1
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Gallagher LT, Lyttle BD, Dawson-Gore C, Vaughn AE, Breckenfelder C, Reynolds R, Zaretsky MV, Derderian SC. The Effect of Steroids on Prenatally Diagnosed Lung Lesions. J Pediatr Surg 2024; 59:969-974. [PMID: 38042733 DOI: 10.1016/j.jpedsurg.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/06/2023] [Accepted: 11/09/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Open fetal resection for large lung lesions has virtually been replaced by maternal steroid administration. Despite this paradigm shift, little is known about the effects steroids have on lung lesion growth in utero. METHODS A 10-year retrospective review of all prenatally diagnosed lung lesions cared for at our fetal care center was performed. We evaluated the effects of prenatal steroids on congenital pulmonary airway malformation (CPAM)-volume-ratio (CVR), distinguishing change in CVR among CPAMs, bronchopulmonary sequestrations (BPS), and bronchial atresias. We also correlated fetal ultrasound and MRI findings with pathology to determine the accuracy of prenatal diagnosis. RESULTS We evaluated 199 fetuses with a prenatal lung lesion. Fifty-four (27 %) were treated with prenatal steroids with a subsequent 21 % mean reduction in the CVR (2.1 ± 1.4 to 1.1 ± 0.4, p = 0.003). Fetuses with hydrops and mediastinal shift who were treated with steroids rarely had resolution of these radiographic findings. Postnatal pathology was available for 91/199 patients (45.7 %). The most common diagnosis was CPAM (42/91, 46 %), followed by BPS (30/91, 33 %), and bronchial atresia (14/91, 15 %). Fetuses who received steroids and had pathology consistent with CPAM were more likely to have a reduction in their CVR (p = 0.02). Fetal ultrasound correctly diagnosed the type of lung lesion in 75 % of cases and fetal MRI in 81 % of cases. CONCLUSIONS Prenatally diagnosed CPAMs are more likely to respond to maternal steroids than BPS or bronchial atresias. Knowing the diagnosis in utero could aid to steward steroid usage, however, fetal imagining modalities are not perfect in distinguishing subtype. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Lauren T Gallagher
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Bailey D Lyttle
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Alyssa E Vaughn
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Regina Reynolds
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael V Zaretsky
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, USA
| | - S Christopher Derderian
- Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, USA; Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.
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2
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Montgomery A, Peiffer S, Mehl S, Lee TC, Keswani SG, King A. Management and Outcomes of Patients With High-Risk (Congenital Lung Malformation Volume Ratio≥ 1.6) Congenital Lung Malformations. J Surg Res 2024; 295:559-566. [PMID: 38086256 DOI: 10.1016/j.jss.2023.11.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/23/2023] [Accepted: 11/16/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION Congenital lung malformations (CLMs) have a variable natural history. Larger lesions with CLM volume ratio (CVR) ≥ 1.6 are associated with hydrops and fetal mortality. The purpose of this study is to describe the management and outcomes of high-risk (CVR ≥ 1.6) CLM patients. METHODS A retrospective cohort study was performed for all fetuses evaluated between May 2015 and May 2022. Demographics, prenatal imaging factors, prenatal and postnatal treatment, and outcomes were collected. Descriptive statistics were used to compare the cohorts. RESULTS Of 149 fetal CLM patients referred to our fetal center, 21/149 (14%) had CVR ≥ 1.6. One CLM patient had intrauterine fetal demise, and 2 patients were lost to follow-up. Of the remaining 18 patients, 11/18 (67%) received maternal steroids. Seven out of 18 patients (39%) underwent resection at the time of delivery with 1/7 (14%) undergoing exutero intrapartum treatment (EXIT)-to-resection, 5/7 (71%) undergoing EXIT-to-exteriorization-to-resection, and 1/7 (14%) undergoing a coordinated delivery to resection; among those undergoing resection, there were 2 fatalities (28.5%). Seven out of 18 (39%) patients required urgent neonatal open lobectomies, and the remaining 4/18 (22%) patients underwent elective thoracoscopic lobectomies with no mortality. CONCLUSIONS The natural history and outcomes of severe CLM patients remain highly variable. The EXIT-to-exteriorization-to-resection procedure may be a safe and effective approach for a subset of CLM patients with persistent symptoms of mass effect and severe mediastinal shift due to the observed decreased operative time requiring placental support observed in our study.
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Affiliation(s)
- Ashley Montgomery
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sarah Peiffer
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Steven Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas.
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3
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Dhanju G, Goubran A, Kirkpatrick I, Wiebe S, Fogel J. Antenatal diagnosis of bronchopulmonary sequestration: A case report and review of the literature. Radiol Case Rep 2024; 19:604-613. [PMID: 38111561 PMCID: PMC10726340 DOI: 10.1016/j.radcr.2023.10.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 10/26/2023] [Indexed: 12/20/2023] Open
Abstract
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.
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Affiliation(s)
- Gurinder Dhanju
- University of Saskatchewan, SK, Canada
- St. Boniface Hospital, Winnipeg, MB, Canada
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4
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Ottomeyer M, Huddleston C, Berkovich RM, Brink DS, Koenig JM, Sobush KT. Early resection of a rare congenital pulmonary airway malformation causing severe progressive respiratory distress in a preterm neonate: a case report and review of the literature. BMC Pediatr 2023; 23:238. [PMID: 37173730 PMCID: PMC10182594 DOI: 10.1186/s12887-023-04049-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/29/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Congenital pulmonary airway malformations (CPAMs) are a heterogenous collection of congenital lung malformations, often diagnosed prenatally. The Stocker Type III CPAM is a rare CPAM sub-type, and, when large, may be associated with hydrops. Furthermore, reports of CPAM management which may include surgical resection in extreme preterm infants are limited. CASE PRESENTATION We report a case of a female neonate born at 28 weeks of gestation with severe respiratory distress and diffuse pulmonary opacification on the right concerning for a large congenital lung lesion. This lesion was not detected on routine antenatal imaging, and she did not have clinical findings of associated hydrops. Her respiratory status improved dramatically after surgical resection of a mass at 12 day of age. The mass was consistent pathologically with a Stocker Type III CPAM. Lung expansion showed subsequent improvement at 16 months of age. CONCLUSIONS Our case describes a preterm neonate with severe respiratory distress that was found postnatally to have a large, unilateral congenital lung lesion despite a normal prenatal ultrasound. Additionally, this lesion required excision early in life due to severity of respiratory compromise. This case highlights that rare congenital lung lesions, like this rare sub-type of CPAM, should remain a diagnostic consideration in neonates with severe respiratory distress. Early lung resection for CPAM in preterm infants is not well described and the favorable outcomes of this case help expand perspectives on potential management strategies.
