Congenital cystic lesions of the lung

Neonatal Outcomes of Multiple Congenital Thoracic Lesions

INTRODUCTION

Congenital pulmonary airway malformations (CPAM), intra- and extralobar bronchopulmonary sequestrations (iBPS/eBPS), CPAM-BPS hybrid lesions (HL), congenital lobar emphysema (CLE), bronchial atresia (BA), and foregut duplication cysts (FDC), collectively referred to as congenital thoracic lesions (CTL), are mostly solitary. Patients with multiple CTL are rare, and reports on such cases are scarce. To address this dearth, we analyzed a large multifocal CTL patient cohort.

METHODS

Retrospective chart review of patients born between September 1, 2013, and March 31, 2023, who underwent surgery for a CTL at our tertiary center. Patients with radiological and surgical diagnosis of multifocal CTL, defined as ≥2 CTL present in more than one lobe were included to record pre-, peri-, and postnatal patient characteristics.

RESULTS

Among 701 CTL patients, 74 (10.5%) had multiple CTL. CTL multifocality was prenatally recognized correctly in 8 (12.9%) patients. Most multiple CTL were right-sided, unilateral multilobar lesions (n = 33, 44%). Bilateral CTL were found in 9 (12.1%) patients. CPAM-CPAM lesions were the most prevalent CTL types (n = 36, 49%). Genetic syndromes were confirmed in 3 (4%) and additional congenital anomalies in 9 (12.9%) patients, 5 of those had multiple congenital anomalies. Of 49 (65%) patients with multilobar CTL, 25 (51%) underwent bilobectomy and 24 (49%) lung-sparing surgery. Length of stay was similar. Mortality was 5.4%.

CONCLUSION

We report on the largest patient cohort with multiple CTL to date. Multiple CTL occurred in 1/10 patients with CTL, and only 12.9% were recognized prenatally. Lung-sparing surgery can be considered. Multiple additional congenital anomalies and genetic syndromes may be more common and genetic testing should be considered. Overall, outcomes in this patient population are favorable.

Beyond Bronchopulmonary Dysplasia: A Comprehensive Review of Chronic Lung Diseases in Neonates

In neonates, pulmonary diseases such as bronchopulmonary dysplasia and other chronic lung diseases (CLDs) pose significant challenges due to their complexity and high degree of morbidity and mortality. This review discusses the etiology, pathophysiology, clinical presentation, and diagnostic criteria for these conditions, as well as current management strategies. The review also highlights recent advancements in understanding the pathophysiology of these diseases and evolving strategies for their management, including gene therapy and stem cell treatments. We emphasize how supportive care is useful in managing these diseases and underscore the importance of a multidisciplinary approach. Notably, we discuss the emerging role of personalized medicine, enabled by advances in genomics and precision therapeutics, in tailoring therapy according to an individual's genetic, biochemical, and lifestyle factors. We conclude with a discussion on future directions in research and treatment, emphasizing the importance of furthering our understanding of these conditions, improving diagnostic criteria, and exploring targeted treatment modalities. The review underscores the need for multicentric and longitudinal studies to improve preventative strategies and better understand long-term outcomes. Ultimately, a comprehensive, innovative, and patient-centered approach can enhance the quality of care and outcomes for neonates with CLDs.

Lower respiratory tract infections in children with congenital lung abnormalities

OBJECTIVE

We aimed to determine if the incidence of lower respiratory tract infections (LRTI) among children with asymptomatic, observationally managed congenital lung abnormalities (CLA) differed from that of symptomatic patients who underwent surgery. Second, we sought to compare the pre- and post-resection incidence of LRTI in patients who underwent surgery.

METHODS

This retrospective cohort study included patients born between 1999 and 2021 with CLA confirmed by CT scan who were enrolled in a prospective longitudinal follow-up program. The LRTI incidence rates at 1, 2, 5, 8, and 12 years were compared between surgically and observationally managed patients using incidence rate ratios (IRR). Differences in pre- and post-resection LRTI incidence rates among patients who underwent CLA-related surgery were assessed through IRR.

RESULTS

Among 217 included patients, 81 (37%) had undergone surgery and 136 (63%) had been observationally managed. The LRTI incidence rates did not significantly differ at any follow-up moment between the surgical and observational groups. Among the children who underwent CLA-related surgery, the pre-resection LRTI incidence rates were significantly higher than the post-resection LRTI incidence rates (IRR of 3.57, 95% confidence interval: [2.00; 6.33], p < .001).

CONCLUSION

We could not demonstrate differences in LRTI incidence throughout childhood between patients with surgically and observationally managed CLA. We recommend discussing cases of LRTI in patients with CLA in a multidisciplinary setting, using additional diagnostics such as chest X-ray to screen for CLA involvement, enabling a well-considered decision on surgical resection of the lesion.

No Pathogenic DICER1 Gene Variants in a Cohort Study of 28 Children With Congenital Pulmonary Airway Malformation

BACKGROUND

Distinguishing congenital pulmonary airway malformations (CPAMs) from pleuropulmonary blastoma (PPB) can be challenging. Previously diagnosed patients with CPAM may have been misdiagnosed and we may have missed DICER1-associated PPBs, a diagnosis with important clinical implications for patients and their families. To gain insight in potential misdiagnoses, we systematically assessed somatic DICER1 gene mutation status in an unselected, retrospective cohort of patients with a CPAM diagnosis.

METHODS

In the Amsterdam University Medical Center (the Netherlands), it has been standard policy to resect CPAM lesions. We included all consecutive cases of children (age 0-18 years) with a diagnosis of CPAM between 2007 and 2017 at this center. Clinical and radiographic features were reviewed, and DICER1 gene sequencing was performed on DNA retrieved from CPAM tissue samples.

RESULTS

Twenty-eight patients with a surgically removed CPAM were included. CPAM type 1 and type 2 were the most common subtypes (n = 12 and n = 13). For 21 patients a chest CT scan was available for reassessment by two pediatric radiologists. In 9 patients (9/21, 43%) the CPAM subtype scored by the radiologists did not correspond with the subtype given at pathology assessment. No pathogenic mutations and no copy number variations of the DICER1 gene were found in the DNA extracted from CPAM tissue (0/28).

CONCLUSIONS

Our findings suggest that the initial CPAM diagnoses were correct. These findings should be validated through larger studies to draw conclusions regarding whether systematic DICER1 genetic testing is required in children with a pathological confirmed diagnosis of CPAM or not.

LEVEL OF EVIDENCE

Level IV.

