# CCAM (congenital Cystic Adenomatoid Malformation) — GCMD Library living collection

Updated: n/a · 4 episodes · 162 cited statements

## Episodes
### Resources
- [Postnatal Management of  Lung Lesions Part III: Pediatric Thoracic Surgery...](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418) — video · 27:56 · [machine version](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418.md)
- [Management of Asymptomatic Lung Lesions: Pediatric Thoracic Surgery Part...](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883) — video · 20:11 · [machine version](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883.md)
- [Fetal Interventions Part II: Lung Lesions](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884) — video · 16:30 · [machine version](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884.md)
- [Lung Lesions: Fetal Interventions Parts I+II](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088) — video · 30:56 · [machine version](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=0) Canadian perspective on asymptomatic lesion management and PPB risk (Ep 1)
- [3:53](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=233) Debate on extralobar sequestration management (Ep 1)
- [5:22](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=322) Surveillance limitations and counseling challenges (Ep 1)
- [7:13](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=433) Operative risk versus observation risk (Ep 1)
- [11:03](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=663) Infection risk data and natural history debate (Ep 1)
- [17:40](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1060) Informed consent and outcome data gaps (Ep 1)
- [20:17](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1217) Rapid-fire clinical questions (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=0) Malignancy risk in cystic lung lesions: CCAM versus PPB (Ep 2)
- [3:44](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=224) Management of extralobar sequestrations (Ep 2)
- [6:05](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=365) Limitations of surveillance for pulmonary lesions (Ep 2)
- [7:08](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=428) Operative risk versus observation risk (Ep 2)
- [11:20](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=680) Natural history debate: infection incidence (Ep 2)
- [16:40](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1000) Shared decision-making and institutional experience (Ep 2)
- [0:00](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=0) Fetal thoracic interventions: techniques and complications (Ep 3)
- [3:43](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=223) Natural history and indications for intervention (Ep 3)
- [6:05](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=365) Disappearing CCAMs and diagnostic accuracy (Ep 3)
- [7:16](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=436) Nomenclature, EXIT procedure indications, and diagnostic pitfalls (Ep 3)
- [10:07](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=607) Pleuro-amniotic shunt indications (Ep 3)
- [12:07](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=727) Referral criteria, CVR thresholds, and imaging protocols (Ep 3)
- [0:00](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=0) EXIT procedure indications and ECMO use in CCAM (Ep 4)
- [3:41](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=221) EXIT procedure training, team requirements, and volume thresholds (Ep 4)
- [7:29](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=449) Management of sequestrations with large feeding vessels (Ep 4)
- [10:10](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=610) Technical aspects of fetal lobectomy (Ep 4)
- [12:50](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=770) Fetal pneumonectomy experience and vessel occlusion techniques (Ep 4)
- [18:09](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1089) Natural history and regression of congenital lung lesions (Ep 4)
- [21:42](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1302) Terminology, EXIT indications, and diagnostic accuracy (Ep 4)
- [25:00](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1500) Pleuro-amniotic shunt indications, referral criteria, and CVR thresholds (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- Most experts now believe CCAMs do not become pleuropulmonary blastoma (PPB); rather, PPB is a de novo tumor that is cystic and cannot be differentiated from CCAM on imaging. — Jean Martin (clinical) [Ep 2 · 0:31](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=31)
- There are cases of prenatally diagnosed cystic lung lesions that turned out to be PPB after resection. — Jean Martin (clinical) [Ep 2 · 0:51](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=51)
- A Toronto series estimates that approximately 4% of cystic lesions that appear to be CCAM will actually turn out to be pleuropulmonary blastoma. — Jean Martin (epidemiological) [Ep 2 · 1:24](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=84)
- There is approximately 1% risk of bronchioloalveolar carcinoma arising from CCAM, typically in teenage years or early adulthood. — Jean Martin (epidemiological) [Ep 2 · 1:34](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=94)
