Bronchopulmonary foregut malformations (BPFMs), also known as

Transcription

1 Dign Interv Rdiol 2010; 16: Turkish Society of Rdiology 2010 PEDIATRIC IMAGING PICTORIAL ESSAY Bronchopulmonry foregut mlformtions presenting s mss lesions in children: spectrum of imging findings Murt Kocoğlu, Donld P. Frush, Mehmet S. Uğurel, İrhim Somuncu ABSTRACT Bronchopulmonry foregut mlformtions re heterogeneous ut interrelted group of normlities tht my contin more thn one histologic feture. Fmilirity with the presenttion nd imging fetures of ronchopulmonry foregut mlformtions presenting s congenitl mss or mss-like lesion is importnt. Moreover, imging plys centrl role in the evlution of these lesions since, when symptomtic, clinicl fetures re usully nonspecific. With imging, the presence of nd fetures of the lesion cn e determined, fcilitting pproprite mngement to prevent the potentil complictions including infection, respirtory compromise nd, very rrely, mlignncy. Key words: respirtory system normlities rdiogrphy computed tomogrphy mgnetic resonnce imging Bronchopulmonry foregut mlformtions (BPFMs), lso known s congenitl lung mlformtions or normlities, re heterogeneous group of disorders involving conducting irwys, lung prenchym, nd lung vsculture. Severl mlformtions tht present s mss lesions hve een descried, some of which include ronchogenic cyst (BC), pulmonry sequestrtion (PS), congenitl cystic denomtoid mlformtion (CCAM) [currently nmed s congenitl pulmonry irwy mlformtion (CPAM)], congenitl lor emphysem (CLA) [currently nmed s congenitl lor overinfltion (CLO)], ronchil tresi, nd congenitl pulmonry cyst (CPC) (1 4). Moreover, comintions of those mlformtions (hyrid mlformtions) hve lso een descried (2, 5 7). These mlformtions cn mnifest in vrious wys from respirtory distress t irth to incidentl findings on chest rdiogrph. Although mlignncies hve een descried with BPFMs, the numer of reported cses is less thn fifteen (8). Etiopthogenetic concepts BPFMs re chrcterized with defective udding, differentition or seprtion of the primitive foregut. Although most lesions hve their individul histologic fetures, presence of histologiclly hyrid lesions suggests tht these entities hve common emryologic origin. In order for common origin to reconcile with vriety of consequent lesions, severl clssifictions, terminologies nd theories relting to the etiology of BPFM hve een suggested (8, 9). Clements nd Wrner (9) proposed tht n interruption of reltive growth nd development of the pulmonry vessels is responsile in etiopthogenesis. For instnce, n erly interruption in the development of the pulmonry rteril tree could result in continued development of the primitive cpillry supply nd susequent norml development of the rteril supply. Lngston (8) hs recently suggested new concept where n in utero irwy ostruction represents the min pthogenetic mechnism for some lesions. The level, degree nd timing of ostruction my e responsile for different ptterns of mlformtions. From the Deprtment of Rdiology (M.K. kocoglumurt@ yhoo.com, M.S.U., İ.S.), Gülhne Militry Medicl School, Ankr, Turkey; nd the Deprtment of Rdiology (D.P.F.), Duke University Medicl Center, Durhm, North Crolin, USA. Received 25 August 2008; revision requested 2 Septemer 2008; revision received 3 Septemer 2008; ccepted 8 Septemer Pulished online 9 Octoer 2009 DOI / DIR Imging evlution Lesions my e detected y prentl ultrsonogrphy (US) or y fetl mgnetic resonnce imging (MRI). In this scenrio, chest rdiogrph with cross-sectionl imging is recommended. When discovered incidentlly on rdiogrphy, or for evlution of non-specific chest signs or symptoms, follow-up rdiogrph should e otined to document persistence since pneumoni (i.e., round pneumoni) cn mimic these lesions. If persistent, cross-sectionl imging is recommended. Computed tomogrphy (CT) is generlly recommended for prenchyml lesions, nd CT or MRI is pproprite for medistinl lesions. For CT evlution, ngi- 153

