Bronchopulmonary sequestration: radiologic findings

Intralobar pulmonary sequestration: a rare cause of hemoptysis: a case report

Overview and significance

Pulmonary sequestration (PS) is a rare congenital anomaly characterized by aberrant formation of nonfunctional lung tissue with anomalous systemic blood supply. Despite its rarity, PS presents significant diagnostic and management challenges, often necessitating a multidisciplinary approach for optimal patient outcomes. This case report provides insights into the clinical presentation, diagnostic modalities, and management strategies for PS.

Case summary

The authors present a case of a 30-year-old male who complained of chronic cough and hemoptysis and was eventually diagnosed with intralobar PS by computed tomography (CT) imaging. The patient underwent a surgical procedure, specifically a lobectomy, to address the lung tissue.

Clinical discussion

The diagnosis of intralobar PS is confirmed by CT imaging, showing features of abnormalities, including irregular cystic communication. A large area with abnormal systemic arterial supply and variable venous fluid. This patient presented with symptoms consistent with PS, including chronic cough and hemoptysis, highlighting the importance of timely diagnosis and intervention to prevent life-threatening complications.

Conclusion

Lung sequestration has diagnostic challenges due to its variable clinical presentation and potential for misdiagnosis. However, advances in technology, such as CT angiography, make accurate diagnosis and precise surgical planning easier. Prompt intervention via lobectomy or transarterial embolization is important to reduce the risk of life-threatening complications associated with PS. These data highlight the importance of multidisciplinary collaboration between physicians, radiologists, and surgeons to effectively manage PS and improve patient outcomes.

Antenatal diagnosis of bronchopulmonary sequestration: A case report and review of the literature

Congenital lung malformations are a constellation of pathologies that can be diagnosed antenatally by ultrasound and fetal MRI. Ultrasound is considered the modality of choice for a routine assessment of second-trimester scans worldwide. Bronchopulmonary sequestration (BPS) and congenital pulmonary airway malformation (CPAM) are the 2 most common echogenic chest masses discovered incidentally during routine ultrasound scans in the second trimester. This paper describes BPS and differentiates it from CPAM sonographically in utero. An extensive literature search involving antenatal ultrasound is undertaken to review the most up-to-date understanding of the BPS. Furthermore, a case study at our institution and the literature review will help better describe the salient features of BPS. A 41-year-old female G3P1 visits our department for a routine second-trimester ultrasound. An echogenic lesion with a cystic component is visualized in this scan. Based on the grayscale and color imaging, this complex echogenic lesion was reported as CPAM and was referred to fetal assessment for confirmation. The fetal assessment diagnosed the lesion as BPS because of the pathognomonic feeding vessel from the thoracic aorta. Regardless of the congenital lung mass, any large mass compromising fetal well-being is an indication for intervention. The prognosis of BPS in the absence of fetal hydrops is excellent. A robust collaboration among radiologists, obstetricians, and pediatricians is required for the best outcome for the pregnancy and the neonate.

Intralobar pulmonary sequestration in 2 extremes of ages: A Case report

Pulmonary sequestration is a relatively rare phenomenon characterized by nonfunctional lung tissue supplied by one or more systemic arteries without direct connection to the tracheobronchial tree. Intra-lobar pulmonary sequestration comprises 75% of the total pulmonary sequestrations. Most patients with pulmonary sequestrations are often diagnosed with a childhood chest infection, so pulmonary sequestration is considered a childhood disease. However, few cases are found in adults and the elderly, with or without symptoms, and imaging findings on computed tomography (CT) or magnetic resonance imaging (MRI) are variable due to infection and inflammation. Failure to diagnose and treat this condition may lead to recurrent pneumonia and fatal hemoptysis. In this case report, we present cases of pulmonary sequestration at extremes of ages, one at 12 and the other at 65.

Comparison of clinical outcomes of pulmonary sequestration in adults between surgery and non-surgery groups

BACKGROUND

Pulmonary sequestration (PS) is a rare congenital lung malformation that can be incidentally diagnosed in adulthood. The natural course of PS in adults is scarcely known.