- If thoracoscopic resection is performed, the specimen should be placed in a bag before extraction to avoid tumor spillage in case the lesion is PPB, as there is a risk of recurrence. — Jean Martin (clinical) [Ep 2 · 2:11](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=131)
- Non-communicating extralobar sequestrations have a very low infection rate; hematogenous infection is possible but rare, similar to any other body tissue. — Jean Martin (clinical) [Ep 2 · 2:39](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=159)
- Malignant transformation of extralobar sequestration is extremely rare, with perhaps one or two cases of squamous cell carcinoma described in world literature. — Jean Martin (epidemiological) [Ep 2 · 3:00](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=180)
- Infection and cancer are not good arguments to resect a non-communicating extralobar sequestration. — Jean Martin (opinion) [Ep 2 · 3:11](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=191)
- The incidence of infection and malignancy in extralobar sequestrations is very low, but has occurred. — Steve (clinical) [Ep 2 · 3:44](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=224)
- Current imaging is not perfect and cannot always definitively diagnose extralobar sequestration or rule out hybrid lesions. — Steve (clinical) [Ep 2 · 3:51](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=231)
- The morbidity of resecting extralobar sequestrations is very low, which favors resection over observation. — Steve (opinion) [Ep 2 · 4:03](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=243)
- There is no role for embolization of extralobar sequestrations; it is much easier to resect them using minimally invasive techniques than to subject an infant or child to embolization. — Steve (opinion) [Ep 2 · 4:49](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=289)
- The differential diagnosis for infradiaphragmatic lesions prenatally includes adrenal hemorrhage and neuroblastoma (including cystic neuroblastoma). — Alan (clinical) [Ep 2 · 5:18](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=318)
- Small infradiaphragmatic lesions can be followed by ultrasound; if they stay the same size or get smaller, they do not require resection. — Alan (clinical) [Ep 2 · 5:24](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=324)
- Adrenal hemorrhage will evolve over time and become recognizable on imaging. — Alan (clinical) [Ep 2 · 5:37](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=337)
- A Children's Oncology Group (COG) study showed it is safe to observe adrenal masses suspicious for neuroblastoma, though they must be watched. — Jean Martin (clinical) [Ep 2 · 5:52](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=352)
- There is no good way to follow pulmonary lesions; CT scan is the best method but induces a certain incidence of malignancy itself. — Alan (clinical) [Ep 2 · 6:17](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=377)
- CT scan cannot differentiate CCAM from pleuropulmonary blastoma, so surveillance imaging will not allow earlier detection of malignancy until stage 2 or 3 disease occurs. — Alan (clinical) [Ep 2 · 6:32](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=392)
- It is almost universal that families cannot be counseled with the word 'cancer' and then choose to watch the lesion. (opinion) [Ep 2 · 6:56](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=416)
- When deciding whether to operate, the risks of not operating must be weighed against the risks of operating. — Jack (opinion) [Ep 2 · 7:10](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=430)
- There has been very little discussion about the risks of performing lobectomy during the panel. — Jack (opinion) [Ep 2 · 7:23](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=443)
- The risks of pulmonary lobectomy are low, especially in experienced hands, but there are still children who die from pulmonary lobectomy, particularly when done thoracoscopically. — Jack (clinical) [Ep 2 · 7:29](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=449)
- Thoracoscopic lobectomy should not be performed unless the surgeon is experienced; in experienced hands, thoracoscopic lobectomy should have no more morbidity than open lobectomy. — Steve (opinion) [Ep 2 · 8:08](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=488)
- Thoracoscopic lobectomy should only be performed by surgeons with advanced thoracic and minimally invasive skills; in such hands, mortality should be zero. — Steve (opinion) [Ep 2 · 8:26](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=506)
- If you do enough of any operation, you will have significant complications, whether open or thoracoscopic. — Jack (opinion) [Ep 2 · 8:40](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=520)
- If massive bleeding occurs during thoracoscopic lobectomy, the chance of salvaging the situation is probably better if the case is already open rather than thoracoscopic. — Jack (opinion) [Ep 2 · 9:04](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=544)
- Pleuropulmonary blastoma (PPB) can be indistinguishable radiologically from CCAM, but the incidence of CCAM/CPAM is markedly higher than the incidence of PPB; PPBs remain extremely rare. — Jack (epidemiological) [Ep 2 · 9:47](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=587)
