Congenital cystic adenomatoid malformation in adults: Report of a case presenting with a recurrent pneumothorax and a literature review of 60 cases

Thoracoscopic surgery for rare congenital pulmonary airway malformations in adults: a decade of retrospective study

Background

Congenital pulmonary airway malformation (CPAM) is a rare benign deformity of the lungs in adults. Our study aimed to evaluate the clinical features and compare the effect of thoracoscopic lobectomy and wedge resection for adult CPAMs.

Methods

This was a retrospective study including eighteen adults with CPAMs recruited between 2013 and 2023. Radiological scans and pulmonary function test (PFT) were performed before operation. All the patients were treated with thoracoscopic approach, which were categorized into groups of lobectomy and wedge resection. The baseline, preoperative, and operative data were evaluated and analyzed.

Results

Four males and fourteen females were diagnosed with CPAMs at a median age of 57.5 years. Cough was the main symptom, reported by 55.6% of the patients. CPAMs were always initially misdiagnosed as other conditions due to heterogeneous computed tomography (CT) characteristics. The mean of PFT results showed normal (>80% predicted) in forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and FEV1 to FVC ratio (FEV1/FVC), but less than 70% predicted in forced expiratory flow (FEF) at 25-75%, 50% and 75% of FVC. All patients underwent video-assisted thoracic surgery (VATS) with a total of nine wedge resections and nine lobectomies. Age at surgery varied statistically between the two groups. Whereas, duration of surgery, blood loss, postoperative drainage, days of drainage, days of hospitalization and postoperative complications showed no statistical difference between the two groups. There were 27.8% of the lesions showing CPAMs mixed with other diseases during histological evaluations.

Conclusions

CPAM in adults showed a complex presentation in terms of clinical symptoms, imaging performance and pathological findings. Half of the patients were detected with small airway dysfunction preoperatively. Thoracoscopic lobectomy and wedge resection for the treatment can achieve satisfactory short-term outcomes.

The underlying molecular mechanism of ciliated epithelium dysfunction and TGF-β signaling in children with congenital pulmonary airway malformations

The aim of this study was to investigate the variation in gene expression in the complete transcripts of Congenitalpulmonary airwaymalformation (CPAM) of the lung using Next Generation Sequencing (NGS) technology. There were 20 cases involving children with CPAM were used for selection of study sample. NGS was used to establish RNA-Seq libraries for the two groups of samples separately, and both groups were conducted to differential expression analysis and Gene Ontology (GO) functional enrichment analysis. The pathways of the differential genes were analyzed to find the enriched target pathways. A total of 592 genes were expressed with significant differences (CPAM vs. normal tissue, P < 0.05). GO functional analysis of DEGs indicated that abnormal ciliary function played a role in the development of CPAM. Subsequently, analysis of these genes pathways showed the TGF-β signaling pathway was significantly enriched. Finally, the results of immunohistochemical analysis of some DEGs showed that a significant reduction in the expression of SMAD6, a gene related to the TGF-β signaling pathway, led to abnormal activation of the pathway. TGF-β signaling pathway involved in the evolution of the disease obtained by DEGs enrichment pathway analysis. SMAD6, a gene involved in this pathway, might be a potential biomarker for the diagnosis and treatment of CPAM.

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.

Congenital pulmonary airway malformation complicated by aspergilloma: A rare adulthood presentation - Case report

Congenital Pulmonary Airway Malformation (CPAM) is an uncommon condition in adults, which typically presents as acute fever and lung abscesses caused by bacterial infections. We present a case of a 39-year-old female with a CPAM in the upper lobe of the right lung, complicated by an aspergilloma, who presented with a history of hemoptysis. The patient underwent an upper lobectomy and is symptom-free in follow-up. 2012 Elsevier Ltd. All rights reserved.

Congenital cystic adenomatoid malformation associated with right aortic arch with mirror image branching and absence of left pulmonary artery in an adult

Background

Congenital cystic adenomatoid malformation is an uncommon developmental anomaly that is diagnosed prenatally or during early childhood and is rare to present in adulthood. Type 2 congenital cystic adenomatoid malformation is often associated with other anomalies such as congenital cardiac anomalies. We present a case of type 2 congenital cystic adenomatoid malformation in an adult male associated with absence of left pulmonary artery and right aortic arch with mirror image branching. To our knowledge, this is the first case report with the combination of all three anomalies.

Case presentation

A 33-year-old male presented to the Department of Pulmonary Medicine with high-grade fever, chills and rigor, breathlessness, and productive cough for a duration of one week. He had multiple similar self-limiting episodes in the past which did not require hospitalization. The plain radiograph showed right aortic arch and a small left hilum. CT thorax showed multiple cystic lesions of size 0.5–2.0 cm in the apico-posterior segment of the left upper lobe; anterior, posterior, and lateral segments of the left lower lobe; and the apical segment of the right upper lobe with a maximal cyst wall thickness of 2 mm. Volume of left lung was reduced with trans-thoracic herniation of the medial segment of the right middle lobe; bronchiectatic changes were seen in the apical, anterior, and posterior segments of the right upper lobe; and fibrotic strands were seen in the apical segment of the right lower lobe and the apico-posterior segment of the right upper lobe. Mediastinal window showed right-sided aortic arch with mirror image branching. The pulmonary trunk was seen to continue as the right pulmonary artery with absent left pulmonary artery.

Conclusions

Though congenital cystic adenomatoid malformation is a disease of infancy and childhood, it should also be considered in adults presenting with recurrent lower respiratory tract infections and/or pneumothorax. Radiologists must be aware of the types of congenital cystic adenomatous malformation (CCAM) and their associations, as type 2 CCAM has a high association with congenital cardiac disease. Proximal interruption of pulmonary artery should be considered if the pulmonary trunk continues as either right or left pulmonary artery.

Unusual Congenital Lesion Masquerading as a Lung Mass in an Adult

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

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

Introduction

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

Case presentation

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

Clinical discussion

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

Conclusion

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