Risk analysis and outcomes of bronchopulmonary sequestrations

Congenital Thoracic Malformations: A Single-Center Retrospective Study From Hong Kong

Background Congenital thoracic malformations (CTMs) are a group of developmental lung anomalies, with congenital pulmonary airway malformation (CPAM) being the most prevalent subgroup of all. There had been controversies over the management approaches in asymptomatic CTMs. The study aims to review the clinical course, management options, and outcomes of CTMs in a Chinese population to provide guidance in the future management of the disease. Methods This retrospective study reviewed electronic medical records of Tuen Mun Hospital, Hong Kong, from 2002 to 2024 to include all cases with the diagnosis of CTM confirmed through computed tomography (CT). Cases were categorised into the antenatally diagnosed (AN) group and postnatally diagnosed (PN) group for further analysis. Results The cohort analyzed 45 cases, of which 18 belonged to the AN group and 27 belonged to the PN group. The majority of patients in the AN group remained asymptomatic throughout follow-up (61.1%); 48.2% of the PN group presented as incidental findings. Pneumonia was the most common complication, affecting 33.3% of the AN group and up to 59.3% of the PN group. Most of the patients had a single uncomplicated pneumonia (AN group: 83.3%; PN group: 75%). Surgeries were performed in 44.4% of the AN group and 66.7% of the PN group, with notable postoperative complications observed (AN: 25%, PN: 22.2%). Importantly, only one case of lymphoepithelioma-like carcinoma in a patient with bronchopulmonary sequestration (BPS) was identified, and no malignancies were found in other CTM entities. Conclusion In view of the relatively indolent and benign course found in this study, a conservative approach with surgery at a later age could be an alternative to early surgery in asymptomatic CTMs.

Respiratory Morbidity Among Children Undergoing Surgical Resection for a Congenital Lung Malformation

BACKGROUND

Congenital lung malformations (CLMs) are the most common condition requiring lung surgery in children. Although surgical resection is generally well tolerated in the immediate postoperative period, long-term outcomes are not well studied. In this paper, we sought to define the risk of childhood respiratory morbidity, specifically asthma and pneumonia, in patients who underwent CLM resection.

METHODS

After IRB approval, a retrospective study was conducted on all pediatric CLM resections performed at a single tertiary care children's hospital between January 2013 and December 2022. The primary outcome measures were the diagnosis of asthma and/or pneumonia more than 30 days after resection. Clinical and demographic characteristics were evaluated in univariate analysis and multivariable logistic regression as appropriate (p < 0.05).

RESULTS

Of the 54 patients who underwent CLM resection, 36 (67%) met inclusion criteria. The median age at resection was 6.2 months (IQR: 4.3-9.0), and the median follow-up period was 3.7 years (IQR: 1.7-5.7). Twelve were subsequently diagnosed with asthma at a median age of 3.3 years (IQR: 2.1-4.5). These observed asthma rates were significantly higher than expected when compared to nonlung surgery controls (33% vs. 6%, p < 0.01). Seven (21%) children were diagnosed with pneumonia, but this was not significantly different.

CONCLUSION

These data suggest that children undergoing lung resection for a CLM may be at an increased risk for the development of early childhood asthma. Given the potential implications for preoperative counseling and postoperative follow-up, multicenter studies to validate these findings are warranted.

Association of Prenatal Congenital Lung Malformation Volume Ratio to Postnatal Computed Tomography Characteristics

INTRODUCTION

Congenital lung malformations (CLMs) are diverse and readily diagnosed on prenatal ultrasound. Postnatal computed tomography (CT) characteristics, including volume, are used in centers for the clinical decision-making of asymptomatic CLM. We aim to evaluate the relationship of prenatal CLM volume ratio (CVR) to postnatal CT characteristics by suspected prenatal diagnosis and postnatal radiological diagnosis.

METHODS

We performed a single-center retrospective review of all patients evaluated with prenatally diagnosed CLM (May 2015-December 2022). Demographics, prenatal imaging findings at initial evaluation, and postnatal radiological diagnosis/imaging findings were analyzed with descriptive statistics. Pairwise correlation coefficient tests were performed to analyze the correlation between prenatal CVR and postnatal CT lesion size stratified by diagnosis.

