Congenital bronchopulmonary malformations

Pulmonary sequestration: What the radiologist should know

Pulmonary sequestration consists of a nonfunctioning mass of lung tissue, either sharing the pleural envelope of the normal lung (intralobar) or with its own pleura (extralobar), lacking normal communication with the tracheobronchial tree and receiving its arterial supply by one or more systemic vessels. It is the second most common congenital lung anomaly according to pediatric case series, but its real prevalence is likely to be underestimated, and imaging plays a key role in the diagnosis and treatment management of the condition and its potential complications. We will give a brief overview of the pathophysiology, clinical presentation and imaging findings of intra- and extralobar pulmonary sequestration, with particular reference to multidetector computed tomography as part of a powerful and streamlined diagnostic approach.

Improved guided bone regeneration by combined application of unmodified, fresh autologous adipose derived regenerative cells and plasma rich in growth factors: A first-in-human case report and literature review

BACKGROUND

Novel strategies are needed for improving guided bone regeneration (GBR) in oral surgery prior to implant placement, particularly in maxillary sinus augmentation (GBR-MSA) and in lateral alveolar ridge augmentation (LRA). This study tested the hypothesis that the combination of freshly isolated, unmodified autologous adipose-derived regenerative cells (UA-ADRCs), fraction 2 of plasma rich in growth factors (PRGF-2) and an osteoinductive scaffold (OIS) (UA-ADRC/PRGF-2/OIS) is superior to the combination of PRGF-2 and the same OIS alone (PRGF-2/OIS) in GBR-MSA/LRA.

CASE SUMMARY

A 79-year-old patient was treated with a bilateral external sinus lift procedure as well as a bilateral lateral alveolar ridge augmentation. GBR-MSA/LRA was performed with UA-ADRC/PRGF-2/OIS on the right side, and with PRGF-2/OIS on the left side. Biopsies were collected at 6 wk and 34 wk after GBR-MSA/LRA. At the latter time point implants were placed. Radiographs (32 mo follow-up time) demonstrated excellent bone healing. No radiological or histological signs of inflammation were observed. Detailed histologic, histomorphometric, and immunohistochemical analysis of the biopsies evidenced that UA-ADRC/PRGF-2/OIS resulted in better and faster bone regeneration than PRGF-2/OIS.

CONCLUSION

GBR-MSA with UA-ADRCs, PRGF-2, and an OIS shows effectiveness without adverse effects.

Thoracoscopic management of a communicating bronchopulmonary foregut malformation in a 23-month-old child

A communicating bronchopulmonary foregut malformation is a rare anomaly characterized by a fistula between an isolated portion of respiratory tissue and the esophagus or stomach. We describe the thoracoscopic management of a communicating bronchopulmonary foregut malformation in a 23-month-old boy by division of an anomalous bronchus and right upper lobectomy.

Congenital lung lesions--underlying molecular mechanisms

Congenital lung lesions comprise a broad spectrum of rare but clinically significant developmental abnormalities, including congenital cystic adenomatoid malformation, bronchopulmonary sequestrations, congenital lobar emphysema, and bronchogenic cysts, which are commonly surgically treated. Although the terms congenital cystic adenomatoid malformation, bronchopulmonary sequestrations, congenital lobar emphysema, and bronchogenic cysts are entrenched in clinical usage and comfortably correspond to rigid pathologic definitions, there is a considerable overlap in the findings. Disregarding the controversy about lesion nomenclature and classification, it is widely accepted that congenital lung lesions result from perturbations in lung and airway embryogenesis. It is generally accepted that both place (level in the tracheobronchial tree) and timing (gestational age) of the embryologic insult correlates with the type of lesion and histopathology that is manifested. The objective of this review is to briefly review normal lung development and to analyze the known molecular mechanisms underlying those diseases.

Pulmonary congenital cystic disease in adults. Spiral computed tomography findings with pathologic correlation and management

PURPOSE

The aim of this study was to assess the computed tomography (CT) features of intrapulmonary congenital cystic diseases in adults and to correlate the imaging features with the pathological findings, with emphasis on the oncogenic potential of the lesions.

