Prenatally Diagnosed Large Lung Lesions: Timing of Resection and Perinatal Outcomes

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.

A complete spectrum of congenital cystic adenomatoid malformation of the lung deceptive clinical presentations and histological surprises; a single institutional study from a tertiary care hospital in North India

Background

Congenital Cystic Adenomatoid Malformations (CCAM) are rare congenital anomalies of the lungs characterised by bronchopulmonary foregut malformations due to a sudden arrest in the development of the bronchial tree in the first trimester of the gestational period.

Aim

: The present study was aimed to describe the clinical and histopathological profiles of the patients and study patient outcomes after 1 year of surgical resection.

Methods

All patients diagnosed with CCAM by histological examination of tissue obtained on surgical resection during the study period were included in the study. Data, such as patient demographics and clinical, radiological and histopathological findings, were recorded, and follow-up information was taken on OPD follow-up till 1 year after surgery regarding respiratory infections, haemoptysis or mortality.

Results

: Out of 21 patients, 11 were female and included in the study between the ages of 1 month and 32 years, with >50% younger than 2 years. Most patients in the study had recurrent pneumonia, with difficulty in breathing being the second most common presenting complaint. All patients had undergone computed tomography (CT) of the lungs, which was able to diagnose cystic lesions accurately in >80% of cases. Histologically, all cases were classified based on recent Strocker's classification, and Type 1 was the most commonly observed with 13 cases, followed by Type 2 in five and Type 3 in three patients. There was no evidence of malignant transformation in any of the cases. There was 100% survival at the end of 1 year, with six patients having respiratory infections and none of the patients getting hospitalised over 1 year after surgery.

Conclusion

CCAM is a rare congenital anomaly associated with significant morbidity and may present at any age. It can be histologically classified into three subtypes, with Type 1 being the most common. Early surgical management is mandatory to prevent complications such as recurrent infections, respiratory distress, pneumothorax, lung abscess and malignant transformation. All patients included in the study had undergone surgical resection, and there was 100% survival at 1-year follow-up.

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 pulmonary airway malformation in a 5 month old boy, complicated by pneumonia

Congenital cystic lesions of the lung are rare. The most common congenital anomaly among them, involving the lower respiratory tract, is congenital cystic adenomatoid malformation (CCAM), currently referred to as congenital pulmonary airway malformation (CPAM). They may be incidentally detected on prenatal or postnatal imaging. They usually present within two years of life, rarely in adults. CPAMs may be asymptomatic at birth. Some may opt for observation alone due to lack of evidence on the incidence of long-term complications. However, rarely has a CPAM remained asymptomatic throughout life and complications eventually develop. Pneumonia is most common, which is not amenable to medical treatment alone. CPAMs are notorious for their known malignant potential and they may also lead to pneumothorax, hemoptysis and hemothorax. Computed Tomography Thorax is the investigation of choice. Surgical resection is known to be safe and is the mainstay of treatment. For patients who are diagnosed prenatally, surgery is recommended at 3 to 6 months, so that compensatory lung growth can occur. A five-month old boy from Bhutan, with cough, intermittent fever, respiratory distress and a history of recurrent lower respiratory tract infections, was diagnosed with CPAM, complicated by pneumonia and underwent surgery at our centre, following optimal medical management viz. antibiotics and supplemental oxygen. The post-operative course was relatively uneventful and he was discharged from hospital in 7 days.

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.

5G connected and automated driving: use cases, technologies and trials in cross-border environments

Cooperative, connected and automated mobility (CCAM) across Europe requires harmonized solutions to support cross-border seamless operation. The possibility of providing CCAM services across European countries has an enormous innovative business potential. However, the seamless provision of connectivity and the uninterrupted delivery of real-time services pose technical challenges which 5G technologies aim to solve. The situation is particularly challenging given the multi-country, multi-operator, multi-telco-vendor, multi-car-manufacturer and cross-network-generation scenario of any cross-border scenario. Motivated by this, the 5GCroCo project, with a total budget of 17 million Euro and partially funded by the European Commission, aims at validating 5G technologies in the Metz-Merzig-Luxembourg cross-border 5G corridor considering the borders between France, Germany and Luxembourg. The activities of 5GCroCo are organized around three use cases: (1) Tele-operated Driving, (2) high-definition map generation and distribution for automated vehicles and (3) Anticipated Cooperative Collision Avoidance (ACCA). The results of the project help contribute to a true European transnational CCAM. This paper describes the overall objectives of the project, motivated by the discussed challenges of cross-border operation, the use cases along with their requirements, the technical 5G features that will be validated and provides a description of the planned trials within 5GCroCo together with some initial results.