RESULTS

Of 123 patients referred and evaluated, suspected prenatal diagnoses consisted of 68 bronchial atresia (BA), 20 intralobar bronchopulmonary sequestration (iBPS), 20 extralobar bronchopulmonary sequestration (eBPS), and nine congenital pulmonary airway malformation (CPAM). Postnatal radiological diagnoses consisted of 53 BA, 22 iBPS, 14 eBPS, and 20 CPAM. Overall correlation coefficient of prenatal CVR to postnatal CT lesion size volume was 0.56. By suspected prenatal diagnosis, correlation coefficients were 0.61 (BA), 0.59 (iBPS), 0.29 (eBPS), and 0.51 (CPAM). For postnatal radiological diagnosis, correlation coefficients were 0.58 (BA), 0.56 (iBPS), 0.33 (eBPS), and 0.62 (CPAM).

CONCLUSIONS

Our results indicate that initial CVR is overall consistent with the postnatal CT lesion size. This correlation is present in suspected prenatal diagnoses of BA and iBPS and postnatal radiological diagnoses of BA, iBPS, and CPAM. Additional studies analyzing long-term follow-up should be conducted to specify the safety of patients who undergo observation rather than surgical intervention.

Efficacy of robot-assisted thoracoscopic surgery in the treatment of pulmonary sequestration in children

Objective

This study was performed to evaluate the efficacy of robot-assisted thoracoscopic surgery (RATS) in the treatment of pulmonary sequestration (PS) in children.

Methods

All video-assisted thoracoscopic surgery (VATS) and RAST performed on patients with PS at a single center from May 2019 to July 2023 were identified. The χ 2 and Wilcoxon tests were used to compare the perioperative outcomes between VATS and RATS groups.

Results

Ninety-three patients underwent RATS while 77 patients underwent VATS. In both two groups, one patient converted to thoracotomy and no surgical mortality case. The median operation time was longer for the RATS group compared with the VATS group (75 min vs. 60 min, p <0.001). A lower ratio of chest tube indwelling (61.3% vs. 90.9%, p <0.001), fewer drainage days (1.0 day vs. 2.0 days, p <0.001), and a shorter postoperative length of stay (5.0 days vs. 6.0 days, p <0.001) were found in the RATS group than that in the VATS group. No significant difference was found in the incidence of short-term postoperative complications (hydrothorax and pneumothorax) between two groups.

Conclusions

RATS was safe and effective in children with PS over 6 months old and more than 7 kg. Furthermore, RATS led to better short-time postoperative outcome than VATS. Multi-institutional studies are warranted to compare differences in long-term outcomes between RATS and VATS.

Rare case of bilateral bronchopulmonary sequestration

Pulmonary sequestration is a rare congenital bronchopulmonary malformation with an estimated incidence of less than 6%. It is described as the abnormal formation of nonfunctional lung tissue that receives its blood supply from systemic circulation rather than the bronchial tree. Most are unilateral, while a miniscule proportion is bilateral. Delayed diagnosis can result in recurrent pneumonia, failure to thrive, regular hospital visits, morbidity and even fatality. Thus, it is important to raise awareness of this condition. Herein, we present a case of a 42-year-old patient with bilateral pulmonary sequestration (BPS) on a triple rule out CT angiography (TRO-CTA).

Previous pulmonary infection impacts thoracoscopic procedure outcomes in patients with congenital lung malformations: a retrospective cohort study

BACKGROUND AND OBJECTIVES

Patients with congenital lung malformations (CLMs) are at high risk for developing pulmonary infection. Nonetheless, prophylactic surgical excision of asymptomatic CLMs is controversial and often delayed to symptoms occurring out of concern for potential operative risks. This study aims to evaluate the impact of previous pulmonary infection on the outcome of thoracoscopic procedures in CLMs patients.

METHODS

This was a retrospective cohort study of CLMs patients who received an elective operation at a tertiary care center from 2015 to 2019. Patients were divided into pulmonary infection (PI) or non-infection of pulmonary (NPI) groups according to the history of pulmonary infection. Propensity score matching was used to minimize the bias between groups. The primary outcome was conversion to thoracotomy. Postoperative outcomes were compared between patients with and without PI.

RESULTS

We identified 464 patients, of whom 101 had a history of PI. Propensity score matching yielded a well-balanced cohort of 174 patients. PI was associated with higher conversion to thoracotomy (adjusted odds ratio = 8.7, 95% confidence interval, CI, 1.1-71.2, p = 0.039), blood loss (p = 0.044), and longer operative time (p < 0.001), chest tube placement time (p < 0.001), length of stay (p < 0.001), and postsurgical length of stay (p < 0.001).

