Quantitative CT imaging analysis to predict pathology features in patients with a congenital pulmonary airway malformation

Neonatal Surgery for Congenital Lung Malformations: Indications, Outcomes and Association With Malignancy

AIM OF THE STUDY

Congenital lung malformations (CLM) are a heterogeneous group of anomalies diagnosed with increasing frequency antenatally. Postnatal management is dictated by the clinical status in the early neonatal period. We report our centre's experience in managing symptomatic neonates with CLM.

METHOD

Single centre retrospective review (January 1995-December 2023) of all infants with CLM that underwent thoracotomy for resectional surgery during the neonatal period. Data are quoted as median (IQR), unless stated otherwise. SPSS version 28 (IBM) and GraphPad Prism were used for analysis of data. A P value of ≤0.05 was regarded as significant.

RESULTS

During the study period 228 patients underwent surgery for CLM. Forty-nine infants (21.5 %) (33 males) required surgery during the first 30 days of life. Surgery in those infants was performed at 5 (1-10) days (emergency surgery, n = 24; expedited, n = 25). The indications included respiratory distress (n = 29; mechanical ventilation n = 16) and size of lesion (n = 20). Antenatal diagnosis was established in 45 (91.8 %) infants and 18 had undergone antenatal intervention with 7 fetuses having more than one procedure. The CLM was left sided in 29 (59 %). Postoperative stay for the surviving infants was 14 (7-21) days with extubation being achieved after 2 (1-4) days. The overall survival was 91.8 % (45/49). Infants that underwent antenatal intervention had a higher rate of postnatal pneumothorax (P = 0.01) and required higher FiO2 delivery (P = 0.01). Infants that underwent surgery in an emergency setting were found to have a higher need for antenatal intervention (P = 0.01), postnatally required intubation (P < 0.001) with higher FiO2 delivery (p < 0.001) and developed pneumothorax (P = 0.002). Histopathology findings showed the entire spectrum of CLM, with 6 cases of CPAM Type 1 associated with mucinous adenocarcinoma. Cross sectional radiological imaging was available for 31 patients and in 4 patients with malignancy, a solid component of the lesion was appreciable on CT. Median follow-up period was 6 (2.1-11) years. Sixteen (35 %) children developed a degree of chest wall deformity through none have required surgical intervention.

CONCLUSIONS

This is one of the largest series documenting the postnatal management of symptomatic neonates with CLM. One fifth of the cohort undergoing surgery for CLM required neonatal intervention. Histology at surgery was heterogeneous with 12 % of cases being associated with mucinous adenocarcinoma.

Impact of pulmonary infection on thoracoscopic surgery outcomes in children with CPAM: a retrospective study

BACKGROUND

Pulmonary infection is a common clinical complication in children with congenital pulmonary airway malformation (CPAM). Surgical intervention has been proven effective in managing this condition. We aim to evaluate the impact of pulmonary infection on the outcomes of total thoracoscopic procedures in children with CPAM.

METHODS

This was a single-center retrospective study. CPAM patients who underwent total thoracoscopic surgery at a tertiary care center from January 2013 to December 2023 were divided into three groups based on pulmonary infection status: non-infection (NI), hidden infection (HI), and pulmonary infection (PI). Clinical characteristics and operation-related outcomes were compared among the groups.

RESULTS

A total of 154 children with CPAM who underwent thoracoscopic surgery were categorized into three groups based on pulmonary infection: the NI group (27 cases), HI group (56 cases), and PI group (71 cases). The conversion rate to thoracotomy was 14.8%, 23.2%, and 29.2% respectively across the three groups. 116 cases were successfully completed thoracoscopically. There were no significant differences in gender distribution among the three groups (p > 0.05), but statistically significant (p < 0.05) in age and weight. Significant differences emerged in operative time and blood loss (p < 0.05), but no significant variations were found in transfusion requirements, chest tube duration, ventilator use duration, or hospital stay length (p > 0.05). In postoperative pulmonary complications, a statistically significant difference was found regarding pneumothorax incidence among all three groups (p < 0.05), whereas no significant differences (p > 0.05) emerged concerning atelectasis or pneumonia incidences across these cohorts.

