The multiple facets of pulmonary sequestration

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.

Congenital lung malformations

Congenital lung malformations (CLMs) are rare developmental anomalies of the lung, including congenital pulmonary airway malformations (CPAM), bronchopulmonary sequestration, congenital lobar overinflation, bronchogenic cyst and isolated congenital bronchial atresia. CLMs occur in 4 out of 10,000 live births. Postnatal presentation ranges from an asymptomatic infant to respiratory failure. CLMs are typically diagnosed with antenatal ultrasonography and confirmed by chest CT angiography in the first few months of life. Although surgical treatment is the gold standard for symptomatic CLMs, a consensus on asymptomatic cases has not been reached. Resection, either thoracoscopically or through thoracotomy, minimizes the risk of local morbidity, including recurrent infections and pneumothorax, and avoids the risk of malignancies that have been associated with CPAM, bronchopulmonary sequestration and bronchogenic cyst. However, some surgeons suggest expectant management as the incidence of adverse outcomes, including malignancy, remains unknown. In either case, a planned follow-up and a proper transition to adult care are needed. The biological mechanisms through which some CLMs may trigger malignant transformation are under investigation. KRAS has already been confirmed to be somatically mutated in CPAM and other genetic susceptibilities linked to tumour development have been explored. By summarizing current progress in CLM diagnosis, management and molecular understanding we hope to highlight open questions that require urgent attention.

Intralobar Pulmonary Sequestration: A Case Report

Pulmonary sequestration is a congenital lung malformation characterized by a mass of nonfunctioning lung tissue that receives its arterial supply from an aberrant systemic artery. If symptomatic, most newborns present with respiratory distress. Recurrent infection is the most common presentation after the neonatal period. It is often diagnosed prenatally and is treated with elective surgical resection between ages six and twelve months. We present a case of an infant diagnosed with congenital pulmonary airway malformation prenatally revealed to be pulmonary sequestration at the age of six months, emphasizing the need for appropriate postnatal imaging.

Intradiaphragmatic pulmonary sequestrations: a surgical challenge. Case series

Bronchopulmonary sequestrations (BPSs) are rare congenital anomalies characterized by non-functioning embryonic lung tissue receiving anomalous blood supply. They are most commonly located within the thorax (supradiaphragmatic) or into the abdominal cavity (infradiaphragmatic). Intradiaphragmatic extralobar BPs (IDEPS) are an exceptionally rare finding, representing a diagnostic and operative challenge. We report three cases of IDEPS and their surgical management, describing our experience and approach to such rare clinical entities. From 2016 to 2022, we treated 3 cases of IDEPS. Surgical techniques, histopathological findings and clinical outcomes were retrospectively evaluated for each case and compared. Three different surgical techniques were used to approach each lesion, from open thoracotomy to a combined laparoscopic and thoracoscopic approach. Histopathological analysis of the specimens revealed hybrid pathological features, proper of both congenital pulmonary airway malformation (CPAM) and extralobar pulmonary sequestration. IDEPS represent a surgical challenge for pediatric surgeons, given their complex surgical planning. In our experience, the thoracoscopic approach is safe and feasible when performed by trained surgeons, even though a combined thoracoscopic-laparoscopic approach allows for optimal vessels control. The presence of CPAM elements within the lesions supports their surgical removal. Additional studies are required to better characterize IDEPS and their management.

Arterial Embolization and Methylene Blue Injection into the Aberrant Artery in Two Infants with Intralobar Sequestration

Bronchopulmonary sequestration is a rare congenital lung dysplasia. An intralobar sequestration (ILS) is a nonfunctional mass within the lung parenchyma without bronchial communication and with aberrant systemic arterial blood supply. Surgical resection or close observation can be proposed in the management of asymptomatic and low-risk ILS, but there is a lack of consensus. Endovascular embolization before thoracoscopic resection of ILS has been described to limit perioperative bleeding. Another technique previously reported is the injection of methylene blue in the feeding artery to macroscopically mark the sequestration from the healthy lung. In that way, a nonanatomical resection can be performed instead of a lobectomy without the risk of leaving abnormal lung tissue in place. We describe the first two cases of these two techniques combined: a 3-year-old girl with an ILS in the right lower lobe with an artery originating from the abdominal aorta, and a 14-month-old girl with an ILS in the right lower lobe with an artery coming from the celiac trunk. The combination of embolization and injection of methylene blue in the aberrant artery leads to a clear macroscopic demarcation of the blue-colored ILS from the healthy lung parenchyma and allowed safe nonanatomical resection of the ILS without risk of bleeding or compromising normal lung tissue.

VATS surgical anatomical resection of bronchopulmonary sequestration presenting as chest sepsis

Background

Bronchopulmonary sequestration (BPS) is a malformation of the lungs resulting in lung tissue lacking direct communication to the tracheobronchial tree. Most cases demonstrate systemic arterial blood supply from the descending thoracic aorta, the abdominal aorta, celiac axis or splenic artery and venous drainage via the pulmonary veins with occasional drainage into azygos vein. BPS is considered a childhood disease and accounts for 0.15–6.40% of congenital pulmonary malformations. BPS is divided into intralobar sequestrations (ILS) and extralobar sequestrations (ELS) with ILS accounting for 75% of all cases.

Methods

Here we present our 11-year experience of dealing with BPS; all cases presented with recurrent chest sepsis in young-late adulthood regardless of the type of pathological sequestration. The surgical technique employed was a minimally invasive video-assisted thoracoscopic anterior approach (VATS).