METHODS

In this retrospective cohort study, medical records and imaging results of adult patients diagnosed with PS between 1994 and 2019 were reviewed. Diagnoses of PS were confirmed by histopathological findings in resected cases, while non-resected cases were diagnosed based on the presence of anomalous systemic arterial supply and abnormal lung parenchyma on enhanced chest computed tomography (CT).

RESULTS

Among 104 patients with PS, the median age at diagnosis was 40.5 years, and 69 (66.3%) patients were asymptomatic. Patients in the surgery group were significantly younger (38.6 vs. 45.3 years, respectively, P=0.016), were more likely to be symptomatic initially (51.6% vs. 28.6%, respectively, P=0.015), and had larger PS (90.0 vs. 66.3 mm, respectively, P<0.001) than the non-surgery group. Of the patients in the surgery group, 29.0% (18/62) experienced postoperative complications. In the surgically resected cases, infections were only detected in intralobar PS, not in extralobar PS. Among 25 subjects without initial symptoms in the non-surgery group, 24 (96.0%) remained asymptomatic at the last follow-up.

CONCLUSIONS

Adults with PS tended to undergo resection if they were young, symptomatic, and had large PS (a median diameter of 90.0 mm). Almost all subjects who were initially asymptomatic and did not undergo surgery remained asymptomatic at the last follow-up. Therefore, considering the indolent course of PS, initially asymptomatic adults with PS could be followed up without surgery.

A case of rare pulmonary sequestration complicated with congenital heart disease treated by arterial embolization and atrial defect closure: A case report and review of literature

Pulmonary sequestration with congenital heart disease is a rare congenital malformation. Herein, we report a 19-month-old toddler diagnosed with right lower pulmonary sequestration, right pulmonary artery dysplasia, right lower pulmonary venous ectopic drainage, and a right-sided heart with an atrial septal defect. The pulmonary sequestration had a rare blood supply, such as confluent arteries with the renal vessels draining into the hepatic veins. Arterial embolization and atrial defect closure were used to treat the rare congenital malformation with satisfactory results.

Revising the classification of lung sequestrations

PURPOSES

The classification of lung sequestrations distinguishes between extralobar and intralobar types, according to their venous drainage - systemic vs pulmonary - and the presence or absence of independent pleura. However, imaging, surgical and/or pathological findings often differ from this description. The objectives of this article are to quantify the percentage of lung sequestrations that do not fit the classic description of extra- and intralobar types and to evaluate the accuracy of the currently used classification.

METHODS

A retrospective search identified all children with a confirmed lung sequestration diagnosed and treated in our Hospital over the last 10 years. Two senior pediatric radiologists reviewed their contrast-enhanced computed tomography chest scans and evaluated the main anatomical features that define sequestrations, including pleura, arterial and venous pattern, airways and lung parenchyma. We compared the imaging-, surgical- and pathological findings to those described for extra- and intralobar sequestrations.

RESULTS

25 children (20 M, 5 F) conform the series. Only 13 lesions (52%) filled all criteria described for an extra- or intralobar sequestration. The remaining 12 lesions (48%) had at least one differing criteria, including incomplete independent pleura (n = 2; 8%), mixed systemic and pulmonary arterial supply (n = 1; 4%) or venous drainage (n = 3; 12%), normal connection to airway (n = 1; 4%) and/or coexistent congenital lung anomalies (n = 11; 44%).

CONCLUSION

Lung sequestrations seem to represent a spectrum of anomalies rather than separated entities. Therefore, a detailed description of their main anatomical features could be more relevant for clinicians and surgeons that the rigid distinction in intra- and extralobar sequestration currently applied.

Pulmonary sequestration: What the radiologist should know

Pulmonary sequestration consists of a nonfunctioning mass of lung tissue, either sharing the pleural envelope of the normal lung (intralobar) or with its own pleura (extralobar), lacking normal communication with the tracheobronchial tree and receiving its arterial supply by one or more systemic vessels. It is the second most common congenital lung anomaly according to pediatric case series, but its real prevalence is likely to be underestimated, and imaging plays a key role in the diagnosis and treatment management of the condition and its potential complications. We will give a brief overview of the pathophysiology, clinical presentation and imaging findings of intra- and extralobar pulmonary sequestration, with particular reference to multidetector computed tomography as part of a powerful and streamlined diagnostic approach.