- Peter Kim's paper used the Stalker classification in which one histological category has been termed PPB, but the natural history of that histological finding is unknown. — Jack (clinical) [Ep 2 · 10:06](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=606)
- At a high-volume center, de novo PPB is seen extremely rarely, approximately once every 3-4 years, while approximately 20-25 new cases of CCAM are seen annually. — Jack (epidemiological) [Ep 2 · 10:28](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=628)
- The incidence of cancer in CCAM remains extremely low and must be balanced against the risk of the operation. — Jack (opinion) [Ep 2 · 10:44](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=644)
- The estimated lifelong risk of infection for observed CCAM is approximately 20-30%, based on institutional data showing 10% infection rate with a mean follow-up of 4 years, tripled to estimate lifetime risk. — Jack (epidemiological) [Ep 2 · 10:54](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=654)
- The only prospective study that followed asymptomatic CCAM patients long-term was small and showed 18 of 21 asymptomatic patients developed symptomatology during follow-up (average 2 years, up to 13 years). — Alan (epidemiological) [Ep 2 · 11:29](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=689)
- Before prenatal diagnosis became common, it was not common for patients to present during teenage years or in adult thoracic surgery units with symptomatic infected CCAMs, though it happened from time to time. — Jack (epidemiological) [Ep 2 · 12:40](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=760)
- In the early career of one surgeon in San Francisco, infected CCAMs were not a rare event and were seen on several occasions in the first few years. — Alan (epidemiological) [Ep 2 · 13:22](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=802)
- Small asymptomatic extralobar sequestrations are a relatively known finding at autopsy, but asymptomatic CCAMs are essentially nonexistent in autopsy series. — Jean Martin (epidemiological) [Ep 2 · 15:44](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=944)
- The majority of CCAMs become symptomatic; CCAM is not a normal variant. — Jean Martin (opinion) [Ep 2 · 16:04](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=964)
- At one institution, all prenatally diagnosed lesions are followed with postnatal CT, and those not operated on are followed with chest X-ray and repeat CT. — Jack (clinical) [Ep 2 · 16:26](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=986)
- One surgeon does not advocate non-operative management of all CCAMs; families are counseled about risks including cancer and infection, and many choose resection after hearing these risks. — Jack (opinion) [Ep 2 · 16:40](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1000)
- A balanced approach should be given to families, allowing them to decide, rather than taking an approach where every single CCAM needs an operation. — Jack (opinion) [Ep 2 · 17:20](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1040)
- In a poll, 25% of respondents do not advocate routine resection of asymptomatic CCAMs. — Jack (epidemiological) [Ep 2 · 17:58](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1078)
- There is a hidden mortality in pediatric surgery because people do not report bad results; the only way to know about them is through lawsuits. (opinion) [Ep 2 · 18:25](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1105)
- Future participation in the American College of Surgeons NSQIP-Pediatric will provide unbiased, large-scale data on thoracoscopic versus open surgery complications and mortality rates. (opinion) [Ep 2 · 18:48](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1128)
- Currently there is insufficient data to make fully informed consent regarding CCAM management. (opinion) [Ep 2 · 18:58](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1138)
- Thoracoscopic lobectomy should not be taken lightly; it requires a major investment in time and learning to become proficient. — Alan (opinion) [Ep 2 · 19:17](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1157)
- Centers that routinely perform thoracoscopic lobectomy and see high volumes of CCAMs can treat them with extremely low morbidity and no mortality. — Alan (opinion) [Ep 2 · 19:29](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1169)
- Infants generally do very well after thoracoscopic lobectomy, typically staying in the hospital for two days before going home. — Alan (clinical) [Ep 2 · 19:46](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1186)
- In a review of the last 100 thoracoscopic lobectomies (not including sequestrations), there were only two transfusions and two prolonged air leaks as complications. — Alan (epidemiological) [Ep 2 · 19:49](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1189)
- There are several cases of prenatally diagnosed lesions that turned out to be PPB after birth. — Jean-Martin (clinical) [Ep 1 · 0:59](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=59)
- If you do thoracoscopic resection, put the specimen in a bag before extraction, because if it turns out to be PPB and you mush it up, there is a risk of recurrence. — Jean-Martin (clinical) [Ep 1 · 2:20](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=140)
