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Start AO, Ryan GA, Cathcart B, Geraghty J, Adams N, Colleran G, Vavasseur C, Caird J, Murray D, Walsh JM. An unusual case of a giant fetal facial tumour and review of the literature. Ir J Med Sci 2023; 192:2881-2885. [PMID: 36964892 PMCID: PMC10691997 DOI: 10.1007/s11845-023-03344-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/09/2023] [Indexed: 03/26/2023]
Abstract
We present the case of a pregnant 32-year-old woman who presented with a giant fetal facial tumour at 22 weeks. The mass, initially 4 × 3.5 × 3 cm in size, was largely cystic with a small solid component. It subsequently increased to 9 × 9 × 10 cm. Significant compression effects on the fetal orbit, temple and infratemporal fossa, with potential compression of the optic nerve, were noted on ultrasound and MRI. The cyst required drainage twice in the pregnancy: firstly to reduce the compression effects and secondly to facilitate caesarean delivery. Postnatally, the baby had significant compression and displacement of the craniofacial skeleton from the mass effect. Postnatal histology revealed a diagnosis of a teratoma. This case highlights the complexities and challenges surrounding the diagnosis and management of a giant fetal facial tumour.
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Affiliation(s)
- Alex O Start
- Fetal Medicine, National Maternity Hospital, Holles Street, Dublin 2, Ireland.
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Gillian A Ryan
- Fetal Medicine, National Maternity Hospital, Holles Street, Dublin 2, Ireland
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, Dublin, Ireland
| | - Barbra Cathcart
- Fetal Medicine, National Maternity Hospital, Holles Street, Dublin 2, Ireland
| | - Jennifer Geraghty
- Department of Neonatology, National Maternity Hospital, Dublin 2, Ireland
| | - Niamh Adams
- Paediatric Radiology, National Maternity Hospital, Dublin 2, Ireland
| | | | - Claudine Vavasseur
- Department of Neonatology, National Maternity Hospital, Dublin 2, Ireland
| | - John Caird
- Neurosurgery, Children's University Hospital, Dublin 1, Ireland
| | - Dylan Murray
- Plastic Surgery, Children's University Hospital, Dublin 1, Ireland
| | - Jennifer M Walsh
- Fetal Medicine, National Maternity Hospital, Holles Street, Dublin 2, Ireland
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, Dublin, Ireland
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2
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Mufti N, Ebner M, Patel P, Aertsen M, Gaunt T, Humphries PD, Bredaki FE, Hewitt R, Butler C, Sokolska M, Kendall GS, Atkinson D, Vercauteren T, Ourselin S, Pandya PP, Deprest J, Melbourne A, David AL. Super-resolution Reconstruction MRI Application in Fetal Neck Masses and Congenital High Airway Obstruction Syndrome. OTO Open 2021; 5:2473974X211055372. [PMID: 34723053 PMCID: PMC8549475 DOI: 10.1177/2473974x211055372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/06/2021] [Indexed: 11/21/2022] Open
Abstract
Objective Reliable airway patency diagnosis in fetal tracheolaryngeal obstruction is crucial to select and plan ex utero intrapartum treatment (EXIT) surgery. We compared the clinical utility of magnetic resonance imaging (MRI) super-resolution reconstruction (SRR) of the trachea, which can mitigate unpredictable fetal motion effects, with standard 2-dimensional (2D) MRI for airway patency diagnosis and assessment of fetal neck mass anatomy. Study Design A single-center case series of 7 consecutive singleton pregnancies with complex upper airway obstruction (2013-2019). Setting A tertiary fetal medicine unit performing EXIT surgery. Methods MRI SRR of the trachea was performed involving rigid motion correction of acquired 2D MRI slices combined with robust outlier detection to reconstruct an isotropic high-resolution volume. SRR, 2D MRI, and paired data were blindly assessed by 3 radiologists in 3 experimental rounds. Results Airway patency was correctly diagnosed in 4 of 7 cases (57%) with 2D MRI as compared with 2 of 7 cases (29%) with SRR alone or paired 2D MRI and SRR. Radiologists were more confident (P = .026) in airway patency diagnosis when using 2D MRI than SRR. Anatomic clarity was higher with SRR (P = .027) or paired data (P = .041) in comparison with 2D MRI alone. Radiologists detected further anatomic details by using paired images versus 2D MRI alone (P < .001). Cognitive load, as assessed by the NASA Task Load Index, was increased with paired or SRR data in comparison with 2D MRI. Conclusion The addition of SRR to 2D MRI does not increase fetal airway patency diagnostic accuracy but does provide improved anatomic information, which may benefit surgical planning of EXIT procedures.
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Affiliation(s)
- Nada Mufti
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Michael Ebner
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Premal Patel
- Radiology Department, Great Ormond Street Hospital for Children, London, UK
| | - Michael Aertsen
- Department of Radiology, University Hospitals Katholieke Universiteit, Leuven, Belgium
| | - Trevor Gaunt
- Radiology Department, Great Ormond Street Hospital for Children, London, UK.,Women's Health Division, University College London Hospitals, London, UK
| | - Paul D Humphries
- Radiology Department, Great Ormond Street Hospital for Children, London, UK
| | | | - Richard Hewitt
- Ear, Nose and Throat Department, Great Ormond Street Hospital for Children, London, UK
| | - Colin Butler
- Ear, Nose and Throat Department, Great Ormond Street Hospital for Children, London, UK
| | - Magdalena Sokolska
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Giles S Kendall
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Women's Health Division, University College London Hospitals, London, UK
| | - David Atkinson
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK.,Centre for Medical Imaging, University College London, London, UK
| | - Tom Vercauteren
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Sebastien Ourselin
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Pranav P Pandya
- Women's Health Division, University College London Hospitals, London, UK
| | - Jan Deprest
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Obstetrics and Gynaecology, University Hospitals Katholieke Universiteit, Leuven, Belgium
| | - Andrew Melbourne
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.,Department of Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Obstetrics and Gynaecology, University Hospitals Katholieke Universiteit, Leuven, Belgium
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3
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Barrette LX, Morales CZ, Oliver ER, Gebb JS, Feygin T, Lioy J, Howell LJ, Hedrick HL, Jackson OA, Adzick NS, Javia LR. Risk factor analysis and outcomes of airway management in antenatally diagnosed cervical masses. Int J Pediatr Otorhinolaryngol 2021; 149:110851. [PMID: 34311168 DOI: 10.1016/j.ijporl.2021.110851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/01/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE To investigate antenatally-determined imaging characteristics associated with invasive airway management at birth in patients with cervical masses, as well as to describe postnatal management and outcomes. STUDY DESIGN A retrospective analysis of 52 patients with antenatally diagnosed neck masses was performed using single-center data from January 2008 to January 2019. Antenatal imaging, method of delivery, management, and outcomes data were abstracted from the medical record and analyzed. RESULTS Antenatal diagnosis of neck masses in this cohort consisted of 41 lymphatic malformations (78.8%), 6 teratomas (11.5%), 3 hemangiomas (5.8%), 1 hemangioendothelioma (1.9%), and 1 giant foregut duplication cyst (1.9%). Mean gestational age at time of diagnostic imaging was 29 weeks 3 days (range: 19w4d - 37w). Overall, 22 patients (42.3%) required invasive airway management at birth, specifically 18 patients (34.6%) required endotracheal intubation and 4 (7.7%) required tracheostomy. 15 patients (28.8%) underwent ex-utero intrapartum treatment (EXIT) for the purposes of securing an airway. Polyhydramnios, tracheal deviation and compression, and anterior mass location on antenatal imaging were significantly associated with incidence of invasive airway intervention at birth, EXIT procedure, and tracheostomy during the neonatal hospitalization (p < 0.025; Fisher's exact test). Logistic regression analysis demonstrated statistically significant association between increasing antenatally-estimated mass volume and incidence of invasive airway management at birth (p = 0.02). Post-natal cervical mass management involved surgical excision (32.7%), sclerotherapy (50%), and adjuvant therapy with rapamycin (17.3%). Demise in the neonatal period occurred in 4 (7.7%) patients. CONCLUSION This series documents the largest single-center experience of airway management in antenatally diagnosed cervical masses. Fetal imaging characteristics may help inform the appropriate method of delivery, airway management strategy at birth, and prenatal counseling.