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Affiliation(s)
- Megan Ottomeyer
- Department of Pediatrics, Division of Neonatology, Saint Louis University, St. Louis, MO, 63104, USA
| | - Charles Huddleston
- Department of Surgery, Division of Pediatric Cardiothoracic Surgery, Saint Louis University, St. Louis, MO, 63104, USA
| | - Rachel M Berkovich
- Department of Radiology, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO, 63104, USA
| | - David S Brink
- Department of Pathology, Division of Pediatric Pathology, Saint Louis University, St. Louis, MO, 63104, USA
| | - Joyce M Koenig
- Department of Pediatrics, Division of Neonatology, Saint Louis University, St. Louis, MO, 63104, USA
- Department of Molecular Microbiology & Immunology, Saint Louis University, St. Louis, MO, 63104, USA
| | - Kurtis T Sobush
- Department of Pediatrics, Division of Pediatric Pulmonary and Sleep Medicine, Saint Louis University, St. Louis, MO, 63104, USA.
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5
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Wilpers A, Lynn AY, Eichhorn B, Powne AB, Lagueux M, Batten J, Bahtiyar MO, Gross CP. Understanding Sociodemographic Disparities in Maternal-Fetal Surgery Study Participation. Fetal Diagn Ther 2022; 49:125-137. [PMID: 35272297 PMCID: PMC9117502 DOI: 10.1159/000523867] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/23/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Although maternal-fetal surgery to treat fetal anomalies such as spina bifida continues to grow more common, potential health disparities in the field remain relatively unexamined. To address this gap, we identified maternal-fetal surgery studies with the highest level of evidence and analyzed the reporting of participant sociodemographic characteristics and representation of racial and ethnic groups. METHODS We conducted a systematic review of the scientific literature using biomedical databases. We selected randomized control trials (RCTs) and cohort studies with comparison groups published in English from 1990 to May 5, 2020. We included studies from across the globe that examined the efficacy of fetal surgery for twin-twin transfusion syndrome (TTTS), obstructive uropathy, congenital diaphragmatic hernia (CDH), myelomeningocele (MMC), thoracic lesions, cardiac malformations, or sacrococcygeal teratoma. We determined the frequency of reporting of age, gravidity/parity, race, ethnicity, education level, language spoken, insurance, income level, and relationship status. We identified whether sociodemographic factors were used as inclusion or exclusion criteria. We calculated the racial and ethnic group representation for studies in the USA using the participation-to-prevalence ratio (PPR). RESULTS We included 112 studies (10 RCTs, 102 cohort) published from 1990-1999 (8%), 2000-2009 (30%), and 2010-2020 (62%). Most studies were conducted in the USA (47%) or Europe (38%). The median sample size was 58. TTTS was the most common disease group (37% of studies), followed by MMC (23%), and CDH (21%). The most frequently reported sociodemographic variables were maternal age (33%) and gravidity/parity (20%). Race and/or ethnicity was only reported in 12% of studies. Less than 10% of studies reported any other sociodemographic variables. Sociodemographic variables were used as exclusion criteria in 13% of studies. Among studies conducted in the USA, White persons were consistently overrepresented relative to their prevalence in the US disease populations (PPR 1.32-2.11), while Black or African-American, Hispanic or Latino, Asian, American-Indian or Alaska-Native, and Native-Hawaiian or other Pacific Islander persons were consistently underrepresented (PPR 0-0.60). CONCLUSIONS Sociodemographic reporting quality in maternal-fetal surgery studies is poor and inhibits examination of potential health disparities. Participants enrolled in studies in the USA do not adequately represent the racial and ethnic diversity of the population across disease groups.
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Affiliation(s)
- Abigail Wilpers
- National Clinician Scholars Program, Yale School of Medicine and Yale School of Nursing, New Haven, (CT), United States
- Fetal Care Center, Yale New Haven Hospital, New Haven, (CT), United States
- Fetal Therapy Nurse Network, United States
- Department of Obstetrics, Gynecology, & Reproductive Sciences, Yale School of Medicine, New Haven, (CT), United States
| | - Anna Y. Lynn
- Department of Biomedical Engineering, Yale School of Medicine, New Haven, (CT), United States
| | - Barbara Eichhorn
- Fetal Therapy Nurse Network, United States
- Fetal Diagnosis and Treatment Centers, UPMC Magee-Womens Hospital, Pittsburgh, (PA), United States
| | - Amy B. Powne
- Fetal Therapy Nurse Network, United States
- UC Davis Fetal Care and Treatment Center, Sacramento (CA), United States
| | - Megan Lagueux
- Fetal Therapy Nurse Network, United States
- Neonatal Intensive Care Unit, Children’s Hospital Colorado, Aurora (CO), United States
| | - Janene Batten
- Department of Research and Education Services, Yale University, New Haven, (CT), United States
| | - Mert Ozan Bahtiyar
- Department of Obstetrics, Gynecology, & Reproductive Sciences, Yale School of Medicine, New Haven, (CT), United States
| | - Cary P. Gross
- National Clinician Scholars Program, Yale School of Medicine and Yale School of Nursing, New Haven, (CT), United States
- Department of Internal Medicine, Yale School of Medicine, New Haven, (CT), United States
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Abstract
This article reviews the contemporary diagnosis and management of antenatally diagnosed congenital lung lesions. These anomalies, which include congenital pulmonary airway malformation (CPAM) (formerly congenital cystic adenomatoid malformation), bronchopulmonary sequestration (BPS), bronchogenic cyst, and congenital lobar emphysema (CLE), are relatively rare but are increasingly encountered by clinicians because of the improved resolution and enhanced sensitivity of fetal ultrasound. Serial assessment of these lesions throughout pregnancy remains the norm rather than the exception. Perinatal management strategies may differ based on initial size and growth patterns of these masses until delivery. Fetal magnetic resonance imaging and other diagnostic testing can sometimes be helpful in providing additional prognostic information. Over the last decade, maternal steroids have become standard of care in the management of larger lesions at risk for nonimmune hydrops. As a result, fetal surgical procedures, including open resection, thoracoamniotic shunting, and ex utero intrapartum treatment (EXIT), are less uncommonly performed. Decisions regarding whether delivery of these fetuses should occur in a tertiary care center with pediatric surgery coverage versus delivery at a local community hospital are now highly relevant in most prenatal counseling discussions with families. Large lung malformations may require urgent surgical removal in the early postnatal period because of respiratory distress. Other complications, such as recurrent pneumonia, pneumothorax, and cancer, are indications for postnatal lung resection on an elective basis. Many children are good candidates for minimally invasive (thoracoscopic) surgical approaches as an alternative to resection by thoracotomy. In the vast majority of cases, the overall prognosis remains excellent.
