New developments in fetal lung surgery

After more than two decades of experimental and clinical work, fetal surgery has become a reasonable treatment modality for selected fetuses with life-threatening anomalies. We review the literature on anatomic anomalies of the fetal lung that are amenable to fetal surgical therapy. Ultrafast fetal magnetic resonance imaging has enhanced the accuracy of prenatal evaluation. Fetal lung masses associated with hydrops are nearly 100% fatal. These lesions can be resected in utero if they are predominantly solid or multicystic. Thoracoamniotic shunting may be effective in the setting of a single large predominant cyst. Fetuses diagnosed with left congenital diaphragmatic hernia before 26 weeks' gestation, who have liver herniation and a sonographic right lung-to-head circumference ratio of less than 1.0, may benefit from temporary fetal tracheal occlusion to enhance lung growth before birth.

MRI of thoracic vascular lesions with emphasis on two-dimensional time-of-flight MR angiography

MRI is a valuable method for evaluating thoracic vascular lesions by virtue of its non-invasiveness and multiplanar capability. In addition, ionizing radiation and iodinated contrast medium are not required. Electrocardiographically gated T1 weighted spin echo MRI remains the principal technique for demonstrating the anatomy and morphology of thoracic vascular diseases. Cine MRI allows dynamic evaluation of vascular flow, whereas MR angiography is particularly useful in the two-dimensional (2D) or three-dimensional (3D) display of vascular anatomy. This pictorial review illustrates the use of 2D time-of-flight MR angiography in the assessment of various thoracic vascular conditions including aortic arch and great vessel anomalies, heterotaxic syndromes, aortic dissection, aortic or arch vessel aneurysms, pulmonary embolism, pulmonary sequestration, axillofemoral bypass and tumour/vessel relationships.

Intra-abdominal pulmonary sequestration: a benign suprarenal mass

A 34-year-old white woman presented with an 8.5-cm left suprarenal mass. Evaluation revealed normal adrenal hormone function. Pathologic examination after surgical removal revealed a rare benign condition, intra-abdominal extralobar pulmonary sequestration (accessory lung).

[Intralobar pulmonary sequestration presenting increased serum CEA, CA 19-9, and CA 125, and associated with asymptomatic pulmonary aspergillosis]

A 44-year-old woman was admitted to our hospital for further evaluation of a consolidated shadow in the left lower lobe and the evaluation of serum tumor markers (CEA 46.3 ng/ml, CA 19-9 1911 U/ml, and CA 125 103 U/ml). Chest computed tomography revealed an irregular shaped, low density mass shadow in the left S10 region, suggesting the diagnosis of pulmonary sequestration or bronchial atresia. However digital subtraction angiography failed to demonstrate an anomalous feeding artery. We could not rule out the possibility that a malignant lesion was included in the consolidated shadow. A left thoracotomy revealed an intralobar pulmonary sequestration of the left lower lobe. Hyphae of aspergillus were found in the lumen of the cystic bronchus of the resected lung. Immunohistochemical studies showed strong expression of CEA, CA 19-9, and CA 125 by bronchial epithelia in the pulmonary sequenstration. The serum values of tumor markers returned to their normal ranges after surgery.

Clinical spectrum of congenital cystic disease of the lung in children

OBJECTIVES

Congenital cystic lesions of the lung are uncommon but share similar embryologic and clinical characteristics. The purpose of this study is to review our institutional experience of congenital cystic lung disease, emphasizing the clinical spectrum of the disease related to age, and present some cases with unusual clinical manifestations.

PATIENTS

Between 1962 and 1996, 26 patients (9 females and 17 males) under 15 years old underwent evaluation and surgical treatment for congenital cystic lung disease. Seven patients were under 1 year old, and 19 were in over 1 year old. There were 13 bronchogenic pulmonary cysts, 6 pulmonary sequestrations, 4 congenital cystic adenomatoid malformations (CCAM), and 3 congenital lobar emphysemas.

RESULTS

All patients under 1 year old showed respiratory distress with mediastinal shift but no episodes of infection. In contrast, 13 of the 19 patients over 1 year old had symptoms of recurrent infection without respiratory distress. Five patients over 1 year old were entirely asymtomatic from birth. There were significant differences (P < 0.05) in the frequencies of respiratory distress and infection between the two groups (chi2-test). Lobectomy was performed in 21 patients, excision in 3 patients, segmentectomy in one patient, and exploration in one patient. There was no incident of postoperative mortality or morbidity except for one patient with CCAM complicated by reexpansion lung edema. Twenty-one patients at long-term follow-up from 2 to 30 years after surgery are doing well with no subsequent limitation of physical activities due to lung resection.