Multidisciplinary management of a large microcystic congenital pulmonary airway malformation: case report and literature review

INTRODUCTION

Congenital pulmonary airway malformations (CPAMs) are rare sporadic lesions frequently associated with poor fetal prognosis. Type 3 CPAMs are characterized by small hyperechogenic cysts (<5 mm). Hydrops often develops secondarily, and the fetal survival rate is approximately 5% in this setting.

CASE PRESENTATION

We present a case of a large type 3 CPAM complicated by fetal hydrops. The lesion was detected at 19 gestational weeks (GW) and confirmed by fetal MRI at 29 GW. At 22 GW, a course of maternal steroids was given as a possible treatment of type 3 CPAM. Peritoneal-amniotic shunt was placed twice to reduce fetal ascites, with unsatisfactory results. Similarly, polyhydramnios was relieved by two amnioreductions, but redeveloped soon after. A baby girl was delivered spontaneously at 33 GW and received a two-stage partial lobectomy in the first three months of life. Desaturations necessitated challenging invasive oscillatory ventilation between stages. Her outcome is unexpectedly positive and she may expect a good quality of life. She now approaches one year of age, with near-to-normal growth and developmental milestones.

DISCUSSION

Type 3 CPAMs complicated by fetal hydrops are associated with high perinatal mortality. While open fetal surgery remains a viable option in select specialist centers, antenatal interventions are typically ineffective. The survival of this infant can be attributed to prenatal management and early postnatal surgical intervention. The lack of guidelines for ventilation in this setting was a significant challenge for neonatal intensivists. Multidisciplinary vigilance and collaboration with frequent specialist follow ups were the key to success for both mother and child.

Rare presentation of pneumothorax in a young woman with underlying congenital pulmonary airway malformation

Congenital pulmonary airway malformation (CPAM) is the most common among a rare group of congenital anomalies of the lower respiratory tract. It has variable presentation depending on its subtype and the patient's age. It may lead to respiratory distress in neonates. It can be a particularly challenging diagnosis in children born asymptomatic but present with complications later in life such as haemoptysis, recurrent chest infections, breathlessness and pneumothorax. Prenatal ultrasound, chest X-ray, CT scan and MRI are helpful in making a radiological diagnosis.A woman in her late teens presented with shortness of breath and right pleuritic chest pain. CT's chest showed a number of bullae of varying sizes on the right, including one huge bulla compressing all three lobes. She underwent lung volume reduction surgery via video-assisted thoracoscopy, and the histology specimen confirmed the diagnosis of CPAM type 1.

Long-term neurodevelopment in children with resected congenital lung abnormalities

To determine whether children who underwent resection of a congenital lung abnormality (CLA) are at higher risk for neurodevelopmental impairments than peers in the general population. The study population consisted of children born between 1999-2018 who underwent resection of a symptomatic CLA. Neurocognitive development (intelligence, memory, attention, visuospatial processing, executive functioning) and motor function of this population are monitored through our structured, prospective longitudinal follow-up program at the ages of 30 months, 5, 8, and 12 years. We compared study population scores with Dutch norm values using one-sample t-tests and one-sample binominal proportion tests. Forty-seven children were analyzed. The 8-year-olds showed significant impairments in sustained attention through the Dot Cancellation Test (mean z-scores -2.4; [-4.1; -0.8], p = 0.006 and -7.1; [-12.8; -1.4], p = 0.02 for execution speed and fluctuations respectively). Visuospatial memory was impaired at 8 years, though only in 1 out of 3 assessment tools (Rey Complex Figure Test z-scores (-1.0; [-1.5; -0.5], p < 0.001). Further neurocognitive outcomes were unimpaired at all tested ages. Regarding motor function outcomes, mean z-scores of total motor functioning were unimpaired across assessed ages. However, at 8 years, significantly more children than expected had definite motor problems (18% vs 5%, 95% CI [0.052; 0.403], p = 0.022).   Conclusion: This evaluation reveals impairment in some subtests of sustained attention, visuospatial memory and motor development. However, globally, normal neurodevelopmental outcomes were found throughout childhood. We recommend testing for neurodevelopmental impairments in children who underwent surgery for CLA only if associated morbidities are present or if caregivers express doubts about their daily functioning. What is Known: • In general, surgically managed CLA cases seldom suffer from long-term surgery-related morbidity and show favorable lung function. What is New: • Long-term neurocognitive and motor function outcome appear unimpaired within surgically managed CLA cases. We recommend testing for neurodevelopmental impairments in children who underwent surgery for CLA only if associated morbidities are present or if caregivers express doubts about their daily functioning.

Congenital pulmonary airway malformation manifesting with severe respiratory distress and pneumothorax in a neonate

Congenital pulmonary airway malformation (CPAM) is congenital pulmonary anomaly characterized by multicystic areas, over-distension, and proliferation of terminal bronchioles with lack of normal alveoli. Clinical presentation may vary from mild respiratory symptoms to severe respiratory distress and frequent pneumothoraxes. We report a rare case of neonatal CPAM type I manifested with neonatal respiratory distress and pneumothorax, which was managed successfully with left lower lobectomy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01510-x.

Early resection of a rare congenital pulmonary airway malformation causing severe progressive respiratory distress in a preterm neonate: a case report and review of the literature

BACKGROUND

Congenital pulmonary airway malformations (CPAMs) are a heterogenous collection of congenital lung malformations, often diagnosed prenatally. The Stocker Type III CPAM is a rare CPAM sub-type, and, when large, may be associated with hydrops. Furthermore, reports of CPAM management which may include surgical resection in extreme preterm infants are limited.

CASE PRESENTATION

We report a case of a female neonate born at 28 weeks of gestation with severe respiratory distress and diffuse pulmonary opacification on the right concerning for a large congenital lung lesion. This lesion was not detected on routine antenatal imaging, and she did not have clinical findings of associated hydrops. Her respiratory status improved dramatically after surgical resection of a mass at 12 day of age. The mass was consistent pathologically with a Stocker Type III CPAM. Lung expansion showed subsequent improvement at 16 months of age.

CONCLUSIONS

Our case describes a preterm neonate with severe respiratory distress that was found postnatally to have a large, unilateral congenital lung lesion despite a normal prenatal ultrasound. Additionally, this lesion required excision early in life due to severity of respiratory compromise. This case highlights that rare congenital lung lesions, like this rare sub-type of CPAM, should remain a diagnostic consideration in neonates with severe respiratory distress. Early lung resection for CPAM in preterm infants is not well described and the favorable outcomes of this case help expand perspectives on potential management strategies.

