1
|
Abstract
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.
Collapse
Affiliation(s)
- Brittany N Hegde
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, USA; Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, USA
| | - KuoJen Tsao
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, USA; Center for Surgical Trials and Evidence-Based Practice (C-STEP), McGovern Medical School at the University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.256, Houston, TX 77030, USA
| | - Shinjiro Hirose
- Division of Pediatric, Thoracic, and Fetal Surgery, University of California-Davis Medical Center, 2335 Stockton Boulevard, Sacramento, CA 95817, USA.
| |
Collapse
|
2
|
El-Ali AM, Strubel NA, Lala SV. Congenital lung lesions: a radiographic pattern approach. Pediatr Radiol 2022; 52:622-636. [PMID: 34716454 DOI: 10.1007/s00247-021-05210-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/29/2021] [Accepted: 09/13/2021] [Indexed: 11/28/2022]
Abstract
Congenital lung malformations represent a spectrum of abnormalities that can overlap in imaging appearance and frequently coexist in the same child. Imaging diagnosis in the neonatal period can be challenging; however, the recognition of several archetypal radiographic patterns can aid in narrowing the differential diagnosis. Major radiographic archetypes include (1) hyperlucent lung, (2) pulmonary cysts, (3) focal opacity and (4) normal radiograph. Here we review the multimodality imaging appearances of the most commonly seen congenital lung malformations, categorized by their primary imaging archetypes. Along with the congenital lung malformations, we present several important imaging mimickers.
Collapse
Affiliation(s)
- Alexander Maad El-Ali
- Division of Pediatric Radiology, Department of Radiology, NYU Grossman School of Medicine, 550 First Ave., New York, NY, 10016, USA.
| | - Naomi A Strubel
- Division of Pediatric Radiology, Department of Radiology, NYU Grossman School of Medicine, 550 First Ave., New York, NY, 10016, USA
| | - Shailee V Lala
- Division of Pediatric Radiology, Department of Radiology, NYU Grossman School of Medicine, 550 First Ave., New York, NY, 10016, USA
| |
Collapse
|
3
|
Fortes IMLP, Junior JRB. Use of Corticosteroids in Prenatal Treatment of Congenital Pulmonary Adenomatoid Malformation: Integrative Review. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:304-310. [PMID: 35108733 PMCID: PMC9948104 DOI: 10.1055/s-0041-1741517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To review data on the use of corticosteroids for the treatment of fetuses with high-risk congenital pulmonary adenomatoid malformation (CPAM). METHODS Integrative review based on the literature available on MEDLINE and LILACS, including articles published until November, 2020. RESULTS The initial search resulted in 87 articles, 4 of which were selected for analysis, with all of them being retrospective descriptive observational studies. In the group of fetuses that received only a single corticosteroid cycle, the hydrops resolution rate was 70%, and the survival rate was 83.8%. In fetuses treated with 2 or more cycles of corticosteroids, there was an improvement in the condition of hydrops or edema in a single body compartment in 47%, and survival of 81.8% of the fetuses. CONCLUSION The use of corticosteroids for the prenatal treatment of high-risk CPAM appears to be associated with an improvement in perinatal outcomes.
Collapse
Affiliation(s)
| | - João Renato Bennini Junior
- Fetal Medicine Program, Department of Gynecology and Obstetrics, Women's Hospital, University of Campinas, Campinas, SP, Brazil
| |
Collapse
|
4
|
Peters NCJ, Hijkoop A, Hermelijn SM, van Schoonhoven MM, Eggink AJ, van Rosmalen J, Otter SCMCD, Tibboel D, IJsselstijn H, Schnater JM, Cohen-Overbeek TE. Prediction of postnatal outcome in fetuses with congenital lung malformation: 2-year follow-up study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:428-438. [PMID: 33206446 DOI: 10.1002/uog.23542] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/09/2020] [Accepted: 10/27/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To identify, in fetuses with a congenital lung malformation (CLM), prenatal predictors of the need for postnatal respiratory support and the need for surgery by calculating the CLM volume ratio (CVR), and to evaluate the concordance between the prenatal appearance and the postnatal type of CLM. METHODS This was an analysis of prenatal, perinatal and postnatal data from fetuses diagnosed with a CLM at the Erasmus University Medical Center - Sophia Children's Hospital in Rotterdam, The Netherlands, between January 2007 and December 2016. For all included fetuses, CVR was measured retrospectively on stored ultrasound images obtained at 18 + 1 to 24 + 6 weeks (US1), 25 + 0 to 29 + 6 weeks (US2) and/or 30 + 0 to 35 + 6 weeks' gestation (US3). Postnatal diagnosis of CLM was based on computed tomography or histology. Primary outcomes were the need for respiratory support within 24 h and surgery within 2 years after birth. RESULTS Of the 80 fetuses with a CLM included in this study, 14 (18%) required respiratory support on the first postnatal day, and 17 (21%) required surgery within 2 years. Only the CVR at US2 was predictive of the need for respiratory support, with a cut-off value of 0.39. Four of 16 (25%) fetuses which showed full regression of the CLM prenatally required respiratory support within 24 h after birth. The CVR at US1, US2 and US3 was predictive of surgery within 2 years. Overall, the prenatal appearance of the CLM showed low concordance with the postnatal type. Prenatally suspected microcystic congenital pulmonary airway malformation (CPAM) was shown on computed tomography after birth to be congenital lobar overinflation in 15/35 (43%) cases. Respiratory support within 24 h after birth and surgical resection within 28 days after birth were needed in all cases of macrocystic CPAM. CONCLUSIONS CVR can predict the need for respiratory support within 24 h after birth and for surgery within 2 years. Regression of a CLM prenatally does not rule out respiratory problems after birth. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. - Legal Statement: This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
Collapse
Affiliation(s)
- N C J Peters
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - A Hijkoop
- Department of Pediatric Surgery and Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - S M Hermelijn
- Department of Pediatric Surgery and Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M M van Schoonhoven
- Department of Pediatric Surgery and Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - A J Eggink
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - J van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S C M Cochius-den Otter
- Department of Pediatric Surgery and Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - D Tibboel
- Department of Pediatric Surgery and Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - H IJsselstijn
- Department of Pediatric Surgery and Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J M Schnater
- Department of Pediatric Surgery and Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - T E Cohen-Overbeek
- Department of Obstetrics and Gynecology, Division of Obstetrics and Fetal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
5
|
Jeong BD, An SA, Lee MY, Won HS, Han M, Yoon H, Lee JH, Cho YJ. Comparison of the Prognostic Factors of Fetuses With Congenital Pulmonary Airway Malformations According to Type. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:2243-2252. [PMID: 32420654 DOI: 10.1002/jum.15335] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 04/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To compare the prognostic factors of fetuses with microcystic and macrocystic congenital pulmonary airway malformations (CPAMs). METHODS We retrospectively evaluated fetuses with CPAMs at Asan Medical Center. The CPAM size, mass effect, and maximum cyst size in macrocystic CPAMs were evaluated prenatally. The adverse postnatal outcomes, including respiratory symptoms, mechanical ventilation, and surgery, were evaluated. RESULTS In 118 cases, 2 fetal deaths and 1 neonatal death occurred. All cases of fetal hydrops and complete regression after birth were in the macrocystic and microcystic CPAM groups, respectively. Twenty-four neonates (20.7%) had respiratory symptoms, and 18 (15.5%) required mechanical ventilation. Sixty-three neonates (54.3%) underwent surgery, of whom 21 (33.3%) required surgery in the neonatal period. The maximum congenital pulmonary airway malformation volume ratio was significantly associated with all postnatal outcomes (P < .05), and the optimal cutoff values were lower for respiratory symptoms, mechanical ventilation, and neonatal surgery in the macrocystic CPAMs. The maximum cyst size was also associated with all postnatal outcomes in macrocystic CPAMs (P < .05). CONCLUSIONS Different cutoff values for the maximum congenital pulmonary airway malformation volume ratio should be applied according to the CPAM type for the prediction of postnatal outcomes. The maximum cyst size can also be a useful prognostic factor in macrocystic CPAMs.
