Carcinoid tumors of the lung: do atypical features require aggressive management?

Recent Advances in the Diagnosis and Management of Carcinoid Syndrome

Carcinoid syndrome, a paraneoplastic condition linked with the release of multiple humoral factors, affects around 30-40% of patients with well-differentiated neuroendocrine tumours. Carcinoid syndrome has a major and unfavourable impact on patients' quality of life; it raises costs when compared to non-functioning neuroendocrine tumours; and it causes patients' lifestyles to alter, such as food, job, physical activity, and social life. Somatostatin analogues have been the first-line therapy for individuals with neuroendocrine tumours and carcinoid disease for decades. While these drugs give considerable relief from carcinoid syndrome symptoms, clinical progression is unavoidable, necessitating further research into newer treatment measures. Carcinoid tumours are sometimes difficult to diagnose because of their vague or nonspecific symptoms. There have been several advancements in all aspects of carcinoid syndrome, as well as novel therapeutics, in the previous few years. New epidemiological studies show that it is becoming more common; increasing insights into the pathogenesis of its various clinical manifestations and its natural history: definition of prognostic factors; new methods to verify its presence; the development of new drugs to treat its various manifestations, both initially and in somatostatin-refractory cases; and an increased understanding of the pathogenesis, natural history, and management of the disease. An all language literature search was conducted on MEDLINE, COCHRANE, EMBASE, and Google Scholar till November 2021. The following search strings and Medical Subject Headings (MeSH) terms were used: "Recent advances", "Carcinoid syndrome", "Neuroendocrine Neoplasms" and "Carcinoid heart disease". We comprehensively reviewed the literature on the pathogenesis, clinical features, and newer treatment modalities for Carcinoid Syndrome. Recent advancements in research and management have resulted from advances in our understanding of the aetiology of carcinoid syndrome. The development of molecular indicators of aggressiveness improved serum tumour markers, and the molecular aetiology of carcinoid heart disease are all possible because of advances in molecular biology. We conducted a comprehensive review to update knowledge regarding the pathophysiology, diagnostic protocols, and current and newer treatments for carcinoid syndrome, which presently requires a multidisciplinary approach, due to the complexity of the illness's aetiology, diagnosis, and therapy.

Epidemiology and outcomes of primary pediatric lung malignancies: Updates from the SEER database

BACKGROUND

Primary pediatric lung malignancies are rare tumors. We provide an updated analysis of the epidemiology and prognosis of these tumors since the last SEER series published in 2009.

METHODS

The SEER 18 database from 1975 to 2016 was analyzed for patients ages 0-19 years with primary lung and/or bronchus neoplasms.

RESULTS

348 patients met inclusion criteria. The majority were white and ≥12 years of age. The most common histologies were neuroendocrine (41.4%) and blastoma (16.4%). 75.4% of patients had local-regional disease and 81.4% underwent surgery. Significant differences between histologies were seen for age, year at diagnosis, tumor laterality and location, stage, and treatment type. Median survival was 36.6 years (95% CI 33.3-37.4). Blastoma (HR 3.47) and squamous cell (HR 6.26) carried a significantly higher risk of death than neuroendocrine cancer diagnosis.

CONCLUSION

Primary pediatric lung malignancies are rare, long-term survival is favorable but histology-dependent. Surgery continues to be an important treatment modality.

[Surgery of tracheobronchial carcinoid tumours: Activity report]

INTRODUCTION

Our purpose is to evaluate our results of surgery for tracheobronchial carcinoid tumour as well as the long-term survival.

METHODS

This is a retrospective and descriptive study performed in the department of thoracic surgery of CHU Hassan II (Marocco) over a period of 9 years. It concerns all patients with a tracheal or bronchial carcinoid tumour who underwent surgery.

RESULTS

Twenty-three patients with a mean age of 39 years were operated on for 24 carcinoid tumours. The sex ratio was 0.29. The diagnostic delay ranged from 3 months to 8 years and the main symptom was haemoptysis in 74% of cases (n=17). The tumour was localized in the right bronchial tree in 70% of cases (n=16). The procedures performed were tracheal resection and end-to-end anastomosis in 1 case, lobectomy in 12 cases including 3 sleeve lobectomies, bilobectomy of middle and lower lobes in 7 cases and pneumonectomy in 4 cases. The prognosis was favourable in 91% after an average follow-up of 29 months.

