformation (CPAM), bronchopulmonary sequestration (BPS) and combined CPAM-BPS hybrid lesions, as well as less common entities including congenital lobar emphysema/obstruction, bronchial atresia, bronchogenic cysts and rare malignant pulmonary lesions such as pleuropulmonary blastoma. Fetal lung lesions occur in approximately 1 in 15,000 live births and are thought to arise from a spectrum of abnormalities related to airway obstruction and malformation, with the lesion type depending on the timing of insult, level of bronchial tree involvement, and severity of obstruction. Lesions vary from small and asymptomatic to large and symptomatic with significant mass effect on surrounding structures. Accurate diagnosis and characterization of these anomalies is crucial for guiding patient counseling as well as perinatal and postnatal management. The goal of this review is to provide an overview of normal fetal lung appearance and imaging features of common and uncommon lesions on both ultrasound and MR imaging, and to discuss key aspects in reporting and evaluating the severity of these lesions.

Prenatal sonographic markers of the outcome in fetuses with bronchopulmonary sequestration

PURPOSE

To evaluate the prenatal sonographic predictive markers of the outcome in fetuses with bronchopulmonary sequestration (BPS).

METHODS

BPS size and diameter of the feeding artery (FA) were measured prenatally and postnatally. Velocity of the FA and the left ventricular-modified myocardial performance index (LV mod-MPI) were also evaluated prenatally.

RESULTS

Forty-seven women were included in the study. Mean gestational age, mass size, diameter and velocity of the FA, and LV mod-MPI at prenatal diagnosis were 23.5 ± 2.2 weeks, 3.6 ± 8.3 cm, 2.3 ± 0.6 mm, 46.6 ± 15.4 cm/s, and 0.46 ± 0.06, respectively. Mean mass diameter and FA diameter measured on postnatal CT examinations were 3.8 ± 1.0 cm and 2.3 ± 0.7 mm, respectively. Five patients had respiratory symptoms after birth. Twenty children (43%) underwent or were scheduled to undergo mass excision, and the remaining 27 (57%) were doing well without any intervention. There was no neonatal death. LV mod-MPI at diagnosis, the FA diameter after birth and the serial change in the FA size were significantly associated with postnatal mass excision.

CONCLUSION

The FA diameter and LV mod-MPI may be additional markers for predicting whether fetuses with BPS should undergo mass excision in early childhood or conservative care.

Prenatal growth characteristics and pre/postnatal management of bronchopulmonary sequestrations

PURPOSE

The prenatal natural history of intralobar and extralobar bronchopulmonary sequestrations (BPSs), including lesion growth patterns and need for prenatal intervention, have not been fully characterized. We review our series of BPSs to determine their natural history and outcomes in the context of the need for prenatal intervention.

METHODS

A retrospective review of the pre/postnatal course of 103 fetuses with an intralobar (n=44) or extralobar BPS (n=59) managed at a single institution between 2008 and 2015 was performed. Outcomes included prenatal lesion growth trajectory, presence of hydrops, need for prenatal intervention, survival, and postnatal surgical management.

RESULTS

Most extralobar (71%) and intralobar BPSs (94%) decreased in size or became isoechoic from initial to final evaluation. Peak lesion size occurred at 26-28weeks gestation. Eight fetuses developed hydrothorax, four of which (all extralobar BPSs) also developed hydrops. All four hydropic fetuses received maternal betamethasone, and three hydropic fetuses underwent thoracentesis and/or thoracoamniotic shunt placement with subsequent hydrops resolution. All fetuses survived. Forty-one intralobar (93%) and 35 extralobar BPSs (59%) were resected after birth.

CONCLUSIONS

BPSs tend to decrease in size after 26-28weeks gestation and rarely require fetal intervention. Lesions resulting in hydrothorax ± hydrops can be effectively managed with maternal steroids and/or drainage of the hydrothorax.

LEVEL OF EVIDENCE

IV.