- Extralobar sequestrations with no communication and no air on CT scan do not have a high infection rate; hematogenous infection is possible but rare. — Jean-Martin (clinical) [Ep 1 · 2:48](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=168)
- Malignant transformation of extralobar sequestration is extremely rare, with maybe one or two cases of squamous cell carcinoma in world literature. — Jean-Martin (epidemiological) [Ep 1 · 3:09](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=189)
- Infection and cancer are not good arguments to resect a non-communicating extralobar sequestration. — Jean-Martin (opinion) [Ep 1 · 3:20](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=200)
- The incidence of infection and malignancy in extralobar sequestration is very low, but it has occurred. — Steve (clinical) [Ep 1 · 3:53](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=233)
- Imaging is not perfect and we cannot always be absolutely sure of the diagnosis or whether it is a hybrid lesion. — Steve (clinical) [Ep 1 · 4:00](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=240)
- The morbidity of resecting extralobar sequestration is so low that removal is favored. — Steve (opinion) [Ep 1 · 4:28](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=268)
- There is no role for embolization of extralobar sequestrations; it is much easier to resect them using minimally invasive techniques. — Steve (opinion) [Ep 1 · 4:58](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=298)
- The differential diagnosis for infradiaphragmatic lesions prenatally is adrenal hemorrhage or neuroblastoma (cystic neuroblastoma). — Alan (clinical) [Ep 1 · 5:26](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=326)
- Small infradiaphragmatic lesions can be followed by ultrasound; if they stay the same or get smaller, they do not require resection. — Alan (clinical) [Ep 1 · 5:33](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=333)
- There is no good way to follow pulmonary lesions; CT scan is the best method but induces a certain incidence of malignancy. — Alan (clinical) [Ep 1 · 6:26](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=386)
- You cannot differentiate CCAM from PPB on CT scan until you have a stage two or three occurrence. — Alan (clinical) [Ep 1 · 6:40](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=400)
- You cannot counsel a family, say the word cancer, and have them watch; that is almost universally unacceptable. — Alan (opinion) [Ep 1 · 7:04](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=424)
- When deciding to operate or not, we must weigh the risks of not doing the operation versus the risks of doing the operation. — Jack (clinical) [Ep 1 · 7:19](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=439)
- There are children who die from pulmonary lobectomy, particularly done thoracoscopically. — Jack (clinical) [Ep 1 · 7:38](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=458)
- Jack knows of two cases of death from thoracoscopic lobectomy that he was asked to review. — Jack (clinical) [Ep 1 · 7:58](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=478)
- Thoracoscopic lobectomy should not be done unless the surgeon is experienced; in experienced hands it should have no more morbidity than open. — Steve (opinion) [Ep 1 · 8:16](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=496)
- The mortality for thoracoscopic lobectomy in experienced hands should be zero. — Steve (opinion) [Ep 1 · 8:41](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=521)
- If you do enough of any operation, you will have significant complications, whether open or thoracoscopic. — Jack (clinical) [Ep 1 · 8:48](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=528)
- If you have massive bleeding when already open, your chance of salvaging the situation is probably better than if you have that bleeding in a thoracoscopic case. — Jack (opinion) [Ep 1 · 9:12](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=552)
- PPB can be indistinguishable radiologically from CCAM, but the incidence of PPB remains extremely rare. — Jack (clinical) [Ep 1 · 9:55](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=595)
- In a high-volume center (Toronto), de novo PPB is seen extremely rarely, like once every 3 or 4 years, while 20-25 new CCAM cases are seen every year. — Jack (epidemiological) [Ep 1 · 10:36](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=636)
- The estimate of lifelong risk of infection for CCAM is somewhere around 20 or 30%. — Jack (epidemiological) [Ep 1 · 11:03](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=663)
- Most infections in CCAM can be treated and lobectomy can be done afterwards. — Jack (clinical) [Ep 1 · 11:15](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=675)
- Jack's data showed 10% infection rate with a mean follow-up of 4 years, which was tripled to estimate 30% lifetime risk. — Jack (epidemiological) [Ep 1 · 12:17](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=737)
- Before prenatal diagnosis, it was not common for people to present in teenage years or adulthood with symptomatic infected CCAMs, though it happened from time to time. — Jack (clinical) [Ep 1 · 12:49](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=769)
- If 25 new prenatally diagnosed asymptomatic CCAM cases are seen per year in Toronto and none were operated on, we should be seeing 25 infected cases per year if the infection rate were 100%. — Jack (clinical) [Ep 1 · 14:03](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=843)
