Surgical versus conservative management of congenital pulmonary airway malformation in children: A systematic review and meta-analysis

A Clinical Comparative Study of Thoracoscopic Anatomical Lesion Resection and Lobectomy in the Treatment of Congenital Lung Malformations

BACKGROUND

To explore the safety and feasibility of HuaXi thoracoscopic anatomical lesion resection (HX-TALR) in the treatment of congenital lung malformations (CLMs) in children.

METHODS

A retrospective review of clinical data was conducted for patients who underwent HX-TALR and thoracoscopic lobectomy (TL) in our hospital from October 2017 to March 2023. Intraoperative and postoperative outcomes were compared between the HX-TALR and TL groups.

RESULTS

There were 485 patients in this study, 267 of whom underwent HX-TALR and 218 of whom underwent TL. All patients underwent thoracoscopic surgery without conversion to open surgery. No patients had major complications, including bronchopleural fistula, hemorrhage, atelectasis, recurrence or reoperation. The operative time, intraoperative bleeding volume, cases with thoracic drainage tubes, postoperative hospital stay, and cases with postoperative fever in HX-TALR were greater than those in TL (P < 0.05).

CONCLUSIONS

HX-TALR is safe, feasible, and retains all normal lung tissue while removing the lesion, which is expected to become the preferable operation for the treatment of CLMs. HX-TALR is a new and technically challenging procedure that needs to be carried out after training.

LEVEL OF EVIDENCE

Level IV.

Utility of Postnatal Chest X-Ray in Newborns for the Evaluation of Prenatally Suspected Congenital Pulmonary Airway Malformation: A Single-Center Experience

OBJECTIVE

The aim of the study is to assess the necessity of chest X-ray (CXR) during the newborn hospitalization for all patients with prenatally suspected congenital pulmonary airway malformation (CPAM).

STUDY DESIGN

This is a retrospective chart review of all infants delivered with prenatally suspected CPAM at our high-risk delivery hospital from January 2013 through April 2020 (n = 44). Nonparametric tests assessed the association between postnatal CXR findings, prescribed follow-up timeline, and neonatal outcomes.

RESULTS

Mean follow-up period recommended was 6.4 weeks regardless of CXR findings in the neonatal period (p = 0.81). Additionally, patients who required respiratory support at or after birth were not more likely to have a lesion identified on chest X-ray (odds ratio [OR] = 0.72, 95% confidence interval [CI], 0.18-2.64, p = 0.71).

CONCLUSION

Neonatal hospital course and future follow-up plan of patients with prenatally suspected CPAM were not altered by information from the CXR obtained in the immediate neonatal period, suggesting that this CXR may not be necessary in the asymptomatic patient.

KEY POINTS

· Immediate postnatal X-ray of prenatally diagnosed CPAM does not alter planned follow-up interval.. · Immediate postnatal X-ray does not alter surgical plan for CPAM.. · Postnatal X-ray is not absolutely required for asymptomatic newborns with CPAM..

The impact of undergoing elective pediatric lung resection during respiratory syncytial virus peak season on patient outcomes: A nationwide retrospective analysis

OBJECTIVES

Observational data to support delaying elective pediatric thoracic surgery during peak respiratory viral illness season is lacking. This study evaluated whether lung surgery during peak viral season is associated with differences in postoperative outcomes and resource utilization.

METHODS

A retrospective observational cohort study was performed using the Pediatric Health Information System (PHIS). Patients with a congenital lung malformation (CLM) who underwent elective lung resection between 1 January 2016 and 29 February 2020 were included. Respiratory syncytial virus (RSV) incidence was used as a proxy for respiratory viral illness circulation. Monthly hospital-specific RSV incidence was calculated from PHIS data, and peak RSV season was defined by Centers for Disease Control data. Multivariable regression models were built to identify predictors of postoperative mechanical ventilation, which was the main outcome measure, as well as secondary outcomes including 30-day readmission after lung resection, postoperative length of stay (LOS) and hospital billing charges.

RESULTS

Of 1542 CLM patients identified, 344 (22.3%) underwent lung resection during peak RSV season. 38% fewer operations were performed per month during peak RSV season than during off-peak months (p < .001). Children who underwent surgery during peak RSV season did not differ from the off-peak group in terms of age at operation, race, or comorbid conditions (i.e., congenital heart disease, newborn respiratory distress, and preoperative pneumonia). There was no association between hospital-specific RSV incidence at the time of surgery and postoperative mechanical ventilation, postoperative LOS, 30-day readmission rate or hospital billing charges.

DISCUSSION

Performing elective lung surgery in children with CLMs during peak viral season is not associated with adverse surgical outcomes or increased utilization of healthcare resources.

Prenatal Measurements of Congenital Lung Malformations: Can They Predict Postnatal Size?

INTRODUCTION

Prenatally diagnosed congenital lung malformations (CLMs) are monitored via ultrasound and measured by congenital pulmonary airway malformation volume ratios (CVRs) which can predict postnatal respiratory symptoms. This study compared CVR to postnatal lesion size to help guide prenatal counseling.

METHODS

A retrospective chart review evaluated the prenatal imaging and postnatal outcomes for patients who were prenatally diagnosed with CLMs and had a postnatal computed tomography (CT) scan at one institution.

RESULTS

Fifty-seven patients were included. Four had symptoms requiring urgent resection. The remaining were discharged and had clinic follow-up with CT scan to determine next steps: five had no identified lesions, eight had lesions whose diagnosis did not warrant an operation, and 40 had lesions whose diagnosis rendered size a factor in operative decision-making. Of these 40, 26/40 patients (65%) underwent elective resection (median maximum CVR 0.97; median lesion size 4 cm) and 14/40 patients (35%) were observed without resection (median maximum CVR 0.5; median lesion size 3 cm). There was a positive correlation between prenatal CVR and postnatal lesion size, with R-squared = 0.46. Maximum CVRs were better than last CVRs when predicting whether postnatal CT size would fall above or below our institution's level of recommended resection, with an area under the curve of 0.85 and a CVR cut-point of 0.61.

CONCLUSIONS

For newborns with asymptomatic CLMs, higher maximum CVRs correlated with larger size on postnatal CT. A maximum CVR ≤0.6 was correlated with a smaller postnatal CT size that may be eligible for nonoperative management. While these results are not intended to recommend surgery based on higher CVRs alone, this information could potentially be used to reassure expectant parents whose babies' prenatal imaging demonstrate lower maximum CVRs.

Selection of potential targets for stratifying congenital pulmonary airway malformation patients with molecular imaging: is MUC1 the one?

Currently there is a global lack of consensus about the best treatment for asymptomatic congenital pulmonary airway malformation (CPAM) patients. The somatic KRAS mutations commonly found in adult lung cancer combined with mucinous proliferations are sometimes found in CPAM. For this risk of developing malignancy, 70% of paediatric surgeons perform a resection for asymptomatic CPAM. In order to stratify these patients into high- and low-risk groups for developing malignancy, a minimally invasive diagnostic method is needed, for example targeted molecular imaging. A prerequisite for this technique is a cell membrane bound target. The aim of this study was to review the literature to identify potential targets for molecular imaging in CPAM patients and perform a first step to validate these findings.A systematic search was conducted to identify possible targets in CPAM and adenocarcinoma in situ (AIS) patients. The most interesting targets were evaluated with immunofluorescent staining in adjacent lung tissue, KRAS+ CPAM tissue and KRAS- CPAM tissue.In 185 included studies, 143 possible targets were described, of which 20 targets were upregulated and membrane-bound. Six of them were also upregulated in lung AIS tissue (CEACAM5, E-cadherin, EGFR, ERBB2, ITGA2 and MUC1) and as such of possible interest. Validating studies showed that MUC1 is a potential interesting target.This study provides an extensive overview of all known potential targets in CPAM that might identify those patients at risk for malignancy and conducted the first step towards validation, identifying MUC1 as the most promising target.