Results

Between May 2010 and September 2021, we have operated on nine adult patients with bronchopulmonary sequestration who presented late with symptoms of recurrent chest sepsis. Most patients in the cohort had lower lobe pathology, with a roughly even split between right and left sided pathology. Moreover, the majority were life-long never smokers and an equal preponderance in males and females. The majority were extralobar sequestrations (56%) with pathological features in keeping with extensive bronchopneumonia and bronchiectasis. There were no major intra-operative or indeed post-operative complications. Median length of stay was 3 days.

Conclusions

Dissection and division of the systemic feeding vessel was readily achievable through a successful anterior VATS approach, regardless of the type of sequestration and without the use of pre-operative coiling of embolization techniques. This approach gave excellent access to the hilar structures yet in this pathology, judicious and perhaps a lower threshold for open approach should be considered.

Management Options for Fetal Bronchopulmonary Sequestration

To evaluate the prenatal course and perinatal outcome of fetuses with bronchopulmonary sequestration (BPS) managed expectantly or using minimally invasive methods. This was a retrospective study of 29 fetuses with suspected BPS managed between 2010 and 2021 in three fetal medicine centers in Poland. Medline was searched to identify cases of BPS managed expectantly or through minimally-invasive methods. In 16 fetuses with BPS, there was no evidence of cardiac compromise. These fetuses were managed expectantly. Thirteen hydropic fetuses with BPS qualified for intrauterine intervention: a thoraco-amniotic shunt (TAS) was inserted in five fetuses, laser coagulation of the feeding vessel was performed in seven cases, and one fetus had combined treatment. In the combined data from the previous and the current study of various percutaneous interventions for BPS associated with hydrops, the survival rate was 91.2% (31/34) for TAS, 98.1% (53/54) for laser coagulation, and 75% (3/4) for intratumor injection of sclerosant. After taking into account cases with available data, the rate of preterm birth before 37 weeks in the group treated with laser coagulation was 14.3% (7/49) compared to 84.6% (22/26) in the group treated with TAS. The need for postnatal sequestrectomy was lower in the group of fetuses treated with laser coagulation 23.5% (12/51) in comparison to fetuses treated with TAS 84% (21/26). In fetuses with BPS without hydrops, progression of the lesion’s volume, leading to cardiac compromise, is unlikely. In hydropic fetuses with BPS, intrauterine therapy using minimally invasive methods prevents fetal demise. Both, the rate of preterm birth and the need for postnatal surgery is significantly lower in the group treated with laser coagulation compared to the group treated with TAS.

An adult with episodic retrosternal chest pain: an unusual presentation of congenital pulmonary airway malformation - case report

Background

Congenital pulmonary airway malformation (CPAM) with partial anomalous pulmonary venous connection presenting as episodic retrosternal chest pain on exertion in an adult has not been described.

Case presentation

A 21-year-old female, non-smoker, presented with a 4-year history of sharp, episodic, retrosternal chest pains brought on with exercise. A contrast-enhanced computed tomography (CT) scan showed a grossly overinflated left lower lobe with partial anomalous pulmonary venous drainage into the left hemi-azygos vein. Lobectomy, the recommended treatment of choice, carried out thoracoscopically, was curative with satisfactory mid-term results. Histology confirmed type-II congenital pulmonary airway malformation.

Conclusions

CPAM can present in young adults with unusual symptoms of chest pain on exertion. When suspected a contrast-enhanced CT scan is the gold standard for establishing the diagnosis. An anatomical lung resection is curative with satisfactory medium term results.

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.

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.

How to optimize the treatment strategy for patients of pulmonary sequestration with an elevated risk of fatal hemorrhage during operation: case discussion

Video-assisted thoracoscopic surgery (VATS) lobectomy, especially uniportal VATS, is increasingly used for pulmonary sequestration (PS). However, there are few descriptions of safe handling of the aberrant artery with atherosclerosis, especially the diameter of arteries exceeds than 2.0 cm, under uniportal VATS approach. Here we report a 56-year-old man who was diagnosed with pulmonary sequestration following trauma. The patient had a long history of cough with purulent sputum. One month before the trauma, he had copious expectoration with foul smell again. A contrast CT scan revealed a 7.5 cm mass in his right lower lobe. The mass was supplied by a thick aberrant atherosclerotic artery (over than 2 cm in diameter), which stemmed from the thoracic aorta with multiple calcifications on both. After adequate preoperative evaluation, we performed a right lower lobectomy under uniportal VATS approach. No surgical-associated complications occurred, and the patient was discharged on the 5th days after the operation. We organized an iMDT (international multidisciplinary team) to discuss the reasonability and optimal treatment pattern for this patient. We found that fully assess the quality of the aberrant arteries of PS following blocking and cutting off in an appropriate way are crucial to avoid the happening of fatal bleeding during the operation.

Intraoperative real-time hemodynamics in intralobar pulmonary sequestration using indocyanine green and near-infrared thoracoscopy

A 33-year-old man with left pulmonary sequestration was admitted to our hospital. We planned left basilar segmentectomy to preserve the lung function, using indocyanine green (ICG) and near-infrared thoracoscopy. The intravenous (IV) administration of ICG (0.1 mg/kg) showed the distribution of fluorescence from the aberrant arteries, blood flow blockage from the aberrant arteries after they were divided, and the superior-basal boundary after the pulmonary artery and vein were divided. In adult patients with intralobar pulmonary sequestration, ICG and near-infrared thoracoscopic techniques are useful to confirm abnormal hemodynamics and demonstrate a safe and successful basilar segmentectomy.