CONCLUSIONS

Elective operation in CLMs patients with a history of PI was associated with an increased risk of conversion to thoracotomy, operative time, blood loss, chest tube placement time, length of stay, and postsurgical length of stay. Elective thoracoscopic procedures in asymptomatic CLMs patients are safe and effective, and earlier surgical intervention may be warranted.

Congenital lung malformation patients experience respiratory infections after resection: A population-based cohort study

PURPOSE

The benefit of elective resection of congenital lung malformations continues to be debated. Proponents of resection endorse a decreased risk of respiratory complications as one indication for surgery. Our study aimed to compare the prevalence of respiratory infections in cases, before and after resection of congenital lung malformations, to controls without a history of congenital lung malformation.

METHODS

We performed a retrospective cohort study of children born from 1991 to 2007 who underwent congenital lung malformation resection. Patients were identified from Winnipeg´s Surgical Database of Outcomes and Management (WiSDOM), and a 10:1 date-of-birth matched control group was generated from a population-based administrative data repository. International Classification of Disease codes were used to assess pulmonary infection outcomes. Relative rates (RR) were calculated to compare the frequency of pneumonia, respiratory infections and influenza between cases and controls.

RESULTS

We included 31 congenital lung malformation cases and 310 controls. Cases consisted of 14 (45.16%) congenital pulmonary airway malformations, 9 (29.03%) bronchopulmonary sequestrations and 8 (25.81%) hybrid lesions. Before resection, pneumonia was more common in cases than controls (RR 6.85; 95%CI 3.89, 11.9), while the risk of acute respiratory infections (RR 1.21; 95%CI 0.79, 1.79) and influenza (RR 0.46; 95%CI 0.01, 3.22) were similar to controls. Post-resection, the risk of pneumonia (RR 9.75; 5.06, 18.50) was still higher in cases than controls, and respiratory infections (RR 1.77; 95%CI 1.20, 2.53) and influenza (RR 3.98; 95%CI 1.48, 9.36) were more common in cases than controls.

CONCLUSION

Our study demonstrated that after resection of congenital lung malformations, children experience more frequent respiratory infections compared to the general population. Resection does not eliminate the increased risk of pneumonia.

Imaging modalities and management of prenatally diagnosed suprarenal masses: an updated literature review and the experience at a high volume Fetal Treatment Center

BACKGROUND/PURPOSE

The differential diagnosis for prenatal suprarenal masses (SRMs) is broad and includes neuroblastoma, adrenal hemorrhage, and subdiaphragmatic extralobar pulmonary sequestration (SEPS). We sought to elucidate the appropriate postnatal management for fetuses found to have an SRM.

METHODS

We conducted a retrospective review of patients prenatally diagnosed with SRM at our institution between 1998 and 2018. Prenatal characteristics, imaging, and neonatal outcomes were collected. We also performed a PubMed literature search and pooled analysis of all patients with a prenatally diagnosed SRM previously described in the literature.

RESULTS

The literature review yielded 32 studies, of which 19 were single case reports. In our case series, 12 patients were included. Seven patients were delivered vaginally, one was terminated. Postnatal diagnoses included: SEPS (n = 5), adrenal hemorrhage (n = 3), polycystic kidney (n = 2), splenic cyst (n = 1), and unknown for one patient. All but two of the final diagnoses had been on the initial diagnostic differential. With the exception of the terminated fetus, all remain alive today. On pooled analysis, patients who underwent operative management were diagnosed later 32 versus 24 weeks and had a significant predominance of left-sided lesions (59.5 versus 39.2%). The published literature demonstrates a trend toward observation versus resection over the past 30 years.

CONCLUSIONS

Patients prenatally diagnosed with an SRM have an excellent prognosis. Our series demonstrates a high incidence of SEPS, which were all resected, and adrenal hemorrhage, which were observed with repeat imaging. These patients can be followed with serial postnatal ultrasounds to determine the diagnosis prior to deciding the appropriate treatment.