Lung Masses of Unusual Histologies Mimicking Malignancy: Flurodeoxyglucose Positron Emission Tomography-Computed Tomography Appearance

18F flurodeoxyglucose positron emission tomography-computed tomography (18F FDG PET-CT) is widely used in the evaluation of patients with lung mass suspicious for malignancy. In addition to malignancy, a variety of benign neoplasms and inflammatory lesions can arise in the lungs, many of which show increased FDG concentration, thereby mimicking malignancy. Awareness of the common mimics of lung cancer and a thorough understanding of their key imaging characteristics on CT as well as FDG PET is helpful in narrowing the differential diagnosis, eventually leading to appropriate therapy. In this article, we enlist these mimics and discuss their metabolic and morphologic characteristics and provide a pathophysiological basis for their FDG uptake.

Clinical presentation and characteristics of 25 adult cases of pulmonary sequestration

BACKGROUND

Pulmonary sequestration (PS) is a rare congenital abnormality of lung tissue. Only few series of adult cases are reported. The aim was to describe clinical characteristics in adult cases of PS and to compare outcomes in different clinical situations.

METHODS

Using MSD engine we searched for cases of PS that have been diagnosed between Jan 1st, 2005 and Dec 31st, 2015. Clinical data was retrospectively gathered. Statistica v.12 (StatSoft, Inc.) was used for statistical analyses.

RESULTS

We found 25 cases (18 females, 7 males), which underwent surgery and were histologically proven. There were 22 cases of intralobar PS. 7 cases were asymptomatic, 12 had infectious history (including 3 cases of lung abscess and pleural empyema), 4 presented with hemoptysis, 2 with chest pain. The average age to undergo surgery was 38.24, in the asymptomatic group 34, in symptomatic 39.89. In the latter the symptoms preceded the surgery for 2.45-year. Great majority of sequestrations was located in lower lobes (96%), 52% on the left. Symptomatic cases were at higher than expected risk of surgical complications, comparing to asymptomatic (chi², P=0.04). In most cases there were surgical and histological signs of infection, only in 9 cases etiological factor was determined: in 5 cases it was A. fumigatus. A 0.53-day longer post-surgical hospital stay was observed in the symptomatic group, no statistical significance was found (U-test, P=0.45).

CONCLUSIONS

Surgical treatment of symptomatic cases of PS is characterized by slightly longer post-surgical hospital stay and higher risk of surgical complications. Fungal infections are the most likely to occur in PS.

Intralobar pulmonary sequestration with bronchial atresia and a systemic artery feeding a normal contralateral lung

We report a case of an intralobar pulmonary sequestration in the left lower lobe presenting with aspects of bronchial atresia associated with an anomalous systemic artery supplying the basal segments of the right lower lobe, which showed no bronchial or parenchymal anomalies. This is an extremely rare occurrence and has been reported only twice in the literature so far.

[Congenital malformations of the lung, the radiologist's point of view]

Congenital lung malformations include a complex range of developmental abnormalities. Currently, most are diagnosed prenatally or during early childhood. They may, however, be discovered later, incidentally or in connection with non-specific symptoms, sometimes severe. Knowledge of their radiological appearances is necessary for their detection. Proper technique and analysis of cross-sectional imaging, computed tomography and magnetic resonance imaging, allow a definitive diagnosis in most patients and pre-treatment evaluation of surgical cases. This review will describe the radiological aspects of congenital pulmonary malformations, especially those which may occur in late childhood or adult life. When present, alternative diagnoses will be discussed. A distinction will be made between anomalies originating from bronchopulmonary structures, such as bronchial atresia, bronchogenic cyst, congenital lobar overinflation, cystic adenomatoid malformation, and forms related to vascular anomalies (vascular rings, anomalous left pulmonary artery, pulmonary underdevelopment, proximal interruption of the pulmonary artery, pulmonary sequestration, scimitar syndrome).

[Persistent pleuropneumopathy in a young woman]

Bronchopulmonary sequestration is a rare malformation characterized by lung tissue fed by one or several aberrant systemic arteries. The authors present the case of a 35-year-old woman in whom extralobar sequestration was fortuitously detected at the time of persistent pleuropneumopathy. Computed tomography was used in the diagnosis of pulmonary sequestration. The most common and recommended treatment is the surgical removal of the pulmonary sequestration.