STARD-compliant article: Comparison of pulmonary sequestrations with thoracic and abdominal aortic arterial supply

Pulmonary sequestrations (PS) are typically supplied by a vessel originating from thoracic aorta, or abdominal aorta. Differences in imaging features between these PS subtypes have not been described.To analyze the imaging features of PS with arterial supply from the thoracic and abdominal aorta.Retrospectively, 23 pathologically proven cases of pulmonary sequestration were analyzed and compared based on the site of feeding artery origin.In 21 cases (21/23), the PS was soft tissue density. 1 (1/23) PS was purely cystic and another heterogeneous with both cystic and solid components (1/23). In 16/23 cases, the feeding vessel(s) arose from the thoracic aorta (male:female ratio 1:7) and in 7/23 cases from the abdominal aorta (male:female ratio 4:3). Feeding vessels from the thoracic aorta were duplicated in 7/16 cases. PS location (P <.05) and size (P <.001) differed based on the origin of the feeding vessel (thoracic aorta: 14/16 left lower lobe, mean volume 962.97 mL; abdominal aorta: 3/7 left lower lobe, mean volume 1120.89 mL). The feeding arteries themselves differed in size depending on their site of origin (thoracic aorta: mean diameter 7.0mm ± 2.7 mm, mean length 44.6mm ± 10.9 mm; abdominal aorta: mean diameter 3.3mm ± 0.6 mm, mean length 103.6mm ± 34.5 mm).PS size and distribution differ depending upon the site of feeding vessel origin as does the size of the feeding vessel itself.

Coil embolization of intralobar pulmonary sequestration - an alternative to surgery: a case report

BACKGROUND

Pulmonary sequestration is a congenital lung disease characterized by nonfunctioning pulmonary tissue that lacks normal communication with the bronchial tree and is supplied by a nonpulmonary systemic artery. Symptomatic bronchopulmonary sequestration is uncommon, seen more frequently in the pediatric population than in adults. It has traditionally been treated with surgical resection; however, a limited but growing number of cases have been treated with angiographic embolization. Given the inherent risks of cardiothoracic surgery, embolization of the anomalous vessel is an enticing alternative treatment. We present a case of a 56-year-old woman with known, symptomatic, intralobar pulmonary sequestration that was successfully treated with coil embolization.

CASE PRESENTATION

A 56-year-old Pacific Islander woman with a history of chronic myeloid leukemia was admitted to the hospital with an episode of hemoptysis. Computed tomography of the chest demonstrated left lower lobe intralobar pulmonary sequestration fed by a large tortuous vessel branching off of the descending thoracic aorta. Surgical resection of the sequestration is the current standard treatment strategy of symptomatic intralobar pulmonary sequestration. The cardiothoracic surgeon noted that given the size and location of arterial blood supply, intervention would involve thoracotomy and lobectomy. The interventional radiologist offered embolization of the lesion as an alternative to surgery. Multiple coils, 6-13 mm in size, were used to embolize the sequestration. No considerable flow distal to the coils was noted postembolization.

CONCLUSIONS

Intralobar pulmonary sequestration is a rare condition that typically requires surgical management. This case demonstrates the efficacy of coil embolization as an alternative management strategy. To date, limited case reports of adults treated with endovascular embolization exist. Treatment of symptomatic pulmonary sequestration with embolization can be considered as an alternative to surgical resection.

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

OBJECTIVES

To assess the ability of prenatal ultrasound (US) in identifying systemic feeding arteries in bronchopulmonary sequestrations and hybrid lesions and report the ability of US in classifying bronchopulmonary sequestrations as intralobar or extralobar.

METHODS

Institutional Review Board-approved radiology and clinical database searches from 2008 to 2015 were performed for prenatal lung lesions with final diagnoses of bronchopulmonary sequestrations or hybrid lesions. All patients had detailed US examinations, and most patients had ultrafast magnetic resonance imaging (MRI). Lesion location, size, and identification of systemic feeding arteries and draining veins were assessed with US.

RESULTS

The study consisted of 102 bronchopulmonary sequestrations and 86 hybrid lesions. The median maternal age was 30 years. The median gestational age was 22 weeks 5 days. Of bronchopulmonary sequestrations, 66 had surgical pathologic confirmation, and 100 had postnatal imaging. Bronchopulmonary sequestration locations were intrathoracic (n = 77), intra-abdominal (n = 19), and transdiaphragmatic (n = 6). Of hybrid lesions, 84 had surgical pathologic confirmation, and 83 had postnatal imaging. Hybrid lesion locations were intrathoracic (n = 84) and transdiaphragmatic (n = 2). Ultrasound correctly identified systemic feeding arteries in 86 of 102 bronchopulmonary sequestrations and 79 of 86 hybrid lesions. Of patients who underwent MRI, systemic feeding arteries were reported in 62 of 92 bronchopulmonary sequestrations and 56 of 81 hybrid lesions. Ultrasound identified more systemic feeding arteries than MRI in both bronchopulmonary sequestrations and hybrid lesions (P < .01). Magnetic resonance imaging identified systemic feeding arteries that US did not in only 2 cases. In cases in which both systemic feeding arteries and draining veins were identified, US could correctly predict intrathoracic lesions as intralobar or extralobar in 44 of 49 bronchopulmonary sequestrations and 68 of 73 hybrid lesions.

CONCLUSIONS

Ultrasound is most accurate for systemic feeding artery detection in bronchopulmonary sequestrations and hybrid lesions and can also type the lesions as intralobar or extralobar when draining veins are evaluated.

