Discussion
CPAM, once referred to as congenital cystic adenomatoid malformation (CCAM), is an uncommon, developmental lung anomaly of unknown cause, presenting as cystic changes to the terminal bronchioles (5). There are a few differential diagnoses to CPAM that include bronchogenic cysts (BC), congenital lobar emphysema (CLE), and bronchopulmonary sequestration (BPS) (1). Antenatally, CPAM can cause some complications in the fetus, the most important of which is Hydrops Fetalis due to the compressing of the mass on other structures, which usually requires an emergency cesarean section (3). At birth, 70% of CPAM are asymptomatic. Among antenatally diagnosed patients, 70% of antenatally diagnosed CPAM are asymptomatic; while the other 30% cause neonatal respiratory distress, with 10% have severe respiratory distress requiring assisted ventilation (1). In some cases, CPAM remains unrecognized until adolescence or later life when complications, such as recurrent pulmonary infections, pneumothorax and lung abscess, start to happen (5). In our case, there was symptomatic, antenatally diagnosed CPAM, associated with Hydrops Fetalis antenatally (requiring caesarean delivery), and severe respiratory distress postnatally (requiring neonatal intensive care unit). Therefore, left lower lobectomy was decided, and open surgery was chosen over thoracoscopy due limited resources (lack of equipment and expert hands). The management of CPAM is highly debatable, and varies from administering maternal betamethasone prenatally (to decrease the size of large CPAMs and reverse hydrops) to minimally invasive or even open surgical resection postnatally, with the most controversial area remains the postnatal management of asymptomatic cases. Prophylactic lung resection in asymptomatic patients is sometimes done, and has advantages that include reduced risk of infection, malignancy and decreased complication rate, while disadvantages include mortality and morbidity associated with operation and cancer risk despite excision. Due to the low incidence and wide spectrum of manifestation of CPAM, it is not surprising that the quality of the evidence on management styles is generally poor (6). David et al (2016) proposed prenatal Fig.5 (A) and postnatal Fig.5 (B) management algorithms (2). A meta-analysis by Naser and Bass (2012), suggested that thoracoscopic resection is a safe and feasible alternative to open resection of congenital lung lesions in experienced hands, and no differences between thoracotomy versus thoracoscopy for management of CPAMs were observed in terms of overall complications and the duration of surgery. However, days with chest tube in place and length of hospitalization period were longer after open surgery (7).