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Affiliation(s)
- Louis-Xavier Barrette
- Division of Otolaryngology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Carrie Z Morales
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Edward R Oliver
- Department of Radiology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Juliana S Gebb
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Tamara Feygin
- Department of Radiology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Janet Lioy
- Division of Neonatology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Holly L Hedrick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Oksana A Jackson
- Division of Plastic and Reconstructive Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Leonard and Madlyn Abramson Pediatric Research Center, 3615 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA; Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Luv R Javia
- Division of Otolaryngology, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
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4
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Kapoor A, Kapoor A, Kapoor R, Kapoor A, Kapoor S. Prenatal Sonographic and MRI Assessment of Early Fetal Neck Immature Teratoma. JOURNAL OF FETAL MEDICINE 2021. [DOI: 10.1007/s40556-020-00272-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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5
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Novoa RH, Quintana W, Castillo-Urquiaga W, Ventura W. EXIT (ex utero intrapartum treatment) surgery for the management of fetal airway obstruction: A systematic review of the literature. J Pediatr Surg 2020; 55:1188-1195. [PMID: 32151401 DOI: 10.1016/j.jpedsurg.2020.02.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 11/24/2019] [Accepted: 02/11/2020] [Indexed: 12/22/2022]
Abstract
PURPOSE To provide a comprehensive overview of the perinatal and maternal outcomes of fetuses undergoing EXIT surgery for the management of fetal airway obstruction secondary to cervical or oral tumors. METHODS A comprehensive search from inception to September 2018 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported an EXIT surgery in singleton were considered eligible. A descriptive analysis was performed. RESULTS Out of the 250 full-text study reports, 120 articles reporting 235 cases of EXIT surgery were included. EXIT surgery was performed at 35.1 weeks of gestation on average. The most frequent diagnosis was teratoma (46.4%, n = 109/235). There were 13 adverse maternal events, and the most frequent one was postpartum hemorrhage (4.7%, n = 11/235). No maternal death was reported. Fetal and neonatal death occurred in 17% (40/235) of the cases. There were 29 adverse fetal events (12.2%), and the most frequent one was the failure of intubation or tracheostomy (3.4%, n = 8/235). CONCLUSION EXIT surgery could be considered for the management of an oral or cervical tumor that's highly suspicious of blocking the fetal airway. This systematic review reports that EXIT surgery poses substantial risks of maternal and fetal adverse events, including neonatal death. LEVEL OF EVIDENCE IV case series with no comparison group.
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Affiliation(s)
- Rommy H Novoa
- Resident trainee in Ob/Gyn Department of Obstetrics and Gynecology, InstitutoNacional Materno Perinatal, Lima, Peru; Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Willy Quintana
- Resident trainee in Ob/Gyn Department of Obstetrics and Gynecology, InstitutoNacional Materno Perinatal, Lima, Peru; Faculty of Medicine, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | | | - Walter Ventura
- Fetal Medicine Unit, Instituto Nacional Materno Perinatal, Lima, Peru; Fetal Medicine Unit, Clinica Delgado, Grupo AUNA, Lima, Peru.
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6
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Feygin T, Khalek N, Moldenhauer JS. Fetal brain, head, and neck tumors: Prenatal imaging and management. Prenat Diagn 2020; 40:1203-1219. [PMID: 32350893 DOI: 10.1002/pd.5722] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 02/06/2020] [Accepted: 04/03/2020] [Indexed: 12/21/2022]
Abstract
Fetal tumors represent an infrequent pathology when compared to congenital malformations, although their true incidence may be underestimated. A variety of benign and malignant neoplasms may occur anywhere in the neural axis. Imaging plays an important role in the fetal tumor diagnosis and evaluation of their resultant complications. Discovery of a fetal mass on obstetric ultrasound necessitates further evaluation with prenatal magnetic resonance imaging (MRI). New MR sequences and new applications of existing techniques have been successfully implemented in prenatal imaging. A detailed assessment may be performed using a variety of MR. Fetal tumors may be histologically benign or malignant, but their prognosis generally remains poor, especially for intracranial lesions. Unfavorable tumor location or heightened metabolic demands on a developing fetus may result in severe complications and a fatal outcome, even in cases of benign lesions. Nowadays, prenatal treatment focuses mainly on alleviation of secondary complications caused by the tumors. In this article we review congenital tumors of the brain, face, and neck encountered in prenatal life, and discuss diagnostic clues for appropriate diagnosis.
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Affiliation(s)
- Tamara Feygin
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- The Center for fetal diagnosis and treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie S Moldenhauer
- The Center for fetal diagnosis and treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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7
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Jiang S, Yang C, Bent J, Yang CJ, Gangar M, Nassar M, Suskin B, Dar P. Ex utero intrapartum treatment (EXIT) for fetal neck masses: A tertiary center experience and literature review. Int J Pediatr Otorhinolaryngol 2019; 127:109642. [PMID: 31479918 DOI: 10.1016/j.ijporl.2019.109642] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 07/17/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Currently no established criteria exist to guide use of ex utero intrapartum treatment (EXIT) for fetal neck mass management. This study aims to correlate prenatal radiographic findings with incidence of ex utero intrapartum treatment and necessity of airway intervention at delivery. METHODS We reviewed our EXIT experience between 2012 and 17. Furthermore, we performed a literature review of articles reporting incidences of fetal neck masses considered for EXIT. Articles that were included (1) discussed prenatal radiographic findings such as size, features, and evidence of compression and (2) reported extractable data on delivery outcomes and airway status. RESULTS Ten cases at our institution were reviewed. Another 137 cases across 81 studies met inclusion criteria. These studies showed aerodigestive tract compression to be significantly associated with neck masses undergoing EXIT. Additionally, there was significantly higher incidence of airway intervention in cases where polyhydramnios, anatomic compression, and solid masses were seen on prenatal diagnostic imaging, while mass location and size did not correlate with airway intervention. CONCLUSION With this data, we propose that any neck mass with anatomic compression on fetal imaging in the 3rd trimester should be considered for EXIT. When radiographic findings do not show compression but do display polyhydramnios or a solid neck mass (regardless of polyhydramnios), an airway surgeon should be available for perinatal airway assistance.
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Affiliation(s)
- Sydney Jiang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA; Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA.
| | - Catherina Yang
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY, 10461, USA
| | - John Bent
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Christina J Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Mona Gangar
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Michel Nassar
- Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center / Children's Hospital of Montefiore, 3400 Bainbridge Avenue 3rd Floor, Bronx, NY, 10467, USA
| | - Barrie Suskin
- Department of Obstetrics and Gynecology, Stamford Hospital, One Hospital Plaza, Whittingham Pavilion, Stamford, CT, 06902, USA
| | - Peer Dar
- Division of Fetal Medicine and OB-Gyn Ultrasound, Albert Einstein College of Medicine / Montefiore Medical Center, 1695 Eastchester Road Room L4, Bronx, NY, 10461, USA
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8
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Zemet R, Amdur-Zilberfarb I, Shapira M, Ziv-Baran T, Hoffmann C, Kassif E, Katorza E. Prenatal diagnosis of congenital head, face, and neck malformations-Is complementary fetal MRI of value? Prenat Diagn 2019; 40:142-150. [PMID: 31664716 DOI: 10.1002/pd.5593] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/30/2019] [Accepted: 10/11/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the role of fetal magnetic resonance imaging (MRI) as a complement to ultrasound (US) in the prenatal diagnosis of craniofacial anomalies. METHODS A historical cohort study including all pregnant women who were referred for fetal MRI because of antenatal diagnosis of craniofacial anomalies on screening US. Prenatal diagnostic US, MRI, and postnatal diagnosis were compared for consistencies and discrepancies. RESULTS Forty-five pregnant women with 73 suspected fetal craniofacial anomalies diagnosed by US underwent MRI. In 40 out of 73 anomalies (54.8%), US and MRI findings were in complete agreement with postnatal diagnoses. MRI correctly ruled out the diagnosis of 24 anomalies suspected on US and diagnosed four additional pathologies that were not demonstrated by US. Out of the 85 anomalies (suspected by imaging or confirmed postnatally), confident diagnosis could be made by MRI in 68 anomalies (80%), not diagnosed in 10 (11.8%), and over-diagnosed in seven (8.2%). By US, confident diagnosis could be made in 44 anomalies (51.8%), not diagnosed in 11 (12.9%), and over-diagnosed in 30 (35.3%). CONCLUSION MRI is valuable in the antenatal evaluation of fetal craniofacial anomalies and may be useful as an adjunct to US in the prenatal work-up of craniofacial anomalies.
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Affiliation(s)
- Roni Zemet
- Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Moran Shapira
- Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tomer Ziv-Baran
- School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Chen Hoffmann
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Diagnostic Radiology, Sheba Medical Center, Ramat Gan, Israel
| | - Eran Kassif
- Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eldad Katorza
- Department of Obstetrics and Gynecology, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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9
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Masahata K, Soh H, Tachibana K, Sasahara J, Hirose M, Yamanishi T, Ibuka S, Okuyama H, Usui N. Clinical outcomes of ex utero intrapartum treatment for fetal airway obstruction. Pediatr Surg Int 2019; 35:835-843. [PMID: 31165248 DOI: 10.1007/s00383-019-04494-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of this study was to evaluate the indications and the clinical outcomes of the fetuses managed with ex utero intrapartum treatment (EXIT) procedures. METHODS We retrospectively reviewed the medical records of all fetuses who underwent EXIT procedures between 2003 and 2018. RESULTS EXIT procedures were performed in nine cases. The prenatal diagnosis of the neonates was congenital high airway obstruction syndrome in four cases, the neck masse in five cases. Although the airway management under the EXIT procedure was successful in eight cases, the airway management failed in one case. During the EXIT procedures, the airway was managed by endotracheal intubation in two cases, whereas six cases underwent tracheostomy. Six cases with fetal airway obstruction survived to discharge, whereas three cases died due to airway management failure or complications of the underlying disease. A case with a cervical teratoma underwent tumor resection the day after birth due to rapid enlargement of the neck mass. Long-term survival was achieved in five cases. CONCLUSIONS We concluded that the EXIT procedure was effective and could be performed safely in the airway management of fetuses with suspected airway obstruction. The treatment strategy for the neck masses should be planned before birth.