Bronchopulmonary foregut malformation presenting as extralobar pulmonary sequestration associated with a bronchogenic cyst: an unusual clinical and radiological feature in an adolescent patient

We present a case of symptomatic complex bronchopulmonary foregut malformation (BPFM), including extralobar pulmonary sequestration and a bronchogenic cyst, in the left anterior mediastinum of a 15-year-old boy. Preoperative computed tomography showed a cystic mass with heterogeneous enhancement of adjacent soft tissue components and pleural effusion. We suggested the infected bronchogenic cyst as the first impression. However, pathological examination after surgical resection revealed extralobar pulmonary sequestration and a bronchogenic cyst with unusual manifestation, which was located in the left upper hemithorax and supplied by the pulmonary artery. In patients presenting with a cystic mass with features of inflammation or infection and collateral vasculature, the possibility of a complex bronchopulmonary foregut malformation should be considered in the differential diagnosis.

Transarterial embolization of intralobar pulmonary sequestration in a young adult with hemoptysis

Intralobar pulmonary sequestration is a rare congenital malformation characterized by the presence of dysplastic lung that does not communicate with the tracheobronchial tree, and has aberrant systemic arterial supply. While most are asymptomatic, they rarely can present with hemoptysis, which has been traditionally managed with surgical resection of the sequestration. We report a case of an 18-year-old male who presented with acute large-volume hemoptysis on a background of recurrent minor episodes of hemoptysis, due to intralobar sequestration. He was successfully treated with transarterial embolization with a combination of polyvinyl alcohol (PVA) particles, gelfoam and coils. Transarterial embolization can be effective in managing emergent hemoptysis from pulmonary sequestration.

Congenital Lung Malformations: Shifting from Open to Thoracoscopic Surgery

BACKGROUND

Over the years the need for surgical treatment, timing of intervention, and the type of surgical approach have been discussed, but the treatment of congenital lung malformations remains controversial. The aim of this study was to compare the thoracotomy approach with the thoracoscopic technique by evaluating different surgical outcomes (duration of surgery, postoperative hospital stay, and complications).

METHODS

All patients operated from January 2011 to March 2015 for suspected congenital cystic lung were included in the study. Patients treated for congenital lobar emphysema and tracheobronchial neoplasms were excluded from the study.

RESULTS

In the analyzed period, 31 asymptomatic patients were treated: 18 lung resections were performed with thoracotomy (Group A) and 13 with the thoracoscopic approach (Group B). No significant differences were observed between the age and weight at surgery, length of the procedures, complications, and the need for postoperative intensive care between the two groups. The postoperative hospital stay in Group A was twice that for Group 2 (p = 0.0009).

CONCLUSION

Comparing thoracoscopic surgery with the traditional open approach, we confirmed the superiority of minimally invasive treatment in terms of postoperative hospital stay. Common technical recommendations can help pediatric centers to develop the thoracoscopic approach for the treatment of congenital pulmonary malformations.

Presentation and management of pulmonary sequestration with total visceral inflow and outflow

Two of the most common types of congenital thoracic malformations are congenital pulmonary airway malformations (CPAMs) and bronchopulmonary sequestrations (BPS). Here we present the first known case of a hybrid lesion, with coexisting features of an extralobar sequestration (ELS) and CPAM type 2, with arterial inflow from the celiac trunk and venous outflow to the portal vein. The clinical presentation, investigative imaging and timing of surgery are discussed.

Prenatal and Postnatal Management of Congenital Pulmonary Airway Malformation

Congenital pulmonary airway malformation (CPAM) is one of the most common lung lesions detected prenatally. Despite the research efforts made in the past few years, controversy and lack of clarity in the literature still exist regarding nomenclature, classification, pathogenesis and the management of CPAM. Therefore, it is of greatest importance to delineate the natural history of CPAMs and to create a consensus to guide the management and follow-up of these lesions. This review will focus on classification systems, highlighting the most recent advancements in pathogenesis, and current practice in the prenatal diagnosis of CPAM. Strategies of prenatal management and postnatal management will be reviewed. Long-term follow-up, including lung cancer risk, is discussed and an outcome perspective is presented.

A case of concomitant intralobar bronchopulmonary sequestration and situs inversus totalis

BACKGROUND AND AIMS

Situs inversus is a rare congenital abnormality involving partial or complete transposition of the thoracic or abdominal viscera. In situs inversus totalis, both the thoracic and abdominal viscera are transposed. The incidence of this condition is 0.01% to 0.02%. Bronchopulmonary sequestration (BPS) is a rare congenital abnormality of the respiratory tract with an incidence of 0.15% to 1.80%. Intralobar sequestration is uncommonly associated with congenital anomalies.

METHODS

A routine chest X-ray of a 41-year-old asymptomatic man showed dextrocardia, a left-sided liver, right-sided stomach, and left paracardiac opacity.

RESULTS

Computed tomography (CT) and CT pulmonary angiography revealed dextrocardia with situs inversus totalis and left paracardiac intralobar BPS in the lingular segment of the left upper lobe.

CONCLUSION

We present a rare case of combined situs inversus totalis and intralobar BPS with an atypical location and feeder artery.