Collapse
Affiliation(s)
- Ba-Da Jeong
- Departments of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Su-Ah An
- Department of Obstetrics and Gynecology, Kangdong Miz Hospital, Seoul, Korea
| | - Mi-Young Lee
- Departments of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hye-Sung Won
- Departments of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Minkyu Han
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
| | - Heemang Yoon
- Department of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji-Hoon Lee
- Departments of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Yoon-Jung Cho
- Departments of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| |
Collapse
|
6
|
Eyerly-Webb S, Nicolas CT, Watson D, Dion E, Amin R, Wagner AJ, Lampland A, Bendel-Stenzel E, Macardle CA, Kunisaki SM, Jorgenson A, Lillegard J, Feltis B. Dynamic discriminant model for predicting respiratory distress at birth based on mass volume ratio in fetuses with congenital lung malformation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:759-766. [PMID: 30834623 DOI: 10.1002/uog.20255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 02/13/2019] [Accepted: 02/22/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The congenital lung malformation volume ratio (CVR) is a prenatal ultrasound measurement that parameterizes congenital lung malformation (CLM) size. The aims of this study were to use serial measurements to create estimated growth curves of fetal CVR for asymptomatic and symptomatic neonates with CLM and to investigate whether a discriminant prognostic model based on these measurements could predict accurately which fetuses with CLM will require invasive respiratory support at delivery and should therefore be delivered at a tertiary-care facility. METHODS This was a retrospective study of fetuses diagnosed prenatally with CLM at three tertiary-care children's hospitals between 2009 and 2016. Those with two or more sonographic measurements of CVR were included. Serial fetal CVR measurements were used to create estimated growth curves for neonates with and those without respiratory symptoms at delivery, defined as requiring invasive respiratory support for the first 24 h after delivery. A discriminant model based on serial CVR measurements was used to calculate the dynamic probability of the need for invasive respiratory support. The performance of this model overall and in preterm and term neonates was compared with those using maximum CVR thresholds of 1.0 and 1.6. RESULTS Of the 147 neonates meeting the inclusion criteria, 16 (10.9%) required postnatal invasive respiratory support. The estimated CVR growth curve models showed different growth trajectories for asymptomatic and symptomatic neonates, with significantly higher CVR in symptomatic neonates, and values peaking late in the second trimester at around 25 weeks' gestation in asymptomatic neonates. All prognostic methods had high accuracy for the prediction of the need for invasive respiratory support in term neonates, but the discriminant model had the best performance overall (area under the receiver-operating characteristics curve (AUC) = 0.88) and in the preterm population (AUC = 0.85). CONCLUSIONS The estimated CVR growth curves showed different growth patterns in asymptomatic and symptomatic neonates with CLM. The dynamic discriminant model performed well overall and particularly in neonates that were carried to term. Development of an externally validated clinical tool based on this analysis could be useful in determining the site of delivery for fetuses with CLM. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- S Eyerly-Webb
- Children's Hospitals and Clinics of Minnesota, Midwest Fetal Care Center, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - C T Nicolas
- Children's Hospitals and Clinics of Minnesota, Midwest Fetal Care Center, Minneapolis, MN, USA
- Mayo Clinic, Division of General Surgery Research, Rochester, MN, USA
| | - D Watson
- Children's Hospitals and Clinics of Minnesota, Research Design and Analytics, Minneapolis, MN, USA
| | - E Dion
- Children's Hospitals and Clinics of Minnesota, Midwest Fetal Care Center, Minneapolis, MN, USA
| | - R Amin
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - A J Wagner
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - A Lampland
- Children's Hospitals and Clinics of Minnesota, Midwest Fetal Care Center, Minneapolis, MN, USA
| | - E Bendel-Stenzel
- Children's Hospitals and Clinics of Minnesota, Midwest Fetal Care Center, Minneapolis, MN, USA
| | - C A Macardle
- St Joseph Mercy Health System, Ypsilanti, MI, USA
| | - S M Kunisaki
- Johns Hopkins Children's Center, Baltimore, MD, USA
| | - A Jorgenson
- Children's Hospitals and Clinics of Minnesota, Midwest Fetal Care Center, Minneapolis, MN, USA
| | - J Lillegard
- Children's Hospitals and Clinics of Minnesota, Midwest Fetal Care Center, Minneapolis, MN, USA
- Mayo Clinic, Division of General Surgery Research, Rochester, MN, USA
- Pediatric Surgical Associates, Minneapolis, MN, USA
| | - B Feltis
- Children's Hospitals and Clinics of Minnesota, Midwest Fetal Care Center, Minneapolis, MN, USA
- Pediatric Surgical Associates, Minneapolis, MN, USA
| |
Collapse
|
7
|
Abbasi N, Morency AM, Langer JC, Chiu PPL, Chami R, Windrim R, Keunen J, Seaward G, Ryan G. Fetal Sclerotherapy for Hydropic Congenital Cystic Adenomatoid Malformations of the Lung Refractory to Steroids: A Case Report and Review of the Literature. Fetal Diagn Ther 2019; 47:24-33. [PMID: 31112955 DOI: 10.1159/000497143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/21/2019] [Indexed: 11/19/2022]
Abstract
Microcystic congenital cystic adenomatoid malformations (CCAM), when associated with hydrops, carry a dismal prognosis. Options for treatment are limited and experimental, including antenatal corticosteroids, open fetal surgery, laser ablation and, more recently, sclerotherapy. We describe a case of a large, predominantly microcystic CCAM in a hydropic fetus treated successfully with direct interstitial injection of a sclerosant agent (3% sodium tetradecyl sulfate) at 23+3 weeks gestation, after multiple failed courses of steroids. Elective thoracoscopic right lower lobectomy was performed at 1 year of life and there have been no respiratory or other medical morbidities since. A literature review of fetal lung masses treated with sclerosants antenatally reveals that sclerotherapy may represent a novel treatment option for large hydropic microcystic CCAMs, which are unresponsive to corticosteroids. Further studies are required to evaluate the utility and safety of fetal sclerotherapy, as this may represent an alternative minimally invasive treatment option to fetal lobectomy.