Congenital lung malformations

Congenital lung malformations (CLMs) are rare developmental anomalies of the lung, including congenital pulmonary airway malformations (CPAM), bronchopulmonary sequestration, congenital lobar overinflation, bronchogenic cyst and isolated congenital bronchial atresia. CLMs occur in 4 out of 10,000 live births. Postnatal presentation ranges from an asymptomatic infant to respiratory failure. CLMs are typically diagnosed with antenatal ultrasonography and confirmed by chest CT angiography in the first few months of life. Although surgical treatment is the gold standard for symptomatic CLMs, a consensus on asymptomatic cases has not been reached. Resection, either thoracoscopically or through thoracotomy, minimizes the risk of local morbidity, including recurrent infections and pneumothorax, and avoids the risk of malignancies that have been associated with CPAM, bronchopulmonary sequestration and bronchogenic cyst. However, some surgeons suggest expectant management as the incidence of adverse outcomes, including malignancy, remains unknown. In either case, a planned follow-up and a proper transition to adult care are needed. The biological mechanisms through which some CLMs may trigger malignant transformation are under investigation. KRAS has already been confirmed to be somatically mutated in CPAM and other genetic susceptibilities linked to tumour development have been explored. By summarizing current progress in CLM diagnosis, management and molecular understanding we hope to highlight open questions that require urgent attention.

Sublobar Pulmonary Resection in Children With Congenital Lung Abnormalities: A Systematic Review

BACKGROUND

Lobectomy is currently the advised resection for symptomatic congenital lung abnormalities (CLA). Sublobar surgery is suggested as an alternative that enables to conserve healthy lung parenchyma. This systematic review aims to explore the outcomes of sublobar surgery in CLA patients as well as the corresponding surgical terminology and techniques.

METHODS

A systematic literature search was performed in adherence to PRISMA-P guidelines. The target population consists of children undergoing sublobar pulmonary resection for CLA. All studies were independently assessed by two reviewers, and evaluated by a third reviewer in case of disagreement.

RESULTS

The literature search yielded 901 studies of which 18 studies were included, comprising 1167 cases. The median chest tube insertion duration was 3.6 days (range 2.0-6.9 days), the median hospital admission was 4.9 days (range 2.0-14.5 days), and residual disease was diagnosed in 2% - leading to re-operation in 70%. The median incidence of postoperative complications was 15% (range 0-67%). Follow-up imaging was standard-of-care in 2/3 of studies. Due to the absence of standardised terminology, operative details and specification of resection type did not typically relate between studies.

CONCLUSIONS

Sublobar resection of CLA lesions could be a viable alternative to lobectomy in certain cases, with the advantage of conserving healthy lung parenchyma. Peri- and postoperative complications are comparable with those reported for conventional lobectomy. The incidence of residual disease following sublobar surgery appears to be lower than commonly stated. To improve comparability between studies, we recommend reporting perioperative characteristics in a structured format.

LEVEL OF EVIDENCE

Level IV.

Congenital Lung Malformations: Pulmonary Function Assessment Before and After Surgery

BACKGROUND

The management of asymptomatic congenital lung malformations (CLM) is debated, and pulmonary function of patients with CLM is seldom discussed. Short-term respiratory outcome in patients operated for CLM was assessed in order to better define surgical impact.

METHODS

A retrospective study on patients operated for CLM between 2012 and 2021 was performed. Respiratory function was assessed with tidal breath analysis (TBA) in spontaneous sleep within 2 years of life. Patients with comorbidities affecting pulmonary function were excluded. Three variables were studied: tPTEF/tE (time to peak tidal expiratory flow/total expiratory time), tV (tidal volume), RR (respiratory rate). Results were assessed as z-score (normal ±1.64) and expressed as median (range). Pre- and post-operative results were compared, as well as post-operative results of disease and surgery type subgroups.

RESULTS

Thirty-nine patients were included. Median pre- and post-operative tPTEF/tE were normal (pre: -0.32 (-2.12; +1.56); post: -0.18 (-1.62; +2.43)). Patients with extralobar sequestration had pre-operative high median RR, which improved after sequestrectomy (pre: +1.99 (-2.49; +7.43); post -0.22 (-3.01; +1.18)). All groups had reduced pre-operative median tV, which restored after surgery (pre: -2.15 (-9.75; +0.91); post: -0.35 (-6.65; +3.14)). Patients undergoing lobectomy and patients with intralobar sequestration showed greater improvement. Median post-operative TBA results were normal for all sub-groups except for reduced tV in patients operated with thoracotomy (-2.27 (-6.12; +5.26)).

CONCLUSIONS

Patients with clinically asymptomatic CLM can have pathologic pulmonary function tests, which improve after surgery. These results add to the elements in favor of an interventional approach.

LEVEL OF EVIDENCE

III, Treatment study.

Introduction of pediatric thoracoscopic lung resections in a low-volume center - feasibility, outcome and cost analysis

BACKGROUND

Early series of pediatric thoracoscopic surgery have reported high conversion rates and significant complications. This study investigated the introduction of pediatric thoracoscopic lung resections in a low-volume center with reference to corresponding open thoracotomy procedures with regards to operative times, length of stay, cost of admission, and outcomes.

METHODS

A single surgeon series. Data from the first 10 consecutive thoracoscopic lung resections were compared to a cohort of 10 consecutive open lung resections performed before the introduction of the thoracoscopic technique. All operations were performed between December 2015 and October 2021. The median follow-up was 34 months (range 4-65).

RESULTS

The cohort included 14 lobectomies (8 thoracoscopic and 6 open) for congenital pulmonary airway malformation (CPAM), and 6 resections (mainly non-anatomic) of pulmonary sequestration (2 thoracoscopic and 4 open). One lobectomy required conversion to thoracotomy, and one patient required reinsertion of a chest drain after open lobectomy due to persistent air leak. No other complications were recorded. All patients were asymptomatic at their follow-up. There was no significant difference in the mean age, mean weight, operative times, and intraoperative blood loss between open and minimally invasive procedures. Thoracoscopic technique was associated with significantly shorter stay at pediatric intensive care unit and shorter overall inpatients stay.

CONCLUSION

Thoracoscopic lung resections can be safely introduced in a low-volume center with comparable cost, operative time, and results and significantly shorter inpatient stay.