To What Extent is Internet Activity Predictive of Psychological Well-Being?

Background

Healthy internet activity (eg, making use of eHealth and online therapy) is positively associated with well-being. However, unhealthy internet activity (too much online time, problematic internet use/PIU, internet dependency/ID, etc.) is associated with reduced well-being, loneliness, and other related negative aspects. While most of the evidence is correlational, some research also shows that internet activity can be predictive for well-being.

Objective

The aim of this article is to elaborate on the question as to what extent internet activity is predictive of psychological well-being by means of (a) a scoping review and (b) theoretical understanding which model the interrelation of internet activity and psychological well-being.

Methodology

We searched different electronic databases such as Web of Science by using the search terms "Internet" OR "App" OR "digital" OR "online" OR "mobile application" AND "Use" OR "Activity" OR "Behavior" OR "Engagement" AND "Well-being" OR "Loneliness" for (a, the scoping review) or CCAM for (b, the theoretical understanding).

Results

The scoping review (a) summarizes recent findings: the extent to which internet activity is predictive for well-being depends on the internet activity itself: internet activity facilitating self-management is beneficial for well-being but too much internet activity, PIU and ID are detrimental to well-being. To understand (b) why, when and how internet activity is predictive for well-being, theoretical understanding and a model are required. While theories on either well-being or internet activity exist, not many theories take both aspects into account while also considering other behaviors. One such theory is the Compensatory Carry-Over Action Model (CCAM) which describes mechanisms on how internet use is related to other lifestyle behaviors and well-being, and that individuals are driven by the goal to adopt and maintain well-being - also called higher-level goals - in the CCAM. There are few studies testing the CCAM or selected aspects of it which include internet activity and well-being. Results demonstrate the potentials of such a multifactorial, sophisticated approach: it can help to improve health promotion in times of demographic change and in situations of lacking personnel resources in health care systems.

Conclusion and Recommendation

Suggestions for future research are to employ theoretical approaches like the CCAM and testing intervention effects, as well as supporting individuals in different settings. The main aim should be to perform healthy internet activities to support well-being, and to prevent unhealthy internet activity. Behavior management and learning should accordingly aim at preventing problematic internet use and internet dependency.

Prenatal natural history of congenital pulmonary malformations: MALFPULM population-based cohort study

OBJECTIVES

To assess prenatal changes in the volume of congenital pulmonary malformations (CPM) and examine whether these changes differ in lesions that appear cystic on ultrasound compared with hyperechoic lesions, and to study the relationship between CPM volume and risk of fetal compression.

METHODS

We conducted a nationally representative, multicenter, prospective cohort study, which included 579 ultrasound examinations in 176 pregnant women with a diagnosis of fetal CPM, between March 2015 and November 2016. Several ultrasound examinations were performed between diagnosis and delivery, including measurement of CPM volume. We modeled changes in CPM volume ratio (CVR) as a function of gestational age, overall and for cystic/mixed vs hyperechoic malformations, and examined the association between CVR and signs of compression during pregnancy.

RESULTS

When modeling CVR changes over time, there was a statistically significant decrease in CVR with increasing gestational age (P < 0.001), but the pattern of change differed according to CPM phenotype at first ultrasound examination: cystic/mixed CPM were characterized by a monotonic decrease in CVR with increasing gestational age (P = 0.002), whereas hyperechoic CPM showed an initial increase in CVR up to 27 weeks of gestation, followed by a decrease thereafter (P < 0.001). Peak CVR values were predicted as early as 21-22 weeks for cystic/mixed CPMs compared with 25-26 weeks for hyperechoic malformations. Regardless of CPM phenotype, fetuses that showed no sign of compression at any point had substantially lower CVR at first CVR measurement, and the CVR remained relatively constant thereafter. Among the subpopulation of fetuses with no sign of compression at first CVR measurement, the odds of a subsequent compression was 7-fold higher (adjusted odds ratio, 7.0; 95% CI, 1.6-29.9) if initial CVR was > 0.4 vs CVR ≤ 0.4 cm² .

