[Non-tumoral vascular disorders of the lung in the adulthood]

Non-tumoral vascular disorders of the lung are multiple, even if cases diagnosed in the adulthood are rare. They include congenital or acquired conditions, which related symptoms, if present, are non specific. This explains why their diagnosis is challenging and usually delayed. Surgery is the cornerstone of their treatment, although interventional radiology represents currently a less invasive alternative option for some of them.

[An analysis of the clinicopathological features and misdiagnosis of 16 adults pulmonary sequestration]

OBJECTIVE

To explore the clinicopathological features of adult pulmonary sequestration and summarize the misdiagnosis experiences.

METHODS

Data of 16 cases of adult pulmonary sequestration (18 years), who were confirmed by surgery and biopsy in our hospital were collected and reviewed.

RESULTS

The median age of all the patients was 38.5 years. The female seemed to be more likely to suffer from adult pulmonary sequestration (n = 12) with cough to be the most frequent symptom (n = 9). CT scans revealed most of the lesions were located in the left lower lobes of the lungs (n = 9). Half of the lesions were characterized by pulmonary cyst-like changes and/or multiple cystic bronchiectasis (n = 8), followed by soft tissue mass in or out of the lung fields (n = 7). Enhanced CT scans showed abnormal arteries from the systemic circulation. Only two cases were diagnosed as pulmonary sequestration correctly in the primary diagnosis. The remaining were mostly misdiagnosed as pulmonary cyst-like changes with bronchiectasis (n = 6) or tumors (n = 6). According to the findings during surgery, 13 cases were intralobar pulmonary sequestrations; 3 cases were extralobars, whose tissues were all detected dysplasia and chronic inflammatory by histopathological examinations.

CONCLUSIONS

The misdiagnosis rate of pulmonary sequestration is high because of its non-specific clinical symptoms. Since it is characterized by abnormal arteries and pulmonary dysplasia, enhanced CT scans should be used as a preferred screening method for suspected cases, especially for those middleaged patients with cystic or mass-like lesions in the left lower lobes of the lungs.

Evaluation of diagnostic accuracy of computed tomography to assess the angioarchitecture of pulmonary sequestration

Bronchopulmonary sequestration is an unusual congenital malformation consisting of abnormal lung tissue that lacks normal communication with the tracheobronchial tree. The diagnosis of pulmonary sequestration is based on identifying this systemic arterial supply. We aimed to evaluate the sensitivity of multidetector computed tomography in demonstrating the feeding artery and draining veins. Between 2003 and 2008, 8 patients (6 males, 2 females) ranging in age from 5 to 49 years with a diagnosis of pulmonary sequestration were identified. All patients underwent evaluation with chest tomography (spiral or multi detector tomography) and digital subtraction angiography. Aberrant systemic arterial supply was demonstrated in all cases: from the descending thoracic aorta (n= 6); arcus aorta (n= 1), internal mammarial artery (n= 1), intercostal arteries (n= 2) and celiac axis (n= 1). Four patients underwent surgery which confirmed the angioarchitecture depicted on angiography. One patient underwent angiography with embolization using. Computed tomography especially multidetector computed tomography is a powerful noninvasive technique for the detection of pulmonary sequestration.

[Clinical case of the month. Intrapulmonary lung sequestration diagnosed in an adult]

Pulmonary sequestration is a rare congenital lung malformation characterized by an abnormal segment of bronchopulmonary tissue supplied by aberrant systemic arteries. Due to the non-specific symptomatology, the diagnosis can be missed. Imaging is the cornerstone of the diagnosis. Complete surgical resection provides the definitive treatment. We report a case of pulmonary sequestration associated with an asymptomatic aspergillosis presenting during adulthood and describe briefly the epidemiology, embryology, histology, imaging and surgical treatment of this congenital abnormality.