Clinical characteristics of 50 children with azygos lobe: a retrospective study

An azygos lobe is a rare anatomic variant of the lung which may be misdiagnosed as other pathological conditions. There is a dearth of information on the clinical characteristics of children with azygos lobe. This study aims to summarize the clinical features of children with azygos lobe, which may be helpful to improve recognition and clinical care of those patients. Clinical findings of the children with imaging findings of azygos lobe were collected and analyzed. In this study, 50 children with azygos lobe were included. A total of 28% cases were found to have azygos lobe incidentally. The remaining 72% cases were diagnosed when they presented with respiratory symptoms including cough (36%), fever (34%), wheezing (18%), dyspnea (14%), and cyanosis (8%). Congenital heart disease, Down syndrome, and other respiratory malformations were also found in a small proportion of these patients. Only 7 (14%) patients suffered from azygos lobe infection and were clinically cured after reasonable anti-infective treatment. Compared with the non-infected group, no valuable risk factors were found to be related to azygos lobe infection. All children who had azygos lobe infections responded to appropriate antibiotics therapy. There was no evidence that an azygos lobe was associated with recurrent infections.Conclusion: The clinical characteristics of children with azygos lobe are nonspecific and diagnosis relies on chest imaging. Some congenital abnormalities may be complicated with azygos lobe. It is reasonable to keep watch over those patients without symptoms. What is Known: • An azygos lobe is a congenital variation of the lung. • Azygos lobe can mimic various pathological conditions leading to misdiagnosis and inappropriate treatment in adults, which presents challenges during thoracic surgical interventions. What is New: • Azygos lobe in children may be complicated with other congenital abnormalities. • There is no evidence that azygos lobe is associated with recurrent infections. • After appropriate anti-infective treatment, those children with azygos lobe infections could be clinically cured.

Revising the classification of lung sequestrations

PURPOSES

The classification of lung sequestrations distinguishes between extralobar and intralobar types, according to their venous drainage - systemic vs pulmonary - and the presence or absence of independent pleura. However, imaging, surgical and/or pathological findings often differ from this description. The objectives of this article are to quantify the percentage of lung sequestrations that do not fit the classic description of extra- and intralobar types and to evaluate the accuracy of the currently used classification.

METHODS

A retrospective search identified all children with a confirmed lung sequestration diagnosed and treated in our Hospital over the last 10 years. Two senior pediatric radiologists reviewed their contrast-enhanced computed tomography chest scans and evaluated the main anatomical features that define sequestrations, including pleura, arterial and venous pattern, airways and lung parenchyma. We compared the imaging-, surgical- and pathological findings to those described for extra- and intralobar sequestrations.

RESULTS

25 children (20 M, 5 F) conform the series. Only 13 lesions (52%) filled all criteria described for an extra- or intralobar sequestration. The remaining 12 lesions (48%) had at least one differing criteria, including incomplete independent pleura (n = 2; 8%), mixed systemic and pulmonary arterial supply (n = 1; 4%) or venous drainage (n = 3; 12%), normal connection to airway (n = 1; 4%) and/or coexistent congenital lung anomalies (n = 11; 44%).

CONCLUSION

Lung sequestrations seem to represent a spectrum of anomalies rather than separated entities. Therefore, a detailed description of their main anatomical features could be more relevant for clinicians and surgeons that the rigid distinction in intra- and extralobar sequestration currently applied.

Non-operative management of extralobar pulmonary sequestration: a safe alternative to resection?

PURPOSE

This retrospective cohort study compares the natural history of patients with extralobar sequestrations (ELS) who do not undergo intervention with those who undergo resection to assess the safety of non-operative management.

METHODS

126 patients with pulmonary sequestrations or congenital pulmonary airway malformations born between 1999 and 2016 were identified. 49 patients had ELS on postnatal imaging, but two were excluded for associated congenital diaphragmatic hernia. Demographic and clinical data were retrospectively reviewed, with phone follow-up for non-operative patients with no records for > 1 year. Statistical analysis was by Fisher's exact test or Wilcoxon signed-rank test (two-tailed p < 0.05).

RESULTS

40% (19/47) were managed non-operatively and 60% (28/47) underwent resection. Non-operative patients were less likely to have an intrathoracic ELS: 47% (9/19) vs. 75% (21/28), p = 0.07. No symptoms were attributable directly to the ELS. Non-operative patients had median follow-up 3.2 years, during which time 88% (15/17) of ELS decreased in size on serial imaging. For patients who underwent resection, there was 100% concordance between imaging and intraoperative findings. There was no evidence of inflammation, infection or malignancy on final pathology, though 57% (16/28) of resected lesions had foci of non-aerated cysts.

CONCLUSIONS

Although further longitudinal study is required, this study supports the safety of non-operative ELS management.

Congenital lung lesions

Diagnosis and management of congenital lung malformations has evolved dramatically over the past several decades. Advancement in imaging technology has enabled earlier, more definitive diagnoses and, consequently, more timely intervention in utero or after birth, when indicated. These advancements have increased overall survival rates to around 95% from historical rates of 60%. However, further refinement of diagnostic technique and standardization of treatment is needed, particularly as the increased sensitivity of diagnostic imaging results in more frequent diagnoses. In this article, we provide an updated review of the diagnostic strategies, management, and prognosis of congenital lung malformations.

