[Pulmonary sequestration: 2 cases (intralobar and extralobar) in surgically treated adults]

We present two cases of pulmonary sequestration, one intralobar and the other extrapulmonary, in young adults. The diagnoses were obtained after surgical resection in both cases. The cases are of interest in that the first (intralobar sequestration) started with massive hemoptysis requiring emergency treatment, and the second (extrapulmonary sequestration) involved an unusual location in the upper mediastinum, requiring surgery by video assisted thoracoscopy.

[Extralobar lung sequestration with fistula to the esophagus]

Pulmonary sequestrations have no communication with the bronchial tree. Therefore they are usually airless. However, in the presence of a fistula to the esophagus or the stomach, they might contain air or could even be emphysematic. Such a case in a newborn is presented. This very rare anomaly is frequently named "communicating bronchopulmonary foregut malformation". This malformation has to be included in the differential diagnosis of multicystic lung diseases. Diagnosis can be made preoperatively by esophagography and Doppler sonography.

Pulmonary sequestration. Experience with eight consecutive cases

Bronchopulmonary sequestration was diagnosed in eight patients, aged 6-47 years during a 13-year period. The sequestration was intralobar in six patients and extralobar in two. Only lower lobes were involved. Recurrent pulmonary infection was the main clinical presentation. Radiographs usually showed an aerated cyst in intralobar sequestration, while extralobar sequestration presented as a homogeneous shadow. Computed tomography of the chest after bolus infusion of contrast medium revealed the anomalous artery in two patients pre-operatively. The main source of arterial supply was the thoracic aorta in both sequestration types, but venous drainage differed between the types. Associated lesions were bronchogenic cyst and extensive bronchiectasis, each in one patient. Surgical treatment was sequestrectomy for extralobar and lobectomy for intralobar sequestration.

Infradiaphragmatic extralobar pulmonary sequestration masquerading as an intra-abdominal, suprarenal mass

Three infants were found to have infradiaphragmatic masses by prenatal ultrasound. Postnatal imaging studies confirmed the presence of these masses, which were suspected of being intra-abdominal malignancies (neuroblastoma). The other principal differential diagnosis was extralobar pulmonary sequestration (EPS). Intraoperative findings were consistent with EPS, which was confirmed by histologic examination. We present these three infants, review the literature, and discuss the evaluation and treatment of infradiaphragmatic EPS.

Retroperitoneal pulmonary sequestration: imaging findings, histopathologic correlation, and relationship to cystic adenomatoid malformation

OBJECTIVE

Retroperitoneal bronchopulmonary sequestrations are rare congenital lesions that have been increasingly reported as incidental findings in utero. We present our case material of congenital retroperitoneal sequestration, discuss the reported imaging and histopathologic characteristics of this entity, and provide an approach to subsequent clinical and surgical management.

CONCLUSION

Our data suggest that the imaging findings in retroperitoneal sequestration are characteristic and that faulty mesenchymal induction of pulmonary tissue within the retroperitoneum renders internal development into cystic adenomatoid malformation the rule rather than the exception. In the typical case, surgical removal is nonemergent.

Intralobar sequestration: radiologic-pathologic correlation

Intralobar sequestration accounts for 75% of pulmonary sequestrations. The lesion consists of lung tissue that lacks normal communication to the tracheobronchial tree, has systemic arterial supply, and shares the pleura of the parent lobe. The majority of intralobar sequestrations are probably acquired lesions. Patients usually present before the age of 20 years with recurrent infection. At pathologic examination, intralobar sequestration is characterized by inflammation and fibrosis. At radiologic examination, intralobar sequestration typically appears as a consolidation or mass, with or without cavitation, within a lower lobe. In many cases, cystic change may be present within the affected lobe. Identification of a systemic arterial supply supports the diagnosis. Patients are treated with surgical excision, and prognosis is favorable.

Extralobar pulmonary sequestration presenting as a mediastinal malignancy

Pulmonary sequestration is an uncommon congenital anomaly usually diagnosed in childhood. It frequently presents as a lower lobe mass with symptoms from vascular shunting, anatomic impingements, or associated anatomic defects. This case report describes an adult with asymptomatic extralobar sequestration involving the mediastinum and left upper lobe. The unusual location and radiographic appearance, suggestive of malignancy, led to prompt surgical exploration. We review the literature on this topic, focusing on anatomic variability and difficulties with preoperative diagnosis.