MATERIALS AND METHODS

We retrospectively reviewed the CT scans in three institutions from August 1996 to December 2008, of nine patients (six men, three women; mean age 48.6 years; range 26-75 years) who had histological diagnosis of pulmonary cystic disease after surgery. Six patients had a diagnosis of intrapulmonary bronchogenic cyst (IBC), and three had a type-I cystic adenomatoid malformation (CAM). In one case, intralobar sequestration (ILS) was associated with type-I CAM.

RESULTS

Three patients were symptomatic and six were asymptomatic. On CT scans, IBCs showed homogeneous fluid attenuation (n=2), air-fluid level (n=2), air attenuation (n=1) or soft-tissue attenuation (n=1). The surrounding lung tissue showed areas of band-like linear attenuation in three IBCs, atelectasia in two and mucocele-like areas in one. On CT, type-I CAM appeared as a unilocular cystic lesion with air-fluid level (n=1) or air content (n=1). Both cases had thin walls surrounded by normal lung parenchyma. ILS appeared as a fluid-filled cyst with afferent and efferent vessels. Of the six IBCs, one occurred in the upper right lobe, two in the middle lobe and three in the lower right lobe. Of the three type-I CAMs, one was in the upper left lobe and one in the middle lobe. The type-I CAM associated with ILS was located in the left lower lobe.

CONCLUSIONS

The similar CT patterns preclude differentiation between IBC and type-I CAM. Surgical resection of all intrapulmonary cystic lesions detected in adults is mandatory because type-I CAM is a precursor of mucinous bronchioloalveolar carcinoma.

Congenital cystic adenomatoid-like malformation in a cynomolgus monkey (Macaca fascicularis)

Congenital cystic adenomatoid malformation (CCAM) is a developmental lung abnormality characterized by abnormal proliferation of mesenchymal elements and failure of bronchiolar structures to mature, ultimately resulting in the compression of normal pulmonary tissue and mediastinal shift with rapid expansion of cysts. Although various clinical and pathologic studies of CCAM in humans exist, CCAM has yet to be reported in animals, even in nonhuman primates. In the present study, histopathologic analyses of a neonatal cynomolgus monkey that died 17 days after birth revealed that normal lung architecture was replaced by disorganized overgrowths of cysts lined with simple cuboidal epithelium. The epithelium projected a few ciliates into the air spaces and produced mucus. To our knowledge, this is the first case study describing CCAM or a CCAM-like lesion in nonhuman primates.

Pulmonary congenital cystic adenomatoid malformation, type I, presenting as a single cyst of the middle lobe in an adult: case report

BACKGROUND

Congenital cystic adenomatoid malformation (CCAM) of the lung is an uncommon fetal development anomaly of the terminal respiratory structures. The large cyst type usually occurs in stillborn infants or newborn infants with respiratory distress. Cases of CCAM have been previously described in adulthood, more often type I with multiloculated cystic lesions.

CASE PRESENTATION

We report a case of type I CCAM presenting as a single, expansive cystic mass in the middle pulmonary lobe in a 38-year-old man, revealed by persistent cough and haemoptysis. Computed tomographic scan showed a single cyst with air fluid level, occupying the lateral segment of the lobe. When the type I CCAM is a single cyst, other cystic pulmonary lesions must be excluded. The intrapulmonary localization and the absence of cartilage in the cyst wall are conclusive findings of CCAM. The pathogenesis, management and differential diagnosis with other lung malformations are discussed along with a review of the literature.

CONCLUSION

The literature data confirm that surgical resection is the treatment of choice in all cases of CCAM and in the cases of cystic pulmonary lesions with uncertain radiological findings, in order to perform a histological examination of the lesion and to prevent infection and the potential neoplastic transformation.

Intralobar sequestration presenting as a large intrapulmonary hematoma and massive hemothorax

Intralobar sequestration is a relatively rare anomaly that is usually diagnosed with symptoms of cough, expectoration, or recurrent pneumonia. We experienced a case of a 27-year-old man with a symptom of massive hemoptysis. His chest computed tomography (CT) scan revealed a large intrapulmonary hematoma and massive hemothorax, mimicking a benign lung tumor ruptured into the pleural cavity. We should keep the possibility of this anomaly in mind if a patient with hemoptysis has a cystic lung tumor and hemothorax on CT scan.