- The majority of CCAMs do become symptomatic; it is not a normal variant. — Jean-Martin (opinion) [Ep 1 · 16:12](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=972)
- Toronto follows all prenatally diagnosed lesions with CT postnatally, and those not operated on are followed with chest X-ray and another CT. — Jack (clinical) [Ep 1 · 16:35](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=995)
- Jack is not advocating non-operative management of all CCAMs; he counsels families about risks including cancer, and many choose surgery. — Jack (opinion) [Ep 1 · 16:49](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1009)
- Jack advocates a balanced approach to families, allowing them to decide, rather than operating on every single lesion. — Jack (opinion) [Ep 1 · 17:29](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1049)
- There is a hidden mortality in pediatric surgery because people do not report bad results; the only way to know is through lawsuits or future unbiased registry data like NSQIP. — Alan (clinical) [Ep 1 · 18:34](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1114)
- We do not have the data to make truly informed consent, so we must give families the whole picture and let them decide. — Alan (opinion) [Ep 1 · 19:06](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1146)
- Centers that do thoracoscopic lobectomy routinely and see high volumes of CCAMs can treat them with extremely low morbidity and no mortality. — Alan (opinion) [Ep 1 · 19:26](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1166)
- In a review of the last 100 thoracoscopic lobectomies (not sequestrations), there were 2 transfusions and 2 latent pneumothoraces as the only complications. — Alan (clinical) [Ep 1 · 19:58](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1198)
- For infected CCAM with abscess, 6 weeks of IV antibiotics is reasonable, but duration depends on symptoms (fever, ongoing symptoms). — Starla (clinical) [Ep 1 · 20:46](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1246)
- Large abscesses in CCAM can be drained percutaneously and treated with antibiotics for a couple of weeks, then re-evaluated for residual mass. — Alan (clinical) [Ep 1 · 21:10](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1270)
- It is very hard to clear infection from a macrocystic CCAM. — Alan (clinical) [Ep 1 · 21:21](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1281)
- MRI is not used as primary study because children require more anesthesia for MRI than for CT. — Starla (clinical) [Ep 1 · 21:53](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1313)
- MRI has been tried for follow-up of non-operated patients, but it does not give as clear a picture as CT. — Jack (clinical) [Ep 1 · 22:09](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1329)
- Bronchial blocker is not needed in infants for single-lung ventilation and is potentially harmful (risk of bronchial stenosis). — Alan (clinical) [Ep 1 · 22:39](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1359)
- The incidence of extralobar sequestration in diaphragmatic hernia is probably 15%; they are often small and can be ignored. — Alan (epidemiological) [Ep 1 · 23:30](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1410)
- Bilateral lung lesions are managed sequentially, not at the same time. — Alan (clinical) [Ep 1 · 23:56](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1436)
- Prophylactic antibiotics are given as one preoperative dose only; patients are not sent home on antibiotics if waiting a month for surgery. — Steve (clinical) [Ep 1 · 24:52](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1492)
- Macrocystic lesions can always be reduced thoracoscopically by chipping away at them with a ligature. — Alan (clinical) [Ep 1 · 25:17](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1517)
- Most CCAM specimens can be removed through a 5 millimeter incision, though hybrid lesions with big arteries are tougher. — Alan (clinical) [Ep 1 · 25:44](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1544)
- You never lose anything by putting a scope in; you can evaluate thoracoscopically and convert to open if the fissure is obliterated or anatomy is difficult. — Steve (opinion) [Ep 1 · 27:32](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=1652)
- Radiofrequency ablation for vessel occlusion in fetal bronchopulmonary sequestrations was a disaster and is not recommended. — Jack (clinical) [Ep 3 · 1:27](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=87)
- Coils were used for vessel occlusion with initial success, but the fetus died about a week later for unclear reasons. — Jack (clinical) [Ep 3 · 1:33](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=93)
- Alcohol injection for vessel occlusion can travel through the vasculature and cause thrombosis in the systemic circulation, including thrombi in the heart chambers. — Alan (clinical) [Ep 3 · 1:52](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=112)
- The effects of systemic alcohol injection on fetal neural development and other organ development have not been studied experimentally, even in sheep models. — Alan (clinical) [Ep 3 · 2:29](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=149)