Long-term neurodevelopment in children with resected congenital lung abnormalities

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

Nationwide Outcomes After Thoracoscopic Versus Open Resection of Congenital Pulmonary Airway Malformations in Newborns

Purpose: Elective resection of congenital pulmonary airway malformations (CPAM) has been debated for decades and varies significantly between individual surgeons. However, few studies have compared outcomes and costs associated with thoracoscopic and open thoracotomy approaches on a national level. This study sought to compare nationwide outcomes and resource utilization in infants undergoing elective lung resection for CPAM. Materials and Methods: The Nationwide Readmission Database was queried from 2010 to 2014 for newborns who underwent elective surgical resection of CPAM. Patients were stratified by operative approach (thoracoscopic versus open). Demographics, hospital characteristics, and outcomes were analyzed using standard statistical tests. Results: A total of 1716 newborns with CPAM were identified. Elective readmission for pulmonary resection was performed in 12% (n = 198), with 63% of resections completed at a different hospital than the newborn stay. Most resections were thoracoscopic (75%), compared to only 25% via thoracotomy. Infants treated with thoracoscopic resection were more often male (78% versus 62% open, P = .040) and were older at the time of resection. Patients who had an open thoracotomy experienced a higher rate of serious complications (40% versus 10% thoracoscopic, P < .001), including postoperative hemorrhage, tension pneumothorax, and pulmonary collapse. Readmission costs were higher for infants treated via thoracotomy (P < .001). Conclusion: Thoracoscopic lung resection for CPAM is associated with lower cost and fewer postoperative complications than thoracotomy. Most resections are performed at different hospitals than the place of birth, which may affect long-term outcomes from single institutional studies. These findings may be used to address costs and improve future evaluations of elective CPAM resections.

Integrated bulk and single-cell RNA-sequencing reveals SPOCK2 as a novel biomarker gene in the development of congenital pulmonary airway malformation

BACKGROUND

Congenital pulmonary airway malformation (CPAM) is the most frequent pulmonary developmental malformation and the pathophysiology remains poorly understood. This study aimed to identify the characteristic gene expression patterns and the marker genes essential to CPAM.

METHODS

Tissues from the cystic area displaying CPAM and the area of normal appearance were obtained during surgery. Bulk RNA sequencing (RNA-seq) and single-cell RNA sequencing (scRNA-seq) were performed for integrating analysis. Iterative weighted gene correlation network analysis (iWGCNA) was used to identify specifically expressed genes to CPAM.

RESULTS

In total, 2074 genes were significantly differentially expressed between the CPAM and control areas. Of these differentially expressed genes (DEGs), 1675 genes were up-regulated and 399 genes were down-regulated. Gene ontology analysis revealed these DEGs were specifically enriched in ciliated epithelium and involved in immune response. We also identified several CPAM-related modules by iWGCNA, among them, P15_I4_M3 module was the most influential module for distinguishing CPAMs from controls. By combining the analysis of the expression dataset from RNA-seq and scRNA-seq, SPOCK2, STX11, and ZNF331 were highlighted in CPAM.

CONCLUSIONS

Through our analysis of expression datasets from both scRNA-seq and bulk RNA-seq of tissues obtained from patients with CPAM, we identified the characteristic gene expression patterns associated with the condition. Our findings suggest that SPOCK2 could be a potential biomarker gene for the diagnosis and therapeutic target in the development of CPAM, whereas STX11 and ZNF331 might serve as prognostic markers for this condition. Further investigations with larger samples and function studies are necessary to confirm the involvement of these genes in CPAM.

COllaborative Neonatal Network for the first European CPAM Trial (CONNECT): a study protocol for a randomised controlled trial

INTRODUCTION

Consensus is lacking on the optimal management of asymptomatic congenital pulmonary airway malformation (CPAM). For future studies, the CONNECT consortium (the COllaborative Neonatal Network for the first European CPAM Trial)-an international collaboration of specialised caregivers-has established consensus on a core outcome set of outcome parameters concerning respiratory insufficiency, surgical complications, mass effect and multifocal disease. These outcome parameters have been incorporated in the CONNECT trial, a randomised controlled trial which, in order to develop evidence-based practice, aims to compare conservative and surgical management of patients with an asymptomatic CPAM.

METHODS AND ANALYSIS

Children are eligible for inclusion after the CPAM diagnosis has been confirmed on postnatal chest CT scan and they remain asymptomatic. On inclusion, children are randomised to receive either conservative or surgical management. Subsequently, children in both groups are enrolled into a standardised, 5-year follow-up programme with three visits, including a repeat chest CT scan at 2.5 years and a standardised exercise tolerance test at 5 years.The primary outcome is exercise tolerance at age 5 years, measured according to the Bruce treadmill protocol. Secondary outcome measures are molecular genetic diagnostics, validated questionnaires-on parental anxiety, quality of life and healthcare consumption-, repeated imaging and pulmonary morbidity during follow-up, as well as surgical complications and histopathology. This trial aims to end the continuous debate surrounding the optimal management of asymptomatic CPAM.

ETHICS AND DISSEMINATION

This study is being conducted in accordance with the Declaration of Helsinki. The Medical Ethics Review Board of Erasmus University Medical Centre Rotterdam, The Netherlands, has approved this protocol (MEC-2022-0441). Results will be disseminated through peer-reviewed scientific journals and conference presentations.

TRIAL REGISTRATION NUMBER

NCT05701514.

Surgical Management of Congenital Lung Malformations

Congenital lung malformations (CLMs) are commonly diagnosed prenatal lesions with varied natural history. Prenatal diagnosis and monitoring help to guide fetal interventions, delivery planning, and need for urgent perinatal surgical interventions. All prenatally diagnosed CLMs should be evaluated postnatally, typically with cross-sectional imaging, because many lesions persist despite the appearance of complete 'regression' in utero. Management of CLMs in asymptomatic infants weighs the surgical and anesthetic risk of prophylactic resection against the risk of expectant management, including the possibility of infection, malignant degeneration, and more complicated surgical resection later with loss of compensatory lung growth.

Long-Term Results of Pediatric Congenital Pulmonary Malformation: A Population-Based Matched Case-Control Study with a Mean 7-Year Follow-Up

Symptomatic congenital pulmonary malformations (CPMs) are a group of anomalies involving the lungs. The long-term outcomes of these patients are not well known. The present research aimed to study the pulmonary function, respiratory morbidity, and health-related quality of life (QoL) of patients treated for CPMs. All children (<16 years of age) treated for CPMs in 2002−2012 (in Oulu University Hospital) were invited to the follow-up visit. Altogether, there were 22 patients, out of which 17 (77%) participated. The mean follow-up time was 6.6 (ranged from 3 to 16) years. Pulmonary function tests, diffusing capacity, respiratory morbidity, and QoL were determined as the primary outcomes. Potential residual malformations and lung anatomy were investigated using computer tomography (CT) imaging. The outcomes were compared to the age- and sex-matched healthy controls. The forced expiratory volume at 1 s (FEV1, Z-score) remained lower in operated patients compared to the healthy controls (−1.57 ± SD 1.35 vs. −0.39 ± SD −0.86, p-value 0.005). There were no differences in respiratory morbidity or QoL between the patients and the controls. The surgical approach (lobectomy vs. partial resection) did not affect lung function. A younger age (<1 year of age) at the time of the surgery seemed to result in a higher lung capacity, but the finding was not statistically significant. Patients with CPMs treated with surgery were satisfied with their wellbeing in the long-term. A lower lung function did not have an impact on their wellbeing. However, there was a slight decrease in lung function compared to the healthy controls, and a clinical follow-up of the patients was recommended.