2 c Figure 1. c. Bronchogenic cyst. Axil contrst enhnced CT imge () through the sucrinl level revels well defined, round, homogeneous, predominntly fluid ttenution mss (heterogeneity is likely due to scn rtifct). Axil T2-weighted () nd T1-weighted (c) MR imges t the sme level demonstrte the mss s hyperintense to cererospinl fluid on T2-weighted scn nd isointense to myocrdium on T1-weighted scn in ccordnce with its proteinceous content. ogrphic technique is recommended to determine potentil rteril supply nd venous dringe. Although the prentl dignosis hs een lrgely fcilitted with the recent dvncements on US techniques, overlpping sonogrphic ppernces render n ccurte dignosis difficult. In this pictoril review, we minly present postntl imging findings of BPFMs with n emphsis on mss nd mss-like lesions. Bronchogenic cyst Bronchogenic cyst (BC) is result of insult t 4 5 weeks of emryonic life. The cyst is lined with respirtory epithelium ssocited with wll contining mucous glnds, crtilge, nd smooth muscle. The cyst fluid my e cler, serous, or my contin proteinceous mteril (10). They my e seen in ny prt of the chest; however, two thirds of BCs re locted in the medistinum nd the reminder is prenchyml (10 12), most often perihilr. However, BC hs lso een reported in severl other sites such s retroperitonel loctions nd the neck, s well s t the se of the tongue (8). BC is visulized s single cystic lesion with n imperceptile wll on prentl US. On chest rdiogrph, BC is well-defined solitry mss in the forementioned res. The cysts re usully homogeneous, nd hve fluid ttenution on CT scns; cysts re hyperintense on T2-weighted MR imges, Figure 2.,. Infected ronchogenic cyst. Frontl chest rdiogrph () demonstrtes well defined right lung mss with n ir fluid level. Axil contrst enhnced CT imge () through the right trium confirms the ir fluid level, nd shows enhncement within thickened cyst wll. nd re isointense to skeletl muscle signl intensity on T1-weighted MR imges (Fig. 1). Cyst content does not enhnce; however, when infected, cysts my demonstrte ir-fluid levels nd wll enhncement (Fig. 2). Presence of 154 June 2010 Dignostic nd Interventionl Rdiology Kocoğlu et l.

3 Figure 3. Cystic esophgel dupliction. Axil T1-weighted MR imge through the ortic rch demonstrtes welldefined low signl intensity medistinl mss. Figure 4. Congenitl pulmonry irwy mlformtion. Fetl US imge through the right hemithorx in prsgittl plne shows lung mss with solid nd cystic res (rrowheds). proteinceous mteril in the cyst my cuse incresed density on CT, nd incresed intensity on T1-weighted MR imges (10). BC nd cystic esophgel dupliction (CED) re oth foregut cysts (1). There re two forms of esophgel dupliction, CED nd complete tuulr dupliction. On esophgogrm, the lumen of the esophgus my communicte with the cyst in complete tuulr dupliction. The imging ppernce of CED on CT nd MRI is sme with the BC; however, the cyst wll of CED my e thicker, nd esophgogrm demonstrtes the displcement of the esophgus to the contrlterl site (1, 13) (Fig. 3). Becuse of the potentil complictions, including infection, rupture, nd hemorrhge, lesions re usully resected (11, 14 17). Imging findings of round pneumoni, rteriovenous mlformtion (AVM), nd norml thymus my mimic BC. Round pneumoni is cteril pneumoni chrcterized y round, well-defined opcity on chest rdiogrms. Symptoms of pneumoni nd chrcteristic rdiogrphic findings re dequte for the dignosis; however, if CT is otined with suspicion of mss, ir ronchogrm inside the round density confirms the dignosis of round pneumoni (18). On chest rdiogrphs, the AVM my e occult; ut if reltively lrge, it ppers s well-defined