Sleeve lobectomy for non-small cell lung cancer and carcinoids: results in 160 cases

Anastomosis Complications after Bronchoplasty: Incidence, Risk Factors, and Treatment Options Reported by a Referral Cancer Center

BACKGROUND

Sleeve lobectomy with bronchoplasty is a safe surgical technique for the management of lung cancer and endobronchial localization of extrapulmonary cancers. However, anastomotic complications can occur, and treatment strategies are not standardized.

METHODS

Data from 280 patients subjected to bronchoplasty were retrospectively analyzed, focusing on surgical techniques, anastomotic complications, and their management. Multivariate analysis was performed, and Kaplan-Meier curves were used to determine survival.

RESULTS

Ninety percent of 280 surgeries were for lung cancer. Anastomotic complications occurred in 6.42% of patients: late stenosis in 3.92% and broncho-pleural fistula in 1.78%. The median survival was 65.90 months (95% CI = 41.76-90.97), with no difference (p = 0.375) for patients with (51.28 months) or without (71.03 months) anastomotic complications. Mortality at 30 days was higher with anastomotic complications (16.7% vs. 3%, p = 0.014). Multivariable analysis confirmed pathological stage (N+) as a risk factor for anastomotic complications (p = 0.016). Our mortality (3.93%) and morbidity rate (41.78%) corresponded to recent series results.

CONCLUSIONS

In our experience, surgery is preferred to avoid life-threatening complications in bronchopleural fistulas. Bronchoscopic balloon dilatation is preferred for benign strictures. The nodal stage is related to complications (p = 0.0014), reflecting the aggressiveness of surgery, which requires extended radical lymphadenectomy.

Pulmonary sleeve resection complications and management

In tumors involving the central airway or vascular structures, achieving local control and preserving pulmonary function can be possible with a pulmonary sleeve resection. In this section, complications and management of pulmonary sleeve resections are discussed.

Is sleeve lobectomy safe after induction therapy?-a systematic review and meta-analysis

BACKGROUND

Sleeve lobectomy (SL) is a lung-sparing procedure, which is accepted as a valid operation for centrally-located advanced tumors. These tumors often require induction treatment by chemotherapy and/or radiotherapy to downstage the disease and thus facilitate subsequent surgery. However, induction therapy may potentially increase the risk of bronchial anastomotic complications and related morbidity. This meta-analysis aims to determine the impact of induction therapy on the outcomes of pulmonary SL.

METHODS

We compared studies of patients undergoing SL or bilobectomy for non-small cell lung cancer (NSCLC) with and without induction therapy. Outcomes of interest were in-hospital mortality, morbidity, anastomosis complication and 5-year survival. Odds ratio (OR) were computed following the Mantel-Haenszel method.

RESULTS

Ten studies were included for a total of 1,204 patients. There was no statistical difference for between patients who underwent induction therapy followed by surgery and patients who underwent surgery alone in term of post-operative mortality (OR: 1.80, 95% confidence interval (CI): 0.76-4.25, P value =0.19) and morbidity (OR: 1.17, 95% CI: 0.90-1.52, P value =0.237). Anastomosis related complications rate were 5.2% and appears increased after induction therapy with a statistical difference close to the significance (OR: 1.65, 95% CI: 0.97-2.83, P value =0.06). Patients undergoing surgery alone showed better survival at 5 years (OR: 1.52, 95% CI: 1.15-2.00, P value =0.003).

CONCLUSIONS

SL following induction therapy can be safely performed with no increase of mortality and morbidity. However, the need for induction therapy before surgery is associated with increased anastomotic complications and poorer survival prognosis at 5 years.

[Diagnostic and therapeutic management of operable bronchopulmonary carcinoid tumours]

INTRODUCTION

Bronchial carcinoid tumours (CT), divided into typical carcinoid (TC) or atypical carcinoid (AC), are rare tumours whose therapeutic management remains unspecified.

METHODS

Retrospective study collecting cases of bronchial CT operated at the thoracic surgery department of Abderrahmane-Mami hospital of Ariana and recruited from the pneumology departments of Northern Tunisia, during a 12-year period.

RESULTS

Ninety patients were collected (74 cases of TC and 16 cases of AC). The mean age was 45 years and the sex ratio H/F=0.5. The chest X-ray was normal in 11 cases, as well as flexible bronchoscopy in seven cases. The tumour was classified: stage IA (10 cases), IIA (28 cases), IIB (31 cases), IIIA (15 cases) and IIIB (six cases). Surgery resulted in a complete resection in 78 patients, an extensive resection in six patients, and a conservative resection in six patients. Adjuvant chemotherapy was given in 10 patients. The survival was 84% at five years and 42% at 10 years.