CONCLUSIONS

Surgery remains the only curative therapeutic option for tracheobronchial carcinoid tumours with acceptable morbidity and mortality.

[Resection concepts for early stage neuroendocrine tumors of the lungs and bronchi]

BACKGROUND

Neuroendocrine tumors of the lungs are a very inhomogeneous group of malignancies. The surgical treatment should be adapted to the anatomical localization and histological subtype and individualized according to the functional reserve.

MATERIAL AND METHODS

We performed a selective review of current literature, which was supplemented by personal experiences.

RESULTS

The currently available outcome data are very inhomogeneous and depend on the histological subtype of neuroendocrine pulmonary tumors. A radical R0 resection is the key for an improvement in long-term overall and disease-free survival.

CONCLUSION

Surgical treatment of carcinoid tumors is the current standard therapy. Sleeve resection should be performed, whenever possible. More aggressive tumors, such as large cell neuroendocrine carcinoma and small cell lung cancer should be treated in a multimodal concept.

Lung and Thymic Carcinoids

Carcinoids of the lung and thymus are rare thoracic cancers. In general, lung carcinoid tumors have a favorable prognosis, particularly when diagnosed at an early stage and treated with surgical resection. Thymic neuroendocrine tumors may be associated with multiple endocrine neoplasia-1 syndrome, tend to have a more aggressive natural history, and relatively frequently secrete ectopic adrenocorticotropic hormone.

Long-term outcomes and prognostic factors of patients with surgically treated pulmonary atypical carcinoid tumors: our institutional experience with 68 patients

Background

Pulmonary atypical carcinoid (AC) tumors are rare malignant neoplasms and controversy exists regarding management and prognosis. The purpose of this retrospective study was to describe characteristics, and outcomes of patients treated for pulmonary AC tumors.

Methods

All patients with a diagnosis of primary pulmonary AC tumor treated from 1999 to 2013 were reviewed. Data collected included demographics, tobacco use, clinical presentation, tumor size and location, pathological stage, immunohistochemical expression, lymph node status, treatment, and survival.

Results

There were 55 men and 13 women with a mean age of 55 years. Symptoms were present in 47 patients (69.1%). Twenty-eight patients (41.2%) had a centrally located tumor and 40 patients (58.8%) presented with peripheral tumor localization. Operations included 49 lobectomies, 10 pneumonectomies, 6 bilobectomies, 2 sleeve lobectomies, and 1 wedge resection. There were no peri-operative mortalities. There were 22 patients in stage I, 27 in stage II, 19 in stage III. Twenty-nine (42.6%) patients died and twenty (29.4%) patients relapsed during the follow-up period. The 5- and 10-year survival rates for the 68 cases were 70.6% and 61.8%, respectively. Relapse-free survival was significantly worsened by increasing Ki-67 index (P<0.01) and lymph-nodes involvement (P=0.02). Multivariate Cox regression indicated that nodal status was significantly associated with survival (P=0.038).

Conclusions

Lymph-nodes involvement is the major adverse prognostic factor in AC. Recurrence is more common among patients with high Ki-67 level. The use of adjuvant chemotherapy postoperatively in patients with pathologically lymphnode-positive and pathologically lymphnode-negative disease seems to have no survival advantage.

[About two huge bilateral bronchial atypical carcinoid tumors]

Carcinoid tumors are well differentiated neuroendocrine tumors of low grade malignancy or attenuated malignancy. Atypical bilateral bronchial forms are rarely reported. They pose a real problem of therapeutic strategy. We report a case of a 36-year-old woman with two large bilateral atypical carcinoid tumors. She received delayed bilateral parenchymal resection with postoperative uneventful course. Through a review of the literature, we discuss the therapeutic strategy. This observation remains special for several reasons. Not only by the rarity of the bilateral and atypical forms but also for the bilateral tumor sizes which led to a difficult intraoperative anesthetic management.