loulted density. Pulmonry CT-ngiogrphy (CTA) technique is recommended to mximize the chnce of identifying the mlformtions. Pulmonry CTA revels the vsculr nture of these lesions, including the tuulr nd nodulr res consistent with feeding rteries, drining veins, nd neurysms (19, 20). Norml thymus decreses in size throughout the first decde of life nd does not displce or compress the djcent irwys nd vessels. Liverlike echotexture on US is considered chrcteristic for thymus (21). Congenitl pulmonry irwy mlformtion Congenitl pulmonry irwy mlformtion (CPAM) hs een suggested s preferred term to CCAM, ecuse only type III is denomtoid, nd not ll types re cystic. CPAM is solid, cystic or mixed mss of pulmonry tissue (3, 22). The emryonic insult occurs during 5-8 weeks of gesttion. Histopthologiclly, CPAM is result of ronchil overgrowth with lmost complete suppression of lveolr development (23). CPAM cn occur in ny portion of the lung. Typiclly, CPAM is restricted to prt of one lung, which cn communicte normlly with the ronchil tree, nd tends to rpidly inflte with ir t irth. The trditionl clssifiction ws y Stocker, consisting of three histopthologic types; however, further clssifictions such s type 0 nd type IV hve een descried y some uthors (24, 25). Type I CPAMs (65%) hve mcroscopic cysts, t lest one lrger thn 2 cm nd lined with mucine secreting epithelium, nd cn contin crtilge pltes. Type II CPAMs (25%) lso hve mcroscopic cysts, ut smller thn 1 cm. They re lined y cilited columnr epithelium. Type III CPAMs hve solid-like content with multiplicity of ronchil memrnes nd ronchiole-resemling histology, without crtilge content. They re lined y cuoidl epithelium nd hve poor prognosis, s they tend to cuse non-immune hydrops fetlis nd pulmonry hypoplsi. In type IV CPAM, lrge cyst is lined y predominntly lveolr type cells. Finlly, type 0 CPAMs originte from trcheoronchil structures. Currently, more simplified clssifiction consisting of microcystic (cysts less thn 1 cm) or mcrocystic types hs lso een suggested (8). Depending on its type, CPAM cn e seen s hyperechoic solid lesion, cystic lesion or mixed cystic/solid mss on prentl US (Fig. 4). The postntl rdiologicl ppernce of CPAM depends on histologic type, presence of residul fetl fluid, or superimposed infection (26 30). On plin rdiogrphy nd CT, mixed ir filled (often with ir-fluid levels) cystic nd solid components re seen (Figs. 5, 6). A norml sudiphrgmtic owel gs pttern helps to differentite this nomly from congenitl diphrgmtic herni (CDH). However, chnge of ppernces in Volume 16 Issue 2 Bronchopulmonry foregut mlformtions 155

4 Figure 5.,. Congenitl pulmonry irwy mlformtion. Frontl chest rdiogrph () demonstrtes heterogeneous uly mss in the left lung displcing the medistinl structures to the opposite site. Axil CT imge () through lung ses shows multiple ir filled cysts with heterogeneous soft tissue density. Figure 6.,. Type I (mcrocystic) congenitl pulmonry irwy mlformtion. Frontl chest rdiogrph () shows right lung mss with ir fluid levels. Corresponding xil CT imge () through the hilr level confirms the multiple ir fluid levels within cysts lrger thn 2 cm in dimeter. Figure 7.,. Congenitl pulmonry irwy mlformtion. Frontl chest rdiogrph () shows incresed lucency of the right lung with medistinl shift. Axil CT imge () demonstrtes huge right lung cyst. position nd pucity of owel gs in the domen with CDH re helpful in dignosis. Moreover, US cn show the diphrgmtic defect. Lrge-cyst type CPAM should e differentited from low-grde pleuropulmonry lstom nd pneumtocele (Fig. 7) (31, 32). Inflmmtory findings of ir spces nd pleurl fluid my e present with superimposed infection (30 34). Associted normlities such s BC cn lso e disclosed y CT (Fig. 8). 156 June 2010 Dignostic nd Interventionl Rdiology Kocoğlu et l.