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Affiliation(s)
- Kazunori Masahata
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Murodoucho 840, Izumi, Osaka, 594-1101, Japan.
| | - Hideki Soh
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Murodoucho 840, Izumi, Osaka, 594-1101, Japan
| | - Kazuya Tachibana
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Jun Sasahara
- Department of Obstetrics, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Masayuki Hirose
- Department of Otolaryngology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Tadashi Yamanishi
- Department of Oral and Maxillofacial Surgery, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Souji Ibuka
- Department of Pediatric Surgery, National Hospital Organization Fukuyama Medical Center, Hiroshima, Japan
| | - Hiroomi Okuyama
- Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Noriaki Usui
- Department of Pediatric Surgery, Osaka Women's and Children's Hospital, Murodoucho 840, Izumi, Osaka, 594-1101, Japan
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10
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Ravelli A, Napolitano M, Rustico M, Riccipetitoni G, Di Leo G, Righini A, Sardanelli F. Prenatal MRI of neck masses with special focus on the evaluation of foetal airway. Radiol Med 2019; 124:917-925. [PMID: 31175537 DOI: 10.1007/s11547-019-01049-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 05/24/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Prenatal magnetic resonance imaging is the best tool to visualize foetal airway. OBJECTIVE To evaluate the performance of MRI in the assessment of foetal airway status in the presence of a neck mass. MATERIALS AND METHODS Two paediatric radiologists with 12- and 2-year experience in foetal imaging retrospectively analysed 23 foetal MRI examinations, performed between 2001 and 2016, after a second-level ultrasound suspicious for presence of a neck mass. Postnatal imaging, postoperative report, histology, autopsy, and clinical outcomes were the reference standard to calculate sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of prenatal MRI in detecting airway patency. We used the Cohen к statistics to estimate the interobserver agreement. We also assessed MRI performance in the diagnosis of the mass nature. RESULTS We obtained data about postnatal airway status in 19 of 23 patients; prenatal MRI demonstrated a sensitivity of 9/9 [100%, 95% confidence interval (CI) 66-100%], specificity 8/10 (80%, 44-98%), accuracy 17/19 (89%, 67-99%), PPV 9/11 (82%, 48-98%), and NPV 8/8 (100%, 63-100%); the interobserver agreement was perfect. Prenatal MRI correctly identified 21 of 23 masses (к = 0.858); the interobserver agreement was almost perfect (к = 0.851). CONCLUSION Prenatal MRI demonstrated high accuracy in assessing foetal airway status and diagnosing mass nature, allowing proper delivery planning.
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Affiliation(s)
- Anna Ravelli
- Department of Pediatric Radiology and Neuroradiology, V. Buzzi Children's Hospital - ASST Fatebenefratelli-Sacco, Via Castelvetro 32, 20154, Milan, Italy.
| | - Marcello Napolitano
- Department of Pediatric Radiology and Neuroradiology, V. Buzzi Children's Hospital - ASST Fatebenefratelli-Sacco, Via Castelvetro 32, 20154, Milan, Italy
| | - Mariangela Rustico
- Department of Obstetrics and Gynecology, V. Buzzi Children's Hospital - ASST Fatebenefratelli-Sacco, Via Castelvetro 32, 20154, Milan, Italy
| | - Giovanna Riccipetitoni
- Department of Pediatric Surgery, V. Buzzi Children's Hospital - ASST Fatebenefratelli-Sacco, Via Castelvetro 32, 20154, Milan, Italy
| | - Giovanni Di Leo
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Milan, Italy
| | - Andrea Righini
- Department of Pediatric Radiology and Neuroradiology, V. Buzzi Children's Hospital - ASST Fatebenefratelli-Sacco, Via Castelvetro 32, 20154, Milan, Italy
| | - Francesco Sardanelli
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Milan, Italy.,Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Morandi 30, 20097, San Donato Milanese, Milan, Italy
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11
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Abstract
Congenital causes of airway obstruction once noted at birth are now diagnosed prenatally. The adoption of ex utero intrapartum treatment has allowed for planned airway stabilization on placental support, dramatically decreasing the incidence of hypoxic injury or peripartum demise related to neonatal airway obstruction. Airway access is gained either through laryngoscopy, bronchoscopy, or a surgical airway. In complete airway obstruction, primary resection of the obstructing lesion may be performed before completion of delivery. This article reviews the current and emerging methods of fetal evaluation, indications for ex utero intrapartum treatment, and provides a detailed description of the procedure and necessary personnel.
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Affiliation(s)
- Kara Prickett
- Department of Pediatrics, Children's Healthcare of Atlanta, Emory University School of Medicine, 1400 Tullie Road, NE, Atlanta, GA 30329, USA.
| | - Luv Javia
- Cochlear Implant Program, Center for Pediatric Airway Disorders, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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12
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Paula Pinho Matos A, Teixeira Castro P, de Barros Duarte L, Dutra Moraes Barbosa A, Daltro P, Fazecas T, Nogueira R, Werner H, Araujo Júnior E. Prenatal diagnosis of cervical masses by magnetic resonance imaging and 3D virtual models: perinatal and long-term follow-up outcomes. J Matern Fetal Neonatal Med 2018; 33:2181-2189. [PMID: 30458651 DOI: 10.1080/14767058.2018.1543393] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Objective: To assess perinatal and long-term follow-up outcomes of fetal cervical masses diagnosed by three-dimensional (3D) magnetic resonance imaging (MRI) and 3D virtual models.Methods: This retrospective cohort study evaluated 15 pregnant women (age, 21-38 years) at 29-40 weeks of singleton gestation, whose fetuses exhibited congenital oral and cervical masses. These women were referred to our facility because of suspected fetal malformations on routine obstetric ultrasound, and the cases were confirmed, excluded, or complemented by MRI. Demographic data and perinatal and long-term follow-up outcomes were assessed.Results: Cervical masses were predominant in females (3:2), and the most frequent diagnosis was lymphatic-venous malformation (71%). The masses were cystic in 53.3% of the cases and solid in 46.7%. The esophagus and trachea were displaced in 46.6% of the cases. Associated malformations were diagnosed in 13.3% of the cases. There was complete agreement between prenatal MRI and postnatal diagnoses. Among the newborns, 40% had complications and 46.6% were admitted to the neonatal intensive care unit. Two infants died from complications due to epignathus. Surgical resection was performed in 33.3% of the cases, including complete resection in 26.6%. Sclerotherapy was administered to 53.3% of the cases, with complete remission achieved in 50% of these cases.Conclusion: Cervical masses diagnosed in the prenatal period had good postnatal outcomes except for cases of epignathus, which were associated with high mortality. MRI demonstrated the relationship between cervical masses and adjacent organs and allowed 3D virtual reconstruction of the airways. There was complete agreement between the prenatal diagnosis of cervical masses on MRI and postnatal diagnosis. Surgical treatment was effective in most cases, and sclerotherapy was satisfactory in cases with intrathoracic components.
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Affiliation(s)
- Ana Paula Pinho Matos
- Department of Radiology, Clínica de Diagnóstico por Imagem (CPDI), Rio de Janeiro, Brazil.,Department of Maternal and Child, Fluminense Federal University (UFF), Niteroi, Brazil
| | - Pedro Teixeira Castro
- Department of Radiology, Clínica de Diagnóstico por Imagem (CPDI), Rio de Janeiro, Brazil
| | | | | | - Pedro Daltro
- Department of Radiology, Clínica de Diagnóstico por Imagem (CPDI), Rio de Janeiro, Brazil
| | - Tatiana Fazecas
- Department of Radiology, Clínica de Diagnóstico por Imagem (CPDI), Rio de Janeiro, Brazil
| | - Renata Nogueira
- Department of Radiology, Clínica de Diagnóstico por Imagem (CPDI), Rio de Janeiro, Brazil
| | - Heron Werner
- Department of Radiology, Clínica de Diagnóstico por Imagem (CPDI), Rio de Janeiro, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
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13
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Abstract
OBJECTIVE The purpose of this study is to determine which MRI parameters of fetal head and neck masses predict high-morbidity neonatal outcomes, including ex utero intrapartum treatment (EXIT) procedure. MATERIALS AND METHODS This retrospective study (2004-2016) included parameters of polyhydramnios (based on largest vertical pocket), mass effect on the trachea, mass midline extension, and morphologic grade and size of masses. The morbid cohort included those requiring an EXIT procedure, difficult intubation at delivery, or lethal outcome. Predictive modeling with a multivariable logistic regression and ROC analysis was then performed. RESULTS Of 36 fetuses, five were delivered by EXIT procedures, there was one neonatal death within 12 hours after delivery, and another neonate required multiple intubation attempts. The remaining 29 fetuses were delivered at outside institutions with no interventions or neonatal morbidity. The largest vertical pocket and mass effect on the trachea were selected as independent predictors by the logistic regression. The cross-validated ROC AUC was 0.951 (95% CI, 0.8795-1). CONCLUSION The largest vertical pocket measurement and mass effect on the trachea were the most contributory MRI parameters that predicted significant morbidity in fetuses with masses of the face and neck, along with other significant parameters. These parameters predict significant morbid neonatal outcomes, including the need for EXIT procedures.
