Congenital cystic adenomatoid malformation complicated by esophageal duplication cyst in a 6-month-old girl

We report a case of congenital cystic adenomatoid malformation (CCAM) complicated by an esophageal duplication cyst in a 6-month-old girl. The patient presented with recurrent pneumonia. Magnetic resonance imaging revealed two cystic lesions in the upper and lower lobes of the right lung. After cystectomy, histopathological investigation revealed that the lower cyst was a CCAM Type I, and the upper cyst was an esophageal duplication cyst. The coexistence of these complex anomalies supports the concept that the esophageal duplication cyst is one entity of a broad spectrum of developmental abnormalities caused by abnormal budding of the primitive foregut.

Neonatal transthoracic puncture in a case of congenital cystic adenomatoid malformation of the lung

A patient with congenital cystic adenomatoid malformation of the lung (CCAM) is presented who showed severe respiratory deterioration in the neonatal period caused by hyperinflation of the cystic component and compression of the contralateral lung. Transthoracic drainage of the cyst was performed to avoid preoperative artificial ventilation. On aspiration, air and liquid was removed from the cyst. After stabilization, surgical intervention was performed within 24 hours. Postoperative recovery was uneventful, and the child was discharged at day 13.

Prenatal diagnosis and management of congenital cystic adenomatoid malformation of the lung

OBJECTIVE

Our purpose was to review the management and outcome of pregnancies with a prenatal diagnosis of fetal congenital cystic adenomatoid malformation of the lung (CCAM).

STUDY DESIGN

A retrospective review was performed of all cases since 1995 with a prenatal diagnosis of fetal CCAM from the sole tertiary perinatal referral center in Western Australia.

RESULTS

Twenty-one pregnancies with CCAM were identified. The gestational age at diagnosis was <22 weeks in 86% of cases. Macrocysts were seen in 76% of cases during ultrasound examination. Seventeen pregnancies continued until term. Regression of the sonographic appearances was observed in 19% of cases. Fetal hydrops complicated two cases. One neonate died within 24 hours of delivery because of pulmonary hypoplasia. Twelve children have required pulmonary lobectomies. No adverse sequelae are evident in surviving children.

CONCLUSION

Most cases of prenatally diagnosed CCAM have had a good outcome. This review has positively influenced the counseling of women with this diagnosis.

Spontaneous pneumothorax resulting from congenital cystic adenomatoid malformation in a pre-term infant: case report and literature review

In the literature there are only three reported cases of spontaneous pneumothorax resulting from congenital cystic adenomatoid malformation in children under 1 year and for whom any resuscitative efforts were made. We present here a fourth case of a pre-term baby girl who was in perfect health, until she suffered a spontaneous pneumothorax as the initial manifestation of congenital cystic adenomatoid malformation of the lung at 10 weeks of age. Atypical segmentectomy with the use of stapling devices was successful. The characteristics of this particular manifestation are discussed.

Inflammation can be present in infantile congenital cystic adenomatoid malformation of the lung

Congenital cystic adenomatoid malformation (CCAM) of the lung is characterized by an excessive overgrowth of the terminal respiratory bronchioles, probably of hamartomatous origin. The absence of inflammation has generally been considered obligatory for the diagnosis of CCAM of the lung in the infantile period. Furthermore, it has been argued that chronic inflammation itself may influence the development of cystic lesions within lung parenchyma. We report a case of an 11-month-old infant with CCAM malformation of the lung type III associated with a super-impossed purulent inflammation and abscess formation. In conclusion, our case clearly demonstrates that CCAM may even in infantile period become inflamed, manifesting itself with different clinical symptoms and signs, such as respiratory distress or recurrent pneumonia.

Primary pulmonary rhabdomyosarcoma arising within cystic adenomatoid malformation: a case report and review of the literature

The current report describes a 13-month-old boy with primary pulmonary rhabdomyosarcoma (RMS) that originated within a congenital cystic adenomatoid malformation (CCAM). To the best of our knowledge, he is the youngest patient of all primary pulmonary RMS cases reported in the English-language literature. The tumor, localized in left upper lobe, was removed completely, and histologic examination showed embryonal subtype. Postoperative systemic chemotherapy was carried out. Recent evaluation 15 months after resection has not identified any residual or recurrent disease. Primary pulmonary RMS, although very rare in the pediatric age group, should be considered in young patients with solitary pulmonary masses and associated cystic lesions.