Thoracoscopy in the management of congenital lung diseases in infancy

BACKGROUND

This study aimed to compare the results of thoracoscopic surgery for congenital lung diseases between infants younger than 6 months and those older than 6 months at the time of surgery in terms of operation duration, surgical complications, chest tube duration, and hospital stay.

METHODS

The charts of 30 thoracoscopic resections for congenital lung diseases were retrospectively reviewed. This study compared 17 children younger than 6 months (mean, 3.94 months; range, 0.37-5.7 months; group 1) with 13 children older than 6 months (mean, 12.05 months; range, 6.2-24.63 months; group 2) at the time of surgery. The median follow-up period was 9 months (range, 1-41 months).

RESULTS

Lobectomy was performed in 27 cases, bilobectomy in 1 case, and nonanatomic excision in 2 cases. The mean operating time for group 1 (176±54 min) was similar to that for group 2 (160±46 min). The difference is not significant. The mean duration of chest tube drainage was similar in the two groups (4.4 days; range, 1-9 days for group 1 vs. 4.1 days; range, 3-8 days for group 2). The complications included 1 major and 10 minor complications, with no statistically significant difference between the two groups. Three surgical procedures in each group were converted. The hospital stay was not statistically different between the two groups (8 days; range, 3-20 days for group 1 vs. 6 days; range, 4-10 days for group 2).

CONCLUSIONS

The study findings showed no statistically significant difference between the two groups in terms of operation time, complication rate, conversion rate, or hospital stay. Lobectomy can be safely and successfully performed by thoracoscopy even for children younger than 6 months.

Intralobar pulmonary sequestration associated with marked elevation of serum carbohydrate antigen 19-9

This report describes a 62-year-old man who experienced elevated serum carbohydrate antigen 19-9 (CA19-9) levels (>500 U/mL) for 4 years, and was finally diagnosed with right intralobar pulmonary sequestration. Surgery confirmed the presence an aberrant artery arising from the descending thoracic aorta and entering the right lower lobe basal segment. Immunohistochemistry demonstrated markedly positive staining of CA19-9 in the ciliated cylindrical epithelia, alveoli, and mucus in the cysts. After pulmonary resection, CA19-9 levels decreased to within a normal range. Therefore, the cause of the elevated serum CA19-9 levels in this case was almost certainly due to intralobar pulmonary sequestration.

[Surgical treatment for intralobar pulmonary sequestration in 50-years old woman with aberrant artery from a. gastrica sin]

A case of 50-years old female, operated on for intralobar sequestration with two 2 anomalous arteries in lig. pulmonale inf., one arising from thoracic aorta and the other--from truncus coeliacus of abdominal aorta. The diagnosis was confirmed by CT scan with i.v. and a left lower lobectomy was carried out with exellent long-term result.

[Cystic pulmonary malformations: clinical and radiological polymorphism. A report on 30 cases]

OBJECTIVES

This report describes different clinical pictures of cystic pulmonary malformation (CPM) and problems in diagnosis.

PATIENTS AND METHODS

Cases of CPM between 01 January 1994 and 31 December 2004 diagnosed in our institution were reviewed.

RESULTS

Thirty-three cases of CPM were diagnosed in 30 children. They consisted of 17 boys and 13 girls ranging from 20 days to 16 years of age at the time of the diagnosis. The CPM included: 17 cases of congenital lobar emphysema (CLE), seven bronchogenic cysts (BC), five cystic adenomatoid malformations (CAM) and four pulmonary sequestrations (PS). Three patients presented two associated lung malformations. The mean ages at the time of diagnosis varied from 2 to 88 months. The symptoms consisted of respiratory distress (n=14, 46.6%); recurrent attacks of respiratory embarrassment (n=6, 20%); pulmonary infection (n=8, 26.6%) associated with haemoptysis in two cases; haemothorax (n=1) and a chance discovery (n=1). Radiological investigations led to the diagnosis in all cases of CLE and CAM although it contributed less to the diagnosis of BC and PS. Twenty-nine patients required chirurgical treatment involving lobectomy (n=22), pneumonectomy (n=2) and cystectomy (n=8). The histopathological examinations confirmed the diagnosis in all cases and rectified the preoperative diagnosis in four cases. Except for one patient with CLE, who died a few days after a lobectomy due to acute nosocomial pneumonia, the postoperative period was uneventful in 26 children with a mean of follow-up of 24 months (4 months to 7 years). Three patients developed transient and episodic attacks of dyspnoea.