[A case of systemic arterial supply to the normal left basal segments with no symptoms]

A 41-year-old man was admitted to Hirakata City Hospital because of an abnormal shadow on chest X-ray film. Chest X-ray film showed a tumorous shadow in the left anterior basal segment (S8). MRI showed aberrant arteries arose from the descending aorta clearly. Broncho-fibers-copy showed no defect of visible bronchi. Aortography showed one aberrant arteries arose from the descending thoracic aorta, circulated in the basal segment of the left lower lobe, and returned to the left pulmonary vein. Pulmonary arteriogram revealed defect of A8-10. Resection of left lower lobe was performed. In the resected specimen, the bronchi of the left lower lobe had a normal structure and showed a normal pattern of distribution.

[Definitive diagnosis of pulmonary sequestration using magnetic resonance. Description of 3 cases]

Pulmonary sequestration is a congenital malformation in which the pulmonary parenchyma is isolated from the rest of the lung and receives irrigation. Traditionally this malformation has been diagnosed by arteriography, but in recent years the usefulness of magnetic resonance, a technique that can probably substitute for arteriography on many occasions, has been emphasized. We report 3 cases of intralobar pulmonary sequestration diagnosed by magnetic resonance, a procedure that provided adequate presurgical assessment. The magnetic resonance images were later shown to be consistent with anatomical findings.

Congenital thoracic masses: imaging features in the adult

Congenital anomalies in the adult thorax are frequently asymptomatic and may remain undetected for many years. Whether they then become symptomatic or are discovered as an incidental finding on an imaging study obtained for unrelated reasons, thoracic anomalies may appear as masses or contour abnormalities that mimic other pathology, particularly neoplastic disease. The aim of this review is to discuss and illustrate a wide variety of congenital thoracic anomalies that can potentially present as a mass in the thorax. For ease of discussion, lesions are classified under numerous headings, including congenital lung anomalies caused by bronchopulmonary malformations and anomalies of pulmonary vasculature, vascular anomalies of the great vessels, diaphragmatic anomalies, and congenital masses of the chest wall. The appearance of these congenital lesions on chest radiographs and other imaging modalities such as CT, MRI, and angiography are illustrated, with emphasis on features that can distinguish these lesions from other intrathoracic masses.

[A case of Pryce's type I pulmonary sequestration with hemoptysis and bruit]

A 20-year-old man was admitted to our hospital with the complaint of hemoptysis. A bruit was best heard at the lower portion of the left posterior chest. CT scan and MRI revealed clearly the existence of a large aberrant vessel from the descending thoracic aorta. Aorto- and pulmonary arteriography demonstrated that a large systemic artery from the descending thoracic aorta supplied the basilar segments of the left lower lobe, and to which there was no pulmonary artery supply. The pulmonary veins from these segments drained into the left atrium. The properative diagnosis was Pryce's type I pulmonary sequestration. A left lower lobectomy was performed. The aberrant vessel was 15 mm in diameter and was elastic walled. The systemic artery of the basilar segments revealed proliferation of media and obstructive changes. Some discussions were made about hemoptysis and bruit in 23 cases of Pryce's type I pulmonary sequestration in Japan.

Imaging approach to the diagnosis of pulmonary sequestration

PURPOSE

To describe the characteristic features of pulmonary sequestration (PS), to evaluate the usefulness of various imaging modalities, and to find a rational approach to accurate diagnosis.

MATERIAL AND METHODS

Twenty-four patients with PS proved by operation and pathology were reviewed retrospectively. Plain chest films were done in all patients, bronchography in 3, sonography in 14, CT in 6 (including CT angiography in 1 case), MR in 8 (including MR angiography in 1 case) and aortography in 12 (including DSA in 1 case).

RESULTS

Plain chest films demonstrated a solid mass in 14 patients and a cystic mass in 10. Bronchograms showed displacement of adjacent bronchi with no filling of contrast medium within the lesion in 2 cases, while another case had a blind intermediate portion of the right bronchus (hypoplasia of middle and lower lobes associated with extralobar sequestration). Sonography demonstrated a solid lung mass in 12 cases and a solid mass with cystic areas in 2, and detected vessel-like structures within the mass or in its surroundings in 12. Doppler analysis showed arterial spectral wave confirming a feeding artery. CT revealed a solid mass in all patients, a mass with low density area in 4, and emphysema surrounding the mass in 3. MR imaging depicted anomalous arteries in all patients and venous drainage in 4 cases. Aortography demonstrated anomalous systemic arterial supply to the PS in all patients. In this series, 21 cases (87.5%) were correctly diagnosed preoperatively by the imaging modalities.

CONCLUSION

Plain chest films can provide a diagnostic clue to PS. Sonography, CT and MR are helpful for showing arterial blood supply and for making a definite diagnosis. We recommend a rational imaging approach for the diagnosis of PS.