Collapse
Affiliation(s)
- Nimrah Abbasi
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada, .,University of Toronto, Toronto, Ontario, Canada,
| | - Anne-Maude Morency
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Jacob C Langer
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Priscilla P L Chiu
- Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Rose Chami
- Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Rory Windrim
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Johannes Keunen
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Gareth Seaward
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Ontario Fetal Centre, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
8
|
Shulman R, Sparks TN, Gosnell K, Blat C, Norton ME, Lee H, Gonzalez-Velez J, Goldstein RB. Fetal Congenital Pulmonary Airway Malformation: The Role of an Objective Measurement of Cardiomediastinal Shift. Am J Perinatol 2019; 36:225-232. [PMID: 30199894 PMCID: PMC6372337 DOI: 10.1055/s-0038-1669909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To examine the relationship between cardiomediastinal shift angle (CMSA) and adverse perinatal outcomes and hydrops in cases of congenital pulmonary airway malformation (CPAM). STUDY DESIGN This retrospective study evaluated CPAM cases referred to our institution from 2008 to 2015. The primary outcome was a composite score for adverse perinatal outcome. CMSA was measured for each case and evaluated for its association with the primary outcome. The prediction accuracy of CMSA for adverse perinatal outcome was assessed using receiver operator characteristic (ROC) curves. RESULTS Eighteen (21.2%) of the 85 cases experienced an adverse perinatal outcome. Increases in CMSA were associated with adverse perinatal outcomes and hydrops in bivariate analyses. Adjusted analyses found each 10-degree increase in CMSA to be associated with increased odds of an adverse perinatal outcome (adjusted odds ratio [aOR] 2.2, 95% confidence interval [CI]: 1.4-3.3) and hydrops (aOR 3.0, 95% CI: 1.5-6.1). CMSA performed well and was comparable to CPAM volume ratio in predicting adverse perinatal outcomes (area under the curve 0.81 and 0.84, respectively). CONCLUSION We describe a novel measurement of mediastinal shift in cases of CPAM and its relationship with adverse perinatal outcomes and hydrops. These findings may shape the evaluation and management of CPAMs, improve our understanding of their prognosis, and influence patient counseling.
Collapse
Affiliation(s)
- Rachel Shulman
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Teresa N. Sparks
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Kristen Gosnell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Fetal Treatment Center, University of California, San Francisco
| | - Cinthia Blat
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Mary E. Norton
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Hanmin Lee
- Department of Surgery, Fetal Treatment Center, University of California, San Francisco
| | - Juan Gonzalez-Velez
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Ruth B. Goldstein
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Fetal Treatment Center, University of California, San Francisco
| |
Collapse
|
9
|
Masmejan S, Baud D, Ryan G, Van Mieghem T. Management of fetal tumors. Best Pract Res Clin Obstet Gynaecol 2019; 58:107-120. [PMID: 30770283 DOI: 10.1016/j.bpobgyn.2019.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 01/07/2019] [Accepted: 01/08/2019] [Indexed: 12/28/2022]
Abstract
In this review article, we discuss the most common fetal tumors, their prenatal management, and outcomes. Overall, the most important outcome predictors are tumor histology, size, vascularity, and location. Very large lesions, lesions causing cardiac failure, and hydrops and lesions obstructing the fetal airway have the poorest outcome, as they may cause fetal death or complications at the time of delivery. Fetal therapy has been developed to improve outcomes for the most severe cases and can consist of transplacental therapy (sirolimus for rhabdomyomas or steroids for hemangiomas and microcystic lung lesions) or surgical intervention (shunting of cystic masses, tumor ablation, occlusion of blood flow or airway exploration, and protection). Given the rarity of fetal tumors, patients should be referred to expert centers where care can be optimized and individualized to allow the best possible outcomes.
Collapse
Affiliation(s)
- Sophie Masmejan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada; Obstetrics Unit, Mother-Child Department, University Hospital Lausanne, Switzerland
| | - David Baud
- Obstetrics Unit, Mother-Child Department, University Hospital Lausanne, Switzerland
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Tim Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada.
| |
Collapse
|
10
|
Schierz IAM, Giuffrè M, Piro E, Leone MC, Pinello G, Corsello G. Clinical cardiac assessment in newborns with prenatally diagnosed intrathoracic masses. Ital J Pediatr 2018; 44:98. [PMID: 30134984 PMCID: PMC6106891 DOI: 10.1186/s13052-018-0543-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/13/2018] [Indexed: 11/17/2022] Open
Abstract
Background Congenital space-occupying thoracic malformations and diaphragmatic hernia have in common pulmonary hypoplasia. Our study aims to assess cardiac involvement during post-natal adaptation. Methods A retrospective study was carried out on newborns with prenatally diagnosed intrathoracic mass. Gathering for respiratory distress syndrome (RDS), 35 neonates were compared for clinical course, cardiovascular enzymes, ECG, and ultrasound. Results The analysis revealed a high left heart defect rate in patients with severe RDS, without being influenced by the laterality. Ultrasound or laboratory assessment did not detect altered cardiac dimension or cardiomyopathy. Solely ECG signs of right ventricular strain were found. Increased QT-dispersion, T-wave and cardiac variability alterations in the first hours were all expression of non-specific cardiac repolarization disorders but predict worse outcome. Conclusions Although RDS is the predominant symptom, slight cardiac dysfunctions should be recognized for prompt treatment. Conventional examinations for postnatal adaption should be integrated by complementary investigations.
Collapse
|
11
|
Chon AH, Korst LM, Abdel-Sattar M, Llanes A, Ouzounian JG, Chmait RH. Types II and III congenital pulmonary airway malformation with hydrops treated in utero with percutaneous sclerotherapy. Prenat Diagn 2018; 38:493-498. [PMID: 29665020 DOI: 10.1002/pd.5266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 04/03/2018] [Accepted: 04/05/2018] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To present outcomes of fetuses with congenital pulmonary airway malformation (CPAM) treated with sclerotherapy. METHODS Retrospective study of 8 patients with a prenatal diagnosis of CPAM type II or III with secondary hydrops treated with percutaneous sclerotherapy using 5% ethanolamine oleate (EO). All patients underwent ultrasonic measurement of the CPAM volume ratio. Results are expressed as median (range). RESULTS Gestational age at initial sclerotherapy was 22.0 weeks (19.6-31.4); 3 patients underwent 2 procedures. Intrauterine fetal demise (IUFD) occurred in 4 cases; 2 died on postoperative day #1 (one from inadvertent intravascular EO injection); 2 died >6 weeks after the procedure. Preoperative CPAM volume ratio was 3.6 (1.6-7.8) in survivors and 2.7 (1.7-4.7) in those with IUFD. The volume of EO at the initial sclerotherapy procedure was 3 mL (2-5) in survivors and 7 mL (6-10) in IUFD cases. The gestational age at delivery of the 4 survivors was 38.4 weeks (37.4-39.3); all underwent postnatal resection. CONCLUSION The efficacy of percutaneous sclerotherapy for CPAM types II and III remains in question. Further studies are needed to determine the optimal dose of sclerotherapy agent and the safety and efficacy of this procedure.