5 c Figure 8. c. Bronchogenic cyst nd type II congenitl pulmonry irwy mlformtion (CPAM). Axil contrst enhnced CT imge through the zygoesophgel recess in medistinl window setting () demonstrtes well defined fluid density mss (rrow) in the middle medistinum. Axil CT imges t the lung se in lung lgorithm (, c) demonstrte the ir filled cystic components of the CPAM. Pulmonry sequestrtion Pulmonry sequestrtion (PS) is portion of lung, which loses its norml communiction with the trcheoronchil tree nd is supplied y systemic rtery (or rteries), frequently originting either from the thorcic nd dominl ort or from their mjor rnches. Sequestrtions clssiclly hve een divided into intrlor (ILS) nd extrlor (ELS) types, in which the former ccounts for 75% of ll PS. ILS is contined within the viscerl pleur of the reminder of the loe, typiclly the posterior lterl segment of the lower loe, nd hs systemic rteril lood supply (the thorcic or dominl ort or one of its primry rnches). ILS usully hs norml pulmonry venous dringe (rrely systemic venous dringe to the hemizygos). Lngston suggested tht ILSs cn no longer e considered cquired lesions (8). In some diseses, such s tuerculosis, ronchiectsis nd pulmonry tromoemolism, hypertrophied norml systemic rteries my provide collterl supply to the lung. Referring to these conditions s pseudosequestrtion my e more ccurte. Moreover, prentl dignoses of ILS support its congenitl origin. ELS is less frequent thn ILS. It is commonly locted in posterior lower chest nd enveloped y seprte pleur. The lung tissue disconnected from the ronchil tree hs systemic rteril supply with multiple feeders in 20% of cses (the ort or primry rnch of it), 15% of which re infrdiphrgmtic. Venous dringe is mostly systemic (zygos, hemizygos, portl) s opposed to ILS. Ptent connections with foregut re much more common in the ELS. Intr-dominl loction is noted in t lest 5% of ELS. Ipsilterl CDH nd other ssocited congenitl nomlies cn e seen in up to 50%. PS presents with hyperechoic thorcic lesions on prentl US. Doppler US cn demonstrte systemic lood supply to the lesion (Fig. 9, ). Plin rdiogrphic ppernces re vrile, nd most commonly s welldefined, homogenous opcity in the lung se. PS my rrely e seen s n re of hyperlucency, when ertion occurs through existing collterl pthwys. IPS my mimic mlignncies when it hs irregulr mrgins. CT ppernce is lso vrile, demonstrting solid mss with or without cystic chnges (Fig. 9c). Emphysemtous chnges round the mss re considered one of the chrcteristic CT findings of PS, which occur secondry to collterl ir entry (12, 35), or sometimes with coexistent ronchil tresi or congenitl lor overinfltion (so-clled hyrid lesions) (Figs. 10, 11). CT ngiogrphy cn illustrte the errnt rtery, which is Volume 16 Issue 2 Bronchopulmonry foregut mlformtions 157

6 c importnt in surgicl plnning. MRI cn lso show the systemic rteriliztion nd venous dringe. Ctheter ngiogrphy hs mostly een replced y CT ngiogrphy nd MR ngiogrphy except in cse of preopertive emoliztion. Congenitl lor overinfltion Congenitl lor overinfltion (CLO) is chrcterized y progressive hyperexpnsion of lung loe, lmost exclusively n upper loe or the right middle loe. Becuse of the overdistension of otherwise norml lveoli without lveolr wll destruction, the term CLO hs een preferred to congenitl lor emphysem in the description of this entity (4, 36). It is thought to occur due to checkvlve mechnism or hypertrophy t the ronchi tht result in progressive hyperinfltion of the lung. In hlf of Figure 9. c. Pulmonry sequestrtion. Prentl US imge t the level of left lung se () shows hyperechoic solid lesion (rrowheds). Postntl color Doppler US () revels the mss (rrows) nd its systemic vessels (rrowheds) originting from the descending ort (strs: skin). Coronl reformtted postcontrst CT imge (c) shows soft tissue mss with feeding