Congenital bronchopulmonary foregut malformations: concepts and controversies

This article addresses the scope, etiology, important associations and imaging features of congenital bronchopulmonary foregut malformations. Etiologic concepts, including airway obstruction and vascular anomalies, are highlighted. Technical imaging advances, especially CT and MR, have greatly enhanced our diagnostic abilities in evaluating these lesions; however, thorough and careful assessment of all aspects of the malformation is still necessary. Several specific lesions are discussed in more detail, particularly regarding controversial issues in classification, understanding, imaging and management.

Pulmonary sequestration

Pulmonary sequestration refers to the situation whereby a portion of lung tissue receives its blood supply from an anomalous systemic artery. Three main variants exist: intralobar, extralobar and communicating bronchopulmonary foregut malformations. Venous drainage is typically via a systemic vein, although drainage into the pulmonary veins is well documented. Pulmonary sequestrations are the second commonest congenital lung anomaly. Affected individuals often have other anomalies which are responsible for most of the mortality associated with sequestrations. Diagnosis requires a high index of suspicion particularly in any child with a chest x-ray suggesting the presence of a mass, those with recurrent chest infections and those with other anomalies seen with the pulmonary sequestration spectrum. Surgical excision is usually advised, although embolisation of the feeding vessel has a role in selected cases.

The multiple facets of pulmonary sequestration

PURPOSE

The goal of this study was to identify the proportion of sequestrations that were atypical or associated with other entities, such as congenital cystic adenomatoid malformations, communicating bronchopulmonary foregut malformations, bronchogenic cyst, and scimitar syndrome.

METHODS

All charts of patients with pulmonary sequestration admitted at 2 children's hospitals from 1982 to July 1999 were reviewed retrospectively. The authors included all anomalies with a systemic arterial supply or without bronchial connection.

RESULTS

Only 22 of the 39 patients (56%) had a classic isolated extralobar or intralobar sequestration, whereas the others presented with a spectrum of anomalies. Of the 13 cases diagnosed prenatally, 85% were asymptomatic at birth. In contrast, 26 cases diagnosed postnatally were all symptomatic, with those patients less than 2 weeks old presenting with various degrees of respiratory distress, and those older than 2 weeks old presenting with respiratory infections. The correct diagnosis was made preoperatively in 59% of cases. Only 4 patients did not undergo resection of their lesion, of which, 1 underwent interventional radiology with embolization of the anomalous arterial supply. Follow-up issues of importance included pneumonia, asthma, gastroesophageal reflux, and pectus excavatum.

CONCLUSIONS

Sequestrations represent a spectrum of anomalies that overlap with other lung lesions. To facilitate management, they should be described according to their (1) connection to the tracheobronchial tree, (2) visceral pleura, (3) arterial supply, (4) venous drainage, (5) foregut communication, (6) histology, (7) mixed/multiple lesions, and (8) whether there are associated anomalies. Surgeons should be aware that approximately 50% of sequestrations could be atypical or associated with other anomalies. This should be kept in mind when weighing the benefits of resection versus conservative management of pulmonary sequestrations.

Combined spinal epidural anesthesia for cesarean section in a patient with left lung agenesis

Agenesis of the lung is a rare developmental defect characterized by complete absence of one lung, or hypoplasia of one or both lungs. The majority of reported cases have been associated with other congenital anomalies. It is usually detected in childhood as a result of either pulmonary symptoms or associated anomalies. Although pulmonary agenesis has been reported in adults, there is no report of the management of a pregnant patient for cesarean section in the anesthetic literature. We report the management of a 23-year-old pregnant female at 36 weeks' gestation with oligohydramnios and left lung agenesis for elective cesarean section. She presented with a history of repeated chest infection and was found to have restrictive lung function. She had no other congenital anomalies. Combined spinal epidural anesthesia was administered for cesarean section. The intraoperative course was uneventful except for bradyarrhythmias followed by tachyarrhythmias on manipulation of the uterus. She was given low dose epidural morphine with local anesthetic and intramuscular diclofenac for postoperative analgesia. We believe that normal pregnancy can safely be undertaken in the presence of left lung agenesis. In view of associated congenital anomalies in more than 50% of the cases, anesthetic management should include a particularly careful survey of other systems. The patient should otherwise be managed like any patient with limited pulmonary reserve. Combined spinal epidural anesthesia is safe and appropriate for such patients.