CONCLUSION

The prognosis of CT depends directly on the histological subtype. It is excellent for TC after complete resection, unlike ACs that are similar to well-differentiated bronchial carcinomas.

For non-small cell lung cancer with T3 (central) disease, sleeve lobectomy or pneumonectomy?

BACKGROUND

Pneumonectomy (PN) has traditionally been the treatment of choice for central lung tumors for which the alternative is sleeve lobectomy (SL). The aim of this study was to compare early and long-term results after SL and PN in focusing on T3 central non-small cell lung cancer (NSCLC).

METHODS

Patients who underwent SL (n=58) or PN (n=42) were retrospectively analyzed. For bias reduction, these 100 patients had been selected according to the following criteria: (I) tumor located in the main bronchus less than 2 cm distal to the carina; (II) there were no N2 disease; (III) no induction therapy was applied; (IV) complete resection (R0) was achieved.

RESULTS

SL and PN patients had comparable mean ages, gender distribution, mean forced expiratory volume in 1 second (FEV1), stage and tumor grade. Postoperative mortality (3.4% vs. 4.8%, P=1.0) and morbidity (41% vs. 38%, P=0.74) were similar between the two groups. Recurrences occurred in 48% of patients after SL and in 31% of those after PN (P=0.08). The 5-year survival after SL (64.8%) and PN (61.4%) was not significantly different (P=0.20). Multivariable survival analysis showed that there were no independent prognostic factors.

CONCLUSIONS

SL does not compromise survival for NSCLC with T3 central disease compared with PN. It is an adequate oncologic resection and should be treated as the first line intervention whenever complete resection can be achieved.

Surgical Treatment of Lung Cancer

In this chapter, we discuss the preoperative evaluation that is necessary prior to surgical resection, stage-specific surgical management of lung cancer, and the procedural steps as well as the indications to a variety of surgical approaches to lung resection.

Carcinoid tumours of the lung and the 'PEPPS' approach: evaluation of preoperative bronchoscopic tumour debulking as preparation for subsequent parenchyma-sparing surgery

BACKGROUND

Preoperative bronchoscopic tumour ablation has been suggested as a beneficial treatment for bronchopulmonary carcinoid tumours, although data regarding its effects and long-term outcome are lacking.

METHODS

In our case-matched cohort study with 208 patients with bronchopulmonary carcinoid tumours we investigated the role of preoperative bronchoscopic interventions before subsequent surgery and analysed the safety of this Procedure of Endobronchial Preparation for Parenchyma-sparing Surgery (PEPPS) based on metastasis and recurrence rates as well as survival data from 1991 to 2010. The subsequent surgery was classified into parenchyma-sparing procedures and classical lobectomies, bilobectomies and pneumonectomies. Data were obtained from the tumour registry and medical reports. Outcomes were the frequency of parenchyma-sparing surgery after bronchoscopic treatment as well as rates of metastasis, recurrence and survival.

RESULTS

132 of 208 carcinoids were located centrally. Among them, 77 patients could be recanalised preoperatively. After bronchoscopic preparation, the rate of subsequent parenchyma-sparing surgery methods was higher (p=0.021). The effect was measured by the number of segments removed. The 10-year survival rate was 89% (typical carcinoids) and 68% (atypical carcinoids), respectively. After applying PEPPS, long-term survival was slightly higher (p=0.23). Metastasis and recurrence rates showed no relevant differences between the bronchoscopically treated or non-treated groups, or between the two types of surgery classes or between the PEPPS and non-PEPPS groups.

CONCLUSIONS

After preoperative bronchoscopic treatment, parenchyma-sparing surgery techniques can be applied more frequently. Furthermore, we detected no negative effects after PEPPS based on metastasis, recurrence and survival rates.

Left lower sleeve lobectomy and systematic lymph node dissection by complete video-assisted thoracic surgery

Sleeve lobectomy for selected cases of central lung cancer has better functional outcomes comparing to pneumonectomy. With improved technology and increased experiences in complete video-assisted thoracic surgery (VATS) lobectomy, complete VATS sleeve lobectomy has been applied in major medical centers recently. A 64-year-old male patient with left lower central lung cancer underwent thoracoscopic sleeve lobectomy and systemic mediastinal lymph node dissection. The major incision, of four incisions in total, was a 4 cm mini-incision in the 4th intercostal space of anterior axillary line. The patient had recovered uneventfully after the surgery.