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14
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Ex utero intrapartum treatment procedure in two fetuses with airway obstruction. Obstet Gynecol Sci 2018; 61:417-420. [PMID: 29780786 PMCID: PMC5956127 DOI: 10.5468/ogs.2018.61.3.417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 07/27/2017] [Accepted: 08/07/2017] [Indexed: 11/08/2022] Open
Abstract
The ex utero intrapartum treatment (EXIT) procedure was introduced to reduce fetal hypoxic damage while establishing an airway in fetuses with upper and lower airway obstruction. Delivery of the fetal head and shoulders while maintaining the uteroplacental circulation offers time to secure the fetal airway. Here, we report two cases of EXIT procedure for fetal airway obstruction, which were successfully managed with extensive preoperative planning by a professional multidisciplinary team.
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15
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Infantile hemangiopericytoma of the tongue-Efficacy of ex utero intrapartum treatment procedure and combined-modality therapy. Auris Nasus Larynx 2017; 45:186-189. [PMID: 28365065 DOI: 10.1016/j.anl.2017.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/27/2017] [Indexed: 11/20/2022]
Abstract
Here we present an extremely rare case of giant infantile hemangiopericytoma (HPC) of the tongue diagnosed prenatally by fetal ultrasonography and MR imaging. Due to airway stenosis, the patient was delivered by the ex utero intrapartum treatment (EXIT) procedure at 36 weeks of pregnancy. Initial diagnosis was infantile hemangioma based on physical examination, diagnostic imaging and the high incidence of hemangioma. The tumor was resistant to conservative treatments. Due to severe tumor hemorrhage, the nutrient vessel was embolized by endovascular treatment on the 73th day after birth. Two days after embolization, a hemiglossectomy was performed. Histological analysis after surgery diagnosed infantile HPC with microscopically positive stumps. After receiving adjuvant chemotherapy, the patient has had no recurrence after 53 months with normal speech and swallowing function resulting in normal growth. Our findings support that infantile HPC is one of the differential diagnosis of infantile hemangioma. The EXIT procedure could be effective for infants with upper respiratory stenosis by head and neck tumor diagnosed prenatally. Though complete resection is required for infantile HPC, our report suggests that a conservative surgical approach followed by adjuvant chemotherapy should be used for giant head and neck infantile HPC.
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16
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Abstract
Advances in prenatal screening and diagnosis, combined with an understanding of the pathophysiology of congenital anomalies, have brought incredible impetus to the field of fetal surgery. Identification of fetal anomalies can lead to counseling of the affected family so that informed decisions can be made on how to proceed with the pregnancy. Counseling may lead to pregnancy termination, changes in the timing or mode of delivery, and, in select cases, prenatal intervention. Open fetal surgery may be considered in severe cases of congenital diaphragmatic hernia, congenital chest lesions, sacrococcygeal teratoma, urinary tract obstruction, and myelomeningocele. The ex utero intrapartum treatment procedure may be lifesaving for fetuses with giant neck masses. Finally, fetoscopic surgery may be offered for select cases of twin-twin transfusion syndrome and twin reversed arterial perfusion sequence. Fetal intervention in all of these cases depends on a team approach to the patient and on the objective comparison of outcomes with and without fetal therapy. In the future, further understanding of the genetic basis of congenital diseases may enable minimally invasive treatments such as stem cell transplantation or gene therapy.
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Affiliation(s)
- Tippi C. Mackenzie
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA
| | - N. Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA.
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17
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Laje P, Tharakan SJ, Hedrick HL. Immediate operative management of the fetus with airway anomalies resulting from congenital malformations. Semin Fetal Neonatal Med 2016; 21:240-5. [PMID: 27132111 DOI: 10.1016/j.siny.2016.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Prenatal diagnosis has transformed the outcome of fetuses with airway obstruction. The thorough evaluation of prenatal imaging allows for categorizing fetuses with airway compromise into those who will require a special mode of delivery and those who can be delivered without any special resources. The ex-utero intrapartum treatment (EXIT) approach allows accessing the airway while the fetus is under placental support, converting a potentially catastrophic situation into a controlled one. An expert multidisciplinary team is the key to success.
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Affiliation(s)
- Pablo Laje
- The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Sasha J Tharakan
- Department of Pediatric Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Holly L Hedrick
- The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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18
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Abstract
Cervical teratomas are rare germ cell tumors affecting the fetus that are associated with significant morbidity and mortality due to an increased risk of airway obstruction at delivery. These tumors can commonly produce polyhydramnios that results from the fetus' impaired ability to swallow amniotic fluid. Improved rates of prenatal diagnosis through comprehensive evaluations and imaging have dramatically impacted the perinatal management of infants with this condition. Here, we report a patient diagnosed with polyhydramnios whose fetus was discovered to have a giant cervical teratoma on imaging studies. The child underwent surgical resection after having the airway secured under the uteroplacental support as part of an ex utero intrapartum treatment procedure performed at 37 weeks. The following gross pathological and magnetic resonance images demonstrate this condition and its currently accepted treatment.
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19
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Leroy A, Garabedian C, Fourquet T, Clouqueur E, Coulon C. [Iconographic imaging (ultrasound/MRI) in prenatal evaluation of cervical cystic lymphatic malformations]. ACTA ACUST UNITED AC 2016; 44:269-73. [PMID: 27118341 DOI: 10.1016/j.gyobfe.2016.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 03/18/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Assess imaging (ultrasound±MRI) in the diagnosis of cervical cystic lymphangioma. METHODS Retrospective, descriptive study of the patients who underwent reference ultrasound screening for fetal anterior cervival masses in multidisciplinary prenatal diagnosis center of the Lille Regional University Hospital from 1997 to 2014. RESULTS Seventeen lymphangiomas were identified. Seventy-three percent of lymphangiomas (n=12) were diagnosed in the baseline ultrasound and 85% (n=11) in MRI. An extra-cervical extension was identified in 10 (62%) with ultrasound and 11 (85%) with MRI. Main sites of mass extension objectived by ultrasound and MRI were respectively the face (4,23%/6,46%), the base of tongue (3, 18%/2, 15%) and buccal floor (3, 18%/3, 15%). Pharyngeal disease (5,38%) and mandible (4,31%) were detected by MRI and not found on ultrasound. Associated malformations detected with ultrasound were 2 (12%) urogenital malformation, 1 (6%) heart defect and 1 (6%) facial anomalies. Lymphangiomas remained stable in volume in 12 (71%) cases and disappeared before birth in 2 (12%) cases. CONCLUSION MRI and ultrasound seem inseparable to assess and optimally manage fetal cervical masses. Detection of associated lesions seems to help in the final lymphangioma diagnosis. Most of the time, lymphangiomas seem to be stable lesion during pregnancy and a good prognosis in cases of uncomplicated cervical lymphatic mass and without pejorative extension.
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Affiliation(s)
- A Leroy
- Service de gynécologie-obstétrique, maternité Jeanne-de-Flandres, centre hospitalier régional universitaire de Lille, 59037 Lille cedex, France.
| | - C Garabedian
- Service de gynécologie-obstétrique, maternité Jeanne-de-Flandres, centre hospitalier régional universitaire de Lille, 59037 Lille cedex, France; Faculté de médecine Henri-Warembourg, université Lille nord de France, avenue Eugène-Avinée, 59045 Lille, France
| | - T Fourquet
- Service d'imagerie de la femme, maternité Jeanne-de-Flandres, centre hospitalier universitaire de Lille, 59037 Lille cedex, France
| | - E Clouqueur
- Service de gynécologie-obstétrique, maternité Jeanne-de-Flandres, centre hospitalier régional universitaire de Lille, 59037 Lille cedex, France
| | - C Coulon
- Service de gynécologie-obstétrique, maternité Jeanne-de-Flandres, centre hospitalier régional universitaire de Lille, 59037 Lille cedex, France
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20
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Ersoy AO, Oztas E, Saridogan E, Ozler S, Danisman N. An Unusual Origin of Fetal Lymphangioma Filling Right Axilla. J Clin Diagn Res 2016; 10:QD09-11. [PMID: 27134953 PMCID: PMC4843338 DOI: 10.7860/jcdr/2016/18516.7513] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 01/27/2016] [Indexed: 01/30/2023]
Abstract
Fetal lymphangioma is a hamartomatous congenital anomaly of the lymphatic system, which is embracing the fetal skin (sometimes mucous membranes) and the subcutaneous tissue. The general consensus is that it occurs as a result of failure in lymphatic drainage. A 36-year-old pregnant woman was referred to our perinatology clinic at 22 weeks' gestation, because of a fetal right-sided axillary mass revealed by ultrasonography. The mass measuring 5x7x7cm in three dimensions had a multilocular structure without colour Doppler flow and well-circumscribed borders. Amniocentesis revealed a normal constitutional karyotyping. Lymphangioma was considered as prediagnosis. A healthy female baby weighing 3470 grams was delivered at term. Neonatal examination and the postnatal MRI confirmed the diagnosis. The baby is still on follow-up with the medical treatment of Sirolimus an anti-proliferative drug, and the mass got smaller significantly in 8 months after delivery.