CONCLUSION

CPM may be responsible for many clinical and radiological pictures that present difficulties in their diagnosis. Polymorphism is related to the type of malformation, its topography and the evolutive complications.

Extralobar pulmonary sequestration revealed by prenatal hydrothorax

BACKGROUND

Pulmonary sequestration is a rare congenital pulmonary anomaly that can be diagnosed in utero.

AIM

Report a New case.

CASE REPORT

In this case report of extralobar pulmonary sequestration, the authors report a case revealed by hydrothorax and describe this disease appearance in different imaging technique (Doppler ultrasonography, magnetic resonance imaging and postnatal multislice CT angiography).

Cryptogenic stroke in the presence of venous bronchopulmonary collateralisation

We report the case of a 37-year-old man with a history of Hodgkin lymphoma and paroxysmal atrial fibrillation, seen because of a transient ischaemic attack with symptoms of temporary aphasia. Transoesophageal echocardiography could not detect a patent foramen ovale. However, CT thorax and flebography showed bilateral occlusion of both subclavian veins and the superior vena cava with an important collateral venous network, most likely responsible for this rare case of acquired cryptogenic stroke.

Systematic review and meta-analysis of the postnatal management of congenital cystic lung lesions

BACKGROUND

Antenatally detected asymptomatic congenital cystic lung lesions may be managed conservatively or by surgical resection. We undertook a systematic review and meta-analysis to quantify the risks of elective surgery, emergency surgery, and observation.

METHODS

All series published between 1996 and 2008, where the postnatal management of congenital cystic lung lesions was described, were reviewed. A meta-analysis was performed to determine whether elective or emergency surgery was associated with a higher risk of adverse outcomes.

RESULTS

There were 41 reports describing 1070 patients (of whom 79% were antenatally detected). Five hundred five neonates survived without surgery into infancy, of whom only 16 (3.2%) became symptomatic. For all ages, elective surgery was associated with significantly less complications than emergency surgery. The risk ratio was 2.8 (95% confidence interval, 1.4-5.5; P < .005) when comparing complications after elective surgery with emergency surgery.

CONCLUSIONS

The risk of asymptomatic cases developing symptoms is small. However, elective surgery is associated with a better outcome than emergency surgery. If elective surgery is undertaken, it should be performed before 10 months. Although no prognostic indicators have so far been identified in the literature, a conservative approach may be appropriate for small lesions.

[Surgical treatment of pulmonary sequestration--20 years experience]

AIM

To study our experience in the diagnostics and treatment of pulmonary sequestration and to evaluate the long-term postoperative results.

MATERIAL AND METHODS

Between Jan 1989 and Jan 2009. 8 patients (3 men, 5 women, mean age of 23.9 years) were operated on for lung sequestration. Sequestration was intralobar in 6 cases and extralobar in 2 cases. The abnormality was discovered by chance in 2 patients. The most frequent clinical manifestation was those of recurrent bronchopneumonia. Chest X-rays showed an apparently benign, posterobasal image in 75% of the cases. Arteriography was performed in 2 patients and revealed an abnormal systemic artery. Computerized tomography imaging with i.v. contrast confirmed the diagnosis in 6 patients. The intralobar type of sequestration was treated by lobectomy, and the extralobar type by sequestrectomy.

RESULTS

The operative mortality and the morbidity rates were nil. The mean in-hospital stay was 7.75 days. The long-term postoperative results (follow-up from 5 to 20 years) are considered excellent.