Sleeve lobectomy for non-small cell lung cancer with N1 nodal disease does not compromise survival

BACKGROUND

We evaluated if sleeve lobectomy had worse survival compared with pneumonectomy for non-small cell lung cancer (NSCLC) with N1 disease, which may be a risk factor for locoregional recurrence.

METHODS

Patients who underwent pneumonectomy or sleeve lobectomy without induction treatment for T2-3 N1 M0 NSCLC at a single institution from 1999 to 2011 were reviewed. Survival distribution was estimated with the Kaplan-Meier method, and multivariable Cox proportional hazards regression was used to evaluate the effect of resection extent on survival.

RESULTS

During the study period, 87 patients underwent pneumonectomy (52 [60%]) or sleeve lobectomy (35 [40%]) for T2-3 N1 M0 NSCLC. Pneumonectomy and sleeve lobectomy patients had similar mean ages (60.9 ± 10.7 vs 63.5 ± 12.7 years, p = 0.30), gender distribution (69.2% [36 of 52] vs 60.0% [21 of 35] male, p = 0.37), mean forced expiratory volume in 1 second (66.3 ± 15.9 vs 63.5 ± 17.6, p = 0.47), stage (61.5% [32 of 52] vs 62.9% [22 of 35] stage II, p = 0.90), and tumor grade (51.9% [27 of 52] vs 31.4% [11 of 35] well/moderately differentiated, p = 0.17). Postoperative mortality (3.8% [2 of 52] vs 5.7% [2 of 35], p = 0.68) and median (interquartile range) length of stay (5 [4 to 7] vs 5 [4 to 7] days, p = 0.68) were similar between the two groups. The 3-year survival after pneumonectomy (46.8% [95% CI, 31.8% to 60.4%]) and sleeve lobectomy (65.2% [95% CI, 45.5% to 79.3%]) was not significantly different (p = 0.23). In multivariable survival analysis that included resection extent, age, stage, and grade, only increasing age predicted worse survival (hazard ratio, 1.03/year; p = 0.03).

CONCLUSIONS

Performing sleeve lobectomy instead of pneumonectomy for NSCLC with N1 nodal disease does not compromise long-term survival.

Results of interventional bronchoscopy in the management of postoperative tracheobronchial stenosis

OBJECTIVES

To investigate the role of bronchoscopic intervention in the management of postoperative tracheobronchial stenosis, a retrospective study was performed at a tertiary referral hospital.

METHODS

Thirty patients who underwent 106 bronchoscopic interventions between January 2000 and July 2010, including ballooning, bouginage, Nd:YAG laser resection, and stent insertion, were included and followed up for a median of 34 months.

RESULTS

Silicone stents were required in 19 of 30 patients (63%) to maintain airway patency. Bronchoscopic intervention provided improvement of dyspnea in 97% of the patients. After airway stabilization, the stents were removed successfully in 7 of 19 patients (37%) a median of 7 months after insertion. In 3 patients (10%), the intervention failed to widen the airway. There were no procedure-related deaths or cases of pneumonia, although additional interventions were needed in 9 patients (30%) within 30 days. Stent-related late complications (70%), such as restenosis (43%), overgrowth of granulation tissue (33%), stent migration (32%), mucostasis (30%), and malacia after stent removal (16%), were controllable at follow-up bronchoscopy.

CONCLUSIONS

Bronchoscopic intervention could be a useful treatment modality for patients with postoperative tracheobronchial stenosis when surgery is not feasible.

Extensive resections: pancoast tumors, chest wall resections, en bloc vascular resections

Infiltration by lung tumor of adjacent anatomic structures including major vessels, main bronchi, and chest wall not only influences the oncologic severity of the disease but also increases the technical complexity of surgery, requiring extended resections and demanding reconstructive procedures. Completeness of resection represents in every case one of the main factors influencing the long-term outcome of patients. Technical and oncologic aspects of extended operations, including resection of Pancoast tumors and chest wall, bronchovascular sleeve resections, and en bloc resections of major thoracic vessels, are reported in this article.