Pleura nodosum: fetal squamous debris in an unusual location

We present a pathologic-radiologic case of a fetus with a right extralobar bronchopulmonary sequestration that required intervention in the form of a thoraco-amniotic shunt for management of a right pleural effusion. The intervention was successful in reducing the pleural effusion and the infant was born at 39 weeks gestational age but required some respiratory support for the 1st day of life. The pulmonary sequestration was excised on day 7 of life and demonstrated several small nodules on its pleural surface. Histologic examination demonstrated that the nodules consisted of granulomatous plaques containing squamous epithelium and hairs. The nodules are similar to those described in amnion nodosum, when the amniotic membrane incorporates fetal skin within the superficial tissue layers of the placenta in cases of oligohydramnios. To our knowledge, this is the 1st reported case of nodules containing amniotic fetal squamous debris to occur on lung visceral pleura.

Cystic lung lesions in newborns and young children: differential considerations and imaging

Numerous diverse entities produce cystic lung changes in neonates and young children. This review provides an evidence-based, age-appropriate, differential diagnostic framework to use when confronted with pulmonary cystic changes. The categories of diseases that have been discussed include congenital cystic bronchopulmonary malformations, neoplastic conditions, infections, collagen or soft tissue abnormalities, and mimics of cystic lung disease. An understanding of the pathophysiology, imaging appearance, and demographics of these entities is essential in guiding optimal care. Important educational points include differentiating bronchopulmonary malformations from neoplasms and the management and surveillance of lung cysts in young children.

Intradiaphragmatic extralobar pulmonary sequestration in adult

Extralobar pulmonary sequestrations may be located in intrathoracic or extrathoracic areas. Extrathoracic intradiaphragmatic extralobar pulmonary sequestrations are an extremely rare subset of bronchopulmonary sequestrations and there have been very few reported cases until now. We describe a 48-year-old Korean woman found to have left peridiaphragmatic lesion on computed tomography. We performed thoracoscopic surgery and successfully resected the tumor. Based on the histological findings, it was diagnosed as an intradiaphragmatic extralobar pulmonary sequestration. Postoperative course was uneventful. Intradiaphragmatic extralobar pulmonary sequestration in adult is extremely rare, so we report the case with a literature review.

Successful endovascular treatment of bilateral intralobar pulmonary sequestration with a bridging isthmus in a child

Pulmonary sequestration refers to aberrant formation of segmental lung tissue that has no connection with the bronchial tree and receives a blood supply from a systemic artery. Bilateral pulmonary sequestration, especially with a bridging isthmus is extremely rare. Although endovascular treatment is regarded as the less invasive alternative for the treatment of pulmonary sequestration, all previously reported bilateral pulmonary sequestrations have been treated surgically. We report the case of a 13-year-old girl who underwent successful endovascular treatment for bilateral pulmonary sequestration with a bridging isthmus. Thoracic CT angiography showed a heterogeneous mass-like consolidation in the both lower lobes connected each other via a bridging isthmus behind the heart. CT also demonstrated an aberrant artery, which originated from the celiac trunk, supplied the sequestration of the left lower lobe, and that a branch from the aberrant artery traversed to the sequestration in the right lower lobe. After percutaneous endovascular embolization using microcoils and gelfoam, the patient had no complications and the bilateral sequestration showed markedly decrease in the size.

Retrospective study of prenatal diagnosed pulmonary sequestration

PURPOSE

To describe the prenatal findings, treatments and outcomes of fetuses with pulmonary sequestrations (PS), which were retrospectively studied.

METHODS

From May 2010 to January 2013, 292 women were referred to the Guangdong Women and Children Hospital, Guangzhou because obstetric ultrasound had demonstrated fetal lung lesions. In 68 fetuses, the echogenic lung masses were pulmonary sequestrations deriving arterial blood supply from clearly identifiable systemic arteries rather than the pulmonary artery. We examined records of the 68 fetuses and measured the lesions and congenital cystic adenomatoid malformation volume ratio (CVR), provided prenatal counseling and treatment, documented the CVR, location of lesion, gestational age at diagnosis, need for fetal intervention, perinatal clinical course (including the development of hydrops, effusions, and neonatal respiratory distress), gestational age at delivery, postnatal ultrasound and CT, operation treatment, survival and pathology.

RESULTS

There were 68 PS in our study. All of 56 cases with CVR ≤ 1.6, survived without prenatal hydrops or postnatal respiratory symptoms. In 12 cases with CVR >1.6, 7 cases (58.3 %, 7/12) had hydrops, 10 cases (83.3 %, 10/12) survived, 2 cases (16.7 %, 2/12) of induced abortion, 8 cases (66 %, 8/12) were postnatal symptomatic. There was statistical significant difference in the incidence rate of hydrops and postnatal respiratory symptoms between the PS with CVR ≤ 1.6 and that with CVR >1.6. 66 cases postnatal survived, two cases of induced abortion. 64 cases had no prenatal treatment, two cases underwent thoracoamniotic shunt. The mean gestational age at birth was 38 weeks (range 34-40 weeks). 21 asymptomatic cases had no surgery. 45 cases (8 symptomatic and 37 asymptomatic) underwent surgical resections, 43 cases without postoperative complications, two cases of postoperative pneumothorax, no wound infection. Postoperative follow-up showed good growth in all surgery cases.

CONCLUSION

PS specific absence of hydrop was a congenital disorder with an excellent prognosis. CVR >1.6 was associated with fetal hydrops and postnatal symptoms. However, absolute CVR value cannot be used to select fetuses for fetal treatment before the development of hydrops. Surgery of PS in neonates or infants presented a good outcome.

Pulmonary atresia with ventricular septal defect and pulmonary sequestration

A 5-day-old girl who had pulmonary atresia with ventricular septal defect, patent ductus arteriosus, intralobar pulmonary sequestration of the right lower lobe, and retroesophageal innominate vein, was referred to our institution. We successfully performed a systemic-to-pulmonary shunt. During cardiopulmonary bypass, the arteries supplying the sequestrated lung were ligated above the diaphragm through the median sternotomy, without a thoracotomy. The postoperative course was uneventful, and we avoided the potential complications of lung infection and ventricular overload.