Collapse
Affiliation(s)
- Andrew H Chon
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lisa M Korst
- Childbirth Research Associates LLC, Los Angeles, CA, USA
| | - Mira Abdel-Sattar
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Arlyn Llanes
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Joseph G Ouzounian
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
12
|
Hellmund A, Berg C, Geipel A, Bludau M, Heydweiller A, Bachour H, Müller A, Müller A, Gembruch U. Prenatal Diagnosis and Evaluation of Sonographic Predictors for Intervention and Adverse Outcome in Congenital Pulmonary Airway Malformation. PLoS One 2016; 11:e0150474. [PMID: 26978067 PMCID: PMC4792474 DOI: 10.1371/journal.pone.0150474] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 02/14/2016] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To describe antenatal findings and evaluate prenatal risk parameters for adverse outcome or need for intervention in fetuses with congenital pulmonary airway malformation (CPAM). METHODS In our retrospective study all fetuses with a prenatal diagnosis of CPAM detected in our tertiary referral center between 2002 and 2013 were analyzed. Sonographic findings were noted and measurements of mass-to-thorax-ratio (MTR), congenital pulmonary airway malformation volume-ratio (CVR) and observed to expected lung-to head-ratio (o/e LHR) were conducted and correlated to fetal or neonatal morbidity and mortality and/or need for prenatal intervention. RESULTS 67 fetuses with CPAM were included in the study. Hydropic fetuses were observed in 16.4% (11/67) of cases, prenatal intervention was undertaken in 9 cases; 7 pregnancies were terminated. The survival rate of non-hydropic fetuses with conservatively managed CPAM was 98.0% (50/51), the survival rate for hydropic fetuses with intention to treat was 42.9% (3/7). 10 (18.2%) children needed respiratory assistance. Fetuses with a CVR of <0.91 were significantly less likely to experience adverse outcome or need for prenatal intervention with sensitivity, specificity and positive/negative predictive value of 0.89, 0.71, 0.62 and 0.93, respectively. A MTR (mass-to-thorax-ratio) of < 0.51 had a positive predictive value of 0.54 and a negative predictive value of 0.96 of adverse events with a sensitivity of 0.95 and a specificity of 0.63. The negative predictive value for o/e LHR of 45% was 0.84 with sensitivity, specificity and positive predictive value of 0.73, 0.68 and 0.52, respectively. CONCLUSIONS The majority of cases with CPAM have a favorable outcome. MTR and CVR are able to identify fetuses at risk, the o/e LHR is less sensitive.
Collapse
Affiliation(s)
- Astrid Hellmund
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
- * E-mail:
| | - Christoph Berg
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
- Division of Prenatal Medicine and Gynecologic Sonography, Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany
| | - Annegret Geipel
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - Meike Bludau
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | | | - Haitham Bachour
- Division of Pediatric Surgery, University of Bonn, Bonn, Germany
| | - Andreas Müller
- Department of Neonatology, University of Bonn, Bonn, Germany
| | - Annette Müller
- Department of Pathology, University of Bonn, Bonn, Germany
| | - Ulrich Gembruch
- Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| |
Collapse
|
13
|
David M, Lamas-Pinheiro R, Henriques-Coelho T. Prenatal and Postnatal Management of Congenital Pulmonary Airway Malformation. Neonatology 2016; 110:101-15. [PMID: 27070354 DOI: 10.1159/000440894] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/06/2015] [Indexed: 11/19/2022]
Abstract
Congenital pulmonary airway malformation (CPAM) is one of the most common lung lesions detected prenatally. Despite the research efforts made in the past few years, controversy and lack of clarity in the literature still exist regarding nomenclature, classification, pathogenesis and the management of CPAM. Therefore, it is of greatest importance to delineate the natural history of CPAMs and to create a consensus to guide the management and follow-up of these lesions. This review will focus on classification systems, highlighting the most recent advancements in pathogenesis, and current practice in the prenatal diagnosis of CPAM. Strategies of prenatal management and postnatal management will be reviewed. Long-term follow-up, including lung cancer risk, is discussed and an outcome perspective is presented.
Collapse
Affiliation(s)
- Mafalda David
- Pediatric Surgery Department, Centro Hospitalar Sx00E3;o Jox00E3;o, Porto, Portugal
| | | | | |
Collapse
|
14
|
Peranteau WH, Boelig MM, Khalek N, Moldenhauer JS, Martinez-Poyer J, Hedrick HL, Flake AW, Johnson MP, Adzick NS. Effect of single and multiple courses of maternal betamethasone on prenatal congenital lung lesion growth and fetal survival. J Pediatr Surg 2016; 51:28-32. [PMID: 26526208 DOI: 10.1016/j.jpedsurg.2015.10.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 10/06/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE Administration of maternal betamethasone (BMZ) is a therapeutic option for fetuses with large microcystic congenital lung lesions at risk for, or causing, hydrops. Not all fetuses respond to a single course of BMZ. We review our experience with the use of single and multiple courses of maternal BMZ for the management of these patients. METHODS A retrospective review of fetuses with congenital lung lesions managed with maternal BMZ from 2003 to 2014 was performed. RESULTS Forty-three patients were managed with prenatal steroids (28 single course, 15 multiple courses). Single course recipients demonstrated a reduction in lesion size and resolution of hydrops in 82% and 88% of patients respectively compared to 47% and 56% in recipients of multiple steroid courses. Survival of multiple course patients (86%) was comparable to that of single course patients (93%) and improved compared to non-treated historical controls. Multiple course recipients demonstrated an increased need for open fetal surgery and postnatal surgery at a younger age. CONCLUSION Fetuses who fail to respond to a single course of BMZ may benefit, as indicated by hydrops resolution and improved survival, from additional courses. However, failure to respond is indicative of a lesion which may require fetal or immediate neonatal resection.