CONCLUSIONS

Predicted changes in CVR during pregnancy differ between cystic and hyperechoic malformations. This may be the result of different pathophysiological mechanisms or differences in the timing of occurrence of these different types of CPM. CVR measured at the initial diagnostic ultrasound examination was strongly associated with the odds of subsequent compression. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Congenital cystic adenomatoid malformation of the lung in adults: report of two cases and review of the literature

Congenital cystic adenomatoid malformation (CCAM) is characterized by adenomatoid proliferation of bronchiole-like structures and cysts formation. It isan uncommon cause of respiratory distress in infants. Most common presentation is in first two years of life with complaints of respiratory distress.Presentation in adulthood is rare. Surgical intervention is the mainstay treatment.We describe two cases of atypical CCAM presenting in adulthood with past history of tuberculosis. To our knowledge only one case of CCAM with tuberculosis has been reported in literature.

Usefulness of fetal magnetic resonance imaging for postnatal management of congenital lung cysts: prediction of probability for emergency surgery

BACKGROUND

Emergency rescue lung resection is rarely performed to treat congenital lung cysts (CLCs) in neonates. Many reports have described fetal CLC treatment; however, prenatal predictors for postnatal respiratory failure have not been characterized. We hypothesized that fetal imaging findings are useful predictors of emergency surgery.

METHODS

We retrospectively studied patients with CLC who underwent lung surgery during the neonatal period in our hospital between January 2001 and December 2015. The demographic data, fetal imaging findings, and intra- and postoperative courses of patients who underwent emergency surgery (Em group) were compared with those of patients who received elective surgery, i.e., non-emergency surgery (Ne group).

RESULTS

The Em group and Ne group included 7 and 11 patients, respectively. No significant difference was noted in gestational age, time at prenatal diagnosis, birth weight, and body weight at surgery. The volumes of contralateral lung per thoracic volume were significantly smaller in the Em group than in the Ne group (p = 0.0188). Mediastinal compression was more common in the Em group (7/7) than in the Ne group (4/11) (p = 0.0128).

CONCLUSIONS

This is the report describing neonatal emergency lobectomy in patients with CLC evaluated by fetal MRI using the lung volume ratio and mediastinal shift. In patients with CLC, mediastinal shift and significant decreases in contralateral lung volumes during the fetal stages are good prenatal predictors of postnatal emergency lung resection.

Pathology of asymptomatic, prenatally diagnosed cystic lung malformations

AIM

The management of asymptomatic congenital cystic lung malformations is controversial. Arguments for excision of asymptomatic lesions are the potential for infection and malignancy. Following antenatal detection, our institute performs a CT at 1month, clinic follow-up by 3months to discuss the controversial management, and offers surgery by 6months of age. We investigated the histopathology of asymptomatic lesions to determine whether there was evidence of subclinical infection or malignancy.

METHODS

A retrospective review of prospectively collected antenatal congenital cystic lung malformations more than a 10year period (2005-2014) was conducted. Information was gathered from the antenatal registry and histopathology reports. Infection was defined by the presence of microabscesses or neutrophil/macrophage infiltration, as per histopathological criteria.

MAIN RESULTS

From the cohort of 99 patients, the study focused on 69 asymptomatic lesions. These cases comprised 34 congenital pulmonary airway malformations (CPAM), 15 pulmonary sequestrations (PS), and 20 hybrid lesions. Eighteen cases (26%) had microscopic disease - 16 cases of infection and 2 tumors. The infectious cases comprised 7 with microabscesses and 9 with neutrophil/macrophage infiltration. There were two cases of tumors, namely pleuropulmonary blastoma. These tumors were followed up by the oncology team with regular imaging until 3years of age and clinical review thereafter.

CONCLUSION

Twenty-six percent of antenatally detected, asymptomatic cystic lung malformations demonstrated either subclinical infection or malignancy. This information can be used for counseling parents and determining the method of treatment.

Effect of single and multiple courses of maternal betamethasone on prenatal congenital lung lesion growth and fetal survival

PURPOSE

Administration of maternal betamethasone (BMZ) is a therapeutic option for fetuses with large microcystic congenital lung lesions at risk for, or causing, hydrops. Not all fetuses respond to a single course of BMZ. We review our experience with the use of single and multiple courses of maternal BMZ for the management of these patients.

METHODS

A retrospective review of fetuses with congenital lung lesions managed with maternal BMZ from 2003 to 2014 was performed.