Noninvasive ablation of rabbit fetal and placental tissue targets in utero using magnetic resonance-guided high-intensity focused ultrasound

OBJECTIVE

Magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) is a potential noninvasive therapy for fetal conditions. In utero MRgHIFU delivery and proton resonance frequency shift (PRFS) thermometry monitoring will control accuracy of HIFU ablation and confirm in situ tissue heating in a rabbit model.

METHODS

High-resolution 3T MR images were acquired in late-gestation rabbits (approximately 30 days, n = 5). HIFU sonications, using magnetic resonance (MR) thermometry as a guide, were delivered to achieve necrosis in relevant fetal targets. Thermometry, posttreatment magnetic resonance imaging (MRI), and follow-up histology confirmed ablation.

RESULTS

Placentas (n = 14) were treated with 127 ± 34 Wac; thermometry-indicated temperatures reached 67°C. Lungs (n = 8) were treated with 85 ± 15 Wac and reached 73°C, livers (n = 6) with 80 ± 15 Wac and reached 74°C, and kidneys (n = 5) with 100 Wac and reached 66°C. Histological changes showed focal areas of necrosis with circumferential hemorrhage and/or vasodilation, which transitioned abruptly to healthy tissue.

CONCLUSION

MRgHIFU therapy can effectively target and thermally treat specific in utero organs in this acute fetal rabbit model. PRFS gives in situ temperature control of therapy on tissues. Conceivably, MRgHIFU therapy may be applicable to specific fetal organ anomalies clinically and has the potential to improve the overall fetal outcome over traditional invasive surgical procedures.

Gene expression profiling reveals differential patterns between microcystic congenital cystic adenomatoid malformation and congenital lobar emphysema

INTRODUCTION

Congenital cystic adenomatoid malformation (CCAM), especially type-III, shares similar sonographic features with congenital lobar emphysema (CLE) in routine ultrasound scan. Thus, prenatal differentiation of CLE from a microcystic CCAM is challenging and difficult in practice. Discovery of molecular biomarkers has important clinical significance.

METHODS

We profiled gene expression in lung tissue from four CCAM type-III and five CLE subjects by microarray. A bioinformatic tool was used for signal pathways enrichment analysis. Further, quantitative reverse transcriptase PCR (qRT-PCR) was used to verify the results.

RESULTS

A total of 426 genes were identified to be significantly differentially expressed (fold-change >2.0, q value <0.05) between microcystic CCAM and CLE. Of these differentially expressed genes (DEGs), 392 were upregulated and 34 were downregulated in microcystic CCAM compared with CLE. Unsupervised clustering of the "expressed" genes could clearly delineate the CCAM and CLE samples. We also confirmed that eight randomly chose genes were differentially expressed at the mRNA level between CCAM and CLE.

CONCLUSIONS

CCAM type-III and CLE have differential gene expression patterns. Our pilot study may gain a deeper understanding of the organogenetic origins and pathogenesis of these conditions. The suggestive candidates may serve as potential biomarkers for definitive diagnosis of congenital cystic lung lesions and eventually to treat them appropriately.

Prenatal diagnosis of suprarenal mass by magnetic resonance imaging: a case series

Objective: The aim of this study was to evaluate the perinatal outcomes and postnatal follow-up of prenatally diagnosed suprarenal masses (SRMs) evaluated by magnetic resonance imaging (MRI). Methods: Thirteen fetuses with SRMs detected during routine prenatal ultrasound screening were evaluated by MRI between February 2007 and May 2015. The prenatal characteristics of the masses, complications of the pregnancies, and related malformations were collected as the postnatal clinical, radiological, and pathological data. Results: The median gestational age at MRI was 30 weeks (18-41), and birth weight was 3285 (1700-3750) g. The mean follow-up period was 6 years (1.3-10). We observed 69.2% of the masses, which were predominantly cystic (69.2%), located on the left side. Associated malformations were found in 23% of the fetuses, with congenital heart defects being more prevalent. During the pregnancy, 15.4% of the fetuses had involution of the SRM, and one fetus had surgical treatment and different ultrasound and MRI diagnoses. Of the 69.2% of the cases, spontaneous resolution occurred in 30.7% during the first year of life and 38.4% the masses presented without modifications or signs of regression since the neonatal period. Conclusions: Prenatal SRMs were associated with congenital heart defects. Spontaneous regression and absence of modifications in the masses were commonly observed in the long-term follow-up of the SRMs.