Collapse
Affiliation(s)
- William H Peranteau
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States.
| | - Matthew M Boelig
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Nahla Khalek
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Julie S Moldenhauer
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Juan Martinez-Poyer
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Alan W Flake
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Mark P Johnson
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment at the Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
15
|
Euser AG, Meyers ML, Zaretsky MV, Crombleholme TM. Comparison of congenital pulmonary airway malformation volume ratios calculated by ultrasound and magnetic resonance imaging. J Matern Fetal Neonatal Med 2015; 29:3172-7. [DOI: 10.3109/14767058.2015.1118038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Anna G. Euser
- Colorado Institute for Maternal and Fetal Health, Children’s Hospital of Colorado, Aurora, CO, USA,
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO, USA,
| | - Mariana L. Meyers
- Colorado Institute for Maternal and Fetal Health, Children’s Hospital of Colorado, Aurora, CO, USA,
- Department of Radiology, University of Colorado Denver, Aurora, CO, USA, and
| | - Michael V. Zaretsky
- Colorado Institute for Maternal and Fetal Health, Children’s Hospital of Colorado, Aurora, CO, USA,
- Department of Obstetrics and Gynecology, University of Colorado Denver, Aurora, CO, USA,
| | - Timothy M. Crombleholme
- Colorado Institute for Maternal and Fetal Health, Children’s Hospital of Colorado, Aurora, CO, USA,
- Department of Surgery, Children’s Hospital of Colorado, Aurora, CO, USA
| |
Collapse
|
16
|
Bush A. Rare Lung Diseases: Congenital Malformations. Indian J Pediatr 2015; 82:833-40. [PMID: 26096865 DOI: 10.1007/s12098-015-1800-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 05/21/2015] [Indexed: 11/30/2022]
Abstract
Increasingly, congenital thoracic malformations (CTMs) are diagnosed on antenatal ultrasound, but we lack the evidence to suggest rational management, not least because descriptive terms are used inconsistently. This review describes a simplified clinical classification of CTMs, and contrasts it with pathological descriptions. The age related presentations of CTM are described, together with the differential diagnoses of cystic masses presenting both antenatally and postnatally. Antenatally diagnosed CTMs rarely require intervention before birth; and urgent treatment is only required postnatally if the baby is symptomatic and does not respond to medical management. The asymptomatic baby with an antenatal diagnosis of a CTM presents a management conundrum. Definitive imaging is with high-resolution computed tomography (HRCT), but the optimal timing of imaging is unclear. Whether surgery should be offered to asymptomatic infants is also unclear; in the medium term, 5 % of asymptomatic babies will require surgery for complications of the disease. The most vexed question is malignant change; the risk in the medium term is probably less than 5 %, but we have no way of delineating a high-risk group. Indeed, malignancy has been described even after complete resection of a CTM. The author's personal management is to advocate surgery in the second year of life for all except for the most trivial CTMs, but many would differ and advocate conservative management. More data are needed if we are to rationalise our approach to these infants.
Collapse
Affiliation(s)
- Andrew Bush
- Department of Pediatrics, Imperial College, London, UK; Department of Pediatric Respiratory Medicine, National Heart and Lung Institute, London, UK and Department of Pediatric Respiratory Medicine, Royal Brompton & Harefield NHS Foundation Trust, London, UK,
| |
Collapse
|
17
|
Derderian SC, Coleman AM, Jeanty C, Lim FY, Shaaban AM, Farrell JA, Hirose S, MacKenzie TC, Lee H. Favorable outcomes in high-risk congenital pulmonary airway malformations treated with multiple courses of maternal betamethasone. J Pediatr Surg 2015; 50:515-8. [PMID: 25840053 DOI: 10.1016/j.jpedsurg.2014.08.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 08/23/2014] [Accepted: 08/26/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND/PURPOSE Congenital pulmonary airway malformations (CPAMs) are rare congenital lung lesions often diagnosed by prenatal ultrasound. High-risk cases can result in hydrops and prenatal or postnatal demise. Antenatal betamethasone has resulted in improved survival but it is unclear how to manage patients who do not respond to a single course. METHODS We present a bi-institutional retrospective review of patients treated with multiple courses of prenatal steroids for high-risk CPAMs between 2007 and 2013. RESULTS Nine patients met inclusion criteria. All but one either had an increased CPAM volume ratio (CVR) or number of fluid-containing compartments involved after a single course of antenatal betamethasone, prompting additional courses. Four patients stabilized, three improved and two progressed after the second course. The two cases with disease progression underwent an in utero resection. There were one in utero fetal demise and two deaths within the delivery room. Both fetuses that underwent a fetal resection died. All but one mother who delivered a viable fetus had complications of pregnancy. CONCLUSIONS Multiple courses of antenatal betamethasone for high-risk fetal CPAMs often result in favorable short-term outcomes without the need for open fetal resection. Pregnancy complications are common and women within this cohort should be monitored closely.
Collapse
Affiliation(s)
- S C Derderian
- Fetal Treatment Center, Department of Surgery at The University of California, San Francisco, CA, USA
| | - A M Coleman
- Cincinnati Fetal Center, Division of Pediatric, General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - C Jeanty
- Fetal Treatment Center, Department of Surgery at The University of California, San Francisco, CA, USA
| | - F Y Lim
- Cincinnati Fetal Center, Division of Pediatric, General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A M Shaaban
- Cincinnati Fetal Center, Division of Pediatric, General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J A Farrell
- Fetal Treatment Center, Department of Surgery at The University of California, San Francisco, CA, USA
| | - S Hirose
- Fetal Treatment Center, Department of Surgery at The University of California, San Francisco, CA, USA
| | - T C MacKenzie
- Fetal Treatment Center, Department of Surgery at The University of California, San Francisco, CA, USA
| | - H Lee
- Fetal Treatment Center, Department of Surgery at The University of California, San Francisco, CA, USA.
| |
Collapse
|
18
|
Baud D, Windrim R, Kachura JR, Jefferies A, Pantazi S, Shah P, Langer JC, Forsey J, Chaturvedi RR, Jaeggi E, Keating S, Chiu P, Ryan G. Minimally invasive fetal therapy for hydropic lung masses: three different approaches and review of the literature. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2013; 42:440-448. [PMID: 23712922 DOI: 10.1002/uog.12515] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To report three different antenatal therapeutic approaches for fetal lung masses associated with hydrops. METHODS Three prospectively followed cases are described, and all 30 previously published minimally invasive cases of fetal therapy for hydropic lung masses are reviewed. RESULTS Three hydropic fetuses with large intrathoracic lung masses presented at 17, 25 and 21 weeks of gestation, respectively. An aortic feeding vessel was identified in each case and thus a bronchopulmonary sequestration (BPS) was suspected. Under ultrasound guidance, the feeding vessel was successfully occluded with interstitial laser (Case 1), radiofrequency ablation (RFA) (Case 2) and thrombogenic coil embolization (Case 3). Complete (Cases 1 and 2) or partial (Case 3) resolution of the lung mass and hydrops was observed. A healthy infant was born at term after laser therapy (Case 1), and the involved lung lobe was resected on day 2 of postnatal life. In Case 2, hydrops resolved completely following RFA, but an iatrogenic congenital diaphragmatic hernia and abdominal wall defect became apparent 4 weeks later. The neonate died from sepsis following spontaneous preterm labor at 33 weeks. In Case 3, despite technical success in complete vascular occlusion with coils, a stillbirth ensued 2 days after embolization. CONCLUSIONS The prognosis of large microcystic or echogenic fetal chest masses associated with hydrops is dismal. This has prompted attempts at treatment by open fetal surgery, with mixed results, high risk of premature labor and consequences for future pregnancies. We have demonstrated the possibility of improved outcome following ultrasound-guided laser ablation of the systemic arterial supply. Despite technical success, RFA and coil embolization led to procedure-related complications and need further evaluation.