Comparative Analysis and Outcomes of Sleeve Resection versus Pneumonectomy

To compare the outcome of sleeve resection or complex sleeve resection versus (Vs) pneumonectomy for lung cancer in a single unit. Between 1998 and 2006, 664 lung resections were carried out. There were 129 (19.4%) pneumonectomies and 79 (11.9%) sleeve resections; Twenty one patients (26.5%) underwent a complex sleeve resection. Operative mortality for the sleeve resections (SR) was 2.5% and for the pneumonectomies 8.53%. Overall 5-year survival after SR was 46.8% and after pneumonectomy 37.1%. The survival curves for the 2 procedures after adjusting for risk factors are different. The area under the curve is higher for the SR (Hazard ratio 1.78 C.I.: 0,92-3,46). The 5-year survival for early stages favors SR. The survival for the complex SR was not influenced by the complexity of the procedure but from the TNM stage of each individual case. Multivariate analysis of risk factors affecting survival after surgery showed: male sex Hazard ratio (HR) 1.19, 0.63–2.27(95%CI), Age >63 1.38(HR), 0.78–2.48, Pneumonectomy 1.78(HR), 0.92–3.46 and stage III 4.44(HR), 1.94–10.16(95% CI). For comparative stages survival appears to be better after sleeves, moreover male sex, sleeve resection, age younger that 63 and early TNM stage are positive predictors for survival.

Comparison of operative mortality and complications between bronchoplastic lobectomy and pneumonectomy in lung cancer patients

Bronchoplastic lobectomy is a lung-saving procedure indicated for central tumors, for which the alternative is pneumonectomy. We compared operative mortality and complications between bronchoplastic lobectomy and pneumonectomy in lung cancer patients. From March 1993 through December 2005, 1,461 patients were surgically resected for non-small cell lung cancer, including 73 who underwent bronchoplastic lobectomy and 258 who underwent pneumonectomy. Bronchoplastic lobectomy was performed on any lesion that could be completely resected by this technique, whereas pneumonectomy was only performed on lesions that could not be removed by bronchoplastic lobectomy. Operative deaths occurred in 1 of 73 (1.4%) bronchoplastic lobectomy and 26 of 258 (10.1%) pneumonectomy patients (p=0.014). Major complications occurred in 16 of 73 (21.9%) bronchoplastic lobectomy and 58 of 258 (22.5%) pneumonectomy patients (p=1.0). Bronchoplastic lobectomy has a lower risk of operative mortality than pneumonectomy. Although the complication rates were similar, bronchoplastic lobectomy was associated with improved postoperative cardiopulmonary status and a low prevalence of fatal complications after bronchial anastomosis. These findings indicate that bronchoplastic lobectomy is a valuable alternative to pneumonectomy for anatomically appropriate patients, regardless of underlying cardiopulmonary function.

Relevance of Lymph Node Micrometastases in Radically Resected Endobronchial Carcinoid Tumors

BACKGROUND

Endobronchial carcinoids may recur even if radically resected. This retrospective study investigates the clinical and prognostic relevance of lymph node micrometastasis in these neoplasms.

METHODS

Fifty-five patients underwent standard anatomic resection (lobectomy or pneumonectomy) with systematic routine (hilar and mediastinal) lymphadenectomy. After an evaluation of conventional prognostic factors, we reanalyzed lymph nodes of pN0 patients for micrometastasis using immunohistochemistry (anti-cytokeratin AE1/AE3 and anti-chromogranin A antibodies).

RESULTS

We performed 9 pneumonectomies, 41 lobectomies, and 5 bilobectomies. Histologic examination showed 47 (85%) typical carcinoid and 8 (14.5%) atypical. Twelve patients were pN1 (8 typical, 4 atypical); after reanalysis another 8 revealed micrometastasis, 6 N1 micrometastasis (5 typical, 1 atypical), and 2 N2 micrometastasis (2 atypical), increasing subjects with nodal involvement (pN1 and N micrometastasis) from 12 (21.8%) to 20 (36.4%; p = 0.01). Micrometastases were more frequent in atypical carcinoids (p = 0.002). Local recurrence developed in 3 (5.4%) patients: 2 pN1 (1 typical, 1 atypical) and 1 N1-micrometastasis (1 typical). Distant relapse occurred in 2 (3.6%) patients, both N2 micrometastasis (2 atypical). After reanalysis, recurrence rate in patients with nodal disease increased from 16.7% to 25% (p = 0.01). All patients with recurrence died: all had pN1 or N micrometastasis. No patient confirmed as N0 had recurrence. Only histologic pattern and node status significantly influenced disease-free (p = 0.002 and p = 0.05) and overall survivals (p = 0.02 and p < 0.001), respectively. Micrometastasis worsen both disease-free (p < 0.0001) and overall (p < 0.001) survival rates at 5 and 10 years.