[Usefulness of chest CT in the diagnosis of pulmonary sequestration]

Pulmonary sequestration is a rare congenital anomaly, characterized by nonfunctional embryonic pulmonary tissue. Pulmonary sequestration accounts for 0.15-6.40% of all congenital pulmonary malformations. This anomaly, which is classified as intralobar or extralobar, involves the lung parenchyma and its vascularization. We report the case of a 56-year-old male presenting with hemoptysis. A chest X-ray showed an area of opacity behind the cardiac silhouette in the base of the left hemithorax. Chest CT scans with intravenous contrast revealed pulmonary sequestration. The patient underwent surgery, in which the anomalous tissue was successful resected. The postoperative evolution was favorable, and the patient was discharged to outpatient treatment.

Extralobar pulmonary sequestration with hemothorax secondary to pulmonary infarction

Pulmonary sequestration is an uncommon condition that accounts for 0.5-6% of all pulmonary malformations and is typically diagnosed in childhood. Of the two forms of pulmonary sequestration, intralobar and extralobar, the latter is less frequently encountered. The current report describes the case of a 32-year-old female patient with chest and abdominal pain. Imaging (chest X-rays and CT scans of the chest) revealed consolidation and pleural effusion. The initial thoracocentesis revealed hemothorax. Subsequent diagnostic video-assisted thoracoscopy revealed extralobar pulmonary sequestration. Consequently, the therapeutic decision was to make the conversion to thoracotomy in order to resect the lesion and safely ligate the intercostal vascular pedicle.

Occlusion of an aberrant artery to an intralobar pulmonary sequestration using an Amplatzer Vascular Plug

Pulmonary sequestration is a rare anomaly and is conventionally treated with surgical excision. This report describes the successful occlusion of a large aberrant artery to an intralobar pulmonary sequestration using an Amplatzer Vascular Plug.

Multidetector CT evaluation of congenital lung anomalies

Congenital lung anomalies vary widely in their clinical manifestation and imaging appearance. Although radiographs play a role in the incidental detection and initial imaging evaluation in patients with clinical suspicion of congenital lung anomalies, cross-sectional imaging such as computer tomography (CT) is frequently required for confirmation of diagnosis, further characterization, and preoperative evaluation in the case of surgical lesions. Recently, with the development and widespread availability of multidetector CT scanners, CT has assumed a greater role in the noninvasive evaluation of congenital lung anomalies. The combination of fast speed, high spatial resolution, and enhanced quality of multiplanar reformation and three-dimensional reconstructions makes multidetector CT an ideal noninvasive method for evaluating congenital lung anomalies. In this article, the authors review the multidetector CT technique for evaluation of congenital lung anomalies. Important clinical aspects, characteristic imaging features, and key points that allow differentiation among various anomalies are highlighted for a variety of common and uncommon conditions.

Extralobar pulmonary sequestration with hemorrhagic infarction in an adult

Symptomatic extralobar pulmonary sequestration in adults is thought to be extremely rare. We present a case of an extralobar pulmonary sequestration, with infarct, in a 28-year-old woman who complained abrupt onset of chest pain. Chest computed tomography and magnetic resonance imaging showed a mass in the left paraspinal area, medial to the left lower lobe, and serial chest radiographs revealed increasing pleural effusion. This was histopathologically confirmed to be a hemorrhagic infarct of the extralobar pulmonary sequestration.

[Abundant hemothorax revealing extralobular pulmonary sequestration]

Hemothorax is an exceptional, serious and misleading manifestation of extralobular sequestration. We report the case of a 15-year-old patient who consulted for chest pain and sudden onset dyspnea. The chest x-ray revealed fluid pleural effusion. Pleural puncture produced a bloody fluid and the angioscan showed a hyperdense formation without a systemic artery. Thoracotomy was performed. A left intrapleural pyramidal formation vascularized with a pedicle from the thoracic aorta was identified and sequestrectomy performed. At two years, the patient has remained symptom free. Extralobular sequestration is an exceptional cause of hemothorax. The absence of an aberrant systemic vessel on the angioscan should not rule out the diagnosis of sequestration. Precautions must be taken at surgery to avoid vessel damage.