RESULTS

Forty-three patients were managed with prenatal steroids (28 single course, 15 multiple courses). Single course recipients demonstrated a reduction in lesion size and resolution of hydrops in 82% and 88% of patients respectively compared to 47% and 56% in recipients of multiple steroid courses. Survival of multiple course patients (86%) was comparable to that of single course patients (93%) and improved compared to non-treated historical controls. Multiple course recipients demonstrated an increased need for open fetal surgery and postnatal surgery at a younger age.

CONCLUSION

Fetuses who fail to respond to a single course of BMZ may benefit, as indicated by hydrops resolution and improved survival, from additional courses. However, failure to respond is indicative of a lesion which may require fetal or immediate neonatal resection.

Surgical intervention strategies for pediatric congenital cystic lesions of the lungs: A 20-year single-institution experience

BACKGROUND

The aim of this study was to assess surgical intervention strategies for congenital cystic lesions of the lungs (CCL), focusing on the safety of lung resection.

MATERIALS AND METHODS

The clinical features of 27 children (CCAM, n=16; bronchial atresia, n=4; bronchogenic cyst, n=3; pulmonary sequestration, n=3; lobar emphysema, n=1) who were treated at our institution between 1995 and 2014 were analyzed.

RESULTS

Of the 27 patients, 14 were asymptomatic, and 13 were symptomatic. The youngest symptomatic patient presented with pneumonia at 9months of age. The mean age at surgery was 4months in the asymptomatic group and 4.1years in the symptomatic group. The mean operating time was 167minutes in the asymptomatic group and 275minutes in the symptomatic group (P<0.001). The mean amount of intraoperative bleeding was 15g in the asymptomatic group and 83.4g in the symptomatic group (P<0.05). All of the prenatally diagnosed patients underwent surgery within six months of birth. Three patients had remnant cystic lesions, all of which involved cystic lesions located over the lobulation anomalies of the lung.

CONCLUSIONS

To minimize surgical invasiveness, surgery for CCL should be performed during the asymptomatic period or within six months after birth.

The argument for operative approach to asymptomatic lung lesions

Antenatal detection of congenital pulmonary airway malformations (CPAM) has improved immeasurably from its initial application in the 1980s and probably encompasses >80% of all such lesions. Accurate diagnosis still remains less reliable and definitive diagnosis requires detailed anatomical imaging (typically with CT scan) in the post-natal period. About 10% of all lesions will present with symptoms during the neonatal period and the choice of surgical intervention is then easy. For those that remain asymptomatic then there is still a degree of controversy about elective surgical resection. This article presents the case for elective surgery within the first year of life and aims to quantify the risks of non-intervention such as abscess, empyema, recurrent pneumonia, air-leak, and pneumothorax and various types of malignancy in such cases. The current surgical approach now includes both open muscle-sparing thoracotomy and thoracoscopic resection.

Congenital lung lesions: Prenatal diagnosis and intervention

Congenital lung lesions are common sonographic findings in pregnancy, usually detected at the routine 20 weeks scan. The most common is cystic adenomatous malformation of the lung (CCAM). This usually causes few prenatal problems; however, fetal hydrops occurs in about 5%. Prenatal intervention for these is possible in many to allow survival to birth. Bronchoplumonary sequestration (BPS), with an aberrant "feeder" vessel arising from the aorta may co-exist but is detectable as a separate entity by visualization of this vessel. Symptomatic or curative prenatal intervention is again possible in the few severe cases where hydrops or pleural effusions develop. Pleural effusions may be due to a primary leak usually of chylous fluid: prenatal thoracoamniotic shunting may prevent pulmonary hyoplasia or cure the consequent fetal hydrops. More often, however, effusions are a consequence of an underlying abnormality, including many structural or chromosomal abnormalities that may also cause co-existing fetal hydrops. Congenital high airway obstruction (CHAOS) is commonly fatal but cases potentially amenable to prenatal intervention or to immediate perinatal management may be identified using ultrasound or MRI.

Fetal MRI lung volumes are predictive of perinatal outcomes in fetuses with congenital lung masses

PURPOSE

The purpose of this study was to evaluate fetal magnetic resonance imaging (MRI) as a modality for predicting perinatal outcomes and lung-related morbidity in fetuses with congenital lung masses (CLM).