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Affiliation(s)
- Ali Ozgur Ersoy
- Medical Doctor, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Healthcare, Training and Research Hospital, Ankara, Turkey
| | - Efser Oztas
- Medical Doctor, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Healthcare, Training and Research Hospital, Ankara, Turkey
| | - Erdinc Saridogan
- Medical Doctor, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Healthcare, Training and Research Hospital, Ankara, Turkey
| | - Sibel Ozler
- Medical Doctor, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Healthcare, Training and Research Hospital, Ankara, Turkey
| | - Nuri Danisman
- Medical Doctor, Department of Obstetrics and Gynecology, Zekai Tahir Burak Women’s Healthcare, Training and Research Hospital, Ankara, Turkey
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21
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Sheikh F, Akinkuotu A, Olutoye OO, Pimpalwar S, Cassady CI, Fernandes CJ, Ruano R, Lee TC, Cass DL. Prenatally diagnosed neck masses: long-term outcomes and quality of life. J Pediatr Surg 2015; 50:1210-3. [PMID: 25863543 DOI: 10.1016/j.jpedsurg.2015.02.035] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 02/13/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE To determine long-term outcomes of fetuses with neck masses (NM), including functional and cosmetic results. METHODS A retrospective review was performed of all fetuses evaluated for NM from November 2001 to March 2014. Quality of life (QOL) was evaluated using the validated PedsQL™ questionnaire. RESULTS Of 35 fetuses evaluated, 9 died perinatally and 1 died late from tracheostomy complications. NM ranged from 4 to 20cm (mean, 9.1cm); 18 were delivered by EXIT. Of 25 surviving patients, 22 had mass resection, 7 requiring more than one procedure. Surviving patients with lymphatic malformations (LM) had the highest incidence of moderate and severe disfigurement and a higher rate of persistent/recurrent disease (100% vs. 31%, p=0.002) and cranial nerve dysfunction (50% vs. 0%, p=0.005) compared to those with non-LM diagnoses. Of 9 children attending school, 78% achieve grades of A/B's. QOL for 13 patients revealed a mean score of 83/100 for physical and 78/100 for psychosocial functioning. Median follow-up was 6 years (7 months-17 years). CONCLUSION Unlike those with teratoma or other lesions, children with congenital cervicofacial LM are at high-risk for persistent disease, nerve dysfunction and moderate-severe disfigurement. There is substantial perinatal morbidity for fetuses with neck masses, but for those surviving, the long-term functional and cognitive outcomes are good.
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Affiliation(s)
- Fariha Sheikh
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Adesola Akinkuotu
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Oluyinka O Olutoye
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Sheena Pimpalwar
- Department of Radiology, Baylor College of Medicine, Houston, TX
| | - Christopher I Cassady
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Radiology, Baylor College of Medicine, Houston, TX
| | | | - Rodrigo Ruano
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Timothy C Lee
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Darrell L Cass
- Texas Children's Fetal Center, Texas Children's Hospital, Houston, TX; Department of Surgery, Baylor College of Medicine, Houston, TX; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Department of Pediatrics, Baylor College of Medicine, Houston, TX.
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22
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Krishnamurthy U, Neelavalli J, Mody S, Yeo L, Jella PK, Saleem S, Korzeniewski SJ, Cabrera MD, Ehterami S, Bahado-Singh RO, Katkuri Y, Haacke EM, Hernandez-Andrade E, Hassan SS, Romero R. MR imaging of the fetal brain at 1.5T and 3.0T field strengths: comparing specific absorption rate (SAR) and image quality. J Perinat Med 2015; 43:209-20. [PMID: 25324440 PMCID: PMC5987203 DOI: 10.1515/jpm-2014-0268] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 09/09/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Our two objectives were to evaluate the feasibility of fetal brain magnetic resonance imaging (MRI) using a fast spin echo sequence at 3.0T field strength with low radio frequency (rf) energy deposition (as measured by specific absorption rate: SAR) and to compare image quality, tissue contrast and conspicuity between 1.5T and 3.0T MRI. METHODS T2 weighted images of the fetal brain at 1.5T were compared to similar data obtained in the same fetus using a modified sequence at 3.0T. Quantitative whole-body SAR and normalized image signal to noise ratio (SNR), a nominal scoring scheme based evaluation of diagnostic image quality, and tissue contrast and conspicuity for specific anatomical structures in the brain were compared between 1.5T and 3.0T. RESULTS Twelve pregnant women underwent both 1.5T and 3.0T MRI examinations. The image SNR was significantly higher (P=0.03) and whole-body SAR was significantly lower (P<0.0001) for images obtained at 3.0T compared to 1.5T. All cases at both field strengths were scored as having diagnostic image quality. Images from 3.0T MRI (compared to 1.5T) were equal (57%; 21/37) or superior (35%; 13/37) for tissue contrast and equal (61%; 20/33) or superior (33%, 11/33) for conspicuity. CONCLUSIONS It is possible to obtain fetal brain images with higher resolution and better SNR at 3.0T with simultaneous reduction in SAR compared to 1.5T. Images of the fetal brain obtained at 3.0T demonstrated superior tissue contrast and conspicuity compared to 1.5T.
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Affiliation(s)
- Uday Krishnamurthy
- Department of Radiology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Biomedical Engineering, College of Engineering, Wayne State University, Detroit, MI, USA
| | - Jaladhar Neelavalli
- Department of Radiology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Biomedical Engineering, College of Engineering, Wayne State University, Detroit, MI, USA
| | - Swati Mody
- Department of Radiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Lami Yeo
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Pavan K. Jella
- Department of Radiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Sheena Saleem
- Department of Radiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Steven J. Korzeniewski
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan; USA
| | - Maria D. Cabrera
- Department of Radiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Shadi Ehterami
- Department of Radiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ray O. Bahado-Singh
- Department of Obstetrics and Gynecology, William Beaumont School of Medicine, Oakland University, Rochester, MI, USA
| | - Yashwanth Katkuri
- Department of Radiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Ewart M. Haacke
- Department of Radiology, Wayne State University School of Medicine, Detroit, MI, USA
- Department of Biomedical Engineering, College of Engineering, Wayne State University, Detroit, MI, USA
| | - Edgar Hernandez-Andrade
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, MD, and Detroit, MI, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan; USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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23
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Abstract
This review addresses specific questions regarding performance and utility of fetal MR. The specific issues addressed are (1) physician qualifications; (2) MR safety; (3) access to fetal MR; (4) timing of MRI in pregnancy; (5) repeat exams; and (6) when MRI is most effective for prenatal diagnosis. Fetal MRI is a problem-solving tool used for specific indications that are driven by ultrasound or at times by family history. Fetal MR should always be performed with knowledge of the sonographic findings from prior targeted scan. The best evidence for utility of MR is in assessment of CNS anomalies and assessment of the fetus with airway obstruction requiring decisions regarding mode of therapy. The type of information provided by MR can profoundly impact patient counseling and management. We recommend a team approach including specialists in obstetric imaging, fetal MRI, and postnatal care in interpreting MR so that the best information can be given to the pregnant patient.
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Affiliation(s)
- Deborah Levine
- Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA.
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24
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Taghavi K, Beasley S. The ex utero intrapartum treatment (EXIT) procedure: application of a new therapeutic paradigm. J Paediatr Child Health 2013; 49:E420-7. [PMID: 23662685 DOI: 10.1111/jpc.12223] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 12/15/2022]
Abstract
The ex utero intrapartum treatment (EXIT) procedure is a term given to a technique that can transform a potentially fatal neonatal emergency to a controlled intervention with an improved outcome. It has revolutionised the care of prenatally diagnosed congenital malformations in which severe upper airway obstruction is anticipated. An extended period of utero-placental circulation can be utilised to avoid profound cardiopulmonary compromise. Its therapeutic applications have been broadened to include fetuses with congenital diaphragmatic hernia after tracheal plugging, high-risk intrathoracic masses, severe cardiac malformations and conjoined twins. It requires the co-ordination of a highly skilled and experienced multidisciplinary team. The recent enthusiasm for the EXIT procedure needs to be balanced against maternal morbidity. Specific indications and guidelines are likely to be refined as a consequence of ongoing advances in fetal intervention and antenatal imaging.
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25
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Koelblinger C, Herold C, Nemec S, Berger-Kulemann V, Brugger PC, Koller A, Tonnhofer U, Bettelheim D, Prayer D. Fetal magnetic resonance imaging of lymphangiomas. J Perinat Med 2013; 41:437-43. [PMID: 23314507 DOI: 10.1515/jpm-2012-0226] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Accepted: 12/04/2012] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the fetal magnetic resonance imaging findings of lymphangiomas. METHODS The magnetic resonance scans of eight fetuses with lymphangiomas were evaluated. Magnetic resonance evaluation included: number; size; signal intensities of the lesions; thickness of the septae; configuration of the margins; presence of blood breakdown products; change in size or signal intensity (in four patients with multiple examinations); exact expansion of the lesions to the adjacent anatomical structures; and concomitant pathological findings. Results were compared with postpartum clinical assessment and imaging in seven patients and with autopsy in one patient. RESULTS Two retroperitoneal, three thoracic, and three cervical lymphangiomas (diameters between 3.3 and 15.6 cm) were included. All lesions consisted of macrocysts, and additional microcystic parts were found in three lymphangiomas. Blood breakdown products were found in one lesion. Agreement with postpartum imaging was excellent. One patient received intrauterine drainage for chylothorax, and one pregnancy was terminated. CONCLUSIONS Fetal lymphangiomas display the same magnetic resonance imaging features as postnatal lymphangiomas. Intrauterine magnetic resonance characterization of lymphangiomas provides the exact delineation, detection of associated and/or concomitant pathologies, and differential diagnosis among other cystic pathologies. Patient management may be altered with respect to the type and/or time of treatment, and with regard to the continuation or termination of pregnancy.