The Role of the miR-548au-3p/CA12 Axis in Tracheal Chondrogenesis in Congenital Pulmonary Airway Malformations

Background

Literature has identified differentially expressed miRNAs in congenital pulmonary airway malformation (CPAM). However, the functional role of these miRNAs in CPAM remains unclear.

Methods

We obtained diseased lung tissues as well as adjacent normal lung tissue from CPAM patients attending the centre. Hematoxylin and eosin (H&E) and Alcian blue staining were performed. Differentially expressed mRNA expression profile was CPAM tissue, and matched normal tissue specimens were examined by high-throughput RNA sequencing. CCK-8 assay, EdU staining, TUNEL staining, flow cytometry, and the Transwell assay were performed to investigate the effect of miR-548au-3p/CA12 axis on proliferation, apoptosis, and chondrogenic differentiation in rat tracheal chondrocytes. mRNA and protein expression levels were determined using reverse transcription-quantitative PCR and western blot analysis, respectively. The relationship between miR-548au-3p and CA12 was evaluated using the luciferase reporter assay.

Results

The expression level of miR-548au-3p was significantly increased in diseased tissues compared with normal adjacent tissues from patients with CPAM. Our results indicate that miR-548au-3p functions as a positive regulator in rat tracheal chondrocyte proliferation and chondrogenic differentiation. At molecular level, miR-548au-3p promoted N-cadherin, MMP13, and ADAMTS4 expressions and reduced E-cadherin, aggrecan, and Col2A1 expressions. CA12 has been previously reported as a predicted target of miR-548au-3p, and here, we show that overexpression of CA12 in rat tracheal chondrocyte mimics the effects of inhibition of miR-548au-3p. On the other hand, CA12 knockdown reversed the effects of miR-548au-3p on cell proliferation, apoptosis, and chondrogenic differentiation.

Conclusions

In conclusion, the miR-548au-3p/CA12 axis plays a role in the pathogenesis of CPAM and may lead to identification of new approaches for CPAM treatment.

Management of Congenital Lung Malformations

Congenital lung malformations represent a spectrum of lesions, each with a distinct cause and tailored clinical approach. This article will focus on the following malformations: congenital pulmonary airway malformations, formally known as congenital cystic adenomatoid malformations, bronchopulmonary sequestration, congenital lobar emphysema, and bronchogenic cyst. Each of these malformations will be defined and examined from an embryologic, pathophysiologic, and clinical management perspective unique to that specific lesion. A review of current recommendations in both medical and surgical management of these lesions will be discussed as well as widely accepted treatment algorithms.

Pitfalls in the surgical treatment of undiagnosed lung lesions and cystic pulmonary hydatidosis

Background

Hydatid cysts can mimic many lung pathologies radiologically, as well as some malignant or benign lung tumors may show hydatid cyst-like radiological features. The aim of our study is to present our clinical experience and recommendations by analyzing the cases that create diagnostic difficulties by presenting a common radiological pattern with a pulmonary hydatid cyst.

Methods

The patients who were operated on with a preliminary diagnosis of hydatid cyst but were diagnosed differently, and who were operated on with different prediagnoses and unexpectedly diagnosed with hydatid cyst were included in the study. The clinical and radiological features of the patients were documented, and the features of the cases that could cause difficulties in diagnosis and treatment for the surgeon were revealed.

Results

A total of 20 patients who were radiologically suggestive of hydatid cyst but were diagnosed differently or unexpectedly diagnosed as hydatid cyst were included in the study. Lung cancer, bronchogenic cyst, or bronchiectasis were detected in 13 patients who were radiologically suggestive of hydatid cyst. There were 7 patients who were diagnosed with hydatid cysts, although they did not have specific radiological findings.

Conclusions

While hydatid cysts can mimic many lung pathologies, many benign or malign parenchymal lung pathologies may exhibit hydatid cyst-like radiological features. Therefore, in regions where a hydatid cyst is endemic, the surgeon should consider all possibilities while managing the cases.

Clinical registration number: Institutional Review Board of the Dr Suat Seren Chest Diseases and Chest Surgery Education and Research Center (No. 49109414-604.02).

Maternal Steroids in High-Risk Congenital Lung Malformations

INTRODUCTION

The purpose of the present study is to evaluate our institutional management of high-risk congenital lung malformations (CLM) with particular consideration of the use of multiple maternal steroid courses and maternal steroids in CLMs with pathologies other than congenital pulmonary airway malformation (CPAM).

METHODS

A single-center retrospective review was performed for all fetuses evaluated for CLM who received maternal steroids and/or had a CLM volume ratio (CVR) ≥ 1.6 (2015-2020). Fetuses were categorized as receiving no steroids, single steroid, or multiple steroid courses. Outcomes evaluated included CVR growth rate, resolution of early hydrops, and resolution of hydrops. Results are reported with a descriptive analysis.

RESULTS

Nineteen patients were identified who had CVR ≥ 1.6 (single steroid course 9/19, multiple steroid courses 6/19, and no steroids 4/19). A majority (n = 13, 68%) of all lesions had a reduction or no change in CVR between initial and final measurements (single steroid course 7/9, 78%; multiple steroid courses 4/6, 67%). When evaluating by pathology, ≥ 50% of each classification had reduction or no growth of CVR (CPAM 7/11, bronchial atresia 2/4, sequestration 3/3, congenital lobar emphysema 1/1). Seventy five percent (3/4) of lesions with early hydrops had resolution following steroid treatment (single steroid course 1, multiple steroid courses 2). Of the four lesions that had hydrops, only one had resolution after receiving multiple steroid courses.

CONCLUSIONS

Our institutional experience reports the majority of CLM (including pathologies other than CPAM) who received steroids had reduction or no change in CVR. Given the low risk-benefit ratio of maternal steroids, physicians could consider use of multiple steroid courses for CLM refractory to a single course.

Congenital lobar emphysema case report: A frequently misdiagnosed disease

Introduction and importance

Case presentation

Clinical discussion

Conclusion

•

Congenital Lobar Emphysema is a rare cystic lesion of the lung which poses a challenge in diagnosis.

•

It is misdiagnosed and managed as pneumonia or pneumothorax.

•

It requires a high index of clinical and radiological suspicion to make an early diagnosis so that timely treatment will be offered.

A national descriptive epidemiologic analysis on congenital pulmonary airway malformation in China, 2010-2019

OBJECTIVE

To depict the epidemiological features of congenital pulmonary airway malformation (CPAM) in Chinese population.