Carcinoma arising in congenital lung cysts

We report on a patient presenting with a bronchioloalveolar carcinoma fortuitously detected in the wall of a bronchogenic cyst. Evidence suggests that unstable epithelial cells contained within the cyst wall may lead to premalignant proliferation and neoplasia. In the current case, we demonstrated an increased proliferative activity in some areas of the cyst consistent with atypical adenomatous hyperplasia. Hence, we stress the importance of close follow-up of all suspected congenital lung cysts because of their potential malignant degeneration.

Lung abscess in congenital cystic adenomatoid malformation: report of one case

Congenital cystic adenomatoid malformation (CCAM) of the lung is an uncommon anomaly of fetal development of terminal respiratory structures. Patients with CCAM may present either in the newborn with progressive respiratory distress, or in older children with recurrent pulmonary infections. Lung abscess is an extremely rare presentation. Herein we report an 8-year-old girl with type 1 CCAM who presented as lung abscess.

Echocardiographic evaluation of the fetus with congenital cystic adenomatoid malformation

OBJECTIVES

The development of nonimmune hydrops is a known complication of congenital cystic adenomatoid malformation (CCAM) in the fetus. The aim of this study was to investigate the impact of CCAM on hemodynamics in the fetus and to determine whether cardiac dysfunction contributes to the development of hydrops in this patient population.

METHODS

The echocardiographic data from 41 consecutive fetuses diagnosed prenatally with CCAM were reviewed. The presence or absence of hydrops was noted in each patient. Two-dimensional ultrasonographic and Doppler data were compared between the two groups (with or without hydrops).

RESULTS

The mean gestational age for the study group at the time of imaging was 23.2 +/- 3.0 weeks. Hydrops was noted in 15 of 41 fetuses (36.5%). The fetuses that developed hydrops had a lower cardiac/thoracic ratio than those which did not develop hydrops (0.18 vs. 0.23, P = 0.001). The fetuses with hydrops also demonstrated an increase in early ventricular filling. The ratio of early ventricular filling to atrial contraction (E/A ratio) at both the tricuspid and mitral valves was significantly higher in the fetuses with hydrops (P = 0.005 and P = 0.03, respectively). Doppler interrogation of the inferior vena cava demonstrated a greater degree of reversal with atrial contraction in the hydrops group (29.7% vs. 15.1%, P = 0.003). The development of significant atrioventricular valve insufficiency was rare in the fetuses with hydrops (one of 15 cases).

CONCLUSIONS

Cystic adenomatoid malformation can result in significant cardiac compression in the fetus. This alters hemodynamics and may result in hydrops on the basis of elevated central venous pressure.

Successful treatment of juvenile laryngeal papillomatosis-related multicystic lung disease with cidofovir: case report and review of the literature

Cidofovir, a nucleoside analog antiviral agent, has been used with moderate success in the treatment of juvenile laryngeal papillomatosis (JLP) by direct intralesional injection. We report the first case where IV cidofovir was used successfully to treat a rare but lethal multicystic lung disease complicating JLP. A 35-year-old woman with a history of JLP requiring multiple laser ablations of laryngeal papillomata each year presented with hemoptysis and was found on CT scan to have bilateral, multiple pulmonary nodules and cysts. The results of BAL fluid analysis demonstrated no evidence of malignancy, and cultures were negative for fungi and mycobacteria. Molecular DNA typing of a biopsy specimen obtained from a laryngeal papilloma confirmed infection with human papilloma virus type 11. She received 12 months of treatment with IV cidofovir followed by 9 months of combined treatmentwith IV cidofovir and subcutaneous interferon-alpha-2A. This therapeutic regime resulted in a markedly decreased requirement for surgical removal of laryngeal papillomata, and CT scanning documented the regression of the lesions in the lung parenchyma that persisted after the discontinuation of therapy. The results of this case demonstrate that cidofovir may be used successfully to treat JLP-related lung disease and suggest that further studies are warranted.