systemic rtery (rrowhed) nd drining vein (rrow) t the left lung se. the cses, the etiology is unknown; however, the res of mlci or stenosis of ronchil crtilge were detected (7, 37). In pproximtely 50% of cses no cuse of ronchil ostruction is identified, suggesting diffuse process in those, such s decresed elstic recoil of the lung prenchym. Congenitl crdiovsculr nomlies re commonly ssocited with CLO. Other cuses of ronchil ostruction leding to lor emphysem must e seprted out from CLO, nd include ronchil stenosis or cysts, mucous plugs, lymph nodes, foreign odies, Cytomeglovirus infection, redundnt ronchil mucos flps nd kinking of the ronchus cused y hernition into medistinum. On initil rdiogrphy, during first few dys of life, n opque mss my e seen in the ffected lung ecuse of the delyed clernce of fetl lung fluid. Lter in life, rdiogrphy demonstrtes hyperlucent expnded upper or middle loe, which cn cuse medistinl shift nd compression of unffected loes (38). CT demonstrtes hyperexpnsion with decresed CT ttenution of the involved loe, helping to differentite CLO from CPAM type I or other cystic lung lesions such s pneumtoceles, or persistent pulmonry interstitil emphysem (Fig. 12) (39). CT virtul ronchoscopy or multiplnr reformtted imges cn demonstrte endoronchil pthologies, which cn mimic CLO (40). Congenitl pulmonry cyst Congenitl pulmonry cysts (CPC) re very rre lesions tht pper during lveolr development following the formtion of terminl lveoli (41, 42). Becuse of the communiction with the trcheoronchil tree, 75% of them re ir-filled; however, they my lso e fluid-filled nd mss-like in ppernce. CPC is normlly singulr, locted peripherlly nd ffects only one loe with cyst dimeter usully greter thn 1 cm. Unlike the BC, CPC is usully symptomtic. Air trpping secondry to ll-vlve mechnism within the cyst results in expnsion nd respirtory distress in neontl period (43). Expnded cysts lso cuse compression of the ipsilterl lung nd diphrgm with medistinl shift, which result in contrlterl lung telectsis. The ltter worsen the respirtory compromise. CPC my mnifest with infection secondry to poor ventiltion. On plin rdiogrphy, CPC presents s well-defined, round, ir density mss (Fig. 13). Complicted cysts cuse mss effect, depressing the ipsilterl diphrgm nd cusing pronounced medistinl shift (41, 42). CT my e required to differentite CPC from CLO. Surgicl resection is generlly recommended, s most CPCs re symptomtic. Bronchil tresi Bronchil tresi is n uncommon condition secondry to focl olitertion of segmentl or susegmentl ronchus (44, 45). The lveoli distl to stenosis re ventilted y collterl irwys nd my demonstrte ir trpping mnifesting itself s hyperinfltion round the stenosis. 158 June 2010 Dignostic nd Interventionl Rdiology Kocoğlu et l.

7 Distl lung is hyperlucent due to ir trpping. CT etter demonstrtes these fetures (46). In conclusion BPFMs re heterogeneous interrelted normlities tht my contin more thn one histologic feture. Fmilirity with the pres c Figure 10. c. Intrlor pulmonry sequestrtion with type I (mcrocystic) congenitl pulmonry irwy mlformtion (CPAM). Axil, non-contrst enhnced CT imge t the level of the lung ses () demonstrtes soft tissue mss in the posterior spect of the left lower loe. On xil contrst enhnced CT imge () systemic rteril supply (rrows) to the mss from the descending ort is noted. Axil CT scn t higher level (c) revels ccompnying type I (mcrocystic) CPAM with lrge ir filled cysts. Figure 11.,. Intrlor pulmonry sequestrtion (IPS) with type I (mcrocystic) congenitl pulmonry irwy mlformtion (CPAM) (hyrid lesion). Axil, contrst enhnced CT imge () demonstrtes type I CPAM t superior level to the IPS shown on (). Coronl reformtted CT imge () demonstrtes n IPS in the posterior spect of the left lower loe with its rteril supply (thin rrow) from the descending ort nd drining vein (thick rrow). The post-stenotic ronchus is filled y mucus to form ronchocele. In hlf of the cses, ronchil tresi is symptomtic. In the neontl period, ronchil tresi revels fluid density secondry to entrpped fetl liquid. Then, the fetl liquid is replced y ir. Mucus ccumultes in distl ronchi nd ronchocele develops. In dults mucus plugs pper s solitry pulmonry nodule. On plin rdiogrphy ronchocele ppers s rounded rorizing opcities with or without ir-fluid level. Volume 16 Issue 2 Bronchopulmonry foregut mlformtions 159