METHODS

Using 2010-2019 data from the Chinese Birth Defects Monitoring Network, we calculated the prevalence rates (PR) and 95% confidence intervals of isolated and nonisolated CPAM according to birth year, infant sex, maternal age and residence area, and examined the secular trends by using Poisson regression models. The perinatal outcomes of affected infants and associated malformations with CPAM were also analyzed.

RESULTS

During this period, a total of 2451 CPAMs were identified among 20,183,999 births, yielding a PR of 1.21, 0.95, and 0.27 per 10,000 live and still births for the overall, isolated and nonisolated CPAM, respectively. Significant upward trends in CPAM PR were observed. The PR varied significantly by infant sex (male vs. female, 1.28/10,000 vs. 1.10/10,000), residence area (urban vs. rural, 1.49/10,000 vs. 0.88/10,000), and by maternal age (<20 years, 0.94/10,000; 20-24 years, 1.04/10,000; 25-29 years, 1.32/10,000; 30-34 years, 1.28/10,000; ≥35 years, 1.05/10,000). Compared with isolated CPAM, much more live births with nonisolated CPAM died in the early neonatal period (5.0% vs. 1.0%). The additional malformations with nonisolated CPAM occurred most frequently in the circulatory system.

CONCLUSIONS

The PR of CPAM in this study are comparable to those reported in non-Chinese populations. The increasing trend in prevalence and poor perinatal outcomes of the affected infants indicate an urgent need to strengthen the clinical and public health interventions of CPAM.

Persistent Pulmonary Interstitial Emphysema With Respiratory Infection: A Clinicopathological Analysis of Six Cases and Detection of Infectious Pathogens by Metagenomic Next-Generation Sequencing (mNGS)

BACKGROUND

Persistent pulmonary interstitial emphysema (PPIE) is known to be related to mechanical ventilation and preterm. However, PPIE is also reported rarely in non-ventilated and full-term infants. Its relationship with respiratory infection is rarely reported in the literature. PPIE is difficult to diagnose and always mimics other congenital thoracic malformations (CTMs), such as congenital cystic adenomatoid malformation (CCAM).

OBJECTIVE

The objective of this study was to evaluate clinicopathological and radiographic features of PPIE with respiratory infection and to detect the possible infectious pathogens.

METHODS

From January 2011 to December 2019, six cases were confirmed pathologically with PPIE from a large cohort of 477 resected CTMs in West China Hospital of Sichuan University. Clinical and radiographic features were obtained from patients' medical records and follow-up. The present study aimed to analyze clinicopathological and radiographic features and to detect the infectious pathogens by metagenomic next-generation sequencing (mNGS).

RESULTS

The six PPIE cases included four girls and two boys, ranging from 2 months to 5 years; 100% (5/5) of the available cases were full-term and without mechanical ventilation. CCAM were suspected in 66.7% (4/6) patients; 66.7% (4/6) cases affected a single lobe, and 33.3% (2/6) cases affected both lung lobes. Clinically, all six PPIEs were presented with symptoms of respiratory infection and diagnosed with pneumonia. All six patients were treated by surgery after anti-infective treatment. The pathologic characteristics showed lung cysts with variable size along the bronchovascular bundles, the cysts had a discontinuous fibrotic wall with a smooth inner surface lined with uninucleated and/or multinucleated macrophages. Streptococcus pneumoniae was detected in patient No. 1. Human beta-herpesvirus 5 was detected in patient No. 2. Neisseria mucosa, Neisseria sicca, Prevotella melaninogenica, Prevotella histicola, and Fusobacterium nucleatum were detected in patient No. 5, and no infectious pathogen was detected in 50% (3/6, No. 3, No. 4, and No. 6) of cases.

CONCLUSION

Six rare cases of PPIE with respiratory infection were treated by surgery after anti-infective treatment. All five available cases were full-term infants without mechanical ventilation. The histological characteristics of PPIE were the wall of cysts composed of a thin layer of discontinuous fibrous tissue and lined with uninucleated or/and multinucleated macrophages.

Unusual Congenital Lesion Masquerading as a Lung Mass in an Adult

Congenital pulmonary airway malformation (CPAM) is a broad spectrum of congenital cystic lung lesions caused by the arrested bronchoalveolar development. Approximately, 80% of CPAMs are diagnosed prenatally or during the neonatal period when patients present with respiratory failure and cyanosis. CPAM is often associated with other organ anomalies and aplasia, and they have poor prognoses. Many CPAMs are detected in infants and school-age children, and infections like pneumonia trigger these diagnoses. It rarely manifests in adults. These often get missed because of the superadded diseases, and hence, it is essential to have a correct approach to their diagnosis to avoid misdiagnosis.

Developmental Pathways Underlying Lung Development and Congenital Lung Disorders

Lung organogenesis is a highly coordinated process governed by a network of conserved signaling pathways that ultimately control patterning, growth, and differentiation. This rigorously regulated developmental process culminates with the formation of a fully functional organ. Conversely, failure to correctly regulate this intricate series of events results in severe abnormalities that may compromise postnatal survival or affect/disrupt lung function through early life and adulthood. Conditions like congenital pulmonary airway malformation, bronchopulmonary sequestration, bronchogenic cysts, and congenital diaphragmatic hernia display unique forms of lung abnormalities. The etiology of these disorders is not yet completely understood; however, specific developmental pathways have already been reported as deregulated. In this sense, this review focuses on the molecular mechanisms that contribute to normal/abnormal lung growth and development and their impact on postnatal survival.

Computer-aided quantitative MSCT measurements may be useful for congenital lung malformations surgical approach selection

PURPOSE

To examine the association between the MSCT quantitative measurements of congenital lung malformations (CLM) and the selection of surgical approaches (lobectomy vs. lung-sparing surgery).

METHODS

This retrospective study evaluated CLM surgical cases at our institution from 2016 to 2018. MSCT quantitative measurements were generated by a semi-automated approach: the volume of the lesion (V_lesion), the volume of the lesion-involved lobe (V_lobe), the volume of the lesion-involved lung (V_lung) and the volume of the total lung (V_{total lung}). The proportions of V_lesion to V_lobe (P_lesion/lobe), V_lesion to V_lung (P_lesion/lung), and V_lesion to V _{total lung} (P_{lesion/total lung}) were calculated. We used Logistics regression to examine whether quantitative measurements were associated with the selection of surgical approaches.