CONCLUSION

The surgery is a method of choice in the treatment of pulmonary sequestration. with low rate of postoperative complications and excellent long-term results.

[Bronchopulmonary sequestration: review of 27 cases]

OBJECTIVE

To explore the clinical manifestations, the diagnosis and the treatment of bronchopulmonary sequestration.

METHODS

Twenty-seven cases of bronchopulmonary sequestration confirmed by histopathological studies were analyzed and related literatures were reviewed.

RESULTS

Among the 27 cases of bronchopulmonary sequestration, 22 were intralobar type, and 5 were extralobar type. All the patients with intralobar type had symptoms including cough, expectoration, fever, hemoptysis, but the 5 cases of extralobar type had no symptoms. Twenty cases were confirmed before operation by chest radiography, plain CT scan, enhanced CT scan, CT angiography, MR angiography, or selective arteriography. Chest operation was performed in all the cases, with successfully recovery after the operation, and no relapse was found.

CONCLUSIONS

The clinical manifestations of bronchopulmonary sequestration are nonspecific. Selective arteriography, although invasive, plays a pivotal role in the diagnosis. Non-invasive angiography including enhanced CT scan, CT angiography, and MR angiography have become important supplements to selective arteriography. Surgery is the optimal treatment, while the effect of interventional therapy needs further study.

Congenital cystic lung disease: contemporary antenatal and postnatal management

Congenital cystic lung disease comprises a broad spectrum of rare but clinically significant developmental abnormalities, including congenital pulmonary adenomatoid malformations, bronchopulmonary sequestrations, bronchogenic cysts, and congenital lobar emphysema that result from perturbations in lung and airway embryogenesis. As congenital lung lesions are now more commonly recognized antenatally, mothers require accurate prenatal counseling and appropriate perinatal management. In light of long-term complications of infection and malignancy, there is growing consensus that infants with asymptomatic lesions should undergo elective excision of congenital pulmonary adenomatoid malformation (CPAM) or bronchopulmonary sequestration (BPS). This review will focus on advancements and current practice in the diagnosis and management of CPAM and BPS, identifying aspects of the literature that are confusing or controversial. Although our knowledge and pre- and postnatal management of lung lesions will continue to evolve and improve, there is a compelling need for a unified clinical and pathological classification system that creates a common platform for discussion, clinical management, and research.

[Pulmonary sequestration]

Pulmonary sequestration is rare and serious dysplasia, which has clinical signs of pneumonia and respiratory distress syndrome and radiological signs of polymorphic shadows. Pulmonary sequestration masses have autonomic blood supply. For confirmation of the diagnosis we use ultrasound examination, CT scan, MRI, angiopulmography and aortography.

AIM OF THE STUDY

To present pathogenesis, diagnostic features and surgical treatment tactics of rare and serious pulmonary dysplasia.

MATERIAL AND METHODS

During the period of 1979-2002, we have examined and treated 9 patients because of pulmonary sequestration. We analyzed clinical signs, results of the examination before operation, indications for operation and results of surgical treatment.

RESULTS

Seven patients after the operation recovered, 1 patient died due to infection and cardiovascular complications. One patient is supposed to be operated on in the near future.

CONCLUSIONS

1. Pulmonary sequestration is rare and serious bronchial - pulmonary dysplasia, which has clinical signs of pneumonia and respiratory distress syndrome and radiological signs of polymorphic shadows. 2. Pulmonary sequestrations are classified as intralobar, extralobar and extrapulmonary sequestration. 3. Pulmonary sequestration is often associated with cardiovascular dysplasias and diaphragmatic malformations. 4. Methods of examination: X-ray examination, CT scan, MRI, ultrasound examination, aortography. 5. Complications of pulmonary sequestration: pneumonia, pleuritis, necrosis of the sequestration, chylothorax, respiratory distress syndrome, hemothorax, cystic transformation, and pneumothorax. 6. Treatment - surgery or embolisation of abnormal supply vessels.