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Affiliation(s)
- Claus Koelblinger
- Department of Radiology, Medical University of Vienna, WaehringerGuertel 18-20, A-1090 Vienna, Austria.
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Kapoor MC, Rangachari V. Airway management in neonates and infants with congenital airway lesions. J Anaesthesiol Clin Pharmacol 2012; 28:285-6. [PMID: 22869931 PMCID: PMC3409934 DOI: 10.4103/0970-9185.98318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Laje P, Johnson MP, Howell LJ, Bebbington MW, Hedrick HL, Flake AW, Adzick NS. Ex utero intrapartum treatment in the management of giant cervical teratomas. J Pediatr Surg 2012; 47:1208-16. [PMID: 22703795 DOI: 10.1016/j.jpedsurg.2012.03.027] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 03/06/2012] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of this study is to present the outcome and technical details of the Ex Utero Intrapartum Treatment (EXIT) procedure performed in the management of the fetus with a giant cervical teratoma. METHODS A retrospective review of the medical records of patients undergoing the EXIT procedure between September 1995 and September 2010 was performed. RESULTS Eighty-seven EXIT procedures were performed. In 20% of cases (17/87), the indication was giant cervical teratoma. There were 10 females and 7 males. Polyhydramnios was present in 82%. Median gestational age at EXIT was 35 weeks (range, 30-39 weeks). Median birth weight was 2.5 kg (range, 1.7-3.7 kg). Access to the airway under placental support was established in all cases via direct laryngoscopy/bronchoscopy in 8 patients (47%) and via surgical exploration (tracheostomy or retrograde intubation) in 9 patients (53%). The mortality rate under placental support was zero. Seven patients had the tumors resected immediately after the EXIT, 6 patients had the resection later, and 4 patients died before resection. The neonatal mortality rate was 23% (4/17 patients). Patients who died had severe pulmonary hypoplasia that resulted from the upward traction by the giant cervical mass on the airway and compression of the lungs against the thoracic apex. CONCLUSIONS We conclude that the EXIT procedure continues to be the optimal delivery strategy for patients with prenatally diagnosed giant cervical teratomas and potential airway obstruction at birth. A thorough evaluation of the prenatal images and an experienced multidisciplinary team are key factors for an effective approach to the obstructed fetal airway.
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MESH Headings
- Airway Management/methods
- Airway Obstruction/congenital
- Airway Obstruction/embryology
- Airway Obstruction/etiology
- Airway Obstruction/surgery
- Airway Obstruction/therapy
- Anesthesia, Obstetrical/methods
- Cesarean Section
- Diseases in Twins
- Elective Surgical Procedures
- Female
- Fetal Therapies/methods
- Gestational Age
- Head and Neck Neoplasms/complications
- Head and Neck Neoplasms/congenital
- Head and Neck Neoplasms/diagnostic imaging
- Head and Neck Neoplasms/embryology
- Head and Neck Neoplasms/pathology
- Head and Neck Neoplasms/surgery
- Humans
- Hydrops Fetalis/etiology
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/embryology
- Infant, Premature, Diseases/surgery
- Intubation, Intratracheal/methods
- Laryngoscopy/methods
- Lung/abnormalities
- Lung/embryology
- Male
- Placenta/physiology
- Polyhydramnios/etiology
- Pregnancy
- Retrospective Studies
- Stress, Mechanical
- Survival Rate
- Teratoma/complications
- Teratoma/congenital
- Teratoma/diagnostic imaging
- Teratoma/embryology
- Teratoma/pathology
- Teratoma/surgery
- Tracheostomy/methods
- Tumor Burden
- Ultrasonography, Prenatal
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Affiliation(s)
- Pablo Laje
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Laya BF, Lee EY. Congenital Causes of Upper Airway Obstruction in Pediatric Patients: Updated Imaging Techniques and Review of Imaging Findings. Semin Roentgenol 2012; 47:147-58. [DOI: 10.1053/j.ro.2011.11.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Although ultrasound remains the screening modality of choice in evaluation of the fetal nervous system, magnetic resonance imaging with its multiplanar imaging ability and high signal-to-noise ratio is highly accurate in illustrating the morphologic changes of the developing brain and fetal brain abnormalities. Fetal magnetic resonance imaging is an established powerful tool for obtaining additional information in evaluation of anomalies of the fetal face, neck, and spine. It is helpful to patients and their health care professionals in making vital management decisions and aids in genetic counseling for future pregnancies.
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Affiliation(s)
- Karuna Shekdar
- Neuro-Radiology Division, Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Lazar DA, Cassady CI, Olutoye OO, Moise KJ, Johnson A, Lee TC, Cass DL. Tracheoesophageal displacement index and predictors of airway obstruction for fetuses with neck masses. J Pediatr Surg 2012; 47:46-50. [PMID: 22244391 DOI: 10.1016/j.jpedsurg.2011.10.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Accepted: 10/06/2011] [Indexed: 11/19/2022]
Abstract
PURPOSE There are no established selection guidelines to determine which fetuses with giant neck masses may benefit from delivery using an ex utero intrapartum treatment procedure. The purposes of this study were to describe the tracheoesophageal displacement index (TEDI), a novel measurement of fetal airway displacement, and to correlate this measurement and other prenatal findings to the extent of airway obstruction at birth. METHODS The medical records of all fetuses with giant neck masses evaluated between 2001 and 2011 were reviewed. At birth, each infant's airway was categorized as uncomplicated or complicated. Prenatal variables were correlated with airway difficulty. RESULTS There were 24 fetuses with large neck masses (11 lymphatic malformations, 10 teratomas, 3 others). One fetus died in utero, and 3 underwent pregnancy termination. Variables associated with a complicated airway at birth included polyhydramnios, teratoma diagnosis, and tracheoesophageal displacement index. Tracheoesophageal displacement index greater than 12 correlated strongly with a complicated airway (area under the curve = 0.80). All fetuses classified with an uncomplicated airway (n = 7) had a diagnosis other than teratoma and normal amniotic fluid volume. CONCLUSION In fetuses with giant neck masses, the presence of polyhydramnios, teratoma diagnosis, or tracheoesophageal displacement index greater than 12 are predictive of a complicated airway at birth. Our data suggest that fetuses without any of these findings may be delivered safely without an ex utero intrapartum treatment approach.
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Affiliation(s)
- David A Lazar
- Texas Children's Fetal Center and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
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Successful prenatal and perinatal management of a massive cervicofacial teratoma. J Med Ultrason (2001) 2011; 38:173-6. [DOI: 10.1007/s10396-011-0305-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Accepted: 03/20/2011] [Indexed: 10/18/2022]
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Jiang L, Hu B, Guo Q. Prenatal sonographic diagnosis of congenital epulis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2011; 39:217-220. [PMID: 21480287 DOI: 10.1002/jcu.20765] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Accepted: 09/20/2010] [Indexed: 05/30/2023]
Abstract
Congenital epulis is a benign gingival tumor that has rarely been diagnosed prenatally. We report a fetus with congenital epulis diagnosed by ultrasound at 37 weeks' gestation. The mass was diagnosed as originating from the inferior alveolar ridge prenatally. After birth, it was completely removed by simple excision under general anesthesia. Histologic examination revealed a congenital granular cell tumor.
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Affiliation(s)
- LiXin Jiang
- Department of Ultrasonography, Shanghai Jiaotong University Affiliated No. 6 Hospital, Yishan Road 600, Shanghai 200233, PR China
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Lazar DA, Olutoye OO, Moise KJ, Ivey RT, Johnson A, Ayres N, Olutoye OA, Rodriguez MA, Cass DL. Ex-utero intrapartum treatment procedure for giant neck masses--fetal and maternal outcomes. J Pediatr Surg 2011; 46:817-22. [PMID: 21616233 DOI: 10.1016/j.jpedsurg.2011.02.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 02/11/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND/PURPOSE For fetuses with giant neck masses and tracheal obstruction, an ex-utero intrapartum treatment (EXIT) procedure allows for safe nonemergent airway management while on placental support. Our objective was to examine fetal and maternal outcomes after EXIT procedure specifically for giant neck masses. METHODS The medical records of all patients referred to a comprehensive fetal center for a giant neck mass between 2001 and 2010 were reviewed retrospectively. RESULTS Among 24 patients referred, an EXIT procedure was performed in 12 with evidence of tracheal compression. An EXIT procedure was not performed because of minimal tracheal involvement (n = 8), elective abortion (n = 2), fetal demise (n = 1), or obstetric complication (n = 1). In all fetuses, the airway was successfully secured; tracheal intubation was achieved with rigid bronchoscopy (n = 10), direct laryngoscopy (n = 1), and tracheostomy (n = 1). Eleven patients survived to discharge, whereas 1 patient with significant pulmonary hypoplasia died 8 days after emergency EXIT procedure. Of 11 surviving infants, 10 are neurodevelopmentally intact. All mothers who desired future pregnancies have subsequently had uncomplicated deliveries (n = 6). CONCLUSIONS Ex-utero intrapartum treatment procedure for giant neck mass can be performed safely for both mother and child. Most fetuses can be orotracheally intubated with minimal long-term morbidity. The potential for future pregnancies is preserved.