Collapse
Affiliation(s)
- D Baud
- Fetal Medicine Unit, Mount Sinai Hospital, Toronto, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Abstract
Building upon over 30 years of experimental and clinical development, fetal surgery can be argued to be a standard of care for selected indications, though application of these techniques remains limited to a small number of highly selected fetuses, and availability to a small number of highly specialized centers. Despite its limited application to date, the field of fetal surgery continues to evolve, spurred both by technological advances allowing earlier and more accurate diagnosis of fetal anomalies as well as improved capability to intervene when appropriate. The efficacy of fetal surgical intervention has now been validated for selected indications by well-designed, randomized controlled trials. In this review, we summarize the evidence or lack thereof supporting the current most common indications for fetal surgical intervention.
Collapse
|
20
|
Fetal lung lesions: can we start to breathe easier? Am J Obstet Gynecol 2013; 208:151.e1-7. [PMID: 23159697 DOI: 10.1016/j.ajog.2012.11.012] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 09/28/2012] [Accepted: 11/13/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The purpose of this study was to develop a simple and accurate approach for risk stratification of fetal lung lesions that are associated with respiratory compromise at birth. STUDY DESIGN We conducted a retrospective review of 64 prenatal lung lesions that were managed at a single fetal care referral center (2001-2011). Sonographic data were analyzed and correlated with perinatal outcomes. RESULTS Hydrops occurred in only 4 cases (6.3%). Among fetuses without hydrops, the congenital pulmonary airway malformation volume ratio (CVR) was the only variable that was associated significantly with respiratory compromise and the need for lung resection at birth (P < .01). Based on a maximum CVR >1.0, the sensitivity, specificity, positive predictive value, and negative predictive value for respiratory morbidity were 90%, 93%, 75%, and 98%, respectively. CONCLUSION Nonhydropic fetuses with a maximum CVR >1.0 are a subgroup of patients who are at increased risk for respiratory morbidity and the need for surgical intervention. These patients should be delivered at a tertiary care center with pediatric surgery expertise to ensure optimal clinical outcomes.
Collapse
|
21
|
Rodríguez MR, de Vega VM, Alonso RC, Arranz JC, Ten PM, Pedregosa JP. MR Imaging of Thoracic Abnormalities in the Fetus. Radiographics 2012; 32:E305-21. [DOI: 10.1148/rg.327125053] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
22
|
van Mieghem T, Baud D, Devlieger R, Lewi L, Ryan G, De Catte L, Deprest J. Minimally invasive fetal therapy. Best Pract Res Clin Obstet Gynaecol 2012; 26:711-25. [DOI: 10.1016/j.bpobgyn.2012.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 03/21/2012] [Indexed: 12/31/2022]
|
23
|
Alamo L, Gudinchet F, Reinberg O, Vial Y, Francini K, Osterheld MC, Meuli R. Prenatal diagnosis of congenital lung malformations. Pediatr Radiol 2012; 42:273-83. [PMID: 22262133 DOI: 10.1007/s00247-011-2303-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Revised: 06/24/2011] [Accepted: 07/03/2011] [Indexed: 12/27/2022]
Abstract
Prenatal diagnosis of congenital lung anomalies has increased in recent years as imaging methods have benefitted from technical improvements. The purpose of this pictorial essay is to illustrate typical imaging findings of a wide spectrum of congenital lung anomalies on prenatal US and MRI. Moreover, we propose an algorithm based on imaging findings to facilitate the differential diagnosis, and suggest a follow-up algorithm during pregnancy and in the immediate postnatal period.
Collapse
Affiliation(s)
- Leonor Alamo
- Unit of Pediatric Radiology, Department of Diagnostic and Interventional Radiology, Centre Hospitaliere Universitaire Vaudois (CHUV), Rue du Bugnon, 46, 1011 Lausanne, Switzerland.
| | | | | | | | | | | | | |
Collapse
|
24
|
Loh KC, Jelin E, Hirose S, Feldstein V, Goldstein R, Lee H. Microcystic congenital pulmonary airway malformation with hydrops fetalis: steroids vs open fetal resection. J Pediatr Surg 2012; 47:36-9. [PMID: 22244389 DOI: 10.1016/j.jpedsurg.2011.10.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Accepted: 10/06/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Congenital pulmonary airway malformations (CPAM) are rare lesions often diagnosed during routine prenatal ultrasound. The presence of hydrops fetalis is an indicator of poor prognosis. Here we present a retrospective review of fetuses undergoing either open fetal surgery or steroids for predominantly microcystic CPAM with hydrops fetalis. METHOD A retrospective review of patients undergoing open fetal surgery or steroids for CPAM at our institution was performed. The primary outcome was survival. RESULTS A retrospective review of all patients referred to our institution with the diagnosis of CPAM was performed. Fetuses with predominantly microcystic CPAM and the presence of hydrops fetalis treated with steroid or surgery were included. Thirteen patients were treated with steroids, and 11 patients underwent open fetal surgery. In the steroid group 12 (92%) of 13 fetuses survived to delivery versus 9 (82%) of 11 in the open fetal surgery group. Only 5 (56%) of 9 of the patients in the open fetal surgery group survived to neonatal discharge compared to 10 (83%) of 12 in the steroid group. CONCLUSIONS In the present retrospective study, improved survival was seen in fetuses with hydrops fetalis and predominantly microcystic CPAM treated with steroids when compared with open fetal surgery. Steroids should be considered for first-line therapy in these cases.
Collapse
Affiliation(s)
- Kenneth C Loh
- Department of Surgery, University of California at San Francisco, San Francisco, CA 94143-0570, USA
| | | | | | | | | | | |
Collapse
|
25
|
Cass DL, Olutoye OO, Ayres NA, Moise KJ, Altman CA, Johnson A, Cassady CI, Lazar DA, Lee TC, Lantin MRL. Defining hydrops and indications for open fetal surgery for fetuses with lung masses and vascular tumors. J Pediatr Surg 2012; 47:40-5. [PMID: 22244390 DOI: 10.1016/j.jpedsurg.2011.10.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2011] [Accepted: 10/06/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to identify the most accurate prenatal predictors of outcomes and need for fetal surgery for fetuses with high-risk lung masses and vascular tumors. METHODS The records of all fetuses with high-risk lung mass (congenital cystic adenomatoid malformation-volume ratio > 1.6 or findings of hydrops) and vascular tumor evaluated between July 2001 and March 2011 were reviewed retrospectively. Hydrops was defined as accumulation of fluid in 2 or more compartments. RESULTS Of fetuses with high-risk lung mass, hydrops was identified in 46% (11/24). Fetuses with hydrops and an abnormal echocardiogram (n = 8) demonstrated poor survival without fetal surgery (13%) compared with 100% survival in fetuses with hydrops and a normal echocardiogram (n = 3; P = .02). Of 21 fetuses with vascular tumor (11 sacrococcygeal and 8 cervical teratomas; 2 hemangioendotheliomas), hydrops was identified in 29% and an abnormal echocardiogram in 57%. All fetuses with hydrops had an abnormal echocardiogram and either died (n = 5) or required fetal surgery (n = 1). However, all fetuses with abnormal echocardiograms alone (n = 7) survived without fetal intervention. CONCLUSIONS For fetuses with lung mass, an abnormal echocardiogram in the setting of hydrops is the best predictor of mortality and need for fetal surgery. For fetuses with vascular tumor, hydrops in the setting of high-output physiology best predicts demise and need for fetal surgery.