CONCLUSIONS

Routine systematic lymphadenectomy with immunohistochemical detection of lymph node micrometastasis contributes to identification of a larger population at risk with a higher recurrence rate, allowing a more accurate staging of endobronchial carcinoids.

Local Control of Disease Related to Lymph Node Involvement in Non-Small Cell Lung Cancer After Sleeve Lobectomy Compared With Pneumonectomy

BACKGROUND

Increasing evidence has suggested that sleeve lobectomy might be a viable alternative procedure for pneumonectomy in non-small cell lung cancer (NSCLC), including patients with adequate pulmonary reserve. This study was designed to compare the outcomes of the two procedures and to determine adequate surgical indications for each procedure.

METHODS

From January of 1989 to December of 1998, sleeve lobectomy was performed in 49 patients, and 200 patients underwent pneumonectomy for NSCLC. By reviewing the computed tomographic scans, bronchoscopic findings, and operative reports, we selected 49 patients on whom sleeve resection could have been performed. The clinical outcomes of the sleeve lobectomies (SL) and pneumonectomies (PN) were analyzed, particularly in relation to nodal status and recurrence patterns.

RESULTS

Operative mortality was 6.1% (3 of 49 patients) in the SL group and 4.1% (2 of 49 patients) in the PN group. Mean follow-up period was 51 months (range, 5 to 149). The overall 5-year survival rate was not substantially different between the two groups (SL: 53.7% vs PN: 59.5%, p = 0.510). Recurrence occurred in 57% (26 of 46 patients) of the SL group and in 30% (14 of 47 patients) of the PN group. The 5-year freedom from recurrence rates were better in the PN group (SL: 45.7% vs PN: 67.9%, p = 0.017). Locoregional recurrences occurred in 32.6% (15 of 46 patients) of the SL group and in 8.5% (4 of 47 patients) of the PN group. In multivariate analysis, performing sleeve resection in patients with a positive N1 lymph node was a significant risk factor for developing locoregional recurrence (p = 0.007).

CONCLUSIONS

Although the overall survival rates were similar, sleeve resection resulted in higher locoregional recurrence, particularly in patients with positive N1 lymph nodes. This finding suggests that sleeve resection should be performed in selected patients, such as those without lymph node metastasis.

Experimental study of extracorporeal lung resection in dogs: ex situ sleeve resection and autotransplantation of the pulmonary lobe after extended pneumonectomy for central lung cancer

OBJECTIVE

Extracorporeal lung resection as an alternative to pneumonectomy for central lung cancer is a procedure in which the unilateral lung is extirpated, removing the pulmonary lobe with the cancers and replanting the residual pulmonary lobe. The aim of this study was to investigate whether extracorporeal lung resection for lung cancer can be performed safely.

METHODS

Nineteen dogs were divided into the control and extracorporeal lung resection groups. The former (n = 5) underwent lung autotransplantion, and the latter was subdivided into ND1 (n = 7) and ND2 (n = 7) groups on the basis of the manner of lymph node dissection. By comparing the 3 groups, the adverse effects of lymph node dissection were examined.

RESULTS

All dogs in the control group had no complications. Four dogs in the ND1 group survived for 90 to 630 days after the operation. In the ND2 group 5 dogs succumbed within 30 days after the operation, although the other 2 dogs survived for 391 and 573 days, respectively. Bronchopulmonary fistulas were seen in 1 of the ND1 dogs and 3 of the ND2 dogs. Two of the latter were free of thrombus formation in the pulmonary arteries and veins of the autografts. In the ND2 group, compared with the control and ND1 group, the tissue blood flow at the bronchial anastomotic site indicated reduction between the 3rd and 14th postoperative days.

CONCLUSION

The extensive lymph node dissection had severe adverse effects on bronchial anastomotic healing in extracorporeal lung resection. Therefore extracorporeal lung resection can be applied to only a very limited number of patients with N0 or N1 disease.

Treatment of carcinoid of the lung

PURPOSE OF REVIEW

Pulmonary carcinoids are rare neuroendocrine malignancies that comprise 2% of primary lung tumors. During the last few years, important information has appeared in the literature in relation to the histopathology, molecular biology, biologic behavior, and treatment of these tumors.