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Affiliation(s)
- David A Lazar
- Texas Children's Fetal Center and Michael E. DeBakey, Department of Surgery, and Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX 77030, USA
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Dighe MK, Peterson SE, Dubinsky TJ, Perkins J, Cheng E. EXIT Procedure: Technique and Indications with Prenatal Imaging Parameters for Assessment of Airway Patency. Radiographics 2011; 31:511-26. [DOI: 10.1148/rg.312105108] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Ben Regaya L, Abbes Z, Fatnassi R, Fekih M, Memmi A, Bouguizene S, Chaieb A, Bibi M, Ghannouchi S, Khairi H. Les masses cervicomédiastinales : problèmes du diagnostic prénatal et de la prise en charge néonatale. À propos de deux observations. IMAGERIE DE LA FEMME 2010. [DOI: 10.1016/j.femme.2010.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Approaches to the management of antenatally diagnosed congenital tumours. Pediatr Radiol 2009; 39:1173-8. [PMID: 19277637 DOI: 10.1007/s00247-009-1163-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 11/23/2008] [Indexed: 10/21/2022]
Abstract
Congenital fetal tumours are rare, but current imaging modalities including US and MRI facilitate antenatal diagnosis and investigation, allowing a presumptive diagnosis and management strategy. Although the prevalence of fetal tumours is difficult to ascertain, an incidence of 7.2 per 100,000 live births has previously been reported, with the incidence of neonatal malignancy estimated at 36.5 per million births. Teratomas and neuroblastomas are the most common solid tumours described. Tumours may be very large or associated with severe hydrops leading to significant dystocia with the potential for difficult vaginal or caesarean delivery. Once the diagnosis of a fetal tumour is made, optimal management incorporates a multidisciplinary approach including obstetrician, neonatologist, paediatric surgeon and paediatric oncologist so that counselling is appropriate and a clear management plan is in place for parents.
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Abstract
MRI is being increasingly used to assess for fetal abnormalities. Although significant progress in the field of fetal MRI has occurred during the past 20 years, continued technical advances will likely contribute to significant growth of the field. Moreover, with continued hardware and software improvements, additional MRI sequences will likely become available. Prenatal MRI complements ultrasound because of larger field-of-view, superior soft tissue contrast, easier and more precise volumetric measurement, and greater accuracy in the demonstration of intracranial and spinal abnormalities. While ultrasound remains the primary modality for fetal imaging, these advantages of MRI make it a valuable adjunct to fetal surgery. Because fetal MRI involves many disciplines, the future of fetal MR will best be achieved through collaborative efforts.
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Affiliation(s)
- Orit A Glenn
- Department of Radiology, University of California, San Francisco, CA 94143, USA.
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Messing-Jünger AM, Röhrig A, Stressig R, Schaper J, Turowski B, Blondin D. Fetal MRI of the central nervous system: clinical relevance. Childs Nerv Syst 2009; 25:165-71. [PMID: 19039594 DOI: 10.1007/s00381-008-0745-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Specific conditions of the mother sometimes reduce the quality of ultrasound. In these cases, fetal magnetic resonance imaging (MRI) can be performed after gestational week (GW) 18. Interpretation of subtle disorders or malformations becomes safe not before GW 23. Clinical development of children with central nervous system (CNS) disorders is not predictable with imaging alone. Statistical evidence and personal experience of the medical team are essential in counseling, but optimized imaging is helpful in being more precise. The value of fetal MRI (fMRI) is evaluated. MATERIALS AND METHODS Twenty-five pregnant women (30.5 +/- 4.5 years) were investigated by additional fMRI. TECHNIQUE Breath-hold technique with T2 half-Fourier acquisition single-shot turbo spin-echo and T1 FLASH-2D images in three dimensions with field of view of 350 x 400 mm. All cases have been correlated with postnatal MRI, ultrasound, and clinical follow-up. RESULTS In all fetuses, diagnostic MRI was performed 3-10 days after ultrasound between GW 22 and 34 (GW 26.1 +/- 3.6). Sedation was not necessary. In eight cases of suspicious ultrasound, fMRI confirmed ultrasound findings. In 13 cases, additional diagnoses or exclusions of suspected findings could be established. Complete revision of diagnosis was realized in four cases. Findings could be confirmed by postnatal MRI in 11 patients. The clinical course was not predictable in cases with ambivalent prognosis. CONCLUSIONS Prenatal diagnosis of CNS pathologies should result in parental counseling. Sufficient diagnostic information, statistical data, and experience of the involved professionals are essential. These results show that in detecting congenital CNS abnormalities fMRI is superior to ultrasound and should be considered in difficult cases.
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Affiliation(s)
- A M Messing-Jünger
- Abteilung für Neurochirurgie, Asklepios Kinderklinik Sankt Augustin, Universität Bonn, Sankt Augustin, Germany.
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Morris LM, Lim FY, Crombleholme TM. Ex utero intrapartum treatment procedure: a peripartum management strategy in particularly challenging cases. J Pediatr 2009; 154:126-131.e3. [PMID: 19187733 DOI: 10.1016/j.jpeds.2008.09.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2008] [Revised: 08/04/2008] [Accepted: 09/24/2008] [Indexed: 10/21/2022]
Affiliation(s)
- Lee M Morris
- The Fetal Care Center of Cincinnati, Division of Pediatric General, Thoracic, and Fetal Surgery, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH 45229-3039, USA
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41
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Abstract
Fetal surgery has emerged from the realm of medical curiosity into an exciting, multidisciplinary specialty now capable of improving patient outcomes for a wide variety of diseases. Recent advances allow prenatal providers to both accurately diagnose and treat many fetal anomalies while maintaining maternal safety. As the initial postnatal health care providers to the majority of these newborns, neonatologists need to be familiar with some of the more recent state-of-the-art procedures currently being used. In this review, the authors discuss the prenatal evaluation process and various operative approaches (ie, open hysterotomy, fetoscopy, and percutaneous) to conduct fetal surgery. They then analyze the effectiveness of some of the more established and experimental prenatal therapies that are being performed for a number of fetal anomalies, including twin-twin transfusion syndrome, thoracic malformations, airway obstruction, congenital diaphragmatic hernia, myelomeningocele, and aortic valve stenosis.
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Affiliation(s)
- Shaun M Kunisaki
- Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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McDevitt H, Kubba H, Macara L, Reynolds B, Simpson J. Four cases of congenital airway obstruction: optimising perinatal management. Acta Paediatr 2007; 96:1542-5. [PMID: 17850403 DOI: 10.1111/j.1651-2227.2007.00177.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Congenital anomalies causing airway obstruction in the newborn are potentially fatal. However if an effective airway can be maintained the long-term prognosis is often excellent. We present four cases of airway obstruction, three of which were diagnosed antenatally. We discuss the role of antenatal imaging and review delivery options including the need for a multidisciplinary team approach. In conclusion, we recommend antenatal imaging with both ultrasound scan and magnetic resonance to inform perinatal management. Polyhydramnios, in association with suspected neonatal airway obstruction, should alert clinicians to a high-risk situation. We recognize that even in skilled hands, securing an airway can be very difficult and alternatives such as maintenance of the fetomaternal circulation or extra-corporeal life support should be considered.
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Affiliation(s)
- Helen McDevitt
- Queen Mother's Hospital, Yorkhill Division, Glasgow, Scotland
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Abstract
PURPOSE Fast MRI has provided detailed and reproducible fetal anatomy. This study was performed to evaluate the usefulness of fetal MRI for prenatal diagnosis. MATERIALS AND METHODS Fifty-six fetuses with congenital abnormalities on ultrasonography were evaluated by fetal MRI from 2001 to 2004 in Severance Hospital. Final diagnosis was made by postnatal pathology, postnatal MRI, and other modalities (such as ultrasound, retrograde pyelogram). A 1.5-Tesla superconductive MR imaging unit was used to obtain half-Fourier acquisition single-shot turbo spin images. RESULTS Of the 56 fetuses, intracranial abnormalities were found in 26 fetuses, intraabdominal abnormalities in 17 fetuses, intrathoracic in 6 fetuses, head and neck in 5 fetuses, and other sites in 2 fetuses. There were six cases in which the diagnoses of fetal MRI and ultrasonography differed. In such cases, fetal MRI provided more exact diagnosis than ultrasonography (5 vs. 0). Three fetuses with intracranial abnormalities on ultrasonography were diagnosed as normal by fetal MRI and in postnatal diagnosis. CONCLUSION Although ultrasonography is known as a screening modality of choice in the evaluation of fetus because of the cost-effectiveness and safety, the sonographic findings are occasionally inconclusive or insufficient for choosing the proper management. Thus, in this study, we suggest that fetal MRI is more useful than ultrasonography for the evaluation of intracranial abnormalities in some instances. For prenatal counseling and postnatal treatment planning, fetal MRI can be informative when prenatal ultrasonography is inadequate and doubtful.