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Affiliation(s)
- Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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7
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Aziz KB, Jelin AC, Keiser AM, Schulkin J, Jelin EB. Obstetrician patterns of steroid administration for the prenatal management of congenital pulmonary airway malformations. J Neonatal Perinatal Med 2021; 14:213-222. [PMID: 33164951 DOI: 10.3233/npm-200526] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Congenital pulmonary airway malformation (CPAM) is the most common prenatally-diagnosed lung malformation. This lesion, classified as macrocystic or microcystic, can lead to significant fetal compromise. Management options include observation, maternal antenatal steroid administration, and fetal surgical intervention. Current evidence suggests that microcystic (but not macrocystic) lesions and those with a cyst volume ratio (CVR) >1.6 are responsive to steroid therapy. The objective of this study was to identify patterns of prenatal steroid administration for the management of CPAMs and to identify characteristics of CPAMs prompting steroid administration. METHODS An 18-question survey was distributed to obstetricians from the Pregnancy-Related Care Research Network (PRCRN) and the North American Fetal Therapy Network (NAFTNet), from January to April 2019, to capture antenatal steroid prescribing patterns. RESULTS Response rates were 28.3% (138/487) for PRCRN and 63.3% (19/30) for NAFTNet. Among PRCRN members, 16.8% administered prenatal steroids, with most (77.2%) doing so for both microcystic and macrocystic CPAMs; corresponding percentages for NAFTNet members were 90.9% and 52.6%. Two thirds (65.6%) of obstetricians who administer steroids do so for a CVR > 1.6, without evidence of mediastinal shift or hydrops fetalis. CONCLUSIONS There is a lack of consensus among obstetricians as to the CPAM characteristics that should prompt administration of prenatal steroids. Many surveyed obstetricians do not use cyst type or CVR to guide decision-making regarding steroid therapy.
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Affiliation(s)
- Khyzer B Aziz
- Division of Neonatology, Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Angie C Jelin
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.,Institute of Genomic Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Amaris M Keiser
- Division of Neonatology, Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Jay Schulkin
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Eric B Jelin
- Department of Pediatric Surgery, Johns Hopkins Children's Center, Baltimore, MD, USA
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8
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Gilad N, Furman Y, Weissmann-Brenner A. A retrospective clinical analysis of 20 cases of congenital lung masses. J Matern Fetal Neonatal Med 2020; 35:3640-3645. [PMID: 33108914 DOI: 10.1080/14767058.2020.1836149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Congenital-pulmonary-airway-malformation (CPAM) and bronchopulmonary-sequestration (BPS) are rare conditions. The objective of this study was to describe the sonographic characteristics and prenatal course of fetal lung mass. METHODS A retrospective study on 20 pregnancies with CPAM and BPS diagnosed during 2018-2018 was performed. Data evaluated included gestational age (GA) at diagnosis, size of lesion, CPAM-volume-ratio (CVR), associated sonographic findings and pregnancy outcome. RESULTS Fourteen cases of CPAM and six cases of BPS were evaluated. The average GA at diagnosis was 22 weeks'-gestation (range 17-26). 66% were macrocystic-multicystic. Five cases of BPS (71.4%) had other structural anomalies. None of the fetuses with CPAM had additional anomalies. Four pregnancies (20%) underwent termination due to severe hydrops fetalis. Two cases of CPAM (15%) had spontaneous resolution by 30 week's-gestation; three cases (20%) continued to grow during pregnancy and all the rest reached their largest size at 25-28 week's-gestation. Most cases delivered at term (average 37.6 range 32.2-41.4). Two children had lobectomy at 11 and 12 months of life. CONCLUSIONS Careful follow-up during pregnancy may result in term delivery of adequate-for-gestational-age newborns, with no need for admission to the NICU, with only 10% need for lobectomy during the first year of life.
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Affiliation(s)
- Noa Gilad
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Furman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alina Weissmann-Brenner
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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9
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Valenzuela I, van der Merwe J, De Catte L, Devlieger R, Deprest J, Lewi L. Foetal therapies and their influence on preterm birth. Semin Immunopathol 2020; 42:501-514. [PMID: 32785752 DOI: 10.1007/s00281-020-00811-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
Foetal therapy aims to improve perinatal survival or to prevent severe long-term handicap. Foetal medicine opens a new territory by treating the foetus as a patient. The mother has nothing to gain in terms of health benefits, yet she is inherently also undergoing treatment. In utero foetal interventions can be divided into ultrasound-guided minimally invasive procedures, fetoscopic procedures and open hysterotomy procedures, which carry an inherent risk of ruptured membranes and preterm birth. In this review, we summarise the conditions that may benefit from foetal therapy and review the current therapies on offer, each with their associated risk of ruptured membrane and preterm birth. We also look into some risk limiting and preventative strategies to mitigate these complications.
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Affiliation(s)
- Ignacio Valenzuela
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Roland Devlieger
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, United Kingdom
| | - Liesbeth Lewi
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven University of Leuven, Leuven, Belgium. .,Department of Obstetrics and Gynaecology, Division Woman and Child, University Hospitals Leuven, Leuven, Belgium.