Surgical Management of Bronchopulmonary Carcinoid Tumors: Experience over 8 years and Review of the Literature

Aims and background

An increased incidence of neuroendocrine tumors in the last decade has been noticed worldwide. Our purpose was to study the characteristics, surgical approaches and outcome in patients with primary bronchopulmonary carcinoid tumors.

Methods

Between 2001 and 2007, bronchopulmonary carcinoid tumors were removed in 11 of a total of 287 patients who underwent surgery for primary lung malignancies in our tertiary referral center.

Results

The patient group consisted of 3 men and 8 women (mean age 52.9 ± 5.2 years, range 19–76 years). At presentation, 10 of 11 patients were symptomatic, with cough, pneumonia, breathlessness and hemoptysis being the most frequent symptoms. Histological findings revealed typical carcinoid in 10 patients and atypical carcinoid in one. The surgical approach included 8 lung resections (6 lobectomies, 1 bilobectomy, 1 segmentectomy), and 3 bronchoplastic tumor removals. In 2008, clinical examination and chest X-ray revealed no recurrence of the carcinoid and no long-term postoperative complications in any patient.

Conclusions

In the light of our study and the review of the literature we conclude that early recognition of primary bronchopulmonary carcinoid tumors followed by adequate surgical removal of the malignancy are essential for complete remission of the disease.

Primary Pulmonary Carcinoid Tumor: A Long-term Single Institution Experience

OBJECTIVES

Primary carcinoid tumors of the lung are rare tumors which comprise approximately 0.5% to 5% of all lung malignancies in adults and roughly 20% to 30% of all carcinoid tumors. The purpose of this retrospective, descriptive study was to describe the incidence, characteristics, and outcomes of patients treated for primary pulmonary carcinoid tumor at a single institution.

MATERIALS AND METHODS

All patients with a diagnosis of primary pulmonary carcinoid tumor treated from 1989 to 2009 were reviewed. Data collected included demographics, pathology, tobacco use, clinical presentation, tumor location, tumor spread, treatment, and survival.

RESULTS

There were 59 cases of pulmonary carcinoid tumors: 47 typical (80%) and 12 atypical (20%). All but 4 patients underwent surgery, including 54 (92%) lung-sparing resections and 1 pneumonectomy. Five of 55 patients received concurrent adjuvant chemoradiation therapy; 4 patients with atypical and 1 with typical histology. Three additional patients with atypical carcinoid were treated only with adjuvant radiotherapy, palliative radiotherapy, or palliative chemotherapy, respectively. The Kaplan-Meier 5- and 10-year overall survivals were both 80% within the entire population. In the 88% of patients who achieved complete remission, disease-free survival was 98%. A review of a large series from the literature is also presented.

CONCLUSIONS

Surgical resection was primary and adequate therapy for most typical carcinoid tumors with high overall survival and disease-free survival. Adjuvant chemotherapy or radiotherapy might be considered for patients with atypical carcinoid tumors who present with adverse pathologic findings.

Management of pulmonary neuroendocrine tumors

Neuroendocrine tumors (NETs) of the lung are divided into 4 major types: small cell lung cancer (SCLC), large cell neuroendocrine carcinoma (LCNEC), atypical carcinoid (AC) or typical carcinoid (TC). Each classification has distinctly different treatment paradigms, making an accurate initial diagnosis essential. The inconsistent clinical presentation of this disease, however, makes this difficult. The objective of this manuscript is to detail the diagnosis and management of the well differentiated pulmonary carcinoid (PC) tumors. A multidisciplinary approach to work up and treatment should be utilized for each patient. A multimodal radiological work-up is used for diagnosis, with contrast enhanced CT predominantly utilized and functional imaging techniques. A definitive diagnosis is based on tissue findings. Surgical management remains the mainstay of therapy and can be curative. In those with advanced disease, medical treatments consist of somatostatin analog (SSA) therapy, targeted therapy, chemotherapy or peptide receptor radionuclide therapy. SSAs are the standard of care in those with metastatic NETs, using either Octreotide long acting repeatable (LAR) or lanreotide as reasonable options, despite a scarcity of prospective data in PCs. Targeted therapies consist of everolimus which is approved for use in PCs, with various studies showing mixed results with other targeted agents. Additionally, radionuclide therapy may be used and has been shown to increase survival and to reduce symptoms in some studies. Prospective trials are needed to determine other strategies that may be beneficial in PCs as well as sequencing of therapy. Successful diagnosis and optimal treatment relies on a multidisciplinary approach in patients with lung NETs. Clinical trials should be used in appropriate patients.