Esophageal lung with multiple congenital anomalies: conundrums in diagnosis and management

BACKGROUND/PURPOSE

Communicating bronchopulmonary foregut malformations (CBPFM) are a diverse group of potentially devastating congenital anomalies with anatomy that may be difficult to delineate. The authors present a case that illustrates conundrums in the diagnosis and management of these complex disorders.

METHODS

A term baby had esophageal atresia (EA), tracheoesophageal fistula (TEF), and tetralogy of Fallot. Initially, a gastrostomy was performed, and a balloon catheter was inserted through the endotracheal tube to occlude the fistula until the patient was hemodynamically stable. Subsequently, the fistula was ligated. Postoperatively, the left lung collapsed, and bronchoscopy showed an atretic left mainstem bronchus. Repeat thoracotomy showed that the fistula ligation was intact. Air was introduced through the gastrostomy tube, and, surprisingly, the left lung inflated, indicating the left mainstem bronchus arose from the esophagus distal to the ligated TEF.

RESULTS

Despite reopening this fistula, ventilation remained poor, and support was withdrawn. Autopsy findings confirmed a unilobed left lung arising from the esophagus, EA, TEF, an atretic left mainstem bronchus, tetralogy of Fallot, and DiGeorge syndrome.

CONCLUSIONS

This is the first report of a combination of EA and distal TEF with a second CBPFM involving the esophagus and the entire left lung. Successful correction of these anomalies will require extensive delineation of the anatomy to plan an operative strategy.

Communicating bronchopulmonary foregut malformations in the adriamycin-induced rat model of oesophageal atresia

BACKGROUND

Communicating bronchopulmonary foregut malformations (CBPFM) are rare abnormalities of the development of the primitive foregut that result in an abnormal communication between the upper gastrointestinal tract and pulmonary tissue. They usually occur in isolation, but sometimes are seen in association with oesophageal atresia (OA).

METHODS

Communicating bronchopulmonary foregut malformations were induced in the offspring of pregnant rats by intraperitoneal injection of Adriamycin (Delta West Pty Ltd, Bentley, Western Australia, Australia). Fetuses harvested by caesarean section were fixed in 10% formalin, transversely sectioned and stained with haematoxylin and eosin. Serial examination of the slides allowed three-dimensional reconstruction of the anatomy of the pulmonary system and the oesophagus.

RESULTS

Communicating bronchopulmonary foregut malformations occurred in nine (30%) of fetuses with OA. Three types of CBPFM were produced: an isolated pulmonary structure (accessory lung) attached to the lower oesophagus via a patent bronchus (6 fetuses); an anomalous bronchus from the lower oesophagus to the lower part of the left lung (two fetuses); and atresia of the trachea (one fetus).

CONCLUSIONS

These observations are consistent with the assertion that CBPFM and OA are variations of a spectrum of abnormalities and may have a similar aetiology. In the rat model it would appear that Adriamycin interferes with the timing and progression of lung bud differentiation at a time when the primitive foregut is developing rapidly. Ultimately, this model may shed light on the embryogenesis of both anomalies.

Bronchopulmonary-foregut malformations: a continuum of paracrine hamartomas?

The bronchopulmonary-foregut malformations (BPFM) are usually sporadic, solitary cystic hamartomas involving conducting airways, arteries, venous drainage, and lung parenchyma. Transitional, compound hamartomas exist, and only their morphology is well-known. Between 1984-1994 we encountered and studied 10 unrelated patients and a stillborn infant with BPFM (out of 24,000 families). Ten were diagnosed in utero and one at birth as having congenital cystic adenomatoid malformation of the lung (CCAML). Postnatally, two diagnoses (20%) were corrected to bronchogenic cyst (BC) and diaphragmatic hernia, respectively. Bilateral lung involvement was present in 1 patient, and in 2 there was a considerable macroscopic regression of the hamartoma. Histologic studies of the six resected CCAML confirmed the diagnosis and implied dysregulated paracrine growth with its cellular and extracellular growth factors, protooncogenes, oncogenes, cytokines, cell-adhesive molecules, and receptors of these regulatory peptides, and their complex interactions as developmental morphogens in time and space.