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10
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Kunisaki SM, Leys CM. Surgical Pulmonary and Pleural Diseases in Children: Lung Malformations, Empyema, and Spontaneous Pneumothorax. Adv Pediatr 2020; 67:145-169. [PMID: 32591058 DOI: 10.1016/j.yapd.2020.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Shaun M Kunisaki
- Division of General Pediatric Surgery, Johns Hopkins Children's Center, Johns Hopkins University, Johns Hopkins University School of Medicine, 1800 Orleans Street, Suite 7353, Baltimore, MD 21287, USA.
| | - Charles M Leys
- Division of Pediatric Surgery, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, 600 Highland Avenue, H4/740 CSC, Madison, WI 53792-7375, USA
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11
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Phillips J, Blask A, DiPoto Brahmbhatt A, Lawrence A, Timofeev J, Badillo A, Andescavage N. Fetal lung interstitial tumor: Prenatal presentation of a rare fetal malignancy. J Neonatal Perinatal Med 2020; 12:473-477. [PMID: 31256075 DOI: 10.3233/npm-180059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Fetal lung interstitial tumor (FLIT) is a rare fetal malignancy that is typically diagnosed in the postnatal period, or, if recognized prenatally can mimic a benign lesion such as congenital pulmonary airway malformation. We present the earliest case of a FLIT tumor described by ultrasound and MRI at 26 weeks of gestation. Our case highlights features suggestive of FLIT including presentation later in gestation in combination with findings on fetal MRI such as a solid appearance with radiating curved bands of high signal within and along the periphery of the lesion (not as intensely high signal as the typical CPAM), possibly detailing a radiographic signature for these tumors. The role of betamethasone for these tumors is not known.
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Affiliation(s)
- J Phillips
- Department of Obstetrics and Gynecology, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - A Blask
- Division of Diagnostic Imaging and Radiology, Children's National Health System, Washington, DC, USA.,Fetal Medicine Institute, Children's National Health System, Washington, DC, USA
| | - A DiPoto Brahmbhatt
- Division of Pathology and Laboratory Sciences, Children's National Health System, Washington, DC, USA
| | - A Lawrence
- Fetal Medicine Institute, Children's National Health System, Washington, DC, USA
| | - J Timofeev
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - A Badillo
- Fetal Medicine Institute, Children's National Health System, Washington, DC, USA.,Department Division of Pediatric Surgery, Children's National Health System, Washington, DC, USA
| | - N Andescavage
- Fetal Medicine Institute, Children's National Health System, Washington, DC, USA.,Department of Neonatology, Children's National Health System, Washington, DC, USA
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12
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Jelin AC, Sobreira N, Wohler E, Solomon B, Sparks T, Sagaser KG, Forster KR, Miller J, Witmer PD, Hamosh A, Valle D, Blakemore K. The utility of exome sequencing for fetal pleural effusions. Prenat Diagn 2020; 40:590-595. [PMID: 31994743 DOI: 10.1002/pd.5650] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/06/2020] [Accepted: 01/07/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE We sought to evaluate the performance of exome sequencing (ES) in determining an underlying genetic etiology for cases of fetal pleural effusions. STUDY DESIGN We examined a prospective cohort series of fetal pleural effusions visualized sonographically between 1 April 2016 and 31 August 2017. Fetal pleural effusions attributed to twin sharing, anemia, or structural anomalies were excluded, as were all cases with a genetic diagnosis established by karyotype or chromosomal microarray analysis. The remaining cases with pleural effusions of unclear etiology were offered ES. ES was performed by clinical sequencing and/or sequencing under the Baylor-Hopkins Center for Mendelian Genomics' (BHCMG) research platform. All cases were evaluated for novel genes or phenotypic expansion of disease-causing genes. RESULTS ES was performed on six probands affected by pleural effusions. A pathogenic variant was identified in one case (16.7%). Four additional cases had variants of uncertain significance (VUS) in candidate genes of pathological interest. Neither clinical nor candidate genes were evident in the final case. CONCLUSION ES should be considered in the evaluation of prenatally detected idiopathic pleural effusions when other diagnostic workup for a genetic etiology has failed.
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Affiliation(s)
- Angie C Jelin
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nara Sobreira
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - Elizabeth Wohler
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | | | - Teresa Sparks
- Department of Obstetrics, Gynecology & Reproductive Sciences, Division of Maternal Fetal Medicine, University of California, San Francisco, CA, USA
| | - Katelynn G Sagaser
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Katherine R Forster
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jena Miller
- Department of Gynecology and Obstetrics, Center for Fetal Therapy, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - P Dane Witmer
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - Ada Hamosh
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - David Valle
- McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA.,Baylor-Hopkins Center for Mendelian Genomics, Baltimore, MD, USA
| | - Karin Blakemore
- Department of Gynecology and Obstetrics, Division of Maternal Fetal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.,McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University, Baltimore, MD, USA
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13
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Kane SC, Ancona E, Reidy KL, Palma-Dias R. The Utility of the Congenital Pulmonary Airway Malformation-Volume Ratio in the Assessment of Fetal Echogenic Lung Lesions: A Systematic Review. Fetal Diagn Ther 2019; 47:171-181. [PMID: 31593968 DOI: 10.1159/000502841] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 08/21/2019] [Indexed: 11/19/2022]
Abstract
Although relatively uncommon, the incidence of fetal echogenic lung lesions - a heterogeneous group of anomalies that includes congenital pulmonary airway malformations (CPAM) and bronchopulmonary sequestrations (BPS) - has increased recently. Two decades ago, the CPAM-volume ratio (CVR) was first described as a tool to predict the development of hydrops, with this outcome found to be unlikely in fetuses with CVRs of ≤1.6 cm2. Since then, no clear international consensus has evolved as to the optimal CVR thresholds for the prediction of fetal/neonatal outcomes. This systematic review aimed to assess all original research studies that reported on the predictive utility of the CVR. Potentially relevant papers were identified through searching for citations of the paper that originally described the CVR, in addition to keyword searches of electronic databases. Fifty-two original research papers were included in the final review. Of these, 34 used the CVR for descriptive purposes only, 5 assessed the validity of established thresholds in different populations, and 13 proposed new thresholds. The evidence identified in this review would suggest that a threshold much lower than 1.6 cm2 is likely to be of greater utility in most populations for many outcomes of perinatal relevance. For neonatal outcomes (mostly respiratory compromise at birth), a CVR on the initial ultrasound scan ranging from 0.5 to 1.0 cm2 appears to have the greatest predictive value. Although a number of studies concurred that 1.6 cm2 was a useful threshold for the prediction of hydrops, many others were unable to assess this due to the rarity of this complication. For this reason, thresholds as low as 0.4 cm2 may be more useful for the prediction of a broader range of fetal concerns, including mediastinal shift and fluid collections. Further large-scale studies are required to determine the true utility of this well-established index.