METHODS

The records of all patients treated for CLM from 2002 to 2012 were reviewed retrospectively. Fetal MRI-derived lung mass volume ratio (LMVR), observed/expected normal fetal lung volume (O/E-NFLV), and lesion-to-lung volume ratio (LLV) were calculated. Multivariate regression and receiver operating characteristic analyses were applied to determine the predictive accuracy of prenatal imaging.

RESULTS

Of 128 fetuses with CLM, 93% (n=118) survived. MRI data were available for 113 fetuses. In early gestation (<26weeks), MRI measurements of LMVR and LLV correlated with risk of fetal hydrops, mortality, and/or need for fetal intervention. In later gestation (>26weeks), LMVR, LLV, and O/E-NFLV correlated with neonatal respiratory distress, intubation, NICU admission and need for neonatal surgery. On multivariate regression, LMVR was the strongest predictor for development of fetal hydrops (OR: 6.97, 1.58-30.84; p=0.01) and neonatal respiratory distress (OR: 12.38, 3.52-43.61; p≤0.001). An LMVR >2.0 predicted worse perinatal outcome with 83% sensitivity and 99% specificity (AUC=0.94; p<0.001).

CONCLUSION

Fetal MRI volumetric measurements of lung masses and residual normal lung are predictive of perinatal outcomes in fetuses with CLM. These data may assist in perinatal risk stratification, counseling, and resource utilization.

Mainstem bronchial atresia: a lethal anomaly amenable to fetal surgical treatment

PURPOSE

The purpose of this study was to review the unique imaging characteristics, prenatal course, and outcomes for fetuses with mainstem bronchial atresia (MBA).

METHODS

The records of all patients referred for a fetal lung malformation from 2001 to 2012 and the medical literature were reviewed to identify cases of MBA.

RESULTS

Of 129 fetuses evaluated, 3 were diagnosed prenatally with right-sided MBA. The first had a CCAM-volume ratio (CVR) of 9, hydrops, mirror syndrome, and preterm delivery of a nonviable fetus. The second (CVR 2.6) had ascites, preterm delivery at 34-weeks, and neonatal demise. The third fetus (CVR 5.7) presented with hydrops at 21-weeks, prompting fetal pneumonectomy. Postoperatively, hydrops resolved, and the contralateral lung grew dramatically, but preterm delivery occurred 3 weeks later. Ventilation could not be sustained, and the infant died. Four similar cases of MBA were in the literature, all right-sided. Two fetuses with hydrops delivered at 25-weeks and died immediately. One pregnancy was terminated. One fetus underwent pneumonectomy at 24-weeks but died intraoperatively.

CONCLUSION

MBA is a rare and lethal lesion that must be distinguished from other right-sided lung masses. Fetal pneumonectomy can be performed with resolution of hydrops and compensatory contralateral lung growth, but remains limited by complications of preterm birth.

Sparing-lung surgery for the treatment of congenital lung malformations

PURPOSE

Congenital lung malformations (CLM) are traditionally treated by pulmonary lobectomy. The foremost indication for surgery is that these lesions predispose to respiratory tract infections and to malignancy. Owing to the improvement of prenatal diagnosis, most patients are operated in a timely manner and prophylactically. In this context, lung-sparing surgery (LS) has gained interest as a lung preservation strategy, especially for asymptomatic patients. In the present study, we evaluated both thoracoscopic and open lung-preserving resections as an alternative to lobectomy for CLM resection.

METHODS

We retrospectively reviewed all patients who underwent lung-sparing resection (segmentectomy and atypical resection) for CLM from 2001 to 2010. Data were collected regarding preoperative diagnostic workup, type of intervention, and follow up.

RESULTS

Fifty-four patients received LS for CLM during the study period. Twenty-six were approached thoracoscopically, with 18 cases requiring open conversion for a complete resection. There were six postoperative complications: three asymptomatic pneumothoraces that resolved without intervention, one tension pneumothorax that required replacement of a drainage catheter, and three instances of intra-operative bleeding requiring blood transfusion. Mean duration of follow-up was 65.2 months. Two patients experienced pneumonia during the follow-up period. A third patient had a cystic lung lesion on postoperative computed tomography (CT) which required a second-look surgery.