CONCLUSIONS

In patients under 1 year old, cystic lesions were discovered by respiratory distress; and in patients over 1 year old signs of infection were the most important clinical features. Early recognition of these relatively rare congenital cystic lung lesions would lead to the immediate, proper surgical intervention.

[Hemoptysis with intralobar pulmonary sequestration]

Pulmonary sequestration is a rare congenital malformation of the pulmonary parenchyma. A case of recurrent haemoptysis and pulmonary infections in an adult is presented. Arteriography was required to identify the aberrant vessel preoperatively. Thoracotomy confirmed an intralobar sequestration type. Anatomical classification, symptoms, and diagnostic approach are discussed. Symptomatic patients benefit from surgical resection.

[Diagnosis and treatment of pulmonary sequestration]

OBJECTIVE

To explore the cause, classification, incidence, diagnosis and treatment of pulmonary sequestration.

METHOD

42 cases analysed and literatures reviewed.

RESULT

42 cases of sequestration were presents which were resected and confirmed by pathology in our department from 1964 to 1997. 29 cases (69%) were confirmed before operation. The incidence rate was 0.32% comparing with the sametime operations. There were 37 cases (88%) of intralobar type, and 5 cases (12%) of extralobar type. 22 cases accompanied with infection, 9 cases with hemoptysis in intralobar type. 1 case with infection and 1 case with hemoptysis in extralobar type, in the latter case, there was a fistula between the affected lung and the esophagus.

CONCLUSION

Pulmonary sequestration is not a rare illness. The diagnosis mainly depends on X-ray. Sometimes, bronchography, retrograde arteriography or CT can also make the diagnosis correctly. Special attention should be paid to avoiding injure to the vessels which supply the isolated lung during operation.

Pulmonary sequestration presenting as mitral valve insufficiency

Although pulmonary sequestrations commonly present with infectious complications, problems relating to high blood flow through the lesion are rarely apparent. A 4-year-old girl was referred for cardiac catheterization and evaluation for mitral valve surgery. An echocardiogram had demonstrated left atrial and ventricular enlargement and significant mitral regurgitation with an enlarged valve annulus. Angiography results showed a very large aorta to left atrial shunt through an unsuspected intralobar sequestration. Lobectomy with removal of the sequestration resulted in significant improvement in cardiac chamber size and function over a 2.5-year follow-up period, thus obviating the need for cardiac surgery and removing a potential source of infection. Careful evaluation of chest imaging studies will lead to the correct diagnosis and treatment in patients with pulmonary sequestration who are thought initially to have primary cardiac disease.

[Pryce type I interlobar pulmonary sequestration with anomalous return to the left inferior pulmonary vein]

A 50-year-old woman was examined because of chest discomfort. Chest X-ray films disclosed a tumorous shadow behind the heart. Chest computed tomography (CT) scans revealed a mass connected to the descending aorta, with increased blood flow in the left basal segment. The patient was admitted for further examination. Chest CT scans and cardioscintigrams were very useful as diagnostic tools, but the final diagnosis was made on the basis of angiography. An anomalous tortuous artery ran from the descending aorta into the left basal segment and returned to the left inferior pulmonary vein. The left pulmonary arterial trunk had no basal branch (A8-A10). A loop corresponding to the superior vein (V6) ran beneath the anomalous tortuous artery. To our knowledge, this is the second case of Pryce type-I interlobar pulmonary sequestration with anomalous return to the left inferior pulmonary vein to be reported in Japan. A left inferior lobectomy was performed. Histological finding from the excised tissues showed prominent interstitial fibrosis, atypical adenomatous hyperplasia, and atherosclerosis. Following surgery, the patient's PaO2 increased from 80.4 Torr to 95.8 Torr, suggesting that left inferior lobectomy was an appropriate treatment.

Intralobar pulmonary sequestration with three aberrant arteries in a 75-year-old patient

A rare case of intralobular pulmonary sequestration (ILS) with three aberrant arteries occurred in a 75-year-old woman. A contrast-enhanced chest CT scan demonstrated a paraaortic, partially enhanced mass shadow and two small liner enhancements in the upper portion of the mass. A definitive diagnosis could not be rendered with a CT scan alone, but the findings suggested bronchopulmonary sequestration with multiple aberrant arteries. Surgery confirmed three fine aberrant arteries arising from the thoracic aorta and entering the left lower lobe basal segment. Judging from the patient's age and multiple aberrant arteries, the sequestrated lung appeared as if it were acquired. However, all aberrant arteries were of the elastic type histologically. This finding suggested that ILS was not an acquired condition but a congenital malformation.