- Radiofrequency ablation cannot be controlled in the fetus due to 90% water content; energy can disperse unpredictably causing collateral damage. — Alan (clinical) [Ep 3 · 3:00](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=180)
- In a laboratory study, a radiofrequency ablation probe placed in one side of a resected fetal teratoma caused the other side to boil when activated. — Alan (clinical) [Ep 3 · 3:12](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=192)
- Probably 95% of CCAMs are now prenatally diagnosed. (epidemiological) [Ep 3 · 3:46](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=226)
- Almost none of prenatally diagnosed lung lesions require prenatal intervention, and very few require intervention the day the child is born. (clinical) [Ep 3 · 3:52](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=232)
- Only one or two centers in the world should be thinking about extreme fetal interventions for lung lesions because the numbers are so small. (opinion) [Ep 3 · 4:09](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=249)
- Many lung lesions have been referred after a recommendation for termination by people who don't understand the natural history. — Alan (clinical) [Ep 3 · 5:20](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=320)
- Even very large prenatal lung lesions can regress and be asymptomatic at birth, or have very good survival rates with appropriate interventions. — Alan (clinical) [Ep 3 · 5:31](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=331)
- The garden variety postnatal CCAM is very different than some prenatal CCAMs. — Alan (clinical) [Ep 3 · 5:44](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=344)
- True cystic CCAMs do not disappear; they regress but remain present and prominent on CT scan a month after birth. — Alan (clinical) [Ep 3 · 6:43](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=403)
- Some lesions that look like CCAMs in utero, such as segmental bronchial stenosis, can be minimally apparent or non-apparent after birth. — Alan (clinical) [Ep 3 · 6:13](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=373)
- Prenatal lung lesions should be called 'congenital lung lesions' (macrocystic, hyperechoic, or mixed) rather than CCAMs, since CCAM is a pathological diagnosis requiring a specimen. — Jean Martin (clinical) [Ep 3 · 7:45](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=465)
- Many tertiary centers have the capacity to perform EXIT procedures with a huge team approach and leadership. — Jean Martin (clinical) [Ep 3 · 8:17](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=497)
- Lung agenesis can be misdiagnosed as a microcystic CCAM with mediastinal shift on prenatal imaging. — Alan (clinical) [Ep 3 · 9:33](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=573)
- EXIT procedures are more invasive than regular C-sections for the mother. — Jean Martin (clinical) [Ep 3 · 9:59](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=599)
- Pleuro-amniotic shunts are used specifically for macrocystic CCAMs with evidence of hydrops. — Alan (clinical) [Ep 3 · 11:08](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=668)
- Hydrops requires pleural effusion, pericardial effusion, and skin or scalp edema; pure ascites alone is not necessarily hydrops. — Alan (clinical) [Ep 3 · 11:18](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=678)
- Pure ascites can be related to mediastinal shift and hepatic venous return rather than true hydrops. — Alan (clinical) [Ep 3 · 11:27](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=687)
- Pleuro-amniotic shunts are not placed prophylactically; large macrocystic lesions may be tapped just prior to delivery to improve ventilation. — Alan (clinical) [Ep 3 · 11:48](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=708)
- A CVR cutoff of 1.6 is used; if a CCAM presents with CVR less than 1.6, the likelihood of evolving hydrops is about 3-5%. — Alan (clinical) [Ep 3 · 13:33](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=813)
- CVR greater than 1.6 requires close watching with much higher likelihood of evolving into hydrops. — Alan (clinical) [Ep 3 · 14:11](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=851)
- Macrocystic lesions are a wild card because the cystic component can grow very rapidly and can be worrisome even if CVR is less than 1.6. — Alan (clinical) [Ep 3 · 14:18](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=858)
- MRI is better for some fetal anomalies and not as good for others; it depends on the specific anomaly. — Alan (clinical) [Ep 3 · 15:55](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=955)
- There is no registry for fetal surgery or EXIT procedures similar to the ECMO registry. — Alan (clinical) [Ep 3 · 16:17](https://library.globalcastmd.com/watch/fetal-interventions-part-ii-lung-lesions-884?t=977)
- One center has performed close to 100 EXIT procedures in the past 10 years. — Alan (clinical) [Ep 4 · 4:56](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=296)
- EXIT procedures have been used for CCAMs with average CVR over 2, which are large lesions. — Alan (clinical) [Ep 4 · 0:46](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=46)
- EXIT is reserved for cases with evidence of compression: diaphragmatic aversion, marked mediastinal shift, often ascites. — Alan (clinical) [Ep 4 · 0:46](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=46)