Thoracoscopic Clockwise Lobectomy May Be a Stylized Procedure for Treating Children with Congenital Lung Malformations

Background: Thoracoscopic lobectomy is a challenging procedure in children with congenital lung malformations (CLMs). This study aims to evaluate the safety and efficacy of thoracoscopic clockwise lobectomy (TCL) in CLMs in children and its potential to be a stylized procedure. Methods: All patients with CLMs who received TCL from 2015 to 2019 in our hospital were retrospectively reviewed. Clinical information was extracted from medical records, including patient demographics, operative details, and outcomes. Results: A total of 184 patients with a median age of 6.8 months (range, 3-156) and a median weight of 9 kg (range, 6-45) received TCL. Lesions were all located in the lower lobe and included congenital pulmonary airway malformation (n = 133), intralobar sequestration (n = 44), bronchiectasis (n = 4), and congenital lobar emphysema (n = 3). The mean (±standard deviation [SD]) operating time was 46 ± 7.5 minutes (range, 35-113). The mean (±SD) blood loss was 3.5 ± 0.8 mL (range, 1-60). Three patients converted to thoracotomy, and 162 patients did not have a chest tube placed. The postoperative course was uneventful in all patients except 2 patients who developed air leaks and 23 patients who developed a mild fever. The median length of postoperative hospital stay was 2 days. A total of 163 patients were followed up for more than 1 year without any complications. Conclusion: TCL is suitable for lower lobectomy and is safe and effective in standard and complicated thoracoscopic lobectomy. It could be recommended as a stylized procedure in treating children with CLMs.

Congenital Lung Malformations: Clinical and Functional Respiratory Outcomes after Surgery

Congenital lung malformations (CLMs) involve anomalies of the lungs and respiratory tree such as congenital pulmonary airway malformation (CPAM), pulmonary sequestration (PS), bronchogenic cysts, congenital lobar emphysema, and bronchial atresia (BA). Although symptomatic lesions require surgical resection, the appropriateness of surgery for patients with asymptomatic malformations is a matter of ongoing debate. Limited data are available concerning the long-term follow-up of affected subjects. In this study, we sought to evaluate the long-term clinical and functional respiratory outcomes in children with CLMs who underwent surgical resection. We carried out a retrospective analysis of 77 children with CLMs who underwent pulmonary resection with at least one year of follow-up. The most common diagnoses were CPAM (50.65%), hybrid lesions (25.97%), lobar emphysema (11.69%), and PS (5.19%). The most common surgical approaches were lobectomy (61.3%), segmentectomy (10.7%), and pneumonectomy (5.3%). Acute post-surgery complications occurred in 31.2% of children. In addition, 73.7% experienced long-term complications, and we found no correlation between the presence of these complications and the sex of the patients, their age at time of surgery, the type of surgery undergone, the presence of symptoms prior to intervention, or acute complications after surgery. Pulmonary function tests revealed FEV1 Z-scores of <−2 SDs in 16 patients, and we found a significant correlation between pneumonectomy and the development of lung function deficit (p = 0.031). In conclusion, clinical and functional respiratory complications may occur in children with CLMs who undergo surgical resection. Long-term monitoring is needed to improve the management of asymptomatic patients.

Arterial Embolization and Methylene Blue Injection into the Aberrant Artery in Two Infants with Intralobar Sequestration

Bronchopulmonary sequestration is a rare congenital lung dysplasia. An intralobar sequestration (ILS) is a nonfunctional mass within the lung parenchyma without bronchial communication and with aberrant systemic arterial blood supply. Surgical resection or close observation can be proposed in the management of asymptomatic and low-risk ILS, but there is a lack of consensus. Endovascular embolization before thoracoscopic resection of ILS has been described to limit perioperative bleeding. Another technique previously reported is the injection of methylene blue in the feeding artery to macroscopically mark the sequestration from the healthy lung. In that way, a nonanatomical resection can be performed instead of a lobectomy without the risk of leaving abnormal lung tissue in place. We describe the first two cases of these two techniques combined: a 3-year-old girl with an ILS in the right lower lobe with an artery originating from the abdominal aorta, and a 14-month-old girl with an ILS in the right lower lobe with an artery coming from the celiac trunk. The combination of embolization and injection of methylene blue in the aberrant artery leads to a clear macroscopic demarcation of the blue-colored ILS from the healthy lung parenchyma and allowed safe nonanatomical resection of the ILS without risk of bleeding or compromising normal lung tissue.

Congenital Cystic Adenomatoid Malformations of the lung, a retrospective study of diagnosis, treatment strategy and postoperative morbidity in surgically-treated patients

OBJECTIVES

The purpose of this study was to evaluate diagnosis, clinical signs and strategy in Congenital Cystic Adenomatoid Malformations (CCAM).

METHODS

In this retrospective study, patients with thoracic surgery for CCAM lesions at the University Hospitals of Leuven from July 1993 to July 2016 were searched. Data on diagnosis, prenatal ultrasound findings, clinical signs, lesion site, CCAM type, associated anomalies, imaging, surgical approach and postoperative morbidity were reviewed. The Fisher's exact and Mann-Whitney tests were used as appropriate.

RESULTS

A total of 55 patients were identified with CCAM. In 65% (n = 36/55), CCAM was detected on prenatal ultrasound. Prenatal symptoms due to hydrops or mass-effect were present in 22% (n = 8/36), of which eventually 6 had need for prenatal intervention (Thoracoamniotic shunting or Intrauterine Puncture). Surgery was performed elective in 40% patients (n = 22/55), while others developed clinical signs with need for semi-urgent surgery, with clinical signs of pulmonary infection and respiratory distress being the most common. Most patients had a single lobectomy via mini-thoracotomy. Postoperative complications and length of stay were observed to be significantly higher in CCAM with preoperative clinical signs.

CONCLUSIONS

Surgery in asymptomatic CCAM patients can be performed safely with few postoperative complications and can be planned at young age in patients with high risk of developing clinical signs later in life.

The Management of Asymptomatic Congenital Pulmonary Airway Malformation: Results of a European Delphi Survey

Consensus on the optimal management of asymptomatic congenital pulmonary airway malformation (CPAM) is lacking, and comparison between studies remains difficult due to a large variety in outcome measures. We aimed to define a core outcome set (COS) for pediatric patients with an asymptomatic CPAM. An online, three-round Delphi survey was conducted in two stakeholder groups of specialized caregivers (surgeons and non-surgeons) in various European centers. Proposed outcome parameters were scored according to level of importance, and the final COS was established through consensus. A total of 55 participants (33 surgeons, 22 non-surgeons) from 28 centers in 13 European countries completed the three rounds and rated 43 outcome parameters. The final COS comprises seven outcome parameters: respiratory insufficiency, surgical complications, mass effect/mediastinal shift (at three time-points) and multifocal disease (at two time-points). The seven outcome parameters included in the final COS reflect the diversity in priorities among this large group of European participants. However, we recommend the incorporation of these outcome parameters in the design of future studies, as they describe measurable and validated outcomes as well as the accepted age at measurement.

A Novel Surgical Method for Congenital Lung Malformations: A Pilot Study

Thoracoscopic surgery for congenital lung malformations (CLMs) has been widely used. However, there are still many shortcomings in the current surgical methods, such as the removal of some normal lung tissue and residual lesions. Thoracoscopic anatomical lesion resection (TALR) may be an effective and safe method to resolve these problems. This retrospective study was conducted to estimate the safety and efficiency of TALR. A retrospective review of clinical data involving patients who underwent TALR in our hospital from October 2019 to January 2021 was performed. Clinical data, including patients' demographic characteristics, manipulative details, and postoperative complications, were extracted and analyzed. A total of 95 cases were included in this study. All cases were operated on under thoracoscope, with no conversion to open surgery. The average operation time was 63.2 ± 15.2 min (range 36-142 min). The average bleeding volume during the operation was 5.8 ± 2.1 mL (range 2-10 mL). The mean diameter of the lesion was 4.4 ± 1.9 cm (range 3-7 cm). All cases had no complications, such as bronchopleurothelial fistula, hemorrhage, atelectasis, or pulmonary infection. Two patients developed pneumothorax 1 month after the operation and were cured by closed thoracic drainage. One month after the operation, chest CT showed regular cysts in 2 cases. The other patients were followed up for over 1 year by chest CT after the operation, and all recovered well without residual lesions or recurrence. Combined with the preoperative thin slice CT and intraoperative lesion boundary, anatomical intrapulmonary dissociation based on the pulmonary vein system, TALR, as a lung-sparing surgery of completely removing the lesion and retaining all normal lung tissue, has high safety and effectiveness in the treatment of CLMs.