CONCLUSIONS

LS for CLM is a safe and effective means of lung parenchymal preservation in pediatric patients. Complication rates are comparable to that of traditional lobectomy. In our experience, this type of lung surgery does not carry a higher risk of residual disease and recurrence if accurately planned in selected patients, i.e., those with small asymptomatic lesions. The complication rate is acceptable and apparently not affected by preoperative symptoms. The thoracoscopic approach is recommended, although open conversion should be advocated to avoid too long operative times.

Antenatally diagnosed congenital cystic adenomatoid malformations (CCAM): Research Review

Prenatal identification of lung abnormalities has increased with prenatal surveillance. With the advent of improved antenatal imaging over the past ten years, the diagnosis, assessment and management of congenital cystic lung abnormalities have changed. These were once considered the exclusive domain of the surgeon, who had the authority to operate on all congenital cystic lung abnormalities regardless of size or clinical signs in order to avoid the risk of cancer and improve lung growth in even asymptomatic infants. Clinicians are reconsidering this approach in the light of the spontaneous improvement and possible resolution that occurs over months to years with many of these lesions, thinking about the opportunity to take a more conservative approach in many minimally symptomatic or asymptomatic infants in the early months of life. The risks of subsequent cancer are poorly understood and probably overstated. Many centers advocate surgery only in cases of symptomatic or significant lesions, although there is little consensus as to what constitutes a significant lesion.This article will review current knowledge (classification, pathogenesis, genetics, prenatal evaluation, clinical implications) on congenital cystic adenomatoid malformations (CCAM) and discuss management options for young children with these lung abnormalities.

Is counselling for CCAM that difficult? Learning from parental experience

OBJECTIVE

Cystic adenomatoid malformations (CCAM) are relatively rare developmental abnormalities of the lung. Despite outcome is usually benign, parents often exhibit high anxiety level. The purpose of the present study was to collect parents'subjective experience of communication of diagnosis when expecting a fetus with CCAM.

METHODS

In the period ranging between 2004 to 2007 all couples referred to our hospital for prenatal suspicion of CCAM, were contacted to participate in the study by means of a questionnaire.

RESULTS

Twenty-seven couples returned fully completed questionnaire and form the object of this study. 13/27 couples were recommended pregnancy termination.MAJOR RISKS PRESENTED WERE: fetal distress (27/27), intrauterine death (16/27), death at birth (12/27).THE MOST DISTRESSING MOMENTS WERE: communication of diagnosis and the time lag between communication of diagnosis and consultation with the surgeon.

CONCLUSIONS

Despite CCAM carries a favourable prognosis, couples often appear to receive incomplete information with risk of fetal distress and demise prevailing over survival rate and long term outcome. To provide the couple with the most accurate information concerning the anomaly and the associated prognosis to make informed decision a referral to a tertiary pediatric surgery unit should be made as soon as possible.

Congenital bronchopulmonary malformations: a single-center experience and a review of literature

PURPOSE:

To present a single-center experience with 25 cases of bronchopulmonary malformations and the review the literature.

MATERIALS AND METHODS:

We conducted a retrospective analysis of the medical records of patients with congenital bronchopulmonary malformations who were operated between July 1997 and July 2007 in our institute; we examined the modes of presentations, management, and outcome. Outcome of all patients was assessed over a short follow-up period (average 1.8 months).

RESULTS:

Out of 25 patients, 18 (72%) were male and 7 (28%) were female. Age of patients ranged from 1 day to 11 years. The histopathological diagnosis was congenital cystic adenomatoid malformations [CCAM; n = 14 (56%)], congenital lobar emphysema [CLE; n = 5 (20%)], pulmonary sequestrations [PS; n = 3 (12%)], and bronchogenic cysts [BC; n = 3 (12%)]. Antenatal diagnosis was available in only 2 (8%) patients. The common presenting symptoms were respiratory distress and chest infections. Lobectomy was the procedure of choice . Mortality was 16% (n = 4; M: F = 3: 1). Two patients died because of overwhelming sepsis, one from compromised cardiac function, and one from aspiration which might possibly have been prevented.

CONCLUSION:

Patients with progressive respiratory distress due to these anomalies may require urgent surgical intervention regardless of age. The surgical outcome is favorable, with manageable complications. Plain x-ray chest and CT of thorax are usually sufficient for diagnosis and planning of treatment. Pathological diagnosis may differ from the imaging diagnosis. Mortality is found to be more in neonates. Apart from initial stabilization, resection of lesion and careful postoperative care is necessary to reduce mortality and morbidity.