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Affiliation(s)
- Stefan C Kane
- Pregnancy Research Centre, Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia, .,Ultrasound Services, Pauline Gandel Women's Imaging Centre, The Royal Women's Hospital, Parkville, Victoria, Australia, .,The University of Melbourne, Department of Obstetrics and Gynaecology, Parkville, Victoria, Australia,
| | - Emanuele Ancona
- Pregnancy Research Centre, Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia.,Ultrasound Services, Pauline Gandel Women's Imaging Centre, The Royal Women's Hospital, Parkville, Victoria, Australia.,Obstetrics and Gynaecology Unit, Department of Women's and Children's Health, The University of Padua, Padua, Italy
| | - Karen L Reidy
- Pregnancy Research Centre, Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia.,Ultrasound Services, Pauline Gandel Women's Imaging Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Ricardo Palma-Dias
- Pregnancy Research Centre, Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, Victoria, Australia.,Ultrasound Services, Pauline Gandel Women's Imaging Centre, The Royal Women's Hospital, Parkville, Victoria, Australia.,The University of Melbourne, Department of Obstetrics and Gynaecology, Parkville, Victoria, Australia
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14
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Abstract
Diagnosis and management of congenital lung malformations has evolved dramatically over the past several decades. Advancement in imaging technology has enabled earlier, more definitive diagnoses and, consequently, more timely intervention in utero or after birth, when indicated. These advancements have increased overall survival rates to around 95% from historical rates of 60%. However, further refinement of diagnostic technique and standardization of treatment is needed, particularly as the increased sensitivity of diagnostic imaging results in more frequent diagnoses. In this article, we provide an updated review of the diagnostic strategies, management, and prognosis of congenital lung malformations.
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Affiliation(s)
- Michael Zobel
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco
| | - Rebecca Gologorsky
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco
| | - Hanmin Lee
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco
| | - Lan Vu
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco.
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15
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Annunziata F, Bush A, Borgia F, Raimondi F, Montella S, Poeta M, Borrelli M, Santamaria F. Congenital Lung Malformations: Unresolved Issues and Unanswered Questions. Front Pediatr 2019; 7:239. [PMID: 31249823 PMCID: PMC6584787 DOI: 10.3389/fped.2019.00239] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/28/2019] [Indexed: 12/30/2022] Open
Abstract
Advances in prenatal and postnatal diagnosis, perioperative management, and postoperative care have dramatically increased the number of scientific reports on congenital thoracic malformations (CTM). Nearly all CTM are detected prior to birth, generally by antenatal ultrasound. After delivery, most infants do well and remain asymptomatic for a long time. However, complications may occur beyond infancy, including in adolescence and adulthood. Prenatal diagnosis is sometimes missed and detection may occur later, either by chance or because of unexplained recurrent or persistent respiratory symptoms or signs, with difficult implications for family counseling and substantial delay in surgical planning. Although landmark studies have been published, postnatal management of asymptomatic children is still controversial and needs a resolution. Our aim is to provide a focused overview on a number of unresolved issues arising from the lack of an evidence-based consensus on the management of patients with CTM. We summarized findings from current literature, with a particular emphasis on the vigorous controversies on the type and timing of diagnostic procedures, treatments and the still obscure relationship between CTM and malignancies, a matter of great concern for both families and physicians. We also present an algorithm for the assessment and follow-up of CTM detected either in the antenatal or postnatal period. A standardized approach across Europe, based on a multidisciplinary team, is urgently needed for achieving an evidence-based management protocol for CTM.
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Affiliation(s)
- Federica Annunziata
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Andrew Bush
- Department of Paediatrics and Paediatric Respiratory Medicine, Imperial College and Royal Brompton Hospital, London, United Kingdom
| | - Francesco Borgia
- Divisions of Cardiology and Cardiothoracic Surgery, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Francesco Raimondi
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Silvia Montella
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Marco Poeta
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Melissa Borrelli
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - Francesca Santamaria
- Division of Paediatrics, Department of Translational Medical Sciences, Federico II University, Naples, Italy
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16
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Chon AH, Stein JE, Gerstenfeld T, Wang L, Vazquez WD, Chmait RH. The Use of Fetal Bronchoscopy in the Diagnosis and Management of a Suspected Obstructive Lung Mass. AJP Rep 2018; 8:e195-e200. [PMID: 30258699 PMCID: PMC6156116 DOI: 10.1055/s-0038-1673378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 08/21/2018] [Indexed: 02/05/2023] Open
Abstract
Etiologies of fetal lung anomalies include congenital pulmonary airway malformation (CPAM), intra- or extralobar pulmonary sequestration, congenital high airway obstruction syndrome (CHAOS), bronchogenic cyst, and bronchial atresia. Fetal tracheobronchoscopy has been reported both as a diagnostic and therapeutic procedure in the setting of severe congenital lung lesions. In this case report, prenatal imaging of a fetus with a large chest mass was suspicious for an obstructive bronchial lesion. The absence of visible normal lung tissue on the right side and mass effect on the left side raised the concern for pulmonary hypoplasia. After antenatal betamethasone and a period observation, hydropic changes developed. Fetal tracheobronchoscopy was then performed in an effort to identify and decompress the suspected obstructive bronchial lesion. Other than release of bronchial debris, no anatomical abnormalities were visualized. However, the right lung lesion and mediastinal shift both decreased after the fetal bronchoscopy. The newborn underwent postnatal resection of a CPAM Type II and is doing well. We hypothesize that fetal tracheobronchoscopy provided the following potential diagnostic and therapeutic benefits: (1) exclusion of an obstructive bronchial lesion; (2) disimpaction of bronchial debris from the saline lavage that we posit may have contributed to the rapid reduction in CPAM size.