RESULTS

151 patients were included (median age at surgery 6 months). 82 patients underwent lung-sparing surgery, and 69 patients underwent lobectomy. V_lesion (OR 1.51, 95% CI 1.09-2.07), P_lesion/lobe (OR 1.78, 95% CI 1.16-2.72), P_lesion/lung (OR 1.63, 95% CI 1.13-2.35), and P_{lesion/total lung} (OR 1.58, 95% CI 1.12-2.22) were positively associated with the selection of lobectomy.

CONCLUSION

The application of quantified MSCT analysis may provide insight into the quantitative characteristics of CLM, which could be potentially useful for surgical approach selection.

An Incidental Finding of Congenital Pulmonary Airway Malformation Type 3 During a Forensic Autopsy for a Sudden Infant Death: A Case Report With a Brief Literature Review

ABSTRACT

Congenital pulmonary airway malformation (CPAM), previously known as congenital cystic airway malformation, is a developmental disorder of the lower respiratory tract. It is subdivided into 5 types based on clinical and pathologic features. Type 3, an adenomatoid type of CPAM, is the second rarest form of CPAM, occurring in approximately 5% of all CPAM cases. This article reports an autopsy of a nearly 11-week-old male infant, found unresponsive in bed with his mother. She had fallen asleep after breastfeeding a few hours prior. Although the autopsy and additional technical examinations did not uncover the exact cause of death, CPAM type 3 was eventually identified on histological examination. Taking into account the context of this case, in which accidental asphyxia/neglect could not be ruled out, it is thought that the presence of CPAM might have contributed to the demise of the infant. As CPAM is a rare congenital disorder, the diagnosis could easily be missed. Therefore, this article aims to raise awareness of this diagnosis and points out the clinical and pathologic features of this disorder.

A rare case of congenital pulmonary airway malformation in a 14-year-old male presenting with spontaneous pneumothorax

Introduction

and importance: Congenital pulmonary airway malformation (CPAM), formerly known as congenital cystic adenomatoid malformation (CCAM), is a rare developmental dysplatic lesion of the fetal tracheobronchial tree. It accounts for approximately 25 % of all congenital lung malformations. It is usually unilateral and involves one lobe with no significant gender or racial predilection. The vast majority of reported CPAM cases were discovered prenatally or within the first 2 years of life; however, it is rarely found in older children and adults.

Case presentation

The purpose of this paper is to present a case of a 14-year-old male with a chest tube inserted 5 days before, as a management to left-sided spontaneous pneumothorax. His vital signs and laboratory tests were all within normal. Chest X-ray showed irregular opacity in the left lung field.

Clinical discussion

CT revealed multiple cystic-like lesions in the upper lobe of the left lung. The clinical impression was pointing towards a congenital lung lesion. The patient then underwent surgery. There were several pleural adhesions. The adhesions were released, and the upper left lobe was resected. Histopathological findings were compatible with type II CPAM. Four days postoperatively, chest X-ray was within the normal.

Conclusion

We report this case to highlight the importance of considering CPAM and other congenital malformations as a differential diagnosis in the adult population, especially in patients with sudden onset of pulmonary symptoms along with multiple cystic-like lesions on CT, as well as to draw attention towards spontaneous pneumothorax as a possible first presentation for CPAM.

Giant Intrapericardial bronchogenic cyst associated with congestive heart failure and atrial fibrillation: a case report

Background

Large intracardiac bronchogenic cysts are rare mediastinal masses. However, they must always be considered in the differential diagnosis of heart failure with abnormal chest X-ray.

Case presentation

We present a 60-year-old female patient with de novo atrial fibrillation, heart failure and a very large intrapericardial mass. The patient underwent successful surgical resection, with pathological findings confirming a bronchogenic cyst.

Conclusions

Large bronchogenic cysts located intrapericardially are very rare. However, they should be included in the differential diagnosis of patients presenting with atrial fibrillation and heart failure with abnormal radiologic studies.

Esophagus-Like Bronchus: A Noncommunicating Bronchopulmonary Foregut Malformation

We describe a previously unreported bronchopulmonary foregut malformation wherein a segment of a bronchus of the lower lobe of the left lung in a 4-year-old girl was entirely esophageal in structure. No communication was identified between the tracheobronchial tree and the esophagus by radiologic examination or at surgery. The esophagus-like bronchus was associated with an adjacent atretic bronchus and a downstream cavity in the lower lobe of the left lung. The child sought clinical attention because of recurrent pulmonary infections localized to the lower lobe of the lung. We posit that this esophagus-like bronchus is a novel noncommunicating bronchopulmonary foregut malformation.

A clinical guideline for structured assessment of CT-imaging in congenital lung abnormalities

OBJECTIVES

To develop a clinical guideline for structured assessment and uniform reporting of congenital lung abnormalities (CLA) on Computed Tomography (CT)-scans.

MATERIALS AND METHODS

A systematic literature search was conducted for articles describing CT-scan abnormalities of congenital pulmonary airway malformation (CPAM), bronchopulmonary sequestration (BPS), congenital lobar emphysema (CLE) and bronchogenic cyst (BC). A structured report using objective features of CLA was developed after consensus between a pediatric pulmonologist, radiologist and surgeon.

RESULTS

Of 1581 articles identified, 158 remained after title-abstract screening by two independent reviewers. After assessing full-texts, we included 28 retrospective cohort-studies. Air-containing cysts and soft tissue masses are described in both CPAM and BPS while anomalous arterial blood supply is only found in BPS. Perilesional low-attenuation areas, atelectasis and mediastinal shift may be found in all aforementioned abnormalities and can also be seen in CLE as a cause of a hyperinflated lobe. We have developed a structured report, subdivided into five sections: Location & Extent, Airway, Lesion, Vascularization and Surrounding tissue.

CONCLUSIONS

CT-imaging findings in CLA are broad and nomenclature is variable. Overlap is seen between and within abnormalities, possibly due to definitions often being based on pathological findings, which is an unsuitable approach for CT imaging. We propose a structured assessment of CLA using objective radiological features and uniform nomenclature to improve reporting.

Pulmonary Manifestations of Genetic Disorders in Children

Congenital bronchopulmonary malformations are relatively common and arise during various periods of morphogenesis. Although some are isolated or sporadic occurrences, others may result from single gene mutations or cytogenetic imbalances. Single gene mutations have been identified, which are etiologically related to primary pulmonary hypoplasia, lung segmentation defects as well as pulmonary vascular and lymphatic lesions. Functional defects in cystic fibrosis, primary ciliary dyskinesias, alpha-1-antitrypsin deficiency, and surfactant proteins caused by gene mutations may result in progressive pulmonary disease. This article provides an overview of pediatric pulmonary disease from a genetic perspective.