Collapse
Affiliation(s)
- Darrell L Cass
- Texas Children's Fetal Center and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Raychaudhuri P, Pasupati A, James A, Whitehead B, Kumar R. Prospective study of antenatally diagnosed congenital cystic adenomatoid malformations. Pediatr Surg Int 2011; 27:1159-64. [PMID: 21519839 DOI: 10.1007/s00383-011-2909-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2011] [Indexed: 12/23/2022]
Abstract
PURPOSE Congenital cystic adenomatoid malformations (CCAMs) are increasingly diagnosed in recent years due to the routine usage of antenatal ultrasound. The aim of this study was to present the natural course and outcome of antenatally diagnosed cystic lung diseases, which were prospectively studied. METHODS Between the period June 2004 and June 2010, 25 fetuses with suspected CCAMs were seen in a single tertiary maternal fetal unit. One child was excluded as the fetal MRI suggested congenital diaphragmatic hernia. Data were prospectively entered into a database including antenatal and postnatal findings which were then analyzed. RESULTS Mean gestational age at the time of diagnosis was 20.8 weeks (range 17-29). Fetal interventions included amnioreduction (n = 2) and fetal thoracocentesis (n = 3) in one child. The mean gestational age at delivery was 38.5 weeks (range 31.6-40.6). None of the mothers underwent termination of pregnancy or spontaneous abortion. All patients underwent postnatal radiological assessment. Of the 24 cases, 5 children were symptomatic in the immediate neonatal period and 19 were asymptomatic. Anatomical surgical resection was undertaken in all symptomatic cases. There was one death in this group due to severe pre-existing pulmonary hypoplasia. Among the 19 asymptomatic cases, 5 children were managed conservatively as the lesions were not significant and the remaining 14 (73%) underwent surgical resection. The mean age at surgery was 11.1 months (range 3.3-34 months). Postnatal pathology confirmed CCAM in all operated cases, except one who had pulmonary sequestration. CONCLUSION Antenatally diagnosed CCAMs have an excellent prognosis except in children with a large lesion and associated with lung hypoplasia. Postnatal investigations are required in all cases to confirm the diagnosis. Symptomatic CCAMs require immediate surgery in the neonatal period with a good outcome. Asymptomatic CCAMs can be safely operated between 9 and 12 months of age.
Collapse
Affiliation(s)
- P Raychaudhuri
- Department of Paediatric Surgery, John Hunter Children's Hospital, Hunter Region Mail Centre, Newcastle, NSW, Australia
| | | | | | | | | |
Collapse
|
27
|
Witlox RS, Lopriore E, Oepkes D, Walther FJ. Neonatal outcome after prenatal interventions for congenital lung lesions. Early Hum Dev 2011; 87:611-8. [PMID: 21798677 DOI: 10.1016/j.earlhumdev.2011.07.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 07/05/2011] [Indexed: 10/17/2022]
Abstract
Congenital lung lesions, mostly congenital cystic adenomatoid malformations (CCAMs) and bronchopulmonary sequestrations (BPSs), are uncommon disorders. Prenatal intervention in severely affected (hydropic) fetuses has drastically improved perinatal survival. Not much is known, however, on the short-term and long-term respiratory and neurodevelopmental outcome. Several small case series have been reported and suggest an increased incidence of neonatal morbidity, mainly associated with prematurity and respiratory failure at birth. Overall, neonatal mortality and morbidity after prenatal interventions for CCAM seems to be worse than for BPS. This review focuses on the neonatal outcome after prenatal intervention for congenital lung lesions and summarizes the results reported in the literature.
Collapse
Affiliation(s)
- Ruben S Witlox
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | | | | | | |
Collapse
|
28
|
Witlox RS, Lopriore E, Oepkes D. Prenatal interventions for fetal lung lesions. Prenat Diagn 2011; 31:628-36. [PMID: 21618254 DOI: 10.1002/pd.2778] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2011] [Revised: 04/20/2011] [Accepted: 04/20/2011] [Indexed: 11/08/2022]
Abstract
The widespread availability of high resolution ultrasound equipment and almost universal routine anatomy scanning in all pregnant women in the developed world has lead to increased detection of abnormalities in the fetal thorax. Already in the 1980s, large pleural effusions and significant macrocystic lesions in the fetus were easily detected on ultrasound. However, smaller lung tumours were often missed. Nowadays, fetal medicine centres receive many referrals for evaluation of fetal lung lesions, of which the most common are congenital cystic adenomatoid malformation and bronchopulmonary sequestration. Almost invariably, both the parents and the referring physicians experience anxiety after detection of large lung masses in the fetus. However, the vast majority of the currently detected fetal lung lesions have an excellent prognosis without the need for prenatal intervention. In the small group of fetuses in which the prognosis is poor, almost exclusively those with concomitant fetal hydrops and cardiac failure, several options for fetal therapy exist, often with a more than 50% survival rate. Indications, techniques, complications and outcomes of these interventions will be described in this review.
Collapse
Affiliation(s)
- Ruben S Witlox
- Department of Paediatrics, Division of Neonatology, Leiden University Medical Centre, Leiden, The Netherlands.
| | | | | |
Collapse
|
29
|
Dighe MK, Peterson SE, Dubinsky TJ, Perkins J, Cheng E. EXIT Procedure: Technique and Indications with Prenatal Imaging Parameters for Assessment of Airway Patency. Radiographics 2011; 31:511-26. [DOI: 10.1148/rg.312105108] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
30
|
Biyyam DR, Chapman T, Ferguson MR, Deutsch G, Dighe MK. Congenital Lung Abnormalities: Embryologic Features, Prenatal Diagnosis, and Postnatal Radiologic-Pathologic Correlation. Radiographics 2010; 30:1721-38. [PMID: 21071385 DOI: 10.1148/rg.306105508] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Deepa R Biyyam
- Department of Radiology, University of Washington Medical Center, Seattle, WA 98195, USA.
| | | | | | | | | |
Collapse
|
31
|
Fetal tumors: imaging features. Pediatr Radiol 2010; 40:1263-73; quiz 1321-2. [PMID: 20309537 DOI: 10.1007/s00247-010-1571-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Revised: 12/29/2009] [Accepted: 01/22/2010] [Indexed: 10/19/2022]
Abstract
Although fetal tumors are rare, the prognostic and decision-making implications are substantial. The purpose of this pictorial essay is to highlight the most common tumors encountered during fetal imaging and to discuss the respective typical imaging findings. When appropriate, limited additional information regarding further considerations for patient care will be included.