Nothing But NET: A Review of Neuroendocrine Tumors and Carcinomas

This review covers the diverse topic of neuroendocrine neoplasms (NENs), a relatively rare and heterogeneous tumor type, comprising ~2% of all malignancies, with a prevalence of <200,000 in the United States, which makes it an orphan disease (Basu et al., 2010).1 For functional purposes, NENs are divided into two groups on the basis of clinical behavior, histology, and proliferation rate: well differentiated (low grade to intermediate grade) neuroendocrine tumors and poorly differentiated (high grade) neuroendocrine carcinoma (Bosman et al., 2010)2; this histological categorization/dichotomization is highly clinically relevant with respect to impact on treatment and prognosis even though it is not absolute since a subset of tumors with a low-grade appearance behaves similarly to high-grade lesions. Given the relative dearth of evidenced-based literature about this orphan disease as a whole (Modlin et al., 2008),3 since the focus of most articles is on particular anatomic subtypes of NENs (i.e., gastroenteropancreatic or pulmonary), the purpose of this review is to summarize the presentation, pathophysiology, staging, current standard of care treatments, and active areas of current research.

Pediatric neuroendocrine carcinoid tumors: Management, pathology, and imaging findings in a pediatric referral center

BACKGROUND

While neuroendocrine (carcinoid) tumors are increasingly recognized in the adult population, they are often not suspected in children.

PROCEDURE

Retrospective review of all well-differentiated neuroendocrine (carcinoid) tumors was performed based on pathology reports from a quaternary pediatric medical center between January 2003 and June 2016. Clinical presentations, treatment approaches, imaging findings, and outcomes were reviewed and analyzed.

RESULTS

A total of 45 cases of pathology-proven carcinoid tumor were reported with an average age of 14.1 years (range: 7-21 years, SD: 2.8 years). Of these cases, 80% (36) were appendiceal, 11% (5) bronchial, 2% (1) colonic, 2% (1) gastric, 2% (1) enteric, and 2% (1) testicular. Metastases were observed in one (3%) appendiceal, one (100%) enteric, and two (40%) bronchial cases. No recurrence was demonstrated in any appendiceal carcinoid cases. Recurrence was seen in one of three extra-appendiceal gastrointestinal tumors. Tumor site and size significantly correlated with metastases and recurrence.

CONCLUSIONS

Contrary to recent epidemiological investigations in adults, appendiceal carcinoid tumors remain the most common site for pediatric carcinoid tumors. Appendiceal carcinoid tumors exhibited benign clinical courses without recurrence during short-term follow-up. Extra-appendiceal gastrointestinal carcinoid tumors exhibited much more aggressive behavior with greater metastases and recurrence. Bronchial carcinoid tumors demonstrated good clinical response to resection even in cases with mediastinal lymph node involvement. While increased use of urine 5-HIAA levels and somatostatin receptor-specific imaging might improve detection and guide management of extra-appendiceal carcinoid tumors, longer-term follow-up is needed.

Adjuvant Chemotherapy Does Not Confer Superior Survival in Patients With Atypical Carcinoid Tumors

BACKGROUND

Although the use of adjuvant chemotherapy in patients with pathologically node-positive (pN+) atypical carcinoid tumor of the lung is an accepted practice, controversy exists about its use in pathologically node-negative (pN0) patients. Our aim was to determine whether a survival advantage exists in patients receiving chemotherapy postoperatively for pN0 or pN+ atypical carcinoid tumors of the lung.

METHODS

Adult patients treated with lobectomy or pneumonectomy for pulmonary atypical carcinoid tumor were identified using the National Cancer Data Base, 2006 to 2011. Propensity scoring (4:1 nearest neighbor algorithm) and survival analysis were used to examine the association between adjuvant chemotherapy and pN+ versus pN0 atypical carcinoid tumors.