Hidden Infection in Asymptomatic Congenital Lung Malformations-A Decade Retrospective Study

BACKGROUND

Whether to operate on asymptomatic patients with congenital lung malformations (CLMs) remains controversial. Our study intended to find out the proportion of hidden infection in CLMs and its effect on surgery, to provide help for the management of asymptomatic CLMs patients.

METHODS

A retrospective review of the medical records of patients with asymptomatic CLMs from January 2011 to December 2020 was performed in our center. Selected asymptomatic patients were divided into a non-hidden infection group (NHI) and a hidden infection group (HI).

RESULTS

A total of 581 asymptomatic CLMs patients were included in this study. Thirty-two percent of asymptomatic CLMs patients had hidden infection in the lesion. Among various CLMs diseases, intralobular pulmonary sequestration had the highest percentage of hidden infection (48.8%). With age, the proportion of HI gradually increased. Patients in the HI and NHI groups were 223 and 121. The incidence of pleural adhesion and focal abscess in the HI group were 14.9 and 7.4%. Statistical significances were shown between the two groups in intraoperative blood loss (p = 0.002), operation time (p = 0.045), chest tube drainage time (p < 0.001), postoperative hospital stay (p < 0.001), and air leak (p = 0.012).

CONCLUSION

The proportion of HI detected by postoperative pathological results was high and they could increase the difficulty and risk of surgery. Therefore, early surgery may be a more appropriate choice for the management of asymptomatic CLMs patients.

Transcriptome analysis of lncRNA expression patterns in human congenital lung malformations

Objectives

To explore the long non-coding RNA (lncRNA) expression pattern of congenital lung malformations on a genome-wide scale and investigate their potential biological function in four subtypes of congenital lung malformations.

Methods

We obtained both lesions and normal lung control tissues from the patients diagnosed with CPAM-I, CPAM-II, ILS, and ILS-CPAM, and underwent lobectomy (i.e., surgical removal of the whole lobe which contains the localized lesion as well as normal lung tissue). Then, we performed lncRNA transcriptome profiling in these tissues by RNA sequencing (RNA-seq). A comprehensive bioinformatics analysis was conducted to characterize the expression profiles and relevant biological functions and for multiple comparisons of lncRNA expression in the different subtypes of congenital lung malformation tissues. Furthermore, the lncRNA-mRNA co-expression network was constructed, and dysregulated mRNAs were functionally analyzed. Finally, gene set enrichment analysis (GSEA) was used to predict the potential molecular mechanism of the identified lncRNAs.

Results

A total of 5921 lncRNA transcripts were identified between congenital lung malformations tissues and normal lung control tissues. Compared with normal lung control, 481of these expressed lncRNAs were upregulated and 142 were downregulated in CPAM-I, 91 were upregulated and 14 were downregulated in CPAM-II, 39 were upregulated and 38 were downregulated in ILS, and 201 were upregulated and 38 were downregulated in ILS-CPAM. Unsupervised clustering and principal component analysis of the expressed lncRNAs visualized the differences between normal lung control and different subtypes of congenital lung malformations samples. We also confirmed significant differences in the composition of differentially expressed genes (DEGs) and the differentially expressed lncRNAs (DE lncRNAs) between CPAM-I and other subtypes of congenital lung malformations, as well as in normal lung control tissues, and observed enrichment of DEGs in the regulation of the immune system, cell projection organization, and inflammatory pathways. Finally, we identified the lncRNA FLJ26850 might be related to congenital lung malformations via ZNF473.

Conclusions

Significant differences in lncRNAs expression patterns were observed between different subtypes of congenital lung malformations and normal control. The lncRNA FLJ26850 might be related to congenital lung malformations via ZNF473.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12864-021-08204-x.

Comparison of thoracoscopy vs. thoracotomy on musculoskeletal outcomes of children with congenital pulmonary airway malformation (CPAM)

BACKGROUND

It has been postulated that video-assisted thoracoscopic surgery (VATS) is superior than conventional thoracotomy for resection of congenital pulmonary airway malformation (CPAM) in terms of shorter hospital length of stay, reduced post-operative complication and better long-term pulmonary outcome. However, there is limited available data concerning the effect of VATS and conventional thoracotomy on musculoskeletal aspects in patients with CPAM. This study aims to compare the long-term effects of both surgical techniques on musculoskeletal outcomes in this group of patients.

METHODS

Thirty-five patients with mean age of 11.38 years old who underwent VATS or conventional thoracotomy for CPAM resection were recruited in this study. The mean follow-up time was 10.42 years (5.48 to 17.71 years). Musculoskeletal examination included screening of musculoskeletal deformities (elevation of shoulder, asymmetry of nipple level, breast/ pectoral muscle maldevelopment, winging of scapula, scoliosis), measurement of bilateral chest wall in relation to anatomical parameter, and testing of shoulder range of motion and power.

RESULTS

The prevalence of winged scapula was significantly lower in patients who underwent VATS than thoracotomy (13% vs 58%, p = 0.008). There is also a smaller reduction in operated-side chest wall vertical distance in VATS patients (0.982 vs 0.956, p = 0.058). There were no significant difference in prevalence of other musculoskeletal deformities, other chest wall measurements, shoulder range of motion and power between two groups.

CONCLUSION

Thoracoscopy decreases the incidence of scapular winging but has no effect on effect on other musculoskeletal deformities.

Is It Better to Operate Congenital Lung Malformations when Patients are Still Asymptomatic?

Context:

Congenital lung malformation (CLM) is a rare developmental anomaly of the lower respiratory tract. The purposes are to define if the presence of respiratory symptoms, in CLM may affect surgical outcomes and to define optimal timing for surgery in asymptomatic patients.

Settings and Design:

Retrospective review of patients with CLM from 2004 to 2018. Asymptomatic and symptomatic patients were compared. Moreover, asymptomatic patients were stratified according to age at surgery (< or >6 months).

Subjects and Methods:

Demographic data, prenatal diagnosis, symptoms, CLM's characteristics, operative and postoperative data were collected. Patients were divided into two groups based on the presence or none of respiratory symptoms.

Statistical Analysis:

Data were compared using the Fisher's exact test for qualitative values and Mann-Whitney test for quantitative values P < 0.05 was statistically significant.

Results:

One hundred and eighty-six patients were treated. Asymptomatic were 137 (74%), while symptomatic were 49 (26%). The most common presenting symptoms were respiratory distress (n = 30, 61%) followed by pneumonia (n = 18, 38%). Prenatal diagnosis of CLM was performed in 98% of asymptomatic patients compared to 30% of symptomatic (P = 0.001). Surgical excision was performed in all cases, and in 50% by thoracoscopy, without difference between the two groups. In 97% of all cases, a lung sparing surgery was performed without difference between the groups. Symptoms are significantly associated with older age, location in the upper lobe, and lobar emphysema. Length of stay in intensive care, postoperative complications, and reintervention rate were higher in the symptomatic group. Eighty-one asymptomatic patients underwent surgery <6 months of life; they had a lower rate of surgical complications (2%) compared with those >6 months (7%).