Spontaneous involution of pulmonary sequestration in children: a report of two cases and review of the literature

BACKGROUND

Two cases of pulmonary sequestration which regressed spontaneously are presented.

OBJECTIVE

To demonstrate the value of imaging studies in the diagnosis and follow-up of some forms of congenital masses of the lung in asymptomatic patients.

MATERIAL AND METHODS

We reviewed the clinical records and imaging studies of two asymptomatic children, one newborn and the other 3 months old, with thoracic masses which demonstrated variable degrees of spontaneous involution.

RESULTS

Abdominal ultrasound performed on the newborn with a palpable mass showed a triangular echogenic mass with a large central feeding vessel arising from the aorta. The mass had disappeared on follow-up US exam performed 6 years later. CT was performed in the 3-month-old patient with a persistent retrocardiac mass. A soft-tissue density mass in the left pulmonary base with a large feeding vessel arising from the aorta was visualised on contrast-enhanced CT. Five years later, a new CT scan showed significant shrinkage of the mass and no vessel.

CONCLUSION

Radiological techniques such as real-time US with Doppler imaging and contrast-enhanced CT may establish the diagnosis of pulmonary sequestration by demonstrating the mass and its systemic vessel, thereby eliminating the need for more aggressive imaging procedures. Partial or total disappearance of these masses represents a further example of involutive pathology and suggests that not all cases of pulmonary sequestration should be surgically treated.

Anomalies and malformations affecting the fetal/neonatal chest

Although significant anomalies of the fetal thorax are uncommon, with improvement in high-resolution ultrasonography, more of these lesions are being diagnosed prenatally. Accurate and specific prenatal diagnosis is important because different lesions have different natural histories and prognosis. Prenatal MRI is an increasingly important adjunct for identification and differentiation of these lesions and may help determine in selected cases when and if in utero fetal intervention is indicated.

Diagnosis of pulmonary sequestration by magnetic resonance imaging

Pulmonary sequestration, an uncommon congenital anomaly, is traditionally best diagnosed using arteriography; however, this is invasive and not without risk of morbidity and mortality. We report two patients with pulmonary sequestration diagnosed using magnetic imaging techniques. The first was a 22-year-old woman and the second a 17-year-old boy, both of whom presented with symptoms of cough and exertional dyspnea. Pulmonary sequestration was suspected from their chest radiographs. Magnetic resonance imaging and magnetic resonance angiography clearly demonstrated the aberrant artery arising from the aorta in a single noninvasive examination that did not require the use of contrast medium. We recommend magnetic resonance imaging as a safe, efficient, and noninvasive modality for the diagnosis of pulmonary sequestration.

[A case of Pryce type I intrapulmonary sequestration]

A twenty-year-old asymptomatic man hospitalized because of a vascular murmur and abnormal shadow in the left lower lung on X-ray film. An aortogram revealed an abnormal artery arising from the descending thoracic aorta and supplying the left basal segment, which had no other pulmonary arteries. Although lung ventilation scintigraphy demonstrated reduced ventilation to the left lower lobe, bronchogram showed an almost normal bronchial tree except that peripheral branches were slightly thin. A clinical diagnosis of Pryce type I intrapulmonary sequestration was made, and left lower lobectomy was performed successfully. We have analyzed 31 cases of Pryce type I intrapulmonary sequestration in Japan. A vascular murmur is often heard, and a chest X-ray usually shows either a mass shadow or increased vascular markings. In most of those cases, an abnormal artery arises from the descending thoracic aorta and it supplies the left basal segment. Because this type of sequestration causes hemoptysis and infections, surgical intervention is indicated.

Sequestration of the lung arising from the circumflex coronary artery

Sequestration is an unusual pulmonary malformation. Systemic blood supply is commonly from the thoracic aorta, but arteries may occasionally arise from other sites including the abdominal aorta or the intercostal vessels. We report a rare form of sequestration with origin from the circumflex coronary artery. Knowledge of uncommon vascular origins, particularly from coronary arteries, is important to avoid injury and possible ischemia, infarction, exsanguination, or death.

[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.