- ECMO is very rare in CCAM patients and has not been used during EXIT procedures; conventional ventilation is tried first. — Alan (clinical) [Ep 4 · 1:39](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=99)
- Referral centers receive complex cases while simple cases stay local, skewing the percentage requiring EXIT and fetal surgery. — Jean-Martin (opinion) [Ep 4 · 2:04](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=124)
- There is no clear reduction in ability to have subsequent pregnancy after fetal surgery, based on approximately 4 published studies. — Alan (epidemiological) [Ep 4 · 2:46](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=166)
- After fetal surgery hysterotomy (equivalent to classical cesarean in upper uterus), patients should never labor with future pregnancies. — Alan (guideline) [Ep 4 · 2:59](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=179)
- No long-term maternal morbidity aside from requirement for cesarean delivery has been observed after fetal surgery. — Alan (clinical) [Ep 4 · 3:12](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=192)
- Feared complications like placenta accreta at the hysterotomy site have not been observed thus far. — Alan (clinical) [Ep 4 · 3:22](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=202)
- EXIT procedure requires an anesthetic team tuned into uterine relaxation and maternal issues, and expertise with hysterotomy. — Alan (clinical) [Ep 4 · 4:03](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=243)
- EXIT procedure can be learned and disseminated more widely than fetal surgery without requiring a full fetal surgery program. — Alan (opinion) [Ep 4 · 4:23](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=263)
- EXIT is valuable for cervical teratomas and airway obstructive problems; most large children's hospitals experience cases that would benefit from EXIT from time to time. — Alan (clinical) [Ep 4 · 4:43](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=283)
- Maternal expertise must be available at the hospital; bringing a mother into a freestanding children's hospital without maternal expertise is a bad idea. (opinion) [Ep 4 · 5:13](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=313)
- There are probably 4 or 5 centers in the US that clearly have the qualifications and background to do good EXIT procedures. — Alan (epidemiological) [Ep 4 · 6:04](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=364)
- EXIT procedure involves weeks of planning, discussions of the entire team, and 15 to 20 people in the operating room. (clinical) [Ep 4 · 6:44](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=404)
- If a center does only one EXIT per year, it is probably not enough to justify doing EXIT procedures; 3 to 5 per year is a reasonable threshold. — Alan (opinion) [Ep 4 · 7:15](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=435)
- Very few BPS cases with large feeding vessels have been seen where high-output failure was thought to be the mechanism of hydrops; most have associated pleural effusions, mediastinal shift, or mass effect. — Alan (clinical) [Ep 4 · 8:23](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=503)
- Injecting alcohol into fetal vessels has potential hazard including neurologic effects and has not been adequately studied. — Alan (opinion) [Ep 4 · 9:06](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=546)
- Alcohol injection can cause thrombosis in systemic circulation; one case showed thrombi in heart chambers that then embolized to various sites. — Alan (clinical) [Ep 4 · 16:18](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=978)
- Radiofrequency ablation cannot be controlled in the fetus due to 90% water content; energy can disperse unpredictably causing collateral damage. — Alan (clinical) [Ep 4 · 17:21](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1041)
- In one experiment, radiofrequency probe placed in one side of a teratoma caused the other side to boil when activated. — Alan (clinical) [Ep 4 · 17:38](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1058)
- Probably 95% of CCAMs seen now are prenatally diagnosed. (epidemiological) [Ep 4 · 18:11](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1091)
- Almost none of prenatally diagnosed congenital lung lesions require prenatal intervention, and very few require intervention the day the child is born. (clinical) [Ep 4 · 18:18](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1098)
- The vast majority of congenital lung lesions do not fall in the realm of extreme treatments; only one or two centers in the world should be thinking about these interventions. (opinion) [Ep 4 · 18:35](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1115)
- The majority of children with prenatal lung lesions can be delivered without fetal distress. (clinical) [Ep 4 · 18:51](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1131)
- Many lesions have been referred after a recommendation for termination by people who don't understand the natural history. — Alan (clinical) [Ep 4 · 19:44](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1184)
- Even very large congenital lung lesions can regress and be asymptomatic at birth, or have very good survival rates with appropriate interventions. — Alan (clinical) [Ep 4 · 19:57](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1197)