8 Figure 12.,. Congenitl lor overinfltion (CLO). Frontl chest rdiogrph () shows rdiolucent re in the right hemithorx with mild shift of the hert to the left. Axil non contrst enhnced CT imge through the hil () demonstrtes lung hyperinfltion representing CLO. Note lso leftwrd shift of the hert. enttion nd imging fetures of BP- FMs presenting s mss-like lesion is importnt in mngement. Imging plys centrl role in the evlution of these lesions. Selection of the pproprite modlity nd technique is fundmentl in this evlution nd in differentition from their mimickers. With the pproprite imging strtegy, the presence nd type of lesion cn e defined nd pproprite mngement e determined to prevent complictions including infection nd respirtory compromise. References 1. Berrocl T, Mdrid C, Novo S, Gutierrez J, Arjonill A, Gomez-Leon N. Congenitl nomlies of the trcheoronchil tree, lung, nd medistinum: emryology, rdiology, nd pthology. Rdiogrphics 2004; 24:e Kousseff BG, Gilert-Brness E, Deich- Spicer D. Bronchopulmonry-foregut mlformtions: continuum of prcrine hmrtoms? Am J Med Genet 1997; 10:68: Evrrd V, Ceulemns J, Coosemns W, et l. Congenitl prenchymtous mlformtions of the lung. World J Surg 1999; 23: Winters WD, Effmnn EL. Congenitl msses of the lung: prentl nd postntl imging evlution. J Thorc Imging 2001; 16: Corn AG, Drongowski R. Congenitl cystic disese of the trcheoronchil tree in infnts nd children. Experience with 44 consecutive cses. Arch Surg 1994; 129: Ng KJ, Hsn N, Gry ES, Jeffrey RR, Youngson GG. Intrlor ronchopulmonry sequestrtion: ntentl dignosis. Thorx 1994; 49: Figure 13. Congenitl pulmonry cyst. Frontl chest rdiogrph revels hyperlucent right lung mss. 7. Stocker JT, Mdewell JE, Drke RM. Congenitl cystic denomtoid mlformtion of the lung. Clssifiction nd morphologic spectrum. Hum Pthol 1977; 8: Lngston C. New concepts in the pthology of congenitl lung mlformtions. Semin Peditr Surg 2003; 12: Clements BS, Wrner JO. Pulmonry sequestrtion nd relted congenitl ronchopulmonry-vsculr mlformtions: nomenclture nd clssifiction sed on ntomicl nd emryologicl considertions. Thorx 1987; 42: McAdms HP, Kirejczyk WM, Rosdode-Christenson ML, Mtsumoto S. Bronchogenic cyst: imging fetures with clinicl nd histopthologic correltion. Rdiology 2000; 217: Nouhr KK, Gorski YC, L Qugli MP, Shmerger RC. Bronchogenic cysts nd esophgel duplictions: common origins nd tretment. J Peditr Surg 1997; 32: Brnes NA, Pilling DW. Bronchopulmonry foregut mlformtions: emryology, rdiology nd qundry. Eur Rdiol 2003; 13: Winslow RE, Dykstr G, Scholten DJ, Den RE. Dupliction of the cervicl esophgus. An unrecognized cuse of respirtory distress in infnts. Am Surg 1984; 50: Heithoff KB, Sne SM, Willims HJ, et l. Bronchopulmonry foregut mlformtions. A unifying etiologicl concept. AJR Am J Roentgenol 1976; 126: June 2010 Dignostic nd Interventionl Rdiology Kocoğlu et l.