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Affiliation(s)
- Andrew H Chon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - James E Stein
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Tammy Gerstenfeld
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Kaiser Permanente San Diego, San Diego, California
| | - Larry Wang
- Department of Pathology and Laboratory Medicine, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, California
| | - Walter D Vazquez
- Department of General Surgery, Kaiser Permanente San Diego, San Diego, California
| | - Ramen H Chmait
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California
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17
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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.
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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
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18
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H Chon A, Takeda MR, Felix JC, Chmait RH. A Complication of Percutaneous Sclerotherapy for Congenital Pulmonary Airway Malformation: Intravascular Injection and Cardiac Necrosis. Fetal Pediatr Pathol 2017; 36:437-444. [PMID: 29206544 DOI: 10.1080/15513815.2017.1346017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION A congenital pulmonary airway malformation (CPAM) type III may become large enough to cause hydrops fetalis. In such circumstances, the fetus can be treated with open fetal resection, maternal betamethasone administration, or percutaneous sclerotherapy. CASE REPORT A 24 week gestation fetus with a CPAM type III was treated by percutaneous sclerotherapy using ethanolamine oleate (EO). The EO inadvertently entered the left atrium and ventricle with subsequent fetal bradycardia and demise. Autopsy revealed myocardial necrosis. CONCLUSION Percutaneous sclerotherapy has been previously described in the literature for the treatment of microcystic CPAMs with secondary hydrops. This is the first reported case of an adverse event after fetal sclerotherapy.
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Affiliation(s)
- Andrew H Chon
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , University of Southern California , Los Angeles , CA , USA
| | - Moe R Takeda
- b Department of Pathology , University of Southern California , Los Angeles , CA , USA
| | - Juan C Felix
- b Department of Pathology , University of Southern California , Los Angeles , CA , USA
| | - Ramen H Chmait
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , University of Southern California , Los Angeles , CA , USA
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19
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Leblanc C, Baron M, Desselas E, Phan MH, Rybak A, Thouvenin G, Lauby C, Irtan S. Congenital pulmonary airway malformations: state-of-the-art review for pediatrician's use. Eur J Pediatr 2017; 176:1559-1571. [PMID: 29046943 DOI: 10.1007/s00431-017-3032-7] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/30/2017] [Accepted: 10/04/2017] [Indexed: 02/06/2023]
Abstract
UNLABELLED Congenital pulmonary airway malformations or CPAM are rare developmental lung malformations, leading to cystic and/or adenomatous pulmonary areas. Nowadays, CPAM are diagnosed prenatally, improving the prenatal and immediate postnatal care and ultimately the knowledge on CPAM pathophysiology. CPAM natural evolution can lead to infections or malignancies, whose exact prevalence is still difficult to assess. The aim of this "state-of-the-art" review is to cover the recently published literature on CPAM management whether the pulmonary lesion was detected during pregnancy or after birth, the current indications of surgery or surveillance and finally its potential evolution to pleuro-pulmonary blastoma. CONCLUSION Surgery remains the cornerstone treatment of symptomatic lesions but the postnatal management of asymptomatic CPAM remains controversial. There are pros and cons of surgical resection, as increasing rate of infections over time renders the surgery more difficult after months or years of evolution, as well as risk of malignancy, though exact incidence is still unknown. What is known: • Congenital pulmonary airway malformations (CPAM) are rare developmental lung malformations mainly antenatally diagnosed. • While the neonatal management of symptomatic CPAM is clear and includes prompt surgery, controversies remain for asymptomatic CPAM due to risk of infections and malignancies. What is new: • Increased rate of infection over time renders the surgery more difficult after months or years of evolution and pushes for recommendation of early elective surgery. • New molecular or pathological pathways may help in the distinction of type 4 CPAM from type I pleuropulmonary blastoma.
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Affiliation(s)
- Claire Leblanc
- Department of Pediatric Pulmonology, APHP Hôpital Armand Trousseau, Paris, France
| | - Marguerite Baron
- Department of Pediatric Pulmonology, APHP Hôpital Armand Trousseau, Paris, France
| | - Emilie Desselas
- Department of Pediatric Pulmonology, APHP Hôpital Armand Trousseau, Paris, France
| | - Minh Hanh Phan
- Department of Pediatric Pulmonology, APHP Hôpital Armand Trousseau, Paris, France
| | - Alexis Rybak
- Department of Pediatric Pulmonology, APHP Hôpital Armand Trousseau, Paris, France
| | - Guillaume Thouvenin
- Department of Pediatric Pulmonology, APHP Hôpital Armand Trousseau, Paris, France.,UPMC Univ Paris 06, Centre de Recherche St Antoine Inserm UMRS.938, Sorbonne Universités, Paris, France
| | - Clara Lauby
- Department of Pediatric Pulmonology, APHP Hôpital Armand Trousseau, Paris, France
| | - Sabine Irtan
- UPMC Univ Paris 06, Centre de Recherche St Antoine Inserm UMRS.938, Sorbonne Universités, Paris, France. .,Department of Pediatric Surgery, APHP Hôpital Armand Trousseau, 26 avenue du Dr Arnold Netter, 75012, Paris, France.
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20
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Abstract
Congenital lung lesions (CLLs) comprise a heterogeneous group of developmental and histologic entities often diagnosed on screening prenatal ultrasound. Most fetuses with CLL are asymptomatic at birth; however, the risk of malignancy and infection drives the decision to prophylactically resect these lesions. The authors describe their approach to minimally invasive lobectomy in children with CLLs, postoperative care, and management of procedure-specific complications.