- The garden variety postnatal CCAM is very different than some prenatal CCAMs. — Alan (clinical) [Ep 4 · 20:10](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1210)
- True cystic CCAMs do not disappear; they regress but remain present and prominent on CT scan one month after birth. — Alan (clinical) [Ep 4 · 20:30](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1230)
- Some things that look like CCAMs in utero (like segmental bronchial stenosis) can give an echogenic microcystic appearance but may be minimally apparent or non-apparent after birth. — Alan (clinical) [Ep 4 · 20:39](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1239)
- Congenital lung lesions should be called macrocystic, hyperechoic, or mixed rather than 'CCAM' prenatally, since CCAM is a pathological diagnosis once the specimen is in the bucket. — Jean-Martin (opinion) [Ep 4 · 22:11](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1331)
- Many tertiary centers have the capacity to do EXIT; it requires a huge team approach and somebody leading the team. — Jean-Martin (opinion) [Ep 4 · 22:40](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1360)
- Good prenatal diagnosis is essential; lung agenesis has been diagnosed as microcystic CCAM elsewhere, leading to potential catastrophic errors. — Alan (clinical) [Ep 4 · 23:45](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1425)
- Pleuro-amniotic shunts are used specifically for macrocystic CCAMs with evidence of hydrops (pleural effusion, pericardial effusion, and skin or scalp edema), not pure ascites alone. — Alan (clinical) [Ep 4 · 25:34](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1534)
- Large macrocystic lesions are sometimes tapped just prior to delivery to improve ventilation, but shunts are not placed prophylactically. — Alan (clinical) [Ep 4 · 26:14](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1574)
- CVR less than 1.6 on presentation predicts about 3% (less than 5%) likelihood of evolving hydrops in microcystic lesions; this has held true in prospective studies and ongoing experience. — Alan (clinical) [Ep 4 · 27:50](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1670)
- CVR greater than 1.6 requires close watching; there is much higher likelihood of evolving into hydrops. — Alan (clinical) [Ep 4 · 28:37](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1717)
- Macrocystic lesions are a wild card because the cystic component can grow very rapidly and can be worrisome even if CVR is less than 1.6. — Alan (clinical) [Ep 4 · 28:44](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1724)
- At one center, all lung lesions get a fetal MRI routinely; MRIs help define anatomy and general size of lesions. — Alan (clinical) [Ep 4 · 29:01](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1741)
- MRIs are not essential for all centers; they can clarify abnormalities if there is ambiguity on ultrasound or confusion about diagnosis. — Alan (opinion) [Ep 4 · 29:33](https://library.globalcastmd.com/watch/lung-lesions-fetal-interventions-parts-i-ii-1088?t=1773)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Management decisions for CCAM should be made selectively based on resources, family preferences, patient factors, and location, rather than a dogmatic approach of operating on everyone. — The host summarizing the discussion [Ep 2 · 17:32](https://library.globalcastmd.com/watch/management-of-asymptomatic-lung-lesions-pediatric-thoracic-surgery-part-883?t=1052)
- Most people believe now that CCAMs do not become PPB, but PPB is a de novo tumor that is cystic and cannot be differentiated on imaging. — Jean-Martin summarizing the discussion [Ep 1 · 0:40](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=40)
- One series out of Toronto estimates that cystic lesions that look like CCAM, about 4% of them will actually turn out to be PPB. — Jean-Martin summarizing the discussion [Ep 1 · 1:33](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=93)
- There is about a 1% risk of bronchioalveolar carcinoma in the teenage years or early adulthood. — Jean-Martin summarizing the discussion [Ep 1 · 1:43](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=103)
- The COG study showed that it was safe to observe adrenal masses (in the context of neuroblastoma concern). — Jean-Martin summarizing the discussion [Ep 1 · 6:00](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=360)
- The paper by Peter Kim used the Stalker classification in which one classification has been termed PPB, but the natural history of that histological finding is unknown. — Jack summarizing the discussion [Ep 1 · 10:14](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=614)
- The only prospective study that followed patients long-term showed 18 of 21 asymptomatic patients developed symptomatology during an interval averaging 2 years up to 13 years. — Alan summarizing the discussion [Ep 1 · 11:38](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=698)
- Autopsy series show that small asymptomatic extralobar sequestration is a relatively known finding, but asymptomatic CCAM on autopsy is nonexistent. — Jean-Martin summarizing the discussion [Ep 1 · 15:43](https://library.globalcastmd.com/watch/postnatal-management-of-lung-lesions-part-iii-pediatric-thoracic-surgery-418?t=943)

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