CONCLUSIONS

Pulmonary infection is the most prevalent complication in CPAM and exhibits a high rate of hidden infections, thereby complicating surgical intervention and increasing associated risks. Early thoracoscopic intervention prior to infection manifestation can optimize surgical outcomes and reduce associated complications.

Integrative analysis of bulk and single-cell RNA sequencing reveals the gene expression profile and the critical signaling pathways of type II CPAM

BACKGROUD

Type II congenital pulmonary airway malformation (CPAM) is a rare pulmonary microcystic developmental malformation. Surgical excision is the primary treatment for CPAM, although maternal steroids and betamethasone have proven effective in reducing microcystic CPAM. Disturbed intercellular communication may contribute to the development of CPAM. This study aims to investigate the expression profile and analyze intercellular communication networks to identify genes potentially associated with type II CPAM pathogenesis and therapeutic targets.

METHODS

RNA sequencing (RNA-seq) was performed on samples extracted from both the cystic area and the adjacent normal tissue post-surgery in CPAM patients. Iterative weighted gene correlation network analysis (iWGCNA) was used to identify genes specifically expressed in type II CPAM. Single-cell RNA-seq (scRNA-seq) was integrated to unveil the heterogeneity in cell populations and analyze the communication and interaction within epithelial cell sub-populations.

RESULTS

A total of 2,618 differentially expressed genes were identified, primarily enriched in cilium-related biological process and inflammatory response process. Key genes such as EDN1, GPR17, FPR2, and CHRM1, involved in the G protein-coupled receptor (GPCR) signaling pathway and playing roles in cell differentiation, apoptosis, calcium homeostasis, and the immune response, were highlighted based on the protein-protein interaction network. Type II CPAM-associated modules, including ciliary function-related genes, were identified using iWGCNA. By integrating scRNA-seq data, AGR3 (related to calcium homeostasis) and SLC11A1 (immune related) were identified as the only two differently expressed genes in epithelial cells of CPAM. Cell communication analysis revealed that alveolar type 1 (AT1) and alveolar type 2 (AT2) cells were the predominant communication cells for outgoing and incoming signals in epithelial cells. The ligands and receptors between epithelial cell subtypes included COLLAGEN genes enriched in PI3K-AKT singaling and involved in epithelial to mesenchymal transition.

CONCLUSIONS

In summary, by integrating bulk RNA-seq data of type II CPAM with scRNA-seq data, the gene expression profile and critical signaling pathways such as GPCR signaling and PI3K-AKT signaling pathways were revealed. Abnormally expressed genes in these pathways may disrupt epithelial-mesenchymal transition and contribute to the development of CPAM. Given the effectiveness of prenatal treatments of microcystic CPAM using maternal steroids and maternal betamethasone administration, targeting the genes and signaling pathways involved in the development of CPAM presents a promising therapeutic strategy.

Congenital Cystic Adenomatoid Malformation (CCAM) Type II: A Rare Case of Sudden Infant Death

Congenital cystic adenomatoid malformation (CCAM) is a developmental lesion of the lungs and terminal respiratory structures, which is characterized by pseudocysts, lesions, and cystically dilated airways. CCAM is also known as congenital pulmonary airway malformation (CPAM). Various classification systems for CCAM have been described, and based on a recent classification, CCAMs are classified morphologically into five different types (Type 0, I, II, III, and IV) based on lesion sizes. The most common manifestation of CCAM in neonates and children is respiratory distress (RD). Spontaneous pneumothorax is a rare manifestation of CCAM. In this case report, we discuss a CCAM type-II case of a 38-day-old female infant with a radiological post-mortem diagnosis of a large left-side spontaneous pneumothorax. The gross examination of the lungs revealed multiple emphysematous air bubbles up to 0.5 cm in diameter, and the histological examination revealed focal pleural fibrosis, accompanied by thickened septa and atelectasis. In this scenario, the routine use of prenatal ultrasonography would be important to obtain a timely prenatal diagnosis. At the same time, improvements in surgical techniques, as well as greatly improved imaging techniques, have improved the outcome of these patients. Finally, it is important to remark on the importance of autopsy in the case of sudden infant death with a suspected CCAM.