Embolization versus surgical resection of pulmonary sequestration: clinical experiences with a thoracoscopic approach

PURPOSE

The goal of this study was to compare the safety and efficacy of treatment for pulmonary sequestration (PS) by transcatheter arterial embolization (TAE) versus surgical resection and to consider the role of a thoracoscopic approach.

METHODS

A retrospective review involving 73 children (≤ 15 years of age) with PS between 2002 and 2011 was performed.

RESULTS

Forty-two patients were managed with TAE, and 31 underwent surgery alone. Their presenting symptoms were pneumonia (n=11), pneumothorax (n=2), pneumomediastinum (n=1) and respiratory distress (n=6).Fifty-three (72.6%) were asymptomatic. The average age at treatment was 17.0 ± 44.4 and 31.3 ± 41.7 months for the TAE and surgery groups, respectively. In the TAE group, complete regression was observed in only 3 patients, 4 showed no regression, and 35 (83.3%) had residual lesions. Four patients developed sepsis or other blood vessel complications after TAE. The results of resection via thoracotomy versus a thoracoscopic approach were evaluated in 34 patients, including 3 who underwent the operation after TAE. Twenty-seven patients underwent thoracotomy, and 7 underwent thoracoscopic resection. There were no significant differences between the groups except time to chest tube removal, which was shorter in the thoracoscopic group (p=0.046). Complications included a wound infection in 1 patient after thoracotomy.

CONCLUSIONS

We believe that even in asymptomatic patients, all PSs should be resected because of the risk of infection, the low rate of natural regression, complications after TAE, and to exclude other pathology. Our experience also shows that thoracoscopic resection of PS is feasible, efficacious, and safe in newborns and infants.

Laparoscopic resection of an intradiaphragmatic pulmonary sequestration: a case report and review of the literature

Extralobar pulmonary sequestrations have been occasionally described in the abdomen but rarely in the diaphragm. We present the case of a 10 month old girl with an intradiaphragmatic pulmonary sequestration. The minimally invasive operative technique is outlined in detail, including the combine use of laparoscopy and thoracoscopy. The case is discussed and the literature is reviewed.

The clinical value of computer tomographic angiography for the diagnosis and therapeutic planning of patients with pulmonary sequestration

OBJECTIVES

This study was conducted to evaluate the clinical value of computed tomographic (CT) angiography for diagnosis and therapeutic planning in patients with pulmonary sequestration.

METHODS

Forty-three patients with suspected pulmonary sequestration underwent CT angiography before undergoing digital subtraction angiography or surgery. For each patient, CT angiography was used to determine whether the pulmonary sequestration was suitable for coil embolization, surgical resection or conservative treatment. The treatments planned using CT angiography were compared with actual treatment decisions made or treatments administered using digital subtraction angiography or surgery.

RESULTS

Digital subtraction angiography and/or surgery confirmed pulmonary sequestration in 37 patients; six patients had no pulmonary sequestration. The diagnostic performance of CT angiography for pulmonary sequestration in the patient-based evaluation yielded an accuracy of 97.7%, sensitivity of 97.3%, specificity of 100%, positive predictive value (PPV) of 100% and negative predictive value (NPV) of 85.7%. The aberrant systemic artery-based evaluation yielded an accuracy of 98.0%, sensitivity of 97.8%, specificity of 100%, PPV of 100% and NPV of 85.7%. Treatments could be correctly planned using CT angiography with 100% accuracy, sensitivity, specificity, PPV and NPV according to the aneurysm-based evaluation.

CONCLUSIONS

We have obtained promising results with a CT angiography-based protocol, rather than a digital subtraction angiography-based protocol, as the only diagnostic and pretreatment planning tool in patients with pulmonary sequestration. The CT angiography-based selection of treatment strategies seems to be safe and effective in the majority of patients with pulmonary sequestration.

The diagnosis and management of intradiaphragmatic extralobar pulmonary sequestrations: a report of 4 cases

BACKGROUND/PURPOSE

Intradiaphragmatic extralobar pulmonary sequestrations (IDEPSs) are a rare subset of bronchopulmonary sequestrations (BPS). We report the largest series of patients with IDEPS and describe the diagnostic and operative challenges associated with this condition.

METHODS

We retrospectively reviewed our experience with fetal and pediatric BPS from 1995 to 2010 to identify patients with IDEPS.

RESULTS

We identified 27 patients with BPS and 4 patients in whom the masses were within the diaphragm. In 1 patient, the prenatal ultrasound correctly identified the mass as being within the diaphragm itself, whereas the remaining cases were thought to be intraabdominal or had discordant preoperative imaging findings. The diagnosis of an IDEPS proved challenging to make prospectively using prenatal ultrasound, computed tomography, or magnetic resonance imaging. All patients underwent attempted resection. Two cases required a combined laparoscopic and thoracoscopic approach to accurately localize the mass. The postoperative recovery of these patients was uneventful.

CONCLUSIONS

We present the largest reported experience of IDEPS. Because preoperative imaging studies cannot always determine whether a sequestration is intraabdominal, intrathoracic, or intradiaphragmatic, operative planning may pose a challenge. However, the use of minimally invasive approaches can allow exploration of both the thoracic and abdominal cavities with low morbidity.