Bronchopulmonary foregut malformation mimicking neuroblastoma

We report the case of a patient with an unusual, complex bronchopulmonary foregut malformation. The malformation included an extralobar sequestration, an esophageal duplication cyst, and a gastric duplication cyst. Postnatal imaging suggested a fetal adrenal neuroblastoma.

Nonimmune hydrops fetalis, pulmonary sequestration, and favorable neonatal outcome

BACKGROUND

The association of pulmonary sequestration and nonimmune fetal hydrops reportedly carries a very poor prognosis for survival. We describe three newborns with good outcomes despite the diagnosis of pulmonary sequestration; two cases were associated with hydrops fetalis and one with isolated fetal ascites.

CASES

Two neonates with severe hydrops fetalis had pulmonary sequestration diagnosed postnatally. A third infant presented early in gestation with marked fetal ascites that regressed spontaneously before delivery; this infant also had pulmonary sequestration. Despite severe respiratory insufficiency requiring aggressive management, all three infants survived after surgical resection of the sequestered lung mass.

CONCLUSION

These cases demonstrate the difficulties associated with antenatal counseling regarding long-term prognosis for infants with nonimmune hydrops and pulmonary sequestration. With optimal care in a tertiary perinatal center, a less pessimistic outlook than previously described in the literature may be appropriate.

Pulmonary pseudosequestration receiving arterial supply from a coronary artery fistula. A case report

A forty-eight-year-old man with a history of pulmonary tuberculosis and scarring of both hila and upper lobes was noted to have bilateral pulmonary pseudosequestration, in which the blood supply originated from a coronary artery fistulous vessel arising from the left circumflex artery and draining into the pulmonary artery. This is the first reported patient with the source of blood supply to the pulmonary pseudosequestration arising from a coronary artery fistula.

[Case of intralobar pulmonary sequestration with increased serum sialyl Lewis X-i (SLX)]

A 37-year-old male whose chief complaint was fever and back pain was admitted to our hospital because of a mass shadow in the left lower P3ng field found in X-ray examination. The level of serum SLX on admission increased to 1,338 U/ml. He was diagnosed intralobar pulmonary sequestration by angiography. The left lower lobe was resected 2 months after second admission. His general condition was steady, and he was discharged 18 days after the operation because the level of serum SLX decreased to 49.9 U/ml.

[Massive haemothorax caused by intralobar pulmonary sequestration]

The authors present the case of a young male with massive haemothorax caused by intralobar bronchopulmonary sequestration. Angiography is necessary for the exact diagnosis of bronchopulmonary sequestration. The most common site of intrapulmonary type sequestration is the left lower lobe of the lung. In this case the aberrant artery was originated from the abdominal aorta. During thoracotomy after ligature of the aberrant vessels S5,S10 segmentectomy was performed. The authors emphasize that the rare cause of rapid anaemia in consequence of haemothorax could be intralobar bronchopulmonary sequestration.

[Intralobar pulmonary sequestration as the cause of neonatal respiratory distress]

A male infant 15 hours old with congenital intralobar pulmonary sequestration is described. The boy was born with tachypnea and cyanosis. A chest film revealed mediastinal displacement secondary to a cystic lesions in the lower left lobe. During surgery the lesion was found to be irrigated by an artery coming from the thoracic aorta and venous drainage was into the inferior vena cava. The lesion was spongiform and microscopic examination revealed alveolar parenchyma with irregular, dilated bronchiolar structures. Intralobar sequestrations have seldom been described in infants. Our case suggests that this malformation is congenital. We discuss the diagnostic possibilities of pulmonary cystic lesions that cause respiratory distress in neonates.

Hydrops fetalis and pulmonary sequestration

The development of fetal hydrops in conjunction with intrathoracic pathology has been described, but rarely in association with pulmonary sequestration. The current report presents three cases of antenatally identified nonimmune hydrops fetalis, seen in association with pulmonary sequestrations. In one case, a left-sided chest mass also was defined. One infant was born by emergency cesarean section because of fetal distress at 34 weeks' gestation; the other two were delivered vaginally at 30 and 36 weeks. Two of the newborns were severely hydropic and required aggressive cardiorespiratory resuscitation that included bilateral chest tubes for massive pleural effusions. The third infant was stable at the time of birth, but thereafter respiratory distress developed, and intubation and ventilation became necessary. Two of the infants had a left-chest mass and the other had a right-sided mass, all identified by chest x-ray. Subsequent ultrasonography showed a chest mass and an identifiable systemic feeding artery in two of the patients. For the third, a specific diagnosis was not made before surgery. After resolution of hydrops, all three infants had successful removal of their intrathoracic pulmonary sequestrations. Two of these were found to be extralobar, and the other was an intralobar sequestration of the left lower lobe.