RESULTS

Of the total 581 patients identified with a diagnosis of atypical carcinoid of the lung, 363 (62.5%) were found to be node negative at the time of operation and 218 (37.5%) had node-positive disease. Adjuvant chemotherapy was used in 15 patients (4.1%) with pN0 disease and 89 patients (40.8%) with pN+ disease. Unadjusted survival, at 12 and 60 months, was similar between pN+ patients who were treated with adjuvant chemotherapy versus patients who received operation alone (adjuvant chemotherapy: 98.9% at 12 months and 47.9% at 60 months versus operation alone: 98.4% and 12 months and 67.1% at 60 months, p = 0.46) and for propensity-matched pN0 (adjuvant chemotherapy: 86.7% at 12 months and 73.3% at 60 months versus operation alone: 87.9% at 12 months and 72.3% at 60 months, p = 0.54).

CONCLUSIONS

In a national-level analysis, the use of adjuvant chemotherapy postoperatively in patients with pN+ and pN0 disease conferred no survival advantage; further study is needed to determine proper chemotherapy use for these patients.

Bronchial and Thymic Carcinoid Tumors

Bronchial and thymic carcinoids are rare. We present epidemiologic data and potential risk factors. The approach to bronchial and thymic carcinoid patients is discussed, from the initial diagnosis and evaluations to treatment. These malignancies follow staging systems of their site of origin. Because bronchial and thymic carcinoids are rare, we use many treatment strategies that have been demonstrated in gastrointestinal and pancreatic neuroendocrine tumors. The lack of information regarding efficacy in bronchial and thymic carcinoids, as well as the scarcity of therapeutic options available, demands the importance of clinical trials that include these patients.

[Metastatic bronchial carcinoid tumors]

Bronchial carcinoids are uncommon pulmonary neoplasms and represent 1 to 2 % of all lung tumors. In early stage of disease, the mainstay and only curative treatment is surgery. Bronchial carcinoids are generally regarded as low-grade carcinomas and metastatic dissemination is unusual. The management of the metastatic stage is not currently standardized due to a lack of relevant studies. As bronchial carcinoids and in particular their metastatic forms are rare, we apply treatment strategies that have been evaluated in gastrointestinal and pancreatic neuroendocrine tumors. However, bronchial carcinoids have their own characteristic. A specific therapeutic feature of these metastatic tumors is that they require a dual approach: both anti-secretory for the carcinoid syndrome, and anti-tumoral.

Cytohistology of papillary carcinoid and emerging concept of pulmonary neuroendocrine neoplasms

This timely review starts by reporting the clinical, cytologic and histologic features of a morphologic variant of pulmonary carcinoid tumor forming exclusively of papillae. This growth pattern is so rare that it was not included in 2014 WHO classification of pulmonary neuroendocrine neoplasms. The current concept is reviewed, and example of spindle cell carcinoid, atypical carcinoid, large cell neuroendocrine carcinoma, and small cell carcinoma are illustrated with fine needle aspiration cytology, surgical and clinical follow-up. Finally, the new findings in cell biology and molecular biology that led to the emerging concept that carcinoids and high-grade neuroendocrine lung carcinomas are separate biological entities are reviewed and summarized in a tumorigenic module.

[Lung-preserving surgical treatment of patients with bronchial carcinoid]

Isolated bronchus resection for central cancer was performed in 25 patients including preoperative bronchoscopic removal of exophytic tumor in 20 (80%) observations in thoracic department of P. Gertsen Moscow Research Cancer Institute. According to morphological study typical carcinoid was diagnosed in 23 (92%) patients, atypical - in 2 (8%) cases. All patients underwent conventional mediastinal lymphadenectomy. Postoperative complications after bronchus resection developed in 6 (33.3%) patients. There were no deaths. Overall 5- and 10-year survival was 100% and 96% respectively. The authors consider that by strict indications combination of endoscopic removal with isolated bronchus resection preserves all pulmonary parenchyma without prejudice for surgical radicalism.