Congenital cystic adenomatoid malformation of the lung: antenatal ultrasound findings and fetal-neonatal outcome. Fifteen years of experience

Seventeen cases of congenital cystic adenomatoid malformation of the lung (CCAM) are reported. They were followed up over a period of 1 month to 15 years. Diagnosis was made by prenatal ultrasound. Our purpose was to evaluate the fetal-neonatal outcome and the prognostic elements observable through ultrasound techniques, and to compare all types of CCAM. The outcome observed ranged from total prenatal resolution to postnatal spontaneous regression of the lesion, to complications due to the presence of nonimmune fetal hydrops (NIFH), intrauterine death and the necessity of surgical intervention. In our experience only hydrops represented a negative predictor of outcome since death occurred in all cases with this pathology. In the absence of NIFH, counselling should stress the prevalence of a positive outcome, even in cases of surgical intervention.

A case of non-immune hydrops fetalis with congenital cystic adenomatoid malformation of the left lung in a twin

Hydrops fetalis is a rare condition that occurs in one out of every 1,400-4,000 pregnancies. There are two types, immune and non-immune. It can be caused by a maternal-fetal incompatibility due to the Rh factor or, more rarely, the Kell factor or due to other antigens to red corpuscles. Non-immune types of hydrops have a complex multiform pathogenesis and in 50% of the cases they are of idiopathic nature. The causes that could determine non-immune hydrops are manifold and in 50% of the cases they are of an idiopathic nature. Independently of the clinical condition, the presented case could be classified in those forms of pathogenesis in which there is the presence of a congenital cystic adenomatoid malformation (CAM), not encountered in the fetal ultrasound performed at the sixteenth week of pregnancy. The particularity of our case is due to the association of the fetal hydrops of the CAM type in only one of the two twins. The presented case is classified in those forms of hydrops that are expressed with a clinical trend towards a worse prognosis, characterized by the intrauterine death of the fetus or the birth of a hydropic fetus that does not survive because of respiratory insufficiency and cardiocirculatory collapse.

Haemopneumothorax from congenital cystic adenomatoid malformation in a cryptorchidism patient

Congenital cystic adenomatoid malformation (CCAM) of the lung is an uncommon congenital anomaly, especially in young adults. This study reports an 18-yr-old male with CCAM involving the right upper lobe, who presented with a moderate spontaneous haemopneumothorax initially. The patient also had bilateral abdominal cryptorchidism which required surgical treatment earlier in childhood. The chest radiographs and contrast-enhanced computed tomographic scan of the chest showed a multicystic lesion with air-fluid levels in the right upper lung. The right upper lobe was resected through a posterolateral thoracotomy. Histological examination confirmed the diagnosis of CCAM. To the authors' knowledge, congenital cystic adenomatoid malformation presenting with spontaneous haemopneumothorax and haemoptysis has never been described in the literature.

[Pulmonary cystic adenomatoid malformation with anomalous vascularization with systemic origin]

We report an infant with the diagnosis of Congenital Cystic Adenomatoid Malformation. He was operated and we found an abnormal systemic blood supply associated in that lobe. We make a review of the literature, and we make a distinction between this rare combination and others like pseudo pulmonary sequestration, or Congenital Cystic Adenomatoid Malformation associated to pulmonary sequestration.

Long-term outcome of congenital cystic adenomatoid malformation

To determine the long-term outcome of congenital cystic adenomatoid malformation (CCAM), the records of all patients with CCAM treated in three Hungarian paediatric surgical centers between 1977 and 1996 were reviewed. Patients were followed for up to 20 years following diagnosis and treatment. In 20 patients CCAM was diagnosed postnatally and in 3 prenatally. Biodata including the operative procedures are presented. Follow-up findings between 18 months and 20 years after diagnosis showed better height and weight growth in patients operated upon in later childhood compared with those operated upon in infancy. The older the patient at the time of diagnosis, the better was the long-term outcome.