Recurrent bronchogenic pseudocyst 24 years after incomplete excision. Report of a case

Bronchogenic cysts (BCs) are uncommon congenital anomalies. Due to the inherent complications, the mere presence of a BC should warrant surgical therapy. Partial excision of these structures leads to recurrence. Complete surgical excision using a thoracotomy or video-assisted thoracic surgery is the goal. We report a case of recurrent bronchogenic pseudocyst 24 years after initial excision. This case supports the argument for complete surgical excision of BCs at the time of diagnosis.

Intralobar pulmonary sequestration and mediastinal bronchogenic cyst

A patient with a bronchogenic cyst and intralobar pulmonary sequestration is presented. Chest radiography showed a posterior mediastinal mass and a computed tomographic scan of the chest revealed, in addition, an abnormality suggestive of pulmonary sequestration. This was confirmed by an aortogram. It is important to be aware of the coexistence of these anomalies to make a diagnosis preoperatively.

Unilateral pulmonary artery agenesis: a rare cause of haemoptysis and pleuritic chest pain

Haemoptysis and pleuritic chest pain are common presentations of cardiopulmonary disease. While a number of common disorders may explain these symptoms, occasionally unusual causes may emerge which should be considered in the differential diagnosis especially if pulmonary embolism is unlikely; so that inappropriate anticoagulation or thrombolytic therapy is avoided. We present a case of unilateral pulmonary artery agenesis, who presented with pleuritic chest pain and haemoptysis, and was initially treated as a case of pulmonary thromboembolism.

A rare intrapericardial mass in a neonate

We describe a rare case of a neonate born with an intrapericardial mass composed of extralobar pulmonary sequestration and a cyst of bronchogenic origin. After an uneventful delivery, this full-term newborn was noted to be grunting and indrawing. He remained tachypneic despite adequate management for bilateral pneumothoraces. Diagnostic studies showed a 3 x 3 x 4 cm diameter cystic lesion in the anterior mediastinum causing posterior-lateral displacement of the superior vena cava. The heart itself was structurally normal. Bronchoscopy and esophagoscopy failed to detect any structural abnormalities. At 3 weeks of age, sternotomy and resection of the lesion was performed. The mass was clearly intrapericardial and consisted of sequestrated pulmonary tissue with a unilocular mucus filled bronchogenic cyst. Small systemic tributaries fed the lesion from the posterior-superior aspect. There was no connection with the heart or great vessels. Postoperative recovery was uneventful.

Communicating bronchopulmonary foregut malformations: classification and embryogenesis

Communicating bronchopulmonary foregut malformations (CBPFMs) are characterized by a fistula between an isolated portion of respiratory tissue (ie, a lung, a lung lobe, or a segment) and esophagus or stomach. We combine our 30-year (1959 to 1989) experience of 6 cases with 51 reported patients to propose a CBPFM classification supported by a proposed embryogenesis theory. Group I (16%): anomaly is associated with esophageal atresia and tracheoesophageal fistula. Group II (33%): one lung originates from the lower esophagus. Group III (46%): an isolated anatomic lung lobe or segment communicates with the esophagus or stomach. Group IV (5%): A portion of the normal bronchial system communicates with the esophagus. The portion of the lung served by the communicating bronchus receives systemic blood supply. The right and left lung sacs curve dorsally to embrace the lower esophagus during normal lung development. At this stage a part of the lung bud joins the esophagus. This segment then breaks away from the main pulmonary anlage to form a CBPFM. CBPFMs should be considered in the workup of infants with respiratory distress and/or recurrent pneumonias. Patients with suspected pulmonary sequestration should undergo contrast studies to exclude a gastrointestinal communication.

Intraabdominal pulmonary sequestration

A left upper quadrant fetal abdominal mass was detected at 24 weeks gestation. The mass was again confirmed in a postnatal ultrasound. Pathological analysis of the excised mass demonstrated an intraabdominal lung sequestration with Stocker type II congenital cystic adenomatoid malformation (CCAM). The sonographic characteristic of these lesions are those of a homogeneous echogenic mass with variable shape passing through or arising from the diaphragm. Surgical excision is recommended because of the uncertainty of the preoperative diagnosis and the possibility of malignant changes in CCAM.

Neonatal pneumonectomy for isolated unilateral pulmonary artery agenesis

A 23-day-old female newborn was evaluated for acyanotic respiratory distress immediately after birth. Echocardiogram and cardiac catheterization revealed absence of the right pulmonary artery. Subsequent course was complicated by necrotizing bronchopneumonia. Despite antibiotic therapy and ventilator support she failed to improve; right pneumonectomy was performed to remove the source of sepsis. This case represents an example in which an infectious complication in a rare congenital pulmonary malformation served as an indication for neonatal pneumonectomy.