Collapse
|
32
|
Sepulveda W, Mena F, Ortega X. Successful percutaneous embolization of feeding vessels of a lung tumor in a hydropic fetus. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2010; 29:639-643. [PMID: 20375383 DOI: 10.7863/jum.2010.29.4.639] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Waldo Sepulveda
- Department of Obstetrics and Gynecology, Fetal Medicine Center, Clinica Las Condes, Santiago, Chile.
| | | | | |
Collapse
|
33
|
Curran PF, Jelin EB, Rand L, Hirose S, Feldstein VA, Goldstein RB, Lee H. Prenatal steroids for microcystic congenital cystic adenomatoid malformations. J Pediatr Surg 2010; 45:145-50. [PMID: 20105595 DOI: 10.1016/j.jpedsurg.2009.10.025] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2009] [Accepted: 10/06/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate the effect of prenatal steroid treatment in fetuses with sonographically diagnosed congenital cystic adenomatoid malformations (CCAMs). METHODS This was an institutional review board-approved retrospective review of 372 patients referred to the University of California, San Francisco (UCSF), for fetal CCAM. Inclusion criteria were (1) a predominately microcystic CCAM lesion sonographically diagnosed at our institution, (2) maternal administration of a single course of prenatal corticosteroids (betamethasone), and (3) no fetal surgery. CCAM volume-to-head ratio (CVR), presence of hydrops, mediastinal shift, and diaphragm eversion were assessed before and after administration of betamethasone. The primary end points were survival to birth and neonatal discharge. RESULTS Sixteen patients with predominantly microcystic CCAMs were treated with prenatal steroids. Three were excluded because of lack of follow-up information. All remaining fetuses (13/13) survived to delivery and 11/13 (84.6%) survived to neonatal discharge. At the time of steroid administration, all patients had CVR greater than 1.6, and 9 (69.2%) also had nonimmune hydrops fetalis. After a course of steroids, CVR decreased in 8 (61.5%) of the 13 patients, and hydrops resolved in 7 (77.8%) of the 9 patients with hydrops. The 2 patients whose hydrops did not resolve with steroid treatment did not survive to discharge. CONCLUSION In high-risk fetal patients with predominantly microcystic CCAM lesions, betamethasone is an effective treatment. This series is a pilot study for a prospective randomized trial comparing treatment of CCAM with betamethasone to placebo.
Collapse
Affiliation(s)
- Patrick F Curran
- The Fetal Treatment Center, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | | | | | | |
Collapse
|
34
|
Lecomte B, Hadden H, Coste K, Gallot D, Laurichesse H, Lemery D, Scheye T, Dechelotte P, Labbé A. Hyperechoic congenital lung lesions in a non-selected population: from prenatal detection till perinatal management. Prenat Diagn 2009; 29:1222-30. [DOI: 10.1002/pd.2407] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
35
|
Abstract
The antenatal finding of a congenital thoracic malformation (CTM) leads to anxiety in the parents and uncertainty as to the optimal management. The antenatal spectrum of CTM includes congenital cystic adenomatoid malformation, sequestration, congenital lobar emphysema, enteric and bronchogenic cysts, and bronchial atresia. Most lesions require no antenatal intervention, and shrink substantially in the third trimester, but if fetal hydrops develops, then antenatal intervention is required, occasionally medical but more usually surgical, because mortality is high. If the baby is symptomatic in the newborn period, then some form of surgical intervention is clearly required. The asymptomatic baby presents a therapeutic dilemma. Advocates of early surgery point to the complications of CTM, which include infection, pneumothorax, bleeding and malignant transformation. Those who are proponents of conservative management retort that some CTM disappear postnatally, and that the complication rate is unknown; many children appear never to need surgery. Furthermore, there is clearcut evidence that excision of a CTM does not totally eliminate the risk of a subsequent malignancy. It is clear that, both antenatally and postnatally, counselling of the family on a case by case basis is needed. The limitations of present evidence should be stressed. Different families will make different decisions about postnatal surgery in an asymptomatic baby. If surgery is performed, morbidity is low, particularly with a video-assisted thoracoscopic (VATS) procedure.
Collapse
Affiliation(s)
- Andrew Bush
- Imperial School of Medicine at National Heart and Lung Institute, UK.
| |
Collapse
|
36
|
Abstract
Congenital cystic adenomatoid malformation (CCAM) is a rare lung lesion that may be diagnosed antenatally by ultrasonography. It is believed to result from an arrest in lung development. The differential diagnosis of a mass in the fetal thorax includes CCAM, congenital diaphragmatic hernia, and pulmonary sequestration. This brief review discusses classifications of CCAM with images of each type, sonographic findings, factors that affect the prognosis, and important aspects of management once the diagnosis is made.
Collapse
Affiliation(s)
- Lisa Moore
- University of New Mexico, Albuquerque, New Mexico,
| | | |
Collapse
|
37
|
Cavoretto P, Molina F, Poggi S, Davenport M, Nicolaides KH. Prenatal diagnosis and outcome of echogenic fetal lung lesions. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2008; 32:769-783. [PMID: 18956429 DOI: 10.1002/uog.6218] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To describe the antenatal findings and outcome of fetuses with echogenic lung lesions. METHODS This was a retrospective study of the prenatal sonographic features, antenatal management and outcome of 193 fetuses with an echogenic lung lesion diagnosed at 18-35 weeks of gestation. There were nine cases of congenital high airway obstruction syndrome (CHAOS), 170 cases of cystic adenomatoid malformation (CAM) and 14 cases of pulmonary sequestration (PS). A literature search was also carried out to compare our data with those of previous series. RESULTS The prognosis in our series of fetuses with CHAOS was invariably poor, but the literature describes a handful of survivors after delivery by Cesarean section and ex-utero intrapartum therapy (EXIT). Of the cases in our series with PS and no pleural effusions, more than 95% survived; in half of these cases the lesion resolved antenatally and in the other half sequestrectomy was carried out postnatally. In cases with PS and pleural effusions, successful treatment was provided by the placement of thoracoamniotic shunts or occlusion of the feeding blood vessel by ultrasound-guided laser coagulation or injection of sclerosants. In cases with CAM and no hydrops, there was more than 95% survival and in up to half of the cases there was sonographic evidence of spontaneous antenatal resolution of the hyperechogenic lesion, which was confirmed by postnatal imaging in about 60% of the cases. Of the cases with CAM with hydrops managed expectantly, more than 95% died before or after birth. Of the cases with macrocystic CAM with hydrops, two-thirds survived after placement of a thoracoamniotic shunt. In cases with microcystic CAM with hydrops, there is some evidence that open fetal surgery with lobectomy could improve survival but such treatment is highly invasive for the mother. CONCLUSIONS CHAOS is a severe abnormality, whereas CAM and PS are associated with a good prognosis. In a high proportion of fetuses with hyperechogenic lung lesion, there is spontaneous antenatal resolution and the underlying pathology may be transient bronchial obstruction.
Collapse
Affiliation(s)
- P Cavoretto
- Department of Fetal Medicine, King's College Hospital, London, UK
| | | | | | | | | |
Collapse
|