Conclusions:

The present study describes a comprehensive picture of CLM. In addition, we emphasize the role of early postnatal management and thoracoscopic surgery, also before 6 months of life, to prevent the onset of symptoms that are associated with worse outcomes.

Morbidity after thoracoscopic resection of congenital pulmonary airway malformations (CPAM): single center experience over a decade

PURPOSE

Video-assisted thoracoscopic (VATS) resection of CPAM in children is an established, albeit controversial strategy for its management. We report a 10-year single center experience.

METHODS

All children underwent VATS (2008-2017) and their current status was reviewed. Patients were grouped: 'symptomatic-P' (if parents reported recurrent lower respiratory tract infections etc.) or 'symptomatic-S' (neonates presenting with respiratory distress/difficulty) or 'asymptomatic'.

RESULTS

73 children, aged 10 m (4d-14yrs) underwent VATS; a neonate as an emergency ('symptomatic-S') and all others electively. The lesion was unilateral in all but one case. Histologically none were malignant. Of the elective 72 cases, 7 (10%) required conversion to open thoracotomy. Twenty (27.7%) were 'symptomatic-P' and the duration of surgery when compared to 'asymptomatic' children was longer 269 (range 129-689) versus 178 (range 69-575) minutes (P = 0.01). Post operatively, 8 children (11%) had a grade III/IV (Clavien-Dindo) complication; persistent air leak/pneumothorax (n = 5), chylothorax (n = 1), pleural effusion (n = 1) and seizure/middle cerebral artery thrombosis (n = 1). There was no mortality. Twenty-four children (33.3%) were reported 'symptomatic-P' post-surgery after a median follow up of 2.18 years. The surgical intervention had no impact on 'symptomatic-P' status (P = 0.46).

CONCLUSION

The risks of surgery may outweigh benefit in asymptomatic children. CLINICALTRIALS.

GOV IDENTIFIER

NCT04449614.

Preoperative Embolization Facilitates Segmental Resection of Pulmonary Sequestration in an Infant

The most common congenital lung malformations are congenital pulmonary airway malformations and pulmonary sequestrations. Many surgeons advocate resection to prevent complications of infection, malignancy, and pneumothorax. The standard of care is lobectomy, but segmentectomy and embolization alone have been reported. These methods avoid the complications of lobectomy but are not widely practiced due to concerns about incomplete resection or involution of the lesion. We present a novel approach to the treatment of a pulmonary sequestration in a 7-month-old male using preoperative embolization followed by a sublobar pulmonary resection. The embolization clearly demarcated the affected lung intraoperatively, thereby facilitating complete removal of the lesion with a segmental lung resection rather than complete lobectomy.

Imaging of fetal tumors and other dysplastic lesions: A review with emphasis on MR imaging

Fetal tumors and other dysplastic masses are relatively rare. They are usually the result of failure of differentiation and maturation during embryonic or fetal life; dysplastic lesions may be the consequence of an obstruction sequence. In this review, we present the most commonly encountered tumors and masses seen during fetal life. Imaging characteristics, tumoral organ of origin, and its effect on the surrounding organs and overall fetal hemodynamics are descriptors that must be relayed to the fetal surgeon and maternal fetal medicine expert, in order to institute most accurate parental counseling and appropriate perinatal treatment plan.

Thoracoscopy versus thoracotomy for congenital lung malformations treatment: A single center experience

INTRODUCTION

Our aim is to compare thoracoscopy to thoracotomy in the treatment of congenital lung malformations (CLM) in children.

MATERIALS AND METHODS

We report a retrospective monocentric cohort study. Patients treated at our Center for CLM (1991-2020) were divided in two groups: patients treated with video-assisted thoracoscopic surgery (VATS) and open thoracotomy (OT). Characteristics of the two groups were compared through statistical analysis (GraphPad Prism7). A p value less than .05 was considered statistically significant.

RESULTS

One hundred six patients were included: 58 in VATS group, 48 in OT group. Prenatal diagnosis was possible in 73.6%. The most frequent surgical procedures were lobectomy (43.4%) and sequestrectomy (22.6%). All VATS patients underwent lung exclusion, mostly by endobronchial blocker (69%). Mean operative time was 146.1 min (±52.04 SD) in VATS and 159.2 (±46.53 SD) in OT (p = .1973). Conversion to OT was necessary in 20.6% of VATS patients, but decreased in the last 5 years (6.2%). There were not any intraoperative complication. Respectively in VATS and OT group, length of stay (LOS) was 4.5 days ± 3.6 SD versus 7.7 ± 3.4 SD (p < .0001), chest tube duration 2.8 days ± 3.4 SD versus 3.7 ± 2.4 SD (p < .0001), antibiotic treatment duration 3.7 days ± 4.7 SD versus 5 ± 2.6 SD (p = .1196). Postoperative complications were described in 22.6%. The commonest histological diagnosis (40.6%) was congenital pulmonary airway malformation.

CONCLUSION

VATS resulted a feasible, effective and safe technique. Operative time and postoperative complications were similar in VATS and OT groups. VATS conversion rate decreased in time. VATS had a statistically significant shorter LOS and chest tube duration.

Is thoracoscopy superior to thoracotomy in the treatment of congenital lung malformations? An updated meta-analysis

Background:

A meta-analysis was performed for a comparison of outcomes between video-assisted thoracoscopic surgery (VATS) and thoracotomy for congenital lung malformations (CLM).

Methods:

Electronic databases, including PubMed, Scopus, Embase, and the Cochrane Library were searched systematically for literature aimed mainly at reporting the therapeutic effects for CLM administrated by VATS and thoracotomy.

Results:

A total of 40 studies meeting the inclusion criteria were included, involving 2896 subjects. VATS was associated with fewer complications [odds ratio (OR) 0.54; 95% confidence interval (CI), 0.42–0.69], less use of epidural anesthesia (OR, 0.08; 95% CI, 0.03–0.23), shorter length of hospital stay [standard mean difference (SMD) −0.98; 95% CI, −1.4 to −0.55] and chest drainage (SMD, −0.43; 95% CI, −0.7 to −0.17), as compared with thoracotomy. However, thoracotomy showed superiority in reduced operative time (SMD, 0.44; 95% CI, 0.04–0.84). Pearson analysis (Pearson r = 0.85, 95% CI, 0.28 to 0.98, p = 0.01) and linear regression (R square 0.73) confirmed a positive correlation between percentage of symptomatic cases and conversion in patients using VATS.

Conclusion:

VATS is associated with fewer complications, less use of epidural anesthesia, shorter length of stay and length of chest drainage, but longer operative time, as compared with thoracotomy. Symptomatic patients with CLM using VATS may be prone to conversion to thoracotomy.

The reviews of this paper are available via the supplemental material section.

A retrospective clinical analysis of 20 cases of congenital lung masses

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.

Thoracoscopic Resection of Congenital Lung Malformation: Looking for the Right Preoperative Assessment

INTRODUCTION

 Consensus on the best postnatal radiological evaluation of congenital lung malformations (CLMs) is still lacking. In recent years, the interest on magnetic resonance imaging (MRI) has grown, but its role is still unknown.

AIM

 The aim of the study was to identify the best preoperative diagnostic assessment for CLM.

