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Bose SK, Stratigis JD, Ahn N, Pogoriler J, Hedrick HL, Rintoul NE, Partridge EA, Flake AW, Khalek N, Gebb J, Teefey CP, Soni S, Hamaguchi R, Moldenhauer J, Adzick NS, Peranteau WH. Prenatally Diagnosed Large Lung Lesions: Timing of Resection and Perinatal Outcomes. J Pediatr Surg 2023; 58:2384-2390. [PMID: 37813715 DOI: 10.1016/j.jpedsurg.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/21/2023] [Accepted: 09/04/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION Fetuses with large lung lesions including congenital cystic adenomatoid malformations (CCAMs) are at risk for cardiopulmonary compromise. Prenatal maternal betamethasone and cyst drainage for micro- and macrocystic lesions respectively have improved outcomes yet some lesions remain large and require resection before birth (open fetal surgery, OFS), at delivery via an Ex Utero Intrapartum Treatment (EXIT), or immediately post cesarean section (section-to-resection, STR). We sought to compare prenatal characteristics and outcomes in fetuses undergoing OFS, EXIT, or STR to inform decision-making and prenatal counseling. METHODS A single institution retrospective review was conducted evaluating patients undergoing OFS, EXIT, or STR for prenatally diagnosed lung lesions from 2000 to 2021. Specimens were reviewed by an anatomic pathologist. Lesions were divided into "CCAMs" (the largest pathology group) and "all lung lesions" since pathologic diagnosis is not possible during prenatal evaluation when care decisions are made. Prenatal variables included initial, greatest, and final CCAM volume-ratio (CVR), betamethasone use/frequency, cyst drainage, and the presence of hydrops. Outcomes included survival, ECMO utilization, NICU length of stay (LOS), postnatal nitric oxide use, and ventilator days. RESULTS Sixty-nine percent (59 of 85 patients) of lung lesions undergoing resection were CCAMs. Among patients with pathologic diagnosis of CCAM, the initial, largest, and final CVRs were greatest in OFS followed by EXIT and STR patients. Similarly, the incidence of hydrops was significantly greater and the rate of hydrops resolution was lower in the OFS group. Although the rate of cyst drainage did not differ between groups, maternal betamethasone use varied significantly (OFS 60.0%, EXIT 100.0%, STR 74.3%; p = 0.0378). Notably, all OFS took place prior to 2014. There was no difference in survival, ventilator days, nitric oxide, NICU LOS, or ECMO between groups. In multiple variable logistic modeling, determinants of survival to NICU discharge among patients undergoing resection with a pathologic diagnosis of CCAM included initial CVR <3.5 and need for <3 maternal betamethasone doses. CONCLUSION For CCAMs that remain large despite maternal betamethasone or cyst drainage, surgical resection via OFS, EXIT, or STR are viable options with favorable and comparable survival between groups. In the modern era there has been a shift from OFS and EXIT procedures to STR for fetuses with persistently large lung lesions. This shift has been fueled by the increased use of maternal betamethasone and introduction of a Special Delivery Unit during the study period and the appreciation of similar fetal and neonatal outcomes for STR vs. EXIT and OFS with reduced maternal morbidity associated with a STR. Accordingly, efforts to optimize multidisciplinary perinatal care for fetuses with large lung lesions are important to inform patient selection criteria and promote STR as the preferred surgical approach in the modern era. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sourav K Bose
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - John D Stratigis
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nicholas Ahn
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jennifer Pogoriler
- Department of Pathology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Holly L Hedrick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Emily A Partridge
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Nahla Khalek
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julianna Gebb
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christina Paidas Teefey
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shelly Soni
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryoko Hamaguchi
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie Moldenhauer
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William H Peranteau
- Division of General, Thoracic and Fetal Surgery, Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Rotenberg O, Fridman D, Doulaveris G, Renz M, Kaplan J, Gebb J, Xie X, Goldberg GL, Dar P. Long-term outcome of postmenopausal women with non-atypical endometrial hyperplasia on endometrial sampling. Ultrasound Obstet Gynecol 2020; 55:546-551. [PMID: 31389091 DOI: 10.1002/uog.20421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 07/15/2019] [Accepted: 07/26/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To assess the long-term outcome of postmenopausal women diagnosed with non-atypical endometrial hyperplasia (NEH). METHODS This was a retrospective study of women aged 55 or older who underwent endometrial sampling in our academic medical center between 1997 and 2008. Women who had a current or recent (< 2 years) histological diagnosis of NEH were included in the study group and were compared with those diagnosed with atrophic endometrium (AE). Outcome data were obtained until February 2018. The main outcomes were risk of progression to endometrial carcinoma and risk of persistence, recurrence or new development of endometrial hyperplasia (EH) ('persistent EH'). Logistic regression analysis was used to identify covariates that were