Cystic adenomatoid malformation of the lung: neonatal management of 21 cases

Currently, congenital cystic adenomatoid malformation of the lung (CCAM) is often diagnosed antenatally by ultrasound, allowing prompt and appropriate medical and surgical management after birth. The authors report 21 cases of CCAM admitted from 1988 to 1997 to a neonatal intensive care unit and treated by high-frequency oscillation (HFO) and early surgery. Six infants developed respiratory distress, of whom 4 required ventilation by HFO. HFO was also the mode of ventilation used in all cases except 1 during the perioperative period. There was no death from respiratory failure. The authors emphasize the usefulness of antenatal diagnosis, the efficiency of HFO in cases with severe respiratory failure, and well-tolerated early surgery.

The glandular component in congenital cystic adenomatoid malformation of the lung

Although severe congenital cystic changes (CCC) of the lung may be fatal, less severe forms may regress or vanish spontaneously. With recent advances in sonography, asymptomatic CCC are increasingly found. Whether all CCC should be promptly excised, or not, is uncertain. Congenital cystic changes conceptually are bronchopulmonary foregut malformations (BPFM) with a predilection for malignant degeneration. Among all BPFM, congenital cystic adenomatoid malformation (CCAM) is most common. We therefore searched for evidence of early malignant transformation in five surgically excised and three autopsy lungs with CCAM. By light microscopy, CCAM resembled poorly formed and dilated bronchi, bronchioles and respiratory air spaces. Four lungs had multiple nodular aggregates of mucus producing cells; the glandular component (GC). By scanning electron microscopy, GC appeared as multiple micropolyps, resembling neuroepithelial bodies. By transmission electron microscopy, GC had a surface proliferation of cells with granules of the mucous type and a basal increase in cells with owl-eyed neuroendocrine granules. The glandular component in CCAM appeared similar to the mucous cells in hyperplastic polyps of the colon and a type of mucus producing bronchioloalveolar carcinoma. Our findings support the hypothesis that CCAM is caused by dysregulated paracrine growth of mature cells and extracellular matrices and that GC could have the potential for malignant transformation. Further clinical and laboratory studies of BPFM are needed for the appropriate management of congenital cystic changes.

Elevated platelet-derived growth factor-B in congenital cystic adenomatoid malformations requiring fetal resection

BACKGROUND

During lung development, platelet-derived growth factor-BB (PDGF-BB) is maximal during the canalicular stage and decreases by the saccular stage. PDGF-BB stimulates lung growth by increasing cell proliferation. Fetal CCAMs have been shown to have an elevated proliferative index, but it is not known why some CCAMs rapidly enlarge in utero and cause fetal hydrops. The authors hypothesized that the high proliferative index and rapid enlargement of some fetal CCAMs may be caused by persistently elevated PDGF-BB production compared with normal fetal lung.

METHODS

To test this hypothesis, tissue was obtained at the time of resection from two fetal CCAMs (22 weeks), three full-term CCAMs, and three normal fetal lungs (21 to 22 weeks). PDGF-BB production by fetal CCAMs was compared with normal age-matched fetal lung using immunohistochemistry, reverse transcriptionase-polymerase chain reaction (RT-PCR), and Western blot analysis.

RESULTS

CCAMs resulting in fetal hydrops and requiring fetal resection had strong mesenchymal immunostaining for PDGF-BB next to epithelial lined cysts, increased PDGF-B gene expression by RT-PCR, and elevated PDGF-BB protein by Western blot, compared with normal age-matched fetal lung. Term CCAMs had minimal PDGF-BB staining, PDGF-B gene expression, and PDGF-BB protein production.

CONCLUSIONS

CCAMs that grew rapidly and progressed to hydrops, requiring in utero resection, demonstrated increased mesenchymal PDGF-B gene expression and PDGF-BB protein production compared with age-matched normal fetal lung, which may, in part, be responsible for the autonomous growth and proliferation seen in hydropic fetal CCAMs.