9 15. Rodgers BM, Hrmn PK, Johnson AM. Bronchopulmonry foregut mlformtions. The spectrum of nomlies. Ann Surg 1986; 203: Gotti G, Hid MM, Volternni L, Sforz V. Unusul mlignncy in the wll of medistinl cyst. J Thorc Crdiovsc Surg 1993; 106: Krous HF, Sexuer CL. Emryonl rhdomyosrcom rising within congenitl ronchogenic cyst in child. J Peditr Surg 1981; 16: Kim YW, Donnelly LF. Round pneumoni: imging findings in lrge series of children. Peditric Rdiol 2007; 37: Todo K, Moriwki H, Higshi M, Kimur K, Nritomi H. A smll pulmonry rteriovenous mlformtion s cuse of recurrent rin emolism. AJNR Am J Neurordiol 2004; 25: Rnkins S, Fling LJ, Pugtch RD. CT dignosis of pulmonry rteriovenous mlformtion. J Comput Assist Tomogr 1982; 6: Hn BK, Suh YL, Yoon HK. Thymic ultrsound. I. Intrthymic ntomy in infnts. Peditr Rdiol. 2001; 31: Cy A, Srihn H. Congenitl mlformtion of the lung. J Crdiovsc Surg 2000; 41: Skndlkis JE, Gry SW, Syms P. The trche nd the lung. In: Skndlkis JE, Gry SW, eds. Emryology for surgeons. 3rd ed. Bltimore: Willims nd Wilkins, 1994; Stocker JT. The respirtory trct. In: Stocker JT, Dejner LP, eds. Peditric pthology. 2nd ed. Phildelphi: Lippincott nd Wilkins, 2001; McSweeney F, Ppginnopoulos K, Goldstrw P, Shepprd MN, Corrin B, Nicholson AG. An ssessment of the expnded clssifiction of congenitl cystic denomtoid mlformtions nd their reltionship to mlignnt trnsformtion. Am J Surg Pthol 2003; 27: Hurd AM, Adzick NS, Cromleholme TM, et l. Congenitl chest lesions: dignosis nd chrcteriztion with prentl MR imging. Rdiology 1999; 212: Mt JM, Cceres J, Lucy J, Grci-Cones JA. CT of congenitl mlformtions of the lung. Rdiogrphics 1990; 10: Shckelford GD, Siegel MJ. CT ppernce of cystic denomtoid mlformtions. J Comput Assist Tomogr 1989; 13: Spence LD, Ahmed S, Keohne C, Wtson JB, O Neill M. Acute presenttion of cystic denomtoid mlformtion of the lung in 9-yer-old child. Peditr Rdiol 1995; 25: Rosdo-de-Christenson ML, Stocker JT. Congenitl cystic denomtoid mlformtion. Rdiogrphics 1991; 11: Dehner LP. Pleuropulmonry lstom is THE pulmonry lstom of childhood. Semin Dign Pthol 1994; 11: Auror P, McHugh K. Pleurl pneumtocoeles mimicking congenitl cystic denomtoid mlformtion of the lung. A cse report. Act Rdiol 1998; 39: Benjmin B. Trcheomlci in infnts nd children. Ann Otol Rhinol Lryngol 1984; 93: Kim WS, Lee KS, Kim IO, et l. Congenitl cystic denomtoid mlformtion of the lung: CT-pthologic correltion. AJR Am J Roentgenol 1997; 168: Rosdo-de-Christenson ML, Frzier AA, Stocker JT, Templeton PA. From the rchives of the AFIP. Extrlor sequestrtion: rdiologic-pthologic correltion. Rdiogrphics 1993; 13: Kuhn C III, West WW, Crighed JE. Lungs. In: Dmjnov I, Linder J, eds. Anderson s pthology, 10th Edition, Mosy: St. Louis, 1996; Riet ME, Copin M-C, Sotos JG, Gosselin BH. Bronchiololveolr crcinom nd congenitl cystic denomtoid mlformtion. Ann Thorc Surg 1995; 60: Stigers KB, Woodring JH, Kng JF. The clinicl nd imging spectrum of findings in ptients with congenitl lor emphysem. Peditr Pulmonol 1992; 14: Donnelly LF, Lucy J, Ozelme V, et l. CT findings nd temporl course of persistent pulmonry interstitil emphysem in neontes: multiinstitutionl study. AJR Am J Roentgenol 2003; 180: Kocoglu M, Bulksi N, Soylu K, Demirg S, Tyfun C, Somuncu I. Thinsection xil multidetector computed tomogrphy nd multiplnr reformtted imging of children with suspected foreign-ody spirtion: is virtul ronchoscopy overemphsized? Act Rdiol 2006; 47: Avery ME, Teusch HW. Schffer s disese of the neworn. 5th ed. Phildelphi: WB Sunders Co., 1984; , Chernick V: Kendig s disorders of respirtory trct in children. 5th ed. Phildelphi: WB Sunders Co., 1990; Wesley JR, Heidelerger KP, DiPietro MA, Cho KJ, Corn AG. Dignosis nd mngement of congenitl cystic disese of the lung in children. J Peditr Surg 1986; 21: Willims AJ, Schuster SR. Bronchil tresi ssocited with ronchogenic cyst: evidence of erly ppernce of tretic segments. Chest 1985; 87: Oh KS, Dorst JP, White JJ. The syndrome of ronchil tresi or stenosis with mucocele nd focl hyperinfltion of the lung. Johns Hopkins Med J 1976; 138: Beigelmn C, Howrth NR, Chrtrnd Lefevre C, Grenier P. Congenitl nomlies of trcheoronchil rnching ptterns: spirl CT spects in dults. Eur Rdiol 1998; 8: Volume 16 Issue 2 Bronchopulmonry foregut mlformtions 161