Congenital lung lesions

Confusion, controversy, and uncertainty are all terms applicable to the diagnosis and management of congenital lung lesions both prenatally and postnatally. This review examines the current status of fetal diagnosis and treatment of these lesions; reviews the various classifications, including congenital cystic adenomatoid malformation/congenital pulmonary airway malformation, sequestrations, variants and hybrid lesions; discusses the risk of malignant transformation or misdiagnosis with pleuropulmonary blastoma; presents the arguments in favor and against resection of asymptomatic lesions, the timing of such resection, and the long-term pulmonary function after resection; and reviews the experience with thoracoscopic resection of congenital lung lesions.

[Congenital lung malformations: natural history and pathophysiological mechanisms]

INTRODUCTION

Congenital lung lesions comprise a broad spectrum of various malformations including congenital cystic adenomatoid malformation (CCAM), bronchopulmonary sequestration (BPS), congenital lobar emphysema, bronchial atresia and bronchogenic cyst. This review aims at the description of their natural history, and of the underlying pathophysiological mechanisms.

STATE OF THE ART

Congenital lung lesions are frequently diagnosed antenatally and many remain asymptomatic after birth. In the absence of antenatal identification, they are usually revealed by the occurrence of infection. In some cases, spontaneous resolution of the malformation can occur. Different pathogenic hypotheses are discussed for the origin of these abnormalities, and common processes appear likely to all of these malformations. Factors involved in the process of branching seem to play a particularly important role.

PERSPECTIVES

Prospective follow-up of operated and unoperated children would complete our knowledge about the natural history of these lesions. The contribution of experimental models has led to advances in the understanding of pathogenic mechanisms. Further studies are needed to identify the factors initiating the malformative process.

Pulmonary sequestration and diaphragmatic eventration in a 6-month-old infant

A congenital pulmonary malformation, such as pulmonary sequestration or congenital cystic adenomatoid malformation, should be suspected in infants with recurrent lower respiratory symptoms or unifocal infiltrations. The possibility of congenital pulmonary malformation associated with additional abnormalities, such as diaphragmatic hernia, is relatively high and can lead to misdiagnosis. We report a case of a 6-month-old girl who presented with relapsing respiratory infection and hematemesis. Computerized axial tomography scan and barium swallowing study were performed, revealing a suspected intralobar pulmonary sequestration associated with sliding gastric hernia. Since the patient's condition was complicated by sliding hernia, pneumonia and pleural effusion, a surgical procedure instead of cardiac catheterization with coil embolization was performed. During surgery, the absence of a sliding gastric hernia but a diaphragmatic eventration was noted. Only a partial portion of the left-side diaphragm was relaxing, making the barium swallowing study difficult to interpret. This case serves as a reminder that if pulmonary sequestration is suspected, a full work-up with a complete set of imaging studies should be ordered for the possible detection of associated gastrointestinal, respiratory and thoracic abnormalities.

Grayscale and Doppler sonographic evaluation of response to in utero treatment of hydrops fetalis caused by extralobar pulmonary sequestration

Pulmonary sequestration is defined as nonfunctional lung tissue that lacks communication with the bronchial tree and that is supplied by an anomalous systemic vessel. In comparatively rare cases, pulmonary sequestration may lead to hydrothorax or hydrops fetalis, which is nearly universally fatal. In this report, we describe a case of pulmonary sequestration with hydrops fetalis, which was successfully treated by thoracoamniotic shunting. A sonographic Doppler study in this case suggested that the underlying mechanism of the hydropic change in a fetus with extralobar pulmonary sequestration may have differed from that in fetuses with primary hydrothorax not associated with a structural anomaly.

[Pulmonary sequestration and enteric cyst, 2 expressions of the same abnormality]

We report the case of an 18-month-old boy operated on for a right lower lobe bronchopulmonary sequestration. At the immediate postoperative check-up, a septic right thoracic effusion appeared, connected to a cystic mediastinal retrocrural formation on CT. After a drainage attempt and medical therapy, the abdominal lesion was resected. Histological examination showed that the cyst cavity was lined with pseudostratified non-ciliated epithelium, without cartilage, consistent with an enteric cyst. Regardless of the embryological theory, a literature review confirmed that in presence of one of these two lesions, one should systematically look for the other.

Factors associated with partial and complete regression of fetal lung lesions

OBJECTIVE

A decrease in the volume of congenital pulmonary malformations (CPM) can be observed on prenatal ultrasonography, but the underlying mechanism for this phenomenon is unknown. Our objective was to identify factors associated with the prenatal reduction in size of cystic and/or hyperechoic lung lesions.

METHODS

This was a retrospective study of cases with a prenatal diagnosis of hyperechoic and/or cystic lung lesion. The extent of reduction in lesion size was calculated from ultrasound measurements. Clinical, ultrasound, radiological and histological data were tested for their relationship with prenatal CPM reduction.

RESULTS

In a 4-year period, 36 patients were referred with a cystic and/or hyperechoic fetal lung lesion diagnosed at a mean gestational age of 23.4 weeks. The lesions were cystic in 16 cases (44%), hyperechoic in 12 (33%) and both in eight (22%). The malformation was no longer visible before birth (apparent disappearance) in nine cases (25%), shrank by 18-90% in 15 (42%) and did not reduce in 12 (33%). Findings on postnatal computed tomography were always abnormal. Isolated hyperechoic lesions were significantly more likely to shrink in utero. The mean reductions were 79%, 35% and 19%, for isolated hyperechoic, cystic and mixed lesions, respectively (P=0.001). Only 8% of hyperechoic lesions demonstrated no volume reduction, as compared to 50% and 42% of cystic and mixed lesions, respectively (P=0.03). Greater gestational age at birth was also associated with a decrease in the incidence of malformations (P=0.02). In cases that underwent surgery, hyperechoic lesions were linked to a variety of pathological diagnoses, whereas cystic lesions were all described histologically as congenital cystic adenomatoid malformations.