Case Report: Prenatal and Postnatal Management for Fetal Bronchogenic Cysts During the COVID-19 Pandemic

Background: A fetal bronchogenic cyst (BC) is a rare congenital anomaly with an incidence of 0.147-0.238‰. The coronavirus disease 2019 (COVID-19) pandemic, as a particular situation, hindered pregnant women from receiving periodic prenatal checkups. Case Description: Until 34⁺⁶ weeks of gestation, a fetal case of the intrathoracic cyst was found by ultrasound examination. Further, MRI examination confirmed the diagnosis of the congenital mediastinal cystic lesion, probably a BC. Genetic testing was not conducted due to the COVID-19 pandemic. At 38⁺⁵ weeks of gestation with maternal COVID-19 testing negative, a live girl was delivered by cesarean section. Five months later, the child underwent bronchocystectomy, and the postoperative pathological lesions confirmed a (right upper mediastinum) BC. Conclusion: Herein, we reported the prenatal and postnatal management for a rare case of the congenital BC by multidisciplinary approaches during the COVID-19 pandemic. Fetal MRI and screening for fetal chromosomal abnormalities are especially recommended. This case contributes to the awareness that the COVID-19 pandemic interferes with regular follow-up schedules during pregnancy and may interfere with timely performed additional tests; which leads to more accurate genetic counseling. A combination of multidisciplinary approaches, including radiology, infection control, genetic counseling, obstetrics, and pediatric surgery, is pivotal for managing fetal BC during the COVID-19 pandemic.

Application of ultrasound in a congenital cystic adenomatoid malformation in an adult: A case report

INTRODUCTION

Congenital cystic adenomatoid malformation (CCAM) is a rare developmental lung abnormality, that typically manifests in neonates and infants but rarely in adults. Ultrasound is an important method of diagnosing CCAM in neonates and infants; however, few articles have reported the value of transthoracic lung ultrasound in the diagnosis of CCAM in adults.

PATIENT CONCERNS

We present a case of a 34-year-old woman with a cavitary lesion in her left lower lobe, that suggested chronic inflammation.

DIAGNOSIS

The patient underwent ultrasound examination and contrast-enhanced ultrasound-guided transthoracic core biopsy; histology suggested the diagnosis of lung hamartoma. Surgical resection of the lesion followed by histopathological analysis confirmed the diagnosis of CCAM.

INTERVENTIONS

The patient underwent transthoracic core biopsy under contrast-enhanced ultrasound guidance. A left lower lobectomy was then performed subsequently.

OUTCOMES

The patient had a smooth recovery and remained asymptomatic during the 12-months of postoperative follow-up.

CONCLUSION

We report a rare case of CCAM to suggest that transthoracic ultrasound combined with contrast-enhanced ultrasound is a safe and effective method of diagnosing the subpleural lung malformations in adults, thereby avoiding multiple radiation exposures and associated complications.

Ultrasound detected prenatal hyperechoic lung lesions and concordance with postnatal findings: A common aspect for multiple diagnoses

OBJECTIVE

Hyperechoic lung lesions are largely detected prenatally but their underlying etiology is still poorly defined. The aim of the study was to determine the concordance between pre and postnatal diagnosis of hyperechoic lung lesions.

METHODS

Prenatal ultrasound (US) evaluation was performed by a fetal medicine specialist. Postnatal diagnosis was based on CT-scan. Pre- and postnatal features were retrieved from medical charts.

RESULTS

Seventy five patients were included from January 2009 to December 2018. Main prenatal diagnoses were bronchopulmonary sequestrations (BPS) (n = 24%-32%), pulmonary cystic malformations (PCM) (n = 19%-25%), congenital lobar emphysemas (CLE) (n = 15%-20%). Mediastinal shift was observed in 18 cases (24%). The prenatal detection of a systemic arterial supply had a diagnostic accuracy of 90%, while the prenatal detection of a cystic component had a diagnostic accuracy of 76.5%. All 16 neonates with prenatal isolated mediastinal shift were asymptomatic at birth. Seven neonates showed respiratory distress that was not predicted prenatally.

CONCLUSIONS

Hyperechoic lung malformations reflect a heterogeneous group of lesions with a good concordance for bronchopulmonary sequestration, but not a satisfying prediction for cystic lesions.

Secuestro pulmonar intralobar y aspergilosis pulmonar: reporte de un caso

El secuestro pulmonar es un tipo de malformación congénita pulmonar poco frecuente, con presentación clínica variable y de usual diagnóstico durante la infancia. Puede coexistir con otras patologías pulmonares, principalmente de tipo infecciosas y su manejo definitivo es mediante un procedimiento quirúrgico. Se presenta el caso de una paciente adulta con secuestro pulmonar, asociado a una infección fúngica, manejada con cirugía mínimamente invasiva.

Pulmonary pneumatoceles in neonates

Pulmonary pneumatoceles were relatively common in neonates in the pre-surfactant era. In the current era of surfactant, noninvasive and gentle invasive ventilation there is a paucity of data on clinical characteristics and outcomes of pneumatoceles in neonates. The lesion generally resolves spontaneously, but a few cases follow a complicated course with formation of extensive and expanding lesions. To better understand the pathophysiology, clinical significance, natural history, complications, treatment options and prognosis of pulmonary pneumatoceles in neonates, an extensive research was performed on the databases of medical literature. The information collected in this review is important for the clinicians in decision-making, especially in the most difficult cases.

A case of one-lung ventilation using a single-lumen tube placed under fiberoptic bronchoscopic guidance in a 4-year-old child: A case report

RATIONALE

One-lung ventilation (OLV) is essential for adequate visualization and exposure of the surgical site via a videoscopic approach. Although many instruments facilitating OLV are available, the choice is limited in pediatric patients.

PATIENT CONCERNS

A 4-year-old female (weight: 18.6 kg, height: 100 cm) was admitted via our pediatric outpatient clinic because of recurrent hemoptysis, 2 weeks in duration. She had no medical or surgical history.

DIAGNOSIS

Contrast-enhanced computed tomography (CT) revealed a 4.5-cm-diameter mass in the left, lower lung lobe. She was diagnosed with a congenital pulmonary airway malformation (CPAM).

INTERVENTIONS

She was scheduled for emergency lobectomy via video-assisted thoracoscopic surgery (VATS). To ensure successful VATS, OLV was essential. As our hospital lacked a small-diameter fiberoptic bronchoscope and a proper bronchial blocker, we decided to use single-lumen tube (SLT) with adult fiberoptic bronchoscope.