independent risk factors for progression to endometrial cancer or persistent EH. RESULTS During the study period, 1808 women aged 55 or older underwent endometrial sampling. The median surveillance time was 10.0 years. Seventy-two women were found to have a current or recent diagnosis of NEH and were compared with 722 women with AE. When compared to women with AE, women with NEH had significantly higher body mass index (33.9 kg/m2 vs 30.6 kg/m2 ; P = 0.01), greater endometrial thickness (10.00 mm vs 6.00 mm; P = 0.01) and higher rates of progression to type-1 endometrial cancer (8.3% vs 0.8%; P = 0.0003) and persistent NEH (22.2% vs 0.7%; P < 0.0001). They also had a higher rate of progression to any type of uterine cancer or persistent EH (33.3% vs 3.5%; P < 0.0001). Women with NEH had a significantly higher rate of future surgical intervention (51.4% vs 15.8%; P < 0.0001), including future hysterectomy (34.7% vs 9.8%; P < 0.0001). On multivariable logistic regression analysis, only NEH remained a significant risk factor for progression to endometrial cancer or persistence of EH. CONCLUSIONS Postmenopausal women with NEH are at significant risk for persistent EH and progression to endometrial cancer, at rates higher than those reported previously. Guidelines for the appropriate management of postmenopausal women with NEH are needed in order to decrease the rate of persistent disease or progression to cancer. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- O Rotenberg
- Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Canter, Bronx, New York, NY, USA
| | - D Fridman
- Department of Obstetrics and Gynecology, Duke University, Durham, NC, USA
| | - G Doulaveris
- Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Canter, Bronx, New York, NY, USA
| | - M Renz
- Department of Obstetrics and Gynecology, Gynecologic Oncology, Stanford University, Stanford, CA, USA
| | - J Kaplan
- Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Canter, Bronx, New York, NY, USA
| | - J Gebb
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA
| | - X Xie
- Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Canter, Bronx, New York, NY, USA
| | - G L Goldberg
- Department of Obstetrics and Gynecology, Gynecologic Oncology, Northwell Health, LIJ Medical Center, New Hyde Park, New York, NY, USA
| | - P Dar
- Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Canter, Bronx, New York, NY, USA
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Zidere V, Gebb J, Vigneswaran T, Charakida M, Simpson JM, Bower S. Spontaneous resolution of large pericardial effusion associated with right ventricular outpouching in four fetuses. Ultrasound Obstet Gynecol 2019; 54:701-702. [PMID: 30549363 DOI: 10.1002/uog.20194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 12/07/2018] [Indexed: 06/09/2023]
Affiliation(s)
- V Zidere
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, London, UK
| | - J Gebb
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, PA, USA
| | - T Vigneswaran
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, London, UK
| | - M Charakida
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, London, UK
- Division of Imaging Sciences, King's College London British Heart Foundation Centre, NIHR Biomedical Research Centre, Guy's & St Thomas', NHS Foundation Trust, London, UK
| | - J M Simpson
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St Thomas' NHS Trust, London, UK
| | - S Bower
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Capone CA, Gebb J, Dar P, Shenoy RU. Favorable neurodevelopmental outcome in a hypothyroid neonate following intracordal amiodarone for cardioversion of refractory supraventricular tachycardia in a fetus. J Neonatal Perinatal Med 2014; 7:305-309. [PMID: 25468615 DOI: 10.3233/npm-14814017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Fetal supraventricular tachycardia (SVT), characterized by a fetal ventricular heart rate faster than 200 beats per minute (bpm), is often diagnosed during routine fetal heart monitoring or prenatal ultrasound examinations. Clinical guidelines for management of fetal SVT have not been determined in standardized trials, nor do we have a clear sense regarding the long-term developmental outcomes and side effects of in utero antiarrhythmic therapy. We describe our approach to the treatment of refractory SVT in a fetus with hydrops using direct umbilical vein treatment with amiodarone coupled with effusion evacuation. We successfully achieved in utero resolution of SVT. There was transient amiodarone-induced hypothyroidism, which we screened for early and treated with Synthroid. Ultimately our patient had normal long-term growth and development as measured by modified Denver office checklists and Ages and Stages questionnaires. Our experience advocates for vigilant screening and management of hypothyroidism in fetuses exposed to in utero amiodarone and suggests that it is possible to achieve good outcomes in high-acuity refractory cases of SVT.
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Affiliation(s)
- C A Capone
- Department of Pediatrics, Division of Pediatric Cardiology, The Children's Hospital at Montefiore-Albert Einstein College of Medicine, Bronx, NY, USA
| | - J Gebb
- Department of Obstetrics, Gynecology & Women's Health, Montefiore Medical Center-Albert Einstein College of Medicine, Bronx, NY, USA
| | - P Dar
- Department of Obstetrics, Gynecology & Women's Health, Montefiore Medical Center-Albert Einstein College of Medicine, Bronx, NY, USA
| | - R U Shenoy
- Department of Pediatrics, Division of Pediatric Cardiology, The Children's Hospital at Montefiore-Albert Einstein College of Medicine, Bronx, NY, USA
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