CONCLUSIONS

Prenatal size reduction of fetal lung malformations is associated with isolated hyperechogenicity and greater gestational age at birth. This might result from the resumption of normal lung development after local disruption of lung growth.

Double venous drainage in scimitar syndrome. Ideal anatomy for percutaneous complete cure

Congenital venolobular or scimitar syndrome is a rare congenital cardiopulmonary anomaly consisting in a partial anomalous pulmonary venous drainage, lung hypoplasia, and anomalous systemic arterial supply to the lung. It can associate with other congenital disorders which will confer the clinical presentation and prognosis of these patients. In most of the cases, the therapeutic approach is partial, as anatomy allows only aberrant arterial embolisation. We present a 6-year-old girl with recurrent pulmonary infections, diagnosed as scimitar syndrome with double collector drainage to the inferior caval vein and left atrium, undergoing interventional catheterisation for complete correction of her disorder. The anomalous systemic artery supply was embolised and the anomalous venous drainage was occluded. The patient was asymptomatic during follow-up, which supports the interventional catheterisation approach as a valid therapeutic option in cases of scimitar syndrome with double venous drainage.

Pulmonary sequestration: a retrospective analysis of 2625 cases in China

OBJECTIVE

Pulmonary sequestration is a congenital lung malformation, which is often misdiagnosed as lung cancer, pulmonary cysts, mediastinal tumors, etc. Therefore, more research on the clinical characteristics of pulmonary sequestration should be carried out to improve the preoperative diagnosis rate.

METHODS

The study used was a retrospective analysis of 2625 cases of pulmonary sequestration well documented in the Chinese National Knowledge Infrastructure from 1998 to 2008. Analysis was performed on the patients' age, gender, symptom, chest computed tomography (CT) scan, chest radiograph, lesion localization, arterial supply, venous drainage, and incorrect preoperative diagnosis.

RESULTS

A total of 2625 cases of pulmonary sequestration was reported in the Chinese National Knowledge Infrastructure from 1998 to 2008, and the male:female ratio was 1.58:1. The symptoms of pulmonary sequestration were cough, sputum, fever, hemoptysis, and chest pain, with 13.36% of patients being asymptomatic. Chest CT scan showed mass lesions (49.01%), cystic lesions (28.57%), cavitary lesions (11.57%), and pneumonic lesions (7.96%). The sequestration was mainly located in the lower lobe, primarily in the left posterior basal segment (66.43%) and in the right posterior basal segment (20.16%). Pulmonary sequestrations were divided into two types, intralobar sequestration (83.95%) and extralobar sequestration (16.05%). Bilateral sequestrations were rare--only three cases had been reported. The arterial supply was mainly provided by branches of thoracic aorta (76.55%) and abdominal aorta (18.47%). The mean incorrect preoperative diagnosis rate was as high as 58.63%. A comparison between pediatric and adult patients indicated that the subtype ratio (intralobar/extralobar) was higher in the adult group than that in the pediatric group (P < 0.001).

CONCLUSIONS

Clinical manifestations of pulmonary sequestration varied and preoperative diagnosis was often incorrect. To improve the preoperative diagnosis rate, we should take full advantage of symptoms, image performance, and localization characteristics. A certain early-onset age, recurrent pneumonias, mass or cyst lesion located in the lower lobe, and aberrant arterial supply are indicators for the diagnosis.

Malformações pulmonares congênitas

As malformações congênitas do pulmão são raras e variam muito na sua forma de apresentação clínica e gravidade, dependendo principalmente do grau de envolvimento pulmonar e de sua localização na cavidade torácica. Elas podem se manifestar em qualquer idade e podem ser fonte de importante morbidade e mortalidade em lactentes e crianças. Os indivíduos com malformações congênitas do pulmão podem apresentar sintomas respiratórios ao nascimento, enquanto outros podem permanecer assintomáticos por longos períodos. Atualmente, com o uso rotineiro da ultrassonografia pré-natal, vem ocorrendo um aumento no diagnóstico mais precoce dessas malformações. A manifestação clínica dessas malformações varia desde uma disfunção respiratória pós-natal imediata a um achado acidental na radiografia de tórax. O diagnóstico precoce e o tratamento imediato oferecem a possibilidade de um desenvolvimento pulmonar absolutamente normal. Quando assintomáticos, a conduta para o tratamento dos pacientes com malformações pulmonares ainda é controversa, uma vez que o prognóstico dessas afecções é imprevisível. O manejo dessas lesões depende do tipo de malformação e de sintomas. Devido ao risco de complicação, a maioria dos autores sugere a ressecção da lesão no momento em que essa é identificada. A lobectomia é o procedimento de escolha, fornecendo excelentes resultados a longo prazo. Este artigo descreve as principais malformações pulmonares congênitas, seu diagnóstico e controvérsias quanto o tratamento.

Association of three different congenital malformations in a same pulmonary lobe in a 5-year-old girl

We report the case of a 5-year-old girl with persistent chest X-ray abnormalities following an episode of pneumonia who has a complex congenital pulmonary malformation comprising of a congenital pulmonary airway malformation, an intralobar sequestration and two bronchogenic cysts, all present within the same lobe. The observation suggests a common embryological origin of these malformations.