OUTCOMES

We performed successful bronchoscopic-guided OLV using a SLT. We aligned the tube to the right upper lobar bronchus and Murphy eye to prevent obstruction of the right upper lobe bronchus. At the end of surgery, the endotracheal tube lumen had been narrowed by blood clots, we decided to exchange the tracheal tube. The tube was immediately exchanged. After re-intubation, the pulse oximetry (SpO2) then gradually increased.

LESSONS

Appropriate preparation and careful management should be considered to perform OLV in pediatric patients without significant complications.

Pleuropulmonary blastoma type I might arise in congenital pulmonary airway malformation type 4 by acquiring a Dicer 1 mutation

Congenital pulmonary airway malformation (CPAM) occurs most commonly in infants. It is divided into 5 types. The most common types 1 and 2 are cystic, type 0 presents as bronchial buds without alveolar tissue, most likely corresponding to alveolar dysgenesis, while type 3 is composed of branching bronchioles and appears as a solid lesion. A defect in the epithelial-mesenchymal crosstalk might be the underlying mechanism for all. Type 4 is a peripheral cystic lesion with a thin cyst wall covered by pneumocytes. CPAM 4 has been mixed up with pleuropulmonary blastoma (PPB) type I and some authors question its existence. We investigated five cases of CPAM type 4 for the presence or absence of rhabdomyoblasts, and for markers associated with CPAM development. In addition, all cases were evaluated for mutations within the Dicer gene and for mutations of the RAS family of oncogenes. All five cases showed smooth muscle actin and desmin-positive cells; however, only one case showed a few cells positive for MyoD. The same case showed a mutation of Dicer 1. All cases were negative for mutations of the RAS family of genes. Fibroblast growth factor 10 was similarly expressed in all cases, and thus cannot be used to differentiate CPAM4 from PPB-I. Low expression of the proliferation marker Ki67 was seen in our CPAM 4 cases and the probable PPB-I case. YingYang-1 protein seems to play an active role in the development of PPB-I. CPAM 4 can be separated from PPB-I based on the presence of rhabdomyoblasts and mutations in Dicer 1 gene. These cells might not be numerous; therefore, all available tissue has to be evaluated. As CPAM 4 morphologically looks very similar to PPB-I, it might be speculated, that there exists a potential for progression from CPAM 4 to PPB-I, by acquiring somatic mutations in Dicer 1.

Non-operative management of extralobar pulmonary sequestration: a safe alternative to resection?

PURPOSE

This retrospective cohort study compares the natural history of patients with extralobar sequestrations (ELS) who do not undergo intervention with those who undergo resection to assess the safety of non-operative management.

METHODS

126 patients with pulmonary sequestrations or congenital pulmonary airway malformations born between 1999 and 2016 were identified. 49 patients had ELS on postnatal imaging, but two were excluded for associated congenital diaphragmatic hernia. Demographic and clinical data were retrospectively reviewed, with phone follow-up for non-operative patients with no records for > 1 year. Statistical analysis was by Fisher's exact test or Wilcoxon signed-rank test (two-tailed p < 0.05).

RESULTS

40% (19/47) were managed non-operatively and 60% (28/47) underwent resection. Non-operative patients were less likely to have an intrathoracic ELS: 47% (9/19) vs. 75% (21/28), p = 0.07. No symptoms were attributable directly to the ELS. Non-operative patients had median follow-up 3.2 years, during which time 88% (15/17) of ELS decreased in size on serial imaging. For patients who underwent resection, there was 100% concordance between imaging and intraoperative findings. There was no evidence of inflammation, infection or malignancy on final pathology, though 57% (16/28) of resected lesions had foci of non-aerated cysts.

CONCLUSIONS

Although further longitudinal study is required, this study supports the safety of non-operative ELS management.

Intramural Bronchogenic Cysts in the Pediatric Population

A bronchogenic cyst is a rare congenital malformation. It occurs due to the development of buds in any part of the tracheobronchial area. It can also lead to fatal complications, especially in the early stages of life. However, data on its diagnosis and treatment are scarce, owing to the rarity of the disease. This review article aimed at evaluating the literature on the manifestations of intramural bronchogenic cysts in the pediatric population. Medical databases were examined thoroughly to explore eligible articles for inclusion. Twenty-three articles appeared in the search result. The produced reports were evaluated against the predecided inclusion criteria. After reviewing the literature, eight articles were eligible for inclusion in this review. The included articles were published between 2000 and 2020. An intramural bronchogenic cyst is a rare condition that should not be neglected in a differential diagnosis. Surgical excision is currently the recommended management strategy. Further extensive studies about the management of the complications of intramural bronchogenic cysts are needed.

Iatrogenic pneumothorax in a 4-week-old girl: new diagnosis of congenital lobar emphysema

A 4-week-old female patient presented with severe respiratory distress, hypoxia and apnoeic episodes on a background of a few-day history of coryza and cough. There was significantly reduced air entry on the left side and a displacement of the apex beat to the right of the chest. The examination findings with oxygen desaturations and a right-sided mediastinal shift on chest X-ray led to a diagnosis of tension pneumothorax following which a needle thoracentesis was undertaken. This appeared to worsen the patient's clinical condition; hence, a chest drain was inserted with unsatisfactory clinical improvement. In view of the presentation and lack of clinical improvement after chest drain insertion, the case was transferred to the paediatric respiratory team in a tertiary centre where the diagnosis was revised to congenital lobar emphysema based on chest computer tomography findings. She subsequently benefited from a left upper lobectomy and lingulectomy and was discharged home 4 days after surgery.

Establishment of a biobank for human lung tissues of congenital diaphragmatic hernia and congenital pulmonary airway malformation

BACKGROUND

Human tissue samples are an invaluable and little available source of information for translational studies of congenital lung diseases such as Congenital Diaphragmatic Hernia (CDH) or Congenital Pulmonary Airway Malformation (CPAM).

PURPOSE

We aimed to establish a human lung tissue biobank of CDH and CPAM patients together with age-matched controls, coupled with a clinical database.

METHODS

Pathology records from autopsies or surgical specimens for CDH and CPAM cases between 1980 and 2017 were reviewed. For surviving individuals, clinical patient data was obtained from corresponding pediatric surgery reports. Formalin-fixed, paraffin-embedded tissues of patients and age-matched controls were systematically stored for further translational studies. RNA integrity was determined on selected CDH blocks.