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Affiliation(s)
- Jarrett Moyer
- Department of Surgery, University of CA - San Francisco, 513 Parnassus Avenue, S-321, San Francisco, CA 94143, USA.
| | - Hanmin Lee
- Professor of Surgery, Division of Pediatric Surgery, Dept of Surgery, Universty of CA - San Francisco, San Francisco, CA
| | - Lan Vu
- Assistant Professor of Surgery, Division of Pediatric Surgery, Dept of Surgery, University of CA - San Francisco, San Francisco, CA
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21
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Treatment of congenital pulmonary airway malformations: a systematic review from the APSA outcomes and evidence based practice committee. Pediatr Surg Int 2017; 33:939-953. [PMID: 28589256 DOI: 10.1007/s00383-017-4098-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2017] [Indexed: 01/15/2023]
Abstract
PURPOSE Variation in management characterizes treatment of infants with a congenital pulmonary airway malformation (CPAM). This review addresses six clinically applicable questions using available evidence to provide recommendations for the treatment of these patients. METHODS Questions regarding the management of a pediatric patient with a CPAM were generated. English language articles published between 1960 and 2014 were compiled after searching Medline and OvidSP. The articles were divided by subject area and by the question asked, then reviewed and included if they specifically addressed the proposed question. RESULTS 1040 articles were identified on initial search. After screening abstracts per eligibility criteria, 130 articles were used to answer the proposed questions. Based on the available literature, resection of an asymptomatic CPAM is controversial, and when performed is usually completed within the first six months of life. Lobectomy remains the standard resection method for CPAM, and can be performed thoracoscopically or via thoracotomy. There is no consensus regarding a monitoring protocol for observing asymptomatic lesions, although at least one chest computerized tomogram (CT) should be performed postnatally for lesion characterization. An antenatally identified CPAM can be evaluated with MRI if fetal intervention is being considered, but is not required for the fetus with a lesion not at risk for hydrops. Prenatal consultation should be offered for infants with CPAM and encouraged for those infants in whom characteristics indicate risk of hydrops. CONCLUSIONS Very few articles provided definitive recommendations for care of the patient with a CPAM and none reported Level I or II evidence. Based on available information, CPAMs are usually resected early in life if at all. A prenatally diagnosed congenital lung lesion should be evaluated postnatally with CT, and prenatal counseling should be undertaken in patients at risk for hydrops.
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22
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Abstract
Therapeutic fetal surgical procedures are predicated upon the ability to make an accurate fetal diagnosis. The earliest open fetal surgical procedures were introduced in the 1960s to treat Rh isoimmunisation. They were introduced when it became possible to predict impending fetal demise. Open procedures were abandoned when percutaneous approaches proved superior. The introduction of fetal ultrasound allowed the diagnosis of other congenital anomalies, some being amenable to fetal interventions. Open fetal surgical procedures were initially utilised, with significant maternal morbidity. For some anomalies, percutaneous approaches became favoured. In general, all of these procedures involved significant risks to the mother, to save a baby that was likely to die before or shortly after birth without fetal intervention. Fetal repair for myelomeningocele was a "sea change" in approach. The same maternal risks were taken to improve the quality of life of the affected fetus, not save its life. The completion of the "MOMs Trial" has occasioned a "tsunami" of centres in North America applying this approach. Others are attempting percutaneous repairs, with mixed results. This paper reviews the history of fetal surgery, focusing on the themes of the tension between accurate diagnosis and prognosis and open versus "minimally invasive" approaches.
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Affiliation(s)
- H Kitagawa
- Pediatric Surgery, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 216-8511, Japan.
| | - K C Pringle
- Paediatric Surgery, Department of Obstetrics and Gynaecology, University of Otago, Wellington, P.O. Box 7343, Wellington South, 6242, Wellington, New Zealand
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23
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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.
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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
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24
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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.
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Affiliation(s)
- Mafalda David
- Pediatric Surgery Department, Centro Hospitalar Sx00E3;o Jox00E3;o, Porto, Portugal
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25
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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
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26
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Takei K, Morikawa M, Cho K, Minakami H. Resolution of tachyarrhythmia-related fetal hydrops after corticosteroid administration for fetal lung maturation. BMJ Case Rep 2015; 2015:bcr-2015-211948. [PMID: 26531736 DOI: 10.1136/bcr-2015-211948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A case of hydrops fetalis (HF) that resolved after corticosteroid therapy despite persisting fetal tachycardia of 190 bpm is reported. The fetus with confirmed normal karyotype had HF in the presence of atrial flutter and sustained ventricular rate of 200-210 bpm at gestational week (GW) 31(-6/7). Aetiologies of HF other than fetal tachyarrhythmia were unlikely in this infant. The patient's family declined pharmacological treatment with maternal digoxin and desired to continue pregnancy with only intensive monitoring of fetal condition. Maternal transplacental β-methasone was given to facilitate fetal lung maturation. The fetal tachyarrhythmia ameliorated to 190 bpm at GW 32(-5/7) and HF gradually disappeared by birth. The otherwise healthy female neonate weighing 3050 g born at GW 37(-0/7) was successfully treated with cardioversion performed 60 min after birth. This case suggested that corticosteroid therapy contributed to the resolution of HF associated with tachyarrhythmia.
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Affiliation(s)
- Kohta Takei
- Maternity and Perinatal Care Center, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Mamoru Morikawa
- Maternity and Perinatal Care Center, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kazutoshi Cho
- Maternity and Perinatal Care Center, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hisanori Minakami
- Maternity and Perinatal Care Center, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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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.
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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.