Long-term follow-up after first-line bronchoscopic therapy in patients with bronchial carcinoids

BACKGROUND

Carcinoid of the lung is considered to be a low-grade malignancy. A subgroup presents as an endobronchial tumour. Surgical resection is considered the standard approach because of its metastatic potential and the possibility of an iceberg phenomenon for the endobronchial subgroup. Advances in non-invasive and minimally invasive technologies seem to justify a more lung parenchyma-sparing approach.

METHODS

In patients presenting with bronchial carcinoids, initial bronchoscopic treatment (IBT) is first attempted for complete tumour eradication and sufficient tissue sampling for the proper differentiation of typical (TC) versus atypical (AC) histological type. Furthermore in cases with postobstruction problems the desobstruction is aimed at improving the patient's condition and by that alleviate surgery if that is needed. High resolution CT is performed 6 weeks post IBT to determine local tumour growth. Surgical resection follows in case of extraluminal disease, residual carcinoid inaccessible for IBT, or late recurrences not salvaged by repeat IBT.

RESULTS

Minimum follow-up was 5 years from start of treatment for 112 patients (65 women, 47 men), with a median age of 47 years (range 16-77 years). Eighty-three patients (74%) had TC, and 29 (26%) AC. IBT only was ultimately curative in 42% of the cases (47/112): 42 TC, 5 AC. Disease-specific mortality including surgical mortality has been 2.6% (3/112) in patients with extraluminal carcinoids (3 AC).

CONCLUSIONS

IBT, if with unsuccessful rescue surgery, is justifiable with excellent long-term outcome. IBT made surgery unnecessary in 42% of the cases. Iceberg phenomenon and metastatic potential in this group of patients with bronchial carcinoids are clinically insignificant.

Clinical presentation and evaluation of neuroendocrine tumors of the lung

Neuroendocrine tumors of the lung encompass a wide spectrum. A carcinoid tumor is either a central smooth endobronchial tumor or a round, well-circumscribed, peripheral parenchymal lesion. Distinguishing typical carcinoid tumors from atypical carcinoid tumors is unreliable from a limited biopsy but can be based on age, presentation, and node enlargement. Large cell neuroendocrine cancer presents similarly to most non-small cell lung cancers. Small cell lung cancer has a characteristic presentation, with a rapid progression of symptoms, and a bulky central and/or mediastinal tumor. A diagnosis is achieved by limited biopsy and is usually reliable.

Pure bronchoplastic resections of the bronchus without pulmonary resection for endobronchial carcinoid tumours

OBJECTIVES

Bronchopulmonary carcinoid tumours are relatively uncommon primary lung neoplasms. A small proportion of these lesions are predominantly endobronchial and do not extend beyond the bronchial wall. Endoscopic resection can be performed, but carries around a one in three risk of local recurrence and, therefore, mandates long-term surveillance. An alternative is complete surgical resection via bronchoplastic resection. We present our experience of surgical resection in patients with endobronchial carcinoids.

METHODS

From 2000 to 2010, 13 patients (age 45±16 years, 10 males) underwent pure bronchoplastic resection, including systematic nodal dissection, for endobronchial carcinoid tumours, without the resection of lung parenchyma.

RESULTS

There was no significant operative morbidity or mortality. This is a retrospective review of a consecutive case series. The last follow-up for all patients was obtained in 2011. The mean maximum tumour size was 18±8 mm. No lymph node invasion was observed. The median follow-up was 6.3±3.3 years, with no regional recurrence. In 1 case, a tumourlet was identified at 5 years in the contralateral airway and viewed as a metachronous new lesion.

CONCLUSIONS

Bronchial sleeve resection is a safe procedure for suitably located endobronchial carcinoid tumours. Endoscopic resection should be reserved for patients who decline, or are unfit, for surgery.

A case of uncontrolled asthma

A 48-year-old female patient with uncontrolled severe asthma was referred to our hospital for anti-IgE therapy. She was suffering with persistent wheezing and dyspnea after a severe asthma attack that had taken place 5 months previously. Her asthma had not been controlled with adequate asthma treatment, including budesonide at 320 μg + formoterol at 9 μg b.i.d. combination, montelukast at 10 mg/day, and oral steroids (30-40 mg/day of prednisolone), during this period. She was hospitalized for evaluation for anti-IgE therapy. Chest radiography revealed a left-sided hilar opacity. Fiberoptic bronchoscopy was performed and showed an endobronchial lesion obstructing the left lower bronchus lumen. Computed tomography also revealed a nodular lesion at the same location. The patient underwent left lower lobectomy and mediastinal lymph node dissection. Pathological examination concluded the diagnosis of typical carcinoid tumor. After surgery, her symptoms disappeared and she has had no recurrence. In conclusion, a diagnosis of severe asthma requires confirmation of asthma. Uncontrolled symptoms that linger despite aggressive therapy warrant evaluation to rule out other etiologies, such as a carcinoid tumor, before selecting new treatment options.