RESULTS

A total of 16 CDH and 18 CPAM and age-matched control lung tissue blocks were included in our biobank. Ages ranged from 22 to 41 weeks of gestation (GA) in CDH (33.9 ± 6.35 weeks) and 26 weeks (GA) and 12 years in CPAM (2.3 ± 3.7 y). RNA isolation from CDH and control blocks yielded good RNA quality (OD 260/280 ratio: 2.01-2.09, OD 260/230 ratio: 2.04-2.09).

CONCLUSION

We established a unique human biobank for CDH and CPAM tissues. The combination with clinical patient data will allow us to design future translational studies to improve our understanding of the disease pathogenesis of these congenital malformations.

Perinatal post-mortem ultrasound (PMUS): radiological-pathological correlation

There has been an increasing demand and interest in post-mortem imaging techniques, either as an adjunct or replacement for the conventional invasive autopsy. Post-mortem ultrasound (PMUS) is easily accessible and more affordable than other cross-sectional imaging modalities and allows visualisation of normal anatomical structures of the brain, thorax and abdomen in perinatal cases. The lack of aeration of post-mortem foetal lungs provides a good sonographic window for assessment of the heart and normal pulmonary lobulation, in contrast to live neonates.In a previous article within this journal, we published a practical approach to conducting a comprehensive PMUS examination. This covered the basic principles behind why post-mortem imaging is performed, helpful techniques for obtaining optimal PMUS images, and the expected normal post-mortem changes seen in perinatal deaths. In this article, we build upon this by focusing on commonly encountered pathologies on PMUS and compare these to autopsy and other post-mortem imaging modalities.

Congenital lung lesions

Diagnosis and management of congenital lung malformations has evolved dramatically over the past several decades. Advancement in imaging technology has enabled earlier, more definitive diagnoses and, consequently, more timely intervention in utero or after birth, when indicated. These advancements have increased overall survival rates to around 95% from historical rates of 60%. However, further refinement of diagnostic technique and standardization of treatment is needed, particularly as the increased sensitivity of diagnostic imaging results in more frequent diagnoses. In this article, we provide an updated review of the diagnostic strategies, management, and prognosis of congenital lung malformations.

Congenital Lung Malformations

Congenital lung malformations (CLM) comprise a spectrum of anatomical anomalies of the lungs and respiratory tree. The prenatal growth pattern of CLMs is unpredictable with larger lesions causing life-threatening complications, such as hydrops fetalis, and smaller lesions remaining asymptomatic and potentially regressing. The most common CLMs are congenital pulmonary adenomatoid malformations, bronchopulmonary sequestrations, congenital lobar emphysema, and bronchogenic cysts. All these lesions have clinically similar presentations when symptomatic, but pathophysiologic differences that must be considered when evaluating and treating. This article reviews the most common CLMs, their pathophysiology, clinical presentation, diagnostic considerations, and current literature on the controversies surrounding CLM management. [Pediatr Ann. 2019;48(4):e169-e174.].

Congenital Lung Malformations: Unresolved Issues and Unanswered Questions

Advances in prenatal and postnatal diagnosis, perioperative management, and postoperative care have dramatically increased the number of scientific reports on congenital thoracic malformations (CTM). Nearly all CTM are detected prior to birth, generally by antenatal ultrasound. After delivery, most infants do well and remain asymptomatic for a long time. However, complications may occur beyond infancy, including in adolescence and adulthood. Prenatal diagnosis is sometimes missed and detection may occur later, either by chance or because of unexplained recurrent or persistent respiratory symptoms or signs, with difficult implications for family counseling and substantial delay in surgical planning. Although landmark studies have been published, postnatal management of asymptomatic children is still controversial and needs a resolution. Our aim is to provide a focused overview on a number of unresolved issues arising from the lack of an evidence-based consensus on the management of patients with CTM. We summarized findings from current literature, with a particular emphasis on the vigorous controversies on the type and timing of diagnostic procedures, treatments and the still obscure relationship between CTM and malignancies, a matter of great concern for both families and physicians. We also present an algorithm for the assessment and follow-up of CTM detected either in the antenatal or postnatal period. A standardized approach across Europe, based on a multidisciplinary team, is urgently needed for achieving an evidence-based management protocol for CTM.

Gene expression profiling reveals differential patterns between microcystic congenital cystic adenomatoid malformation and congenital lobar emphysema

INTRODUCTION

Congenital cystic adenomatoid malformation (CCAM), especially type-III, shares similar sonographic features with congenital lobar emphysema (CLE) in routine ultrasound scan. Thus, prenatal differentiation of CLE from a microcystic CCAM is challenging and difficult in practice. Discovery of molecular biomarkers has important clinical significance.

METHODS

We profiled gene expression in lung tissue from four CCAM type-III and five CLE subjects by microarray. A bioinformatic tool was used for signal pathways enrichment analysis. Further, quantitative reverse transcriptase PCR (qRT-PCR) was used to verify the results.

RESULTS

A total of 426 genes were identified to be significantly differentially expressed (fold-change >2.0, q value <0.05) between microcystic CCAM and CLE. Of these differentially expressed genes (DEGs), 392 were upregulated and 34 were downregulated in microcystic CCAM compared with CLE. Unsupervised clustering of the "expressed" genes could clearly delineate the CCAM and CLE samples. We also confirmed that eight randomly chose genes were differentially expressed at the mRNA level between CCAM and CLE.

CONCLUSIONS

CCAM type-III and CLE have differential gene expression patterns. Our pilot study may gain a deeper understanding of the organogenetic origins and pathogenesis of these conditions. The suggestive candidates may serve as potential biomarkers for definitive diagnosis of congenital cystic lung lesions and eventually to treat them appropriately.

Pleural loculated empyema masking a CPAM 3 in a newborn infant: A case report with breef literature review

Congenital pulmonary airway malformations (CPAMs) are a heterogeneous group of hamartomatous cystic and noncystic lung lesions that result from early airway maldevelopment. Usually they are distinguished according to Stocker's classification in type 0, 1, 2, 3 and 4.

We present the case of a 2 weeks old baby who was admitted to hospital with RDS symptoms and left pleural effusion: X rays and CT were suggestive for a pulmonary cystic lesion with pleural complications. Because of the persistence of pleural empyema and the development of a pneumothorax the baby underwent surgery. The histological examination revealed a type 3 CPAM associated with pleural loculated empyema.

According to this case, in newborns with RDS loculated pleural empyema may mimick pulmonary cystic lesions; a treatment-resistant pleural empyema or pyopneumothorax in a newborn can recognize a CPAM 3 as a probable underlying condition, even in the absence of lung suppurative changes; CPAM 3 involving only two lung segments can have an excellent prognosis after surgical excision.