Intralobar sequestration with cystic adenomatoid malformation and atypia

Pulmonary sequestration and congenital cystic adenomatoid malformation are infrequent congenital lung disease and the combination of these two entities is rare. Here a case of left pulmonary sequestration with congenital cystic adenomatoid malformation in an asymptomatic elderly woman who presented with recent massive haemoptysis is reported. Fine needle aspiration cytology showed hypercellularity with micro-acinar pattern and mild pleomorphism. Computerised tomography scan depicted a round mass with rim of peripheral enhancement at left lower lobe of the lung. Intra-operative findings were suggestive of an intralobar sequestration with multiple aberrant vascularisation. Histologically intralobar sequestration was associated with congenital cystic adenomatoid malformation and epithelial atypia.

Clinical spectrum and management of congenital pulmonary cystic lesions

INTRODUCTION

Congenital cystic lesions of the lung in children are uncommon but potentially life-threatening and warrant an urgent diagnostic work-up. Pulmonary sequestration (PS), congenital cystic adenomatoid malformation (CCAM), congenital lobar emphysema (CLE), and bronchogenic cyst (BC) are the four major congenital cystic lesions, but they share similar embryologic and clinical characteristics. The purpose of this study is to review our institutional experience with congenital cystic lung disease emphasizing on diagnosis and management.

PATIENTS AND METHODS

Between January 1975 and October 2007, 109 patients have been treated, of which 57 males and 52 females, the age ranged from the birth to 13 years. 104 patients presented solitary lesions: CCAM (47), CLE (16), PS (22), BC (19). The remainders 5 patients presented two simultaneous lesions: intralobar PS and CCAM (2), CLE and CCAM (3).

RESULTS

All the lesions have been treated surgically: in the first cases, only symptomatic patients underwent surgery, while in the last years, patients have systematically been submitted operated.

CONCLUSIONS

A meaningful percentage of CCAM joins to PS and CLE; instead the BC are generally isolated, probably deriving by a more precocious embryogenetic defect. The treatment of these lesions is surgical: CCAM (type I-II) and CLE should be treated promptly in newborns for respiratory distress and pneumothorax; CCAM (type II) and BC generally become symptomatic gradually and expose to degenerative risk; intralobar PS generally becomes symptomatic and surgery prevents the risk of infections. Extralobar PS and the asymptomatic BC are not exempted by surgical approach whenever accidentally described as masses of uncertain nature. Asymptomatic cysts in children should be resected, to avoid later complications of the cysts, which could make operation more difficult. Conservative anatomic resections should be attempted to preserve functional lung tissue. Careful histologic examination of the resection specimen is mandatory to identify occult malignancy. In conclusion a correct embryogenetic organization and a clinical evaluation of the congenital cystic lung diseases allow a precocious and effective surgical timing.

Prenatal diagnosis of pulmonary sequestration by ultrasound and magnetic resonance imaging

A 36-year-old multigravida, G2P1, underwent routine ultrasound scan at 22+1 weeks of gestation, which revealed a single normally growing fetus with left intrathoracic mass and left displacement of the cardiac apex. The left intrathoracic wedge-shaped hyperechogenic mass, measuring 32 x 25 mm in size, was situated at the lower portion of the left lung. A combination of color and power Doppler ultrasound allowed visualization of a vessel arising from the descending aorta, which supplied the mass. The diagnosis of extralobar pulmonary sequestration was made. Magnetic resonance imaging (MRI) was also performed and revealed a well-defined mass with homogeneous high-signal intensity when compared with normal lung tissue in the left upper lung field, which was compatible with pulmonary sequestration. The pulmonary mass was followed up by color and power Doppler every 2 weeks. The peak velocity of 11.85 cm/sec and the diameter of the feeding artery of 1.19 mm gradually decreased and disappeared 8 weeks later. The intrathoracic mass disappeared 10 weeks later at 32+1 gestational weeks. Repeat MRI also revealed spontaneous regression of the mass in favor of resorption of sequestration. The fetus was delivered at 38+1 gestational weeks. A male newborn weighing 2,520 g was spontaneously delivered with an Apgar score of 8 at 1 minute and 9 at 5 minutes. In our patient, it is suggested that progressive decreases in the peak velocity of the feeding vessel heralded the spontaneous regression of pulmonary sequestration not associated with hydrops/hydrothorax.