Treatment of pulmonary neuroendocrine tumours: state of the art and future developments

The current classification of pulmonary neuroendocrine tumours includes four subtypes: low-grade typical carcinoid tumour (TC), intermediate-grade atypical carcinoid tumour (AC), and two high-grade malignancies: large cell neuroendocrine carcinoma and small cell lung cancer (SCLC). Unfortunately, with the exclusion of SCLC, no large phase II and III trials for pulmonary neuroendocrine tumours have been published. Thus, several treatment approaches are available for their treatment but none of them has been validated in appropriately designed and adequately sized clinical trials. The main problem of the published studies is that they include neuroendocrine tumours from various sites of origin with different clinical behaviour. It is important that future studies consider these tumours separately. In this regard, increased awareness and referral of these patients to tertiary centres, in which a multidisciplinary management is available, may be of value. The aim of this review is to evaluate the state of the art and discuss future developments in the management of pulmonary neuroendocrine tumours excluding SCLC which we consider should be addressed in a different issue.

[Multidetector computed tomography assessment of the degree of differentiation of bronchial carcinoid tumors]

OBJECTIVE

To define the CT findings for bronchial carcinoid tumors and to determine whether these findings enable these tumors to be classified as typical or atypical.

MATERIAL AND METHODS

We reviewed the chest CT studies performed between 1 January 2001 and 31 December 2009 in patients at our hospital diagnosed with bronchial carcinoid tumors. The sample consisted of 52 patients (23 women and 29 men) with a mean age of 47 years (range 11-77 years). The 52 cases were classified as typical or atypical on the basis of the following radiological findings: size, location, focality, type of growth, calcifications, signs secondary to bronchial obstruction, and the presence of significant lymph node enlargement or metastases. These findings were then compared with the histological findings.

RESULTS

Typical carcinoid tumors were the most prevalent (46 cases). The variables associated with atypical tumors were: male sex, advanced age at onset, and size >3cm. The accuracy of CT in classifying atypical tumors correctly increased with the number of variables indicative of atypical carcinoid tumors. A negative result for atypical nature made it possible to rule out an atypical carcinoid tumor in 95% of the cases.

CONCLUSION

CT is useful for defining and characterizing carcinoid tumors into typical or atypical, although a precise formula for differentiating between the two types remains to be defined.

Overdiagnosis of a typical carcinoid tumor as an adenocarcinoma of the lung: a case report and review of the literature

Background

Overdiagnosis of bronchopulmonary carcinoid tumors together with overtreatment can cause serious postoperative consequences for the patient. We report of a patient with a typical bronchopulmonary carcinoid tumor, which was initially misdiagnosed and treated as an adenocarcinoma of the lung. GnrH receptors and the associated Raf-1/MEK/ERK-1/2-pathway are potential targets for analogs in cancer treatment. We suspected a correlation between the lack of tumor growth, application of leuprolide and the Raf-1/MEK/ERK-1/2-pathway. Therefore, we examined GnrH receptor status in the examined specimen.

Case presentation

In 2010 a 77 year-old male patient was shown to have a tumor mass of about 1.7 cm diameter in the inferior lobe of the left lung. Since 2005, this tumor had hitherto been known and showed no progression in size. The patient suffered from prostate cancer 4 years ago and was treated with TUR-P, radiation therapy and the application of leuprolide. We conducted an explorative thoracotomy with atypical segment resection. The first histological diagnosis was a metastasis of prostate cancer with lymphangiosis carcinomatosa. After several immunohistochemical stainings, the diagnosis was changed to adenocarcinoma of the lung. We conducted a re-thoracotomy with lobectomy and systematic lymphadenectomy 12 days later. The tumor stage was pT1 N0 MX G2 L1 V0 R0. Further immunohistochemical studies were performed. We received the results 15 days after the last operation. The diagnosis was ultimately changed to typical carcinoid tumor without any signs of lymphatic vessel invasion. The patient recovered well from surgery, but still suffers from dyspnea and lack of physical performance. Lung function testing revealed no evidence of impairment.