MATERIALS AND METHODS

 All patients with a prenatal suspicion of CLM between January 2014 and February 2018 were studied. Asymptomatic newborns underwent MRI, during spontaneous sleep without contrast. Patients with a positive MRI were scheduled for computed tomography (CT) within the fourth month of life. Thoracoscopic resection was performed in cases with a pathological CT. MRI, CT, and surgical findings were compared based on dimension, localization, and features of the CLM using the Cohen's kappa test (K).

RESULTS

 A total of 20 patients were included (10 males). No difference was found in the diameter and site of the lesions always localized in the same side (K = 1) and in the same pulmonary lobe (K = 1). Infants who underwent thoracoscopic resection included: three congenital pulmonary airway malformations (CPAMs), five extralobar and eight intralobar sequestrations (bronchopulmonary sequestrations [BPSs]), three bronchogenic cysts, and one congenital emphysema. The concordance between MRI and CT and between radiological investigations and pathology was satisfactory for the greatest part of the studied variables. MRI showed sensitivity of 100%, specificity of 82%, positive predictive value of 50% and negative predictive value of 100% for CPAM and 77, 100, 100, and 80% for BPS, respectively.

CONCLUSION

 MRI proved to be a reliable diagnostic investigation for CLM with high sensitivity and specificity. Early MRI in spontaneous sleep without contrast and preoperative contrast CT scan is a valuable preoperatory assessment.

The prenatal ultrasonic character and postnatal follow-up of 227 microcystic and macrocystic congenital cystic adenomatoid malformations

The objective of our study was to compare microcystic and macrocystic congenital cystic adenomatoid malformation (CCAMs) through prenatal characteristics, perinatal outcome, postnatal management and development after consultation in our prenatal diagnosis centre. We conducted a retrospective cohort study of 227 cases prenatally diagnosed as CCAM in our hospital within three years. One hundred and eighty-one cases continued their pregnancy and 46 pregnancies were terminated. One hundred and fifteen of 227 cases were microcystic and 112 were macrocystic. The prenatal ultrasound characteristics of two types showed no statistically significant differences, despite that CVR of macrocystic CCAMs was mildly greater than microcystic. None of recorded cases received surgical intervention in utero. Compared with healthy foetuses, CCAMs presented with higher percentage of polyhydramnios and male foetuses, larger amount of postpartum blood loss and longer duration of NICU hospitalisation. Compared with 46 legal abortions, continued pregnancy cases had a smaller CVR, less polyhydramnios, cardiac shift and hydrops. One hundred and seventy-nine cases were followed up after birth and 174 babies were asymptomatic. Thirty one cases received successful surgical resection. In conclusion, the prenatally diagnosed CCAMs have a good short-term prognosis and conservative management is a reasonable option in asymptomatic fetuses. Microcystic and macrocystic CCAMs both presented similar prenatal courses and perinatal prognoses. Conservative management, prenatally and postnatally, could be accepted in selected cases.Impact statementWhat is already known on this subject? Congenital cystic adenomatoid malformation is a well-known developmental abnormality of the lung. The prognosis for most CCAMs is good, but the prenatal and postnatal management remains controversial.What do the results of this study add? This study is one of the largest case cohorts to conclude that microcystic and macrocystic CCAMs both presented similar prenatal courses and perinatal prognoses. Conservative management is a reasonable option in asymptomatic babies.What are the implications of these findings for clinical practice and/or further research? A comprehensive assessment by an experienced multidisciplinary team is necessary to forbid blinding abortions of CCAMs. Conservative management prenatally and postnatally could be accepted in most asymptomatic cases.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Asymptomatic Congenital Lung Malformations: Timing of Resection Does Not Affect Adverse Surgical Outcomes

Background: Optimal timing for resection of asymptomatic congenital lung malformations (CLMs) remains controversial. The aim of this study is to define optimal timing for surgical intervention of patients with CLMs and define clinical variables that affect surgical outcomes. Methods: An IRB-approved retrospective analysis was conducted for patients undergoing surgery for CLMs between 2012 and 2017. Subjects were divided into cohorts based on timing of operative intervention. "Early intervention" was defined as surgery within 4 months of birth; "intermediate intervention"-between 4 and 6 months; and "late intervention"-6-12 months. Surgical outcomes including intraoperative estimated blood loss (EBL), surgical time, post-operative pneumothorax, length of time chest tube stayed in, and hospital length of stay were compared among the three groups using Fisher's exact test or Chi-squared test for categorical variables and one-way analysis of variance test for continuous variables. Results: We analyzed 63 patients who underwent surgery for CLM. There were no significant differences in baseline characteristics. Timing of surgery did not significantly correlate with post-operative outcomes. Specifically, there was no difference in operative time, EBL, post-operative pneumothorax, or length of hospital stay among the early, intermediate, and late intervention groups. Even after controlling for cyst-volume ratio (CVR), timing of surgery still did not affect post-operative outcomes. Conclusions: Surgical outcomes for resection of CLMs are not significantly affected by timing of surgery. We advocate for early intervention to decrease the incidence of associated complications that can occur with later intervention.

Congenital Cystic Lung Lesions: Redefining the Natural Distribution of Subtypes and Assessing the Risk of Malignancy

Asymptomatic cystic lung lesions-congenital pulmonary airway malformations (CPAMs), sequestrations, and bronchogenic cysts-are commonly diagnosed prenatally. Indications to resect are to eliminate risk of malignancy or infection. CPAMs consist of a spectrum of malformations, with type 1 historically considered the most common. Mucinous cell clusters, seen almost exclusively in type 1, are premalignant lesions at risk for progression to mucinous adenocarcinoma. We reviewed and classified 2.5 years of consecutive, prenatally diagnosed lesions as extralobar sequestration, intralobar sequestration, type 1 CPAM, type 2 CPAM/bronchial atresia, or "other" to determine the distribution of lesion types and risk of malignancy. One hundred eighty-four lesions in 174 patients showed type 1 CPAM to be least common subtype. Type 1 CPAMs had more severe presentation, infrequently had features of obstruction, and usually had cysts ≥2 cm. Fifteen of eighteen type 1 CPAMs had mucinous cell clusters (total risk, 8%), with mucous cells outside main cyst in 12/15. No pleuropulmonary blastomas were identified. Additional historic cases were reviewed to further evaluate risk of malignancy. Over 14 years, 28 infants with fetal/type 1 lesions were identified, with clusters of mucinous cells in 75% of cases. A total of 9 pleuropulmonary blastomas were diagnosed in 6 patients over 16 years. Contrary to historical studies, type 1 CPAMs are much less common than type 2, likely related to detection of asymptomatic lesions prenatally. A majority of type 1 CPAMs contain mucinous cell clusters. This data is useful in management of patients in centers that do not resect asymptomatic lesions.

Clinical presentation and outcome in congenital pulmonary malformation: 25 year retrospective study in Thailand

BACKGROUND

Congenital pulmonary malformations (CPM) are a group of rare abnormal lung development lesions that can have various presentations. The aim of this study was to define the differences in the clinical presentations of CPM in neonates, infants, and children, and to review the outcomes.

METHODS

A retrospective study was conducted at a tertiary care hospital in southern Thailand between 1992 and 2016.