Clinical spectrum of bronchogenic cysts of the mediastinum and lung in the adult

Bronchogenic cysts are closed sacs considered to be the result of an abnormal budding of the respiratory system. They are lined by ciliated epithelium and have focal areas of hyaline cartilage, smooth muscle, and bronchial glands within their walls. They are seldom seen in the adult, and most are thought to be asymptomatic and free of complications. During a 20-year period, 86 patients underwent resection of a bronchogenic cyst of the mediastinum (66 patients) and lung (20 patients). There were 47 women and 39 men whose ages ranged from 16 to 69 years. Seventy-two percent of patients (67% with mediastinal cysts and 90% with cysts of the lung) were symptomatic at the time of operation, and the majority had two or more symptoms. Despite extensive investigations, which in some cases included computed tomographic scanning (n = 12) and angiography (n = 22), a positive diagnosis was never made preoperatively even if it was suspected in 57% of patients. In nearly all patients, the operative approach was that of a posterolateral thoracotomy. All but two mediastinal bronchogenic cysts could be locally excised, but all bronchogenic cysts of the lung required pulmonary resection (lobectomy, 13; limited resection, 6; pneumonectomy, 1). Major operative difficulties were encountered in 35 patients, all of whom were symptomatic preoperatively. Thirty-three patients had a complicated cyst; the complications consisted of fistulization (n = 16), ulcerations of the cyst wall (n = 13), hemorrhage (n = 2), infection without fistulization (n = 1), and secondary bronchial atresia (n = 1). Overall, 82% of patients had a bronchogenic cyst that was either symptomatic or complicated or both.(ABSTRACT TRUNCATED AT 250 WORDS)

Aberrant bronchi and cardiovascular anomalies

In an investigation of malformation associations in consecutive perinatal autopsies, 4 infants were identified as having a displaced or supernumerary bronchus. Each had a different type of bronchial abnormality and 3 had congenital heart defects and other malformations. Review of the literature found 38 other cases of aberrant bronchi with additional defects, especially cardiovascular or costovertebral anomalies. Structural cardiac defects were more common in patients with super-numerary tracheal bronchi (67%) than in those with displaced tracheal bronchi (27%) or bronchoesophageal connections (23%). There was also a strong negative association (P = 0.01) of cardiovascular and costovertebral defects unless multiple anomalies were present. The combinations of anomalies seen appear to reflect relatively specific developmental field defects affected both by the spatial relationships of organs near the developing foregut and by temporal sequence. Recognition of these patterns has clinical and embryological importance. Aberrant bronchi should be considered when children with cardiac defects or multiple anomalies such as the VACTERL association have unexplained respiratory symptoms and surgeons planning to treat such bronchial abnormalities should be aware of the high frequency of abnormal vessels in these cases.

Extralobar pulmonary sequestration and mediastinal bronchogenic cyst

A child with coexisting mediastinal bronchogenic cyst and extralobar pulmonary sequestration is presented. Two distinct lesions were suggested by barium esophagram and confirmed by a chest computed tomography scan. The diagnostic and embryologic relationship of the two lesions is discussed.

Review of bronchopulmonary foregut malformations

The term bronchopulmonary foregut malformation (BFM) describes rare cases of pulmonary sequestrations that communicate with the upper gastrointestinal tract. An unusual type of BFM is described; it consisted of esophageal atresia, proximal and distal tracheoesophageal fistulae, and bilateral extralobar pulmonary sequestrations communicating with a common bronchial structure that replaced the distal esophagus. This case is related to other reported cases in the literature, and serves as the basis for a proposed theory of the embryonic development of BFM.

Asymptomatic bronchogenic cyst of the mediastinum

Bronchogenic cysts of the mediastinum are benign anomalies of the ventral foregut. The majority of adult patients are asymptomatic. Chest roentgenograms and computed tomographic scans are the primary diagnostic tools. Other procedures may be required, depending on the presentation and the entities being considered. Thoracotomy and complete resection are the recommended treatment. The patient described here represents a typical case of asymptomatic bronchogenic cyst detected on routine roentgenography.