RECENT FINDINGS

Histologic subclassification of carcinoid tumors into atypical and typical is of paramount importance. Genetic changes in these subclasses are now well-known and are helpful for the differentiation. The biologic behavior of typical and atypical carcinoids is completely different, and treatment planning is based on this information. Surgery is the treatment of choice for localized carcinoid tumors and includes lymphadenectomy. In metastatic disease, chemotherapy with a cisplatin-based or streptozotocin-based combination is moderately effective. Palliation with biotherapy including interferon, somatostatin analogs, and octreotide is encouraging. Liver embolization is an option for symptomatic liver involvement.

SUMMARY

Pulmonary carcinoids are rare tumors, and our understanding of their histopathology and biologic behavior are the most important factors for treatment planning. Surgery is the treatment of choice for cure.

Sleeve lobectomy or pneumonectomy: optimal management strategy using decision analysis techniques

BACKGROUND

The choice between sleeve lobectomy and pneumonectomy is controversial for patients with early-stage lung cancer and who have acceptable lung function.

METHODS

We performed a meta-analysis of results of sleeve lobectomy and pneumonectomy published in English from 1990 to 2003. A decision model was developed with 5-year survival, quality-adjusted life years (QALY), and cost effectiveness as the outcomes, and sensitivity analyses were performed.

RESULTS

The model favored sleeve lobectomy (3.5 percentage point survival advantage) when the reward was 5-year survival; the results were influenced primarily by the 5-year survival rates for patients who did not develop recurrent cancer. Sleeve lobectomy was strongly favored when the reward was QALY (1.53 QALY advantage). Sleeve lobectomy was more cost effective than pneumonectomy, and had an incremental cost effectiveness ratio of $1,300/QALY.

CONCLUSIONS

In patients with anatomically appropriate early-stage lung cancer, sleeve lobectomy offers better long-term survival and quality of life than does pneumonectomy and is more cost effective.

The natural history of recurrence after bronchoplastic procedures for non-small cell lung cancer

BACKGROUND

The natural course of recurrence after bronchoplastic procedures for non-small cell lung cancer (NSCLC) has not been described.

METHODS

Sex, age, tnm-stage, histology, neoadjuvant chemotherapy, disease-free interval (months), exact localisation of tumour recurrence, time between first and second recurrence (months), survival after first and second recurrence (months), causes of death were retrospectively recorded in 83 patients operated between December 1993 and July 2001.

RESULTS

One patient was lost to follow-up, five resections were nonradical. Survivors' follow-up lasted 5 to 100.7 months (mean 43.3). Fourteen patients (14.4%) died tumor free. Eleven (13.2%) distant recurrences were diagnosed 1 to 42 months (mean 10.6) postoperatively, eight (9.6%) died 0 to 17 months (mean 7.55) after diagnosis. Nine local recurrences (10.8%)-5 unifocal, 4 multifocal-occurred 2 to 35 months (mean 17.3) postoperatively, eight died 0 to 8 months (mean 2.13) after diagnosis. Nine mixed recurrences (10.8%)-1 synchronous, 8 metachronous-were found (14.8%) 2 to 21 months postoperatively (mean 8.3). All died 4 to 41 months (mean 17.83) after diagnosis. Fourteen mediastinal lymph node recurrences occurred, ten as a primary recurrence and four as secondary. Lymph nodes were involved in all multifocal recurrences. Intrabronchial recurrence was observed in five patients and was always a result of progressive regional lymph node recurrence.

CONCLUSIONS

The pattern and natural history of recurrence cannot be sufficiently explained by stage and surgical radicality and suggest different genetic characteristics of the primary tumor. In case of reoperation due to intrabronchial recurrence adjuvant mediastinal irradiation should be considered.

Pulmonary carcinoid tumors

Carcinoid tumors of the lung are an uncommon group of neoplasms of neuroendocrine origin. Pulmonary carcinoid tumors are typically benign and slow growing. However, more aggressive subtypes may develop early nodal and distant metastases. Although several histologic classification strategies have been proposed to distinguish benign from more aggressive subtypes, the lack of uniformity in terminology has resulted in increased ambiguity and confusion. Because these tumors are generally resistant to chemotherapy, complete surgical resection is the primary form of therapy. Long-term survival for patients with typical carcinoid is excellent but is decreased in those with the atypical subtype. Complete tumor resection with preservation of uninvolved pulmonary parenchyma remains the fundamental goal in the surgical treatment of this unusual clinical entity.