[Diagnosis and treatment of intralobar pulmonary sequestration]

OBJECTIVE

To summarize the diagnosis and surgical treatment of intralobar pulmonary sequestration (PS).

METHODS

The clinical data of 7 cases of intralobar PS, 5 males and 2 females, aged 15 - 38, was collected and analyzed. Macroscopic and microscopic pathological findings were recorded. The expression of protein p53 and carcinoembryonic antigen (CEA) was evaluated immunohistochemically in 6 samples obtained from lobectomy.

RESULTS

All 7 patients were admitted with major features of intermittent lung infection. Diagnosis was confirmed in all 7 cases before operation by contrast enhanced helical CT or MRI. All patients were treated with surgical excision, of which lobectomy was performed in 6 cases and wedge resection in 1 case. No surgical death was reported. All the aberrant systemic arteries arose from the thoracic aorta. The histological pictures showed polycystic lesion in sequestrated area with fibrosis formation and chronic inflammatory cell infiltration in the surrounding pulmonary stroma. Hyperplasia of epithelium occurred in some parts of the cystic lesions. Positive protein p53 staining and diffuse CEA expression were detected in all the 6 cases, showing stronger protein p53 staining in whose superficial layer of hyperplastic epithelium than in the basal layer. The normal bronchial epithelium was not stained with p53 or CEA.

CONCLUSION

The diagnosis of intralobar PS can be confirmed by enhanced contrast helical CT with 3-dimensional reconstruction, a non-invasive method. Surgical intervention, such as lobectomy, can be applied after complete control of pulmonary infection. Aberrant accumulation of p53 protein and CEA expression in the cystic epithelium inside PS tissues show a relationship with chronic inflammation.

Giant Carcinoid Tumor Mimicking Pulmonary Sequestration

A 42-year-old woman who previously underwent two consecutive thoracotomies for a lower lobe mass in her right lung was referred to our clinic for further management. Both procedures were abandoned due to excessive bleeding. Computed tomographic angiography demonstrated an infra-diaphragmatic systemic arterial supply of the mass similar to pulmonary sequestration. However the lobe had a normal venous drainage to the left atrium. Then a right lower lobectomy was undertaken through a hemi-clamshell incision, and histopathology revealed an atypical carcinoid tumor. The patient was discharged home after a satisfactory postoperative period. She still remains disease free at 14 months follow-up.

Surgical treatment of infected intralobar pulmonary sequestration: a collective review of patients older than 50 years reported in the literature

We report on the rare and surgical treatment of a senile patient of infected intralobar pulmonary sequestration. A 56-year-old male who had complained of headache, vomiting, cough, sputum production, and high fever was admitted to our hospital. Chest computed tomography (CT) showed an infected intralobar pulmonary sequestration as an 8x6 cm cystic mass with multiple air-fluid cavities in the left lower basal segment and severe pneumonia in the left upper and lower lobes around the mass. A 3-D CT showed an aberrant artery entering the consolidation from the descending aorta. A standard lower lobectomy was performed with a ligation of the aberrant artery with a diameter of 1 cm supplying the posterior segment of the left lower lobe. A histological examination of the lung revealed acute and chronic broncho-bronchiolitis with cystic dilatation consistent with intralobar pulmonary sequestration. We discuss the characters of senile patients compared with juvenile patients, with reference to a collective review of patients older than 50 reported in the literature.