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28
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Desseauve D, Dugué-Marechaud M, Maurin S, Gatibelza MÈ, Vequeau-Goua V, Mergy-Laurent M, Levard G, Pierre F. Performance du diagnostic anténatal et évolution postnatale des malformations pulmonaires congénitales. ACTA ACUST UNITED AC 2015; 43:278-83. [DOI: 10.1016/j.gyobfe.2015.02.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 02/05/2015] [Indexed: 10/23/2022]
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Norton ME, Chauhan SP, Dashe JS, Dashe JS. Society for maternal-fetal medicine (SMFM) clinical guideline #7: nonimmune hydrops fetalis. Am J Obstet Gynecol 2015; 212:127-39. [PMID: 25557883 DOI: 10.1016/j.ajog.2014.12.018] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 12/12/2014] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Nonimmune hydrops is the presence of ≥2 abnormal fetal fluid collections in the absence of red cell alloimmunization. The most common etiologies include cardiovascular, chromosomal, and hematologic abnormalities, followed by structural fetal anomalies, complications of monochorionic twinning, infection, and placental abnormalities. We sought to provide evidence-based guidelines for the evaluation and management of nonimmune hydrops fetalis. METHODS A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and Cochrane Library. The search was restricted to English-language articles published from 1966 through June 2014. Priority was given to articles reporting original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Evidence reports and guidelines published by organizations or institutions such as the National Institutes of Health, Agency for Health Research and Quality, American Congress of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Grading of Recommendations Assessment, Development, and Evaluation methodology was employed for defining strength of recommendations and rating quality of evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence. RESULTS AND RECOMMENDATIONS Evaluation of hydrops begins with an antibody screen (indirect Coombs test) to determine if it is nonimmune, detailed sonography of the fetus(es) and placenta, including echocardiography and assessment for fetal arrhythmia, and middle cerebral artery Doppler evaluation for anemia, as well as fetal karyotype and/or chromosomal microarray analysis, regardless of whether a structural fetal anomaly is identified. Recommended treatment depends on the underlying etiology and gestational age; preterm delivery is recommended only for obstetric indications including development of mirror syndrome. Candidates for corticosteroids and antepartum surveillance include those with an idiopathic etiology, an etiology amenable to prenatal or postnatal treatment, and those in whom intervention is planned if fetal deterioration occurs. Such pregnancies should be delivered at a facility with the capability to stabilize and treat critically ill newborns. The prognosis depends on etiology, response to therapy if treatable, and the gestational age at detection and delivery. Aneuploidy confers a poor prognosis, and even in the absence of aneuploidy, neonatal survival is often <50%. Mirror syndrome is a form of severe preeclampsia that may develop in association with fetal hydrops and in most cases necessitates delivery.
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Affiliation(s)
| | | | | | - Jodi S Dashe
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
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30
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Mallmann MR, Geipel A, Bludau M, Matil K, Gottschalk I, Hoopmann M, Müller A, Bachour H, Heydweiller A, Gembruch U, Berg C. Bronchopulmonary sequestration with massive pleural effusion: pleuroamniotic shunting vs intrafetal vascular laser ablation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:441-446. [PMID: 24407869 DOI: 10.1002/uog.13304] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/29/2013] [Accepted: 12/31/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To assess the incidence of complications among a relatively large cohort of fetuses with bronchopulmonary sequestration (BPS) and the success of two different intrauterine treatment modalities. METHODS All cases with a prenatal diagnosis of BPS detected in a 10-year period (2002-2011) in two tertiary referral centers were reviewed retrospectively for intrauterine course and outcome. Up to May 2010 severe pleural effusions were treated with pleuroamniotic shunting. Thereafter, they were treated with ultrasound-guided laser coagulation of the feeding artery. RESULTS A total of 41 fetuses with BPS were included in the study. In 29 (70.7%) there was no pleural effusion or hydrops and they were treated conservatively. In 19/29 (65.5%) there was partial or complete regression of the lesion during the course of pregnancy. All were born alive (median age at delivery, 38.3 (interquartile range (IQR), 34.0-39.6) weeks) and 16 (55.2%) required sequestrectomy. Intrauterine intervention was performed in all 12 (29.3%) fetuses with pleural effusion. Seven fetuses were treated with pleuroamniotic shunting. One fetus with severe hydrops died in utero. There was no complete regression in any case of BPS in this group. Six infants were born alive (median age, 37.2 (IQR, 30.3-37.4) weeks), of which five (83.3%) required sequestrectomy. Five fetuses were treated with laser ablation of the feeding vessel. In all cases of BPS there was regression after laser ablation. All infants were delivered at term (median age, 39.1 (IQR, 38.0-40.0) weeks). One (20.0%) neonate required sequestrectomy after birth. Following intrauterine shunt placement complete regression of the lesion was significantly less frequent (0/7 (0%) with shunt placement vs 4/5 (80%) with intrafetal laser treatment) and gestational age at birth was significantly lower, compared to treatment with intrafetal laser. Complete regression of the lesion was also significantly more frequent in the laser group compared to cases without intervention. CONCLUSION In the absence of pleural effusion, the likelihood of spontaneous regression of BPS is high and the prognosis is therefore favorable. In cases with massive pleural effusion, treatment by laser ablation of the feeding vessel seems to be more effective than is pleuroamniotic shunting, with fewer complications. It might also reduce the need for postnatal surgery.
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Affiliation(s)
- M R Mallmann
- Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
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31
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Abstract
The management of congenital lung malformations is controversial both in the prenatal and postnatal periods. This article attempts to inform best practice by reviewing the level of evidence with regard to prenatal diagnosis, prognosis, and management and postnatal management, including imaging, surgical indication, surgical approach, and risk of malignancy. We present a series of clinically relevant statements along those topics and analyze the evidence for each. In the end, we make a plea for an adequate description of the lesions, both before and after birth, which will allow future comparisons between management options and the initiation of prospective registries.
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Affiliation(s)
- Robert Baird
- Department of Pediatric Surgery, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, QC, Canada
| | - Pramod S Puligandla
- Department of Pediatric Surgery, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, QC, Canada; Department of Pediatrics, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Jean-Martin Laberge
- Department of Pediatric Surgery, McGill University, Montreal Children׳s Hospital, McGill University Health Center, Montreal, QC, Canada.
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32
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Prenatal imaging and postnatal presentation, diagnosis and management of congenital lung malformations. Curr Opin Pediatr 2014; 26:315-9. [PMID: 24739492 DOI: 10.1097/mop.0000000000000091] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Congenital lung malformations (CLMs) vary in their clinical presentation and severity. Increases in prenatal diagnosis, observed regression of certain lesions, and prognostic uncertainty are driving an evolution in management. RECENT FINDINGS There has been an increase in the early diagnosis of these malformations, a change that is attributable to the routine use of prenatal ultrasound. Although prenatal diagnosis of CLMs using ultrasound and MRI has increased, chest radiography and computed tomography still play important roles in diagnosis. The management of these lesions depends on the type of malformation and symptoms. The treatment of asymptomatic patients with lung malformations is controversial, because the prognosis of these lesions is largely unknown. Proponents of early intervention argue that the complications of CLM, which may include infection, pneumothorax, bleeding and malignant transformation, justify surgery. Advocates of conservative management note that some CLMs disappear postnatally, and that the long-term complication rate following surgery is unknown. There is a need to obtain natural history data regardless of the therapeutic recommendations. SUMMARY This article reviews the prenatal radiographic features and postnatal clinical findings of various CLMs and the dilemmas regarding treatment.
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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.
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