Update Course Rewind: Congenital Lung Lesions 2022

The incidence of congenital lung lesions has increased over the past decades because more prenatal screening has been occurring, really worldwide. These lesions can often lead to malignancy or recurrent infections, both of which may require surgical workup and management. In today's update course rewind, we welcome Dr. Chuck Snyder to discuss the best practices for the workup and management of children with congenital lung lesions. A six-month-old boy had a chest x-ray uh due to chronic cough and right lower lobe cystic lung mass was seen. Subsequent chest CT scan demonstrated a macrocystic 4 cm lesion in the right lower lobe with a question of a feeding vessel. Mother had serial prenatal ultrasounds for placental position and no lesion was ever seen. Which factor is most concerning for possible malignancy in this child? In 2021, the Midwest Pediatric Surgery Consortium reviewed 521 primary lung lesions from 11 children's hospitals, and they aim to identify specific risk factors associated with malignancy. In that series, no prenatally diagnosed lesions were malignant. Roughly 10% of them that were diagnosed postnatally were malignant, and then about half of the malignant lesions were associated with a dicer 1 mutation. There was no malignant lesion that had a systemic feeding vessel. Overall, CT scan had poor sensitivity and specificity for malignancy. However, suspicion for malignancy by CT scan and bilateral disease were predictive. We looked at the same article. Actually these series asked like I think 400 cystic lesions and there was not a single patient who had antenatal diagnosis who was found to have a PPB. If you have prenatal diagnosis, the chances of being PPB, it's close to zero. I'm saying that as a prenatal diagnosis is before you know if they're symptomatic or not, I take them all out. Some would argue that look, if you diagnose these prenatally and they don't ever get symptoms, you don't have to take these out. I think that's the argument because the numbers are so low. Maybe it could be near zero, but it's not zero. That's the thing. Asymptomatic or what is not symptomatic, it's not zero. So at the end of the day, at some point you'll have a patient with a malignant tumor undiagnosed that you're keeping the thing inside forever. Ultrasound technology is so good. And then these moms then get a fetal MRI, and then they get all these consultations, and then we see them, and they get a CT scan after birth. And a lot of these turn out to be nothing. Either it's not there, it's some sort of mucus plug that's gone away. CPAM becomes the general bucket for these lesions in the fetal world. And as the ability to identify specific lesions gets better with technological advances, our management needs to change too. Four, five, six, seven, eight, nine years old that have had recurrent pneumonias and it's all of us have probably been there. It is a mess. And the chances of them having a successful thoracoscopic resection are much lower in that age group than they are in the perinatal period or in that first year of life. So I think my reason for taking them out is to prevent that. When I counsel parents, I say that it's not the cancer. I worry about these recurrent pneumonias and real problems with bronchiectasis. I agree with that. Just one last thing, but remembering the range of anomaly. Sometimes these are trivial little cysts and probably don't make much different one way or the other. Other times they are actually multi-lobar and what it's going to mean if you're going to take them out is that you're going to do a pneumonectomy and that doesn't seem sensible either. So, I think as pediatric surgeons we're all, we've got to tailor ours to what that actual pathology is. I think it's opening our eyes that we don't know it yet. Every year we're learning a little more. We're tailoring, I think that's the best phrase. This probably doesn't solidify any new practice plan for anyone, but I think it's we're getting more information with each year, so it was a good discussion. So basically, reasons to resect the lesion include infection and risk of malignancy. And really, malignancy risk might be a more minor reason for most people. Thanks for joining Dr. Snyder along with the rest of the APsa Professional Development Committee for this update course rewind. Remember to check out the Stay current app for more content related to pediatric surgery and more.