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Affiliation(s)
- Yong-Seok Sohn
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
| | - Myung-Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Ja-Young Kwon
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Han Kim
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong-Won Park
- Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea
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Kim SK, Won HS, Lee SW, Kim JK, Shim JY, Lee PR, Kim A. Prenatal diagnosis of congenital epulis by three-dimensional ultrasound and magnetic resonance imaging. Prenat Diagn 2007; 26:171-4. [PMID: 16470675 DOI: 10.1002/pd.1368] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Congenital epulis is a benign intraoral tumor that has rarely been diagnosed prenatally. We report a fetus with congenital epulis diagnosed by three-dimensional (3-D) ultrasound and fetal magnetic resonance imaging (MRI) at 35 weeks' gestation. We show an image of congenital epulis using a new ultrasound technique, the 3-D multislice view, which shows images similar to CT or MRI. This is a short case report of congenital epulis diagnosed prenatally by 3-D ultrasound using multislice view and MRI.
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Affiliation(s)
- Sun-Kwon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Mota R, Ramalho C, Monteiro J, Correia-Pinto J, Rodrigues M, Guimarães H, Spratley J, Macedo F, Matias A, Montenegro N. Evolving Indications for the EXIT Procedure: The Usefulness of Combining Ultrasound and Fetal MRI. Fetal Diagn Ther 2006; 22:107-11. [PMID: 17135754 DOI: 10.1159/000097106] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2005] [Accepted: 04/05/2006] [Indexed: 11/19/2022]
Abstract
The EXIT procedure (EX utero Intrapartum Treatment) encompasses a multidisciplinary approach to situations in which airway obstruction is anticipated. Uteroplacental circulation is maintained to avoid neonatal hypoxemia while intubation is attempted. Not only is it useful in congenital diaphragmatic hernia with intrauterine tracheal occlusion, but new indications have been proposed. We present two cases in which EXIT procedure was adopted (huge cervical mass with tracheal compression and a highly vascularized cephalocervical mass) for the same purpose on different grounds. Our two cases stress once more the importance of combining fetal ultrasound and magnetic resonance imaging in the characterization of cervical masses and its usefulness in programming the procedure with a multidisciplinary team.
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Affiliation(s)
- Raquel Mota
- Center of Prenatal Diagnosis, Department of Gynecology and Obstetrics, University of Porto, Hospital S João, and Imagiology, SMIC, Porto, Portugal
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Martino F, Avila LF, Encinas JL, Luis AL, Olivares P, Lassaletta L, Nistal M, Tovar JA. Teratomas of the neck and mediastinum in children. Pediatr Surg Int 2006; 22:627-34. [PMID: 16838188 DOI: 10.1007/s00383-006-1724-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2006] [Indexed: 11/27/2022]
Abstract
This retrospective study reviews a series of teratomas of the neck and mediastinum aiming at defining the features of these particular locations. We recorded prenatal diagnosis, perinatal management, clinical and radiologic features, pathology, surgical strategies and results in cervical and mediastinal teratomas treated over the last 10 years. During this period we treated 66 children with teratoma of which 11 (6 male and 5 female) had cervicomediastinal locations. Five babies had cervical teratomas extended into the anterior mediastinum in two cases. Prenatal diagnosis was made in three (two with polyhydramnios). Four babies were born by C-section and only one had a successful EXIT procedure. The diagnosis was confirmed by imaging and increased AFP. Surgical treatment involved total tumor removal and in one case subsequent removal of lymph node metastases. All children survived except one in whom airway could not be cleared at birth. Two children bear mild hypothyroidism. During the same period six patients aged 0-17 years were treated for mediastinal teratoma. Only one was prenatally diagnosed and only two had some dyspnea. Removal was performed either by median sternotomy, thoracotomy, or thoracoscopy. They all survive and are free of disease. Teratomas of the neck may cause fetal disease and unmanageable neonatal airway obstruction. Prenatal diagnosis and planned multidisciplinary management are mandatory at birth. In contrast, only some mediastinal tumors cause respiratory embarrassment. Although benign, these tumors are sometimes immature and may metastasize to regional lymph nodes. Total surgical removal is curative. Thyroid insufficiency may be present at birth in cervical teratomas and may be aggravated by surgery.
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Affiliation(s)
- Francesca Martino
- Department of Pediatric Surgery, Hospital Universitario La Paz, Paseo de la Castellana, 261, 28046 Madrid, Spain
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Abstract
Although performing procedures on a fetus before severing the umbilical cord has previously been reported, the principles of the ex utero intrapartum treatment (EXIT) procedure were first fully developed for reversing tracheal occlusion in fetuses with severe congenital diaphragmatic hernia. The EXIT procedure offers the advantage of insuring uteroplacental gas exchange while on placental support. The lessons learned in the development of the principles that underlie the EXIT procedure have improved outcomes when applied in other conditions, most notably in cases of airway obstruction. The range of indications for the EXIT procedure has expanded and currently includes giant fetal neck masses, lung or mediastinal tumors, congenital high airway obstruction syndrome, and EXIT to ECMO (extracorporeal membrane oxygenation), among others. This review summarizes the underlying principles of the EXIT procedure, the expanding indications for its use, the pitfalls of management, and the progress that has been made in its successful application.
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Affiliation(s)
- Ahmad Marwan
- Fetal Care Center of Cincinnati, Division of Pediatric General, Thoracic, and Fetal Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA
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Wedegärtner U, Schröder HJ, Adam G. Fetal MRI in experimental tracheal occlusion. Eur J Radiol 2006; 57:271-7. [PMID: 16406439 DOI: 10.1016/j.ejrad.2005.11.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2005] [Revised: 11/14/2005] [Accepted: 11/16/2005] [Indexed: 11/21/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is associated with a high mortality, which is mainly due to pulmonary hypoplasia and secondary pulmonary hypertension. In severely affected fetuses, tracheal occlusion (TO) is performed prenatally to reverse pulmonary hypoplasia, because TO leads to accelerated lung growth. Prenatal imaging is important to identify fetuses with pulmonary hypoplasia, to diagnose high-risk fetuses who would benefit from TO, and to monitor the effect of TO after surgery. In fetal imaging, ultrasound (US) is the method of choice, because it is widely available, less expensive, and less time-consuming to perform than magnetic resonance imaging (MRI). However, there are some limitations for US in the evaluation of CDH fetuses. In those cases, MRI is helpful because of a better tissue contrast between liver and lung, which enables evaluation of liver herniation for the diagnosis of a high-risk fetus. MRI provides the ability to determine absolute lung volumes to detect lung hypoplasia. In fetal sheep with normal and hyperplastic lungs after TO, lung growth was assessed on the basis of cross-sectional US measurements, after initial lung volume determination by MRI. To monitor fetal lung growth after prenatal TO, both MRI and US seem to be useful methods.
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Affiliation(s)
- Ulrike Wedegärtner
- Department of Diagnostic and Interventional Radiology, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20251 Hamburg, Germany.
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Abstract
Ultrasound is the imaging modality of choice for pregnant patients. However, MRI is increasingly utilized in patients in whom the sonographic diagnosis is unclear. These include maternal conditions unique to pregnancy such as ectopic pregnancy, placenta accreta, and uterine dehiscence. MRI is also being increasingly utilized in the assessment of abdominopelvic pain in pregnancy, in particular in assessment for appendicitis. Fetal MRI is performed to assess central nervous system (CNS) abnormalities and patients who are considering fetal surgery for conditions such as neural tube defects, congenital diaphragmatic hernia, and masses that obstruct the airway. In the future, functional MRI and fetal volumetry may provide additional information that can aid in our care of complicated pregnancies.
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Affiliation(s)
- Deborah Levine
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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Liechty KW, Hedrick HL, Hubbard AM, Johnson MP, Wilson RD, Ruchelli ED, Howell LJ, Crombleholme TM, Flake AW, Adzick NS. Severe pulmonary hypoplasia associated with giant cervical teratomas. J Pediatr Surg 2006; 41:230-3. [PMID: 16410139 DOI: 10.1016/j.jpedsurg.2005.10.081] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The use of the ex utero intrapartum treatment (EXIT) procedure has salvaged many fetuses with giant neck masses. Despite an adequate airway, a subset of these patients die from an inability to achieve adequate gas exchange. METHODS We reviewed our experience with the EXIT procedure from 1996 to 2004. The EXIT was used to deliver 23 fetuses with giant neck masses. RESULTS Three fetuses with giant cervical teratomas died of severe pulmonary hypoplasia. On postmortem, these patients had severe airway distortion by the mass. The carina was retracted superiorly to the first or second rib resulting in compression of the lungs in the apices of the chest and pulmonary hypoplasia. Hypoplasia was reflected in the lung weights of 24 vs 38 g and 17 vs 34 g for age-matched normal lung. CONCLUSIONS Unsuspected obstructive fetal neck masses can be fatal because of an inability to secure an airway. Prenatal ultrasonography can identify fetuses at risk, allowing the fetus to be salvaged using the EXIT procedure. Despite obtaining airway control, a subset of these patients will die because of pulmonary hypoplasia. When counseling patients with large cervical masses it is important to discuss potential pulmonary hypoplasia in these patients.
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Affiliation(s)
- Kenneth W Liechty
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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