RESULTS

Fifty-four patients were diagnosed with CPM, and the median age at onset was 1.7 months (IQR, 0.03-10 months). There were 33 cases (61.1%) of congenital pulmonary airway malformations, two (3.7%) of bronchogenic cyst, eight of (14.8%) congenital lobar emphysema, seven of (13.0%) pulmonary sequestrations, and four of (7.4%) congenital lung cysts. Twenty patients under 1 month old and 16 patients who were 1-12 months old had symptoms of respiratory distress. In contrast, 13 patients >1 year old had symptoms of pulmonary infection. There were significant differences in the numbers of patients who had cyanosis (P = 0.006), cough (P < 0.001), and fever (P < 0.001) between the three age groups. Thirty-eight patients (70%) required surgical treatment involving lobectomy (78.9%). Median follow-up duration was 28.1 months (IQR, 3.7-9.4 months). Nine of 10 patients had abnormal lung function tests, and 80.6% of patients had no subsequent limitations in physical activities.

CONCLUSIONS

Respiratory distress is the important clinical feature in neonates and infants, whereas the signs of pulmonary infection usually occur in children >1 year old. Good outcomes usually occur after surgery but need long-term follow up including lung function assessment.

Congenital lung lesions

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

A chest tube may not necessary in children thoracoscopic lobectomy

Drainage of the thorax postoperatively using chest tubes is a standard procedure in thoracic surgery. However, chest tubes can induce pain and immobilization, increase risk of infection, deteriorate the ventilation capacity, and increase difficulty of postoperative management, particularly in children. This study aimed to investigate the safety and effect of excluding chest tubes after performing thoracoscopic lobectomy in selected children.A retrospective review of medical records was performed in West China Hospital of Sichuan University from January 2014 to June 2018. Patients who underwent thoracoscopic lobectomy without chest tubes were recorded. Patients with accompanying severe pulmonary infection, extensive thoracic adhesions, or undeveloped interlobar fissure were excluded.In total, 246 patients underwent thoracoscopic lobectomy without a chest tube, and none required chest drain insertion or reintervention during hospitalization and follow-up at 90 days postoperatively. Among them, 2 (0.81%) patients developed a delayed pneumothorax which was found after being discharged, and resolved spontaneously in 2 weeks. No hemothorax, atelectasis, and bronchial fistula were found. Furthermore, 202 (82.1%) patients developed subcutaneous emphysema, which was asymptomatic and spontaneously resolved within 3 to 7 days. The length of postoperative hospital stay was 2 days; patients were discharged in the 3rd day postoperatively. Patients could recover to free mobilization and resume regular diet at 6 hours postoperatively. All patients were followed up for at least 3 months; no other complications were found, and all patients recovered well.This study showed that chest tube placement in selected patients may be unnecessary in children undergoing thoracoscopic lobectomy. The minimally invasive procedure and meticulous resection have been the preconditions of this procedure, which may contribute to a rapid recovery and can avoid the chest tube-related complications effectively.

Visualization of pleural fissures in infants on computed tomography

Purpose

For infants with prenatally detected lung lesions, a chest CT is performed prior to surgery. The chest CT is performed as close to the surgery date as possible, because it is presumed that the visualization of lung fissures would be poor in the immediate neonatal setting. However, this presumption has never been formally studied. The purpose of this study is to assess differences in lung fissure visualization on chest CT in different infant age groups.

Methods

This was a retrospective study of clinically indicated chest CT approved by the institutional review board performed in infants of different ages. The visibility of pleural fissures was subjectively assessed by three pediatric radiologists who were blinded to age group.

Results

In the 0–2 months age group, 80% of all fissure segments were visible versus 92% in the 5–6 months group (p=0.04) and 95% in the 7–9 months group (p=0.01).

Conclusions

The ability to visualize pleural fissures on CT increases with infant age. This observation should be taken into consideration when choosing the optimal timing of preoperative CT for asymptomatic congenital lung lesions.

Congenital Lung Malformations: Unresolved Issues and Unanswered Questions

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

Expert surgical consensus for prenatal counseling using the Delphi method

BACKGROUND

Pediatric surgeons frequently offer prenatal consultation for congenital pulmonary airway malformation (CPAM) and congenital diaphragmatic hernia (CDH); however, there is no evidence-based consensus to guide prenatal decision making and counseling for these conditions. Eliciting feedback from experts is integral to defining best practice regarding prenatal counseling and intervention.

METHODS

A Delphi consensus process was undertaken using a panel of pediatric surgeons identified as experts in fetal therapy to address current limitations. Areas of discrepancy in the literature on CPAM and CDH were identified and used to generate a list of content and intervention questions. Experts were invited to participate in an online Delphi survey. Items that did not reach first-round consensus were broken down into additional questions, and consensus was achieved in the second round.

RESULTS

Fifty-four surgeons (69%) responded to at least one of the two survey rounds. During round one, consensus was reached on 54 of 89 survey questions (61%), and 45 new questions were developed. During round two, consensus was reached on 53 of 60 survey questions (88%).

CONCLUSIONS

We determined expert consensus to establish guidelines regarding perinatal management of CPAM and CDH. Our results can help educate pediatric surgeons participating in perinatal care of these patients.

LEVEL OF EVIDENCE

V.

Symptom development in originally asymptomatic CPAM diagnosed prenatally: a systematic review

PURPOSE

For the approximately three quarters of patients with a prenatal diagnosis of congenital pulmonary airway malformation (CPAM) who are asymptomatic at birth, the chance of eventually developing symptoms is unknown. We sought to explore the natural history of asymptomatic CPAM.

METHODS

We searched EMBASE, MEDLINE, and the first 50 results from Google Scholar. Studies describing the natural history of prenatally diagnosed, initially asymptomatic CPAM were included. For asymptomatic patients initially managed non-surgically, we tabulated the proportion who went on to develop symptoms as well as the median age at symptom development.

RESULTS

We included data from 19 retrospective studies on 353 patients. Of the 128 patients managed expectantly, 31 (24.2%) developed symptoms requiring surgical intervention. The median age at symptom development was 7.5 months (range 15 days-5 years).

CONCLUSION

The risk for developing respiratory symptoms exists with originally asymptomatic CPAM patients, but the exact risk is difficult to predict. Parents may be given the value of approximately 1 in 4 as an estimate of the proportion of asymptomatic CPAM patients who go on to develop symptoms, which will help them make an informed decision regarding the option of elective surgery.

Asymptomatic congenital lung malformations: Is nonoperative management a viable alternative?

INTRODUCTION

The purpose of this study was to evaluate clinical outcomes in children with asymptomatic congenital lung malformations (CLM) who were initially managed nonoperatively.

METHODS

An IRB-approved retrospective review was performed on all CLMs at a single tertiary care referral center (Jan 2006-Dec 2016, n=140). Asymptomatic cases that did not undergo elective resection were evaluated for subsequent CLM-related complications based on clinical records and a telephone quality of life survey.

RESULTS

Out of 39 (27.9%) who were initially managed nonoperatively, 13 (33%) developed CLM-related symptoms and underwent surgical intervention at a median age of 6.8years (range, 0.7-19.8years). The most common indication for conversion to operative management was pneumonia (78%). Larger lesions, as measured by CT scan, were significantly associated with the need for subsequent surgical intervention (mean maximal diameter, 5.7 vs. 2.9cm; p=0.005). Based on survey data with a median follow up of 3.9years (range, 0.2-13.2years), 17% developed chronic pulmonary symptoms, including cough (11%) and asthma requiring bronchodilators (12%).

CONCLUSION

Although these data support nonoperative management as a viable alternative to surgical resection, at least one-third of CLM children eventually develop pneumonia or other pulmonary symptoms. Larger lesions are correlated with an increased risk for eventual surgical resection.

LEVEL OF EVIDENCE

Level IV.