Correct!
5. Resection of the right lung lesion
The multicystic lesion shows no relation to the pulmonary arteries, and no pulmonary artery anomaly, aneurysm, or arteriovenous malformation is seen, so catheter pulmonary angiography is unlikely to be beneficial to the patient. Catheter aortography, particularly for examination of the bronchial arterial circulation and any anomalous systemic arterial vessels supplying the lung, can be useful in some patients, particularly those with intralobar sequestration or inflammatory myofibroblastic tumors, but is typically used to treat such vessels [with embolotherapy] when they have already been identified at contrast-enhanced thoracic CT. In this patient, no such vessels are present, and therefore catheter aortography would not be useful. Contrast-enhanced thoracic MRI is unlikely to add any additional information to that already known though thoracic CT, particularly for a lung lesion. Mediastinoscopy is primarily used for assessment of mediastinal lesions (paratracheal, anterior subcarinal), either masses, or, more commonly, lymph nodes [in the setting of lung cancer staging], but would not be useful in this patient with a normal-appearing mediastinum and a multicystic lesion in the peripheral right lung. Observation of the lesion could be appropriate, depending on the patient’s preferences, but is not offered as one of the choices above..
The patient elected to undergo resection of the right lung multicystic lesion because the lesion was previously infected and there was concern for potential re-infection. Pathological examination showed cystic adenomatoid malformation, with a small focus of bronchial atresia as well
Diagnosis: Congenital pulmonary airway malformation (previously known as congenital cystic adenomatoid malformation)
Post-script: The spectrum if congenital pulmonary airway malformation imaging appearances is presented in Figure 5.
Figure 5. Congenital pulmonary airway malformation: imaging appearances: A-E: Frontal chest radiography (A) in a 30-year-old woman shows faint right upper lobe lucency and nodularity, barely perceptible and non-specific. B and C, axial focused thoracic CT shows a multicystic right upper lobe congenital pulmonary airway malformation. D and D, Axial focused CT images at a point when the patient was clinically infected shows patchy consolidation between the cysts and cyst wall thickening. F and G: Pediatric congenital pulmonary airway malformation: Frontal chest radiography shortly after birth (F) shows a vague, but solid, left upper lung lesion (arrow). Axial thoracic CT performed several days following chest radiography shows a multicystic left lung lesion peripherally, representing a congenital pulmonary airway malformation that has undergone clearing of the intracystic fluid. H: Congenital pulmonary airway malformation presenting as multiple larger cysts. I: Congenital pulmonary airway malformation presenting as a fluid-filled mass with no gas. J and K: Congenital pulmonary airway malformation: infected and uninfected. Axial focused CT (J) shows multicystic lesion (larger cysts) in the left lung base with several air-fluid levels, representing infection. Note the resolution of the air-fluid levels on the follow up CT after treatment of infection (K). L and M: prenatal sonography using gray-scale imaging in the axial plane (L) and sagittal power Doppler (MP shows a hyperechoic mass in the thorax (arrow, L) displacing the heart (arrowhead, L). The Power Doppler image shows no evidence of an anomalous systemic arterial supply to the lesion (arrow= thoracoabdominal aorta, arrowheads= mass), which favors cystic pulmonary airway malformation over sequestration.
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