Conclusion

The use of several immunohistochemical markers, careful evaluation of hematoxylin-eosin sections and the Ki-67 labelling index are important tools in discriminating between carcinoids and other bronchopulmonary carcinomas. Although we could not detect GnrH-receptors in the examined specimen, there may be individual differences in expression. GnrH receptor profiles in typical and atypical carcinoids should be scrutinized. This could lead to new therapeutical options, since the GnrH receptor has already been described on atypical carcinoids. Clinically tested drugs such as leuprolide could come to use.

[Diagnosis and therapy of bronchopulmonary carcinoid tumors]

支气管肺类癌是罕见的肺部肿瘤，总体生长缓慢、预后尚可。根据其临床特征往往可以推测支气管肺类癌的诊断和亚型并指导治疗。其中年轻、CT表现为中心型肿瘤且无肺门或纵隔淋巴结肿大的病例，典型类癌的可能性较大。此亚型远处转移几率小，在手术治疗前除胸增强CT外可以不进行其它的常规术前分期检查。中心型肿瘤临床怀疑纵隔淋巴结累及或周围型肿瘤临床怀疑肺门纵隔淋巴结累及的病例，可能为不典型类癌。此亚型应做全面术前评估和分期。累及纵隔淋巴结的不典型类癌预后相对较差，应行多学科积极治疗。支气管肺类癌虽然其生物学特性不活跃，但均为恶性肿瘤，放化疗效果差，手术切除是最主要的治疗手段。彻底切除肿瘤、最大限度保留正常的肺组织是此类肺肿瘤外科治疗的基本目标。

Imaging of neuroendocrine tumors

Neuroendocrine tumors (NETs) constitute a large group of diverse neoplasms with a wide spectrum of clinical, imaging, and pathologic findings. Imaging diagnosis of NETs can be challenging, and several complementary imaging modalities may be needed during the diagnostic workup. Accurate interpretation of the imaging findings is important to facilitate diagnosis and contribute to patient management. This article discusses the gastrointestinal site-specific features and the tumor-specific features of several NETs and the role of several imaging modalities such as computed tomography, MR imaging, ultrasonography, and positron emission tomography in the evaluation of these NETs.

In vitro cytotoxicity of novel platinum-based drugs and dichloroacetate against lung carcinoid cell lines

INTRODUCTION

Chemotherapy for advanced well-differentiated carcinoids is characterised by low response rates and short duration of responses. The present study aimed to assess the in vitro activity of novel platinum-based chemotherapeutic drugs in combination with dichloroacetate (DCA), a sensitiser to apoptosis, against lung carcinoid cell lines.

METHODS

Three permanent cell lines (UMC-11, H727 and H835) were exposed to 14 different established cytotoxic drugs and the novel platinum-based compounds as satraplatin, JM118 and picoplatin in combination with DCA, and viability of the cells was measured using a tetrazoliumbased dye assay.

RESULTS

With exception of the highly chemoresistant UMC- 11 line, the carcinoid cell lines (H727, H835) were sensitive to the majority of chemotherapeutics in vitro. Among the platinum-based drugs, carboplatin and oxaliplatin showed highest efficacy. H835 cells growing as multicellular spheroids were 2.7-8.7-fold more resistant to picoplatin, satraplatin and its metabolite compared to single cell suspensions. DCA (10 mM) inhibited the growth of UMC- 11 cells by 22% and sensitised these highly resistant cells to carboplatin, satraplatin and JM118 1.4-2.4-fold.

CONCLUSION

The highly resistant UMC-11 lung carcinoid cells are sensitive to carboplatin, oxaliplatin and the satraplatin metabolite JM118, but multicellular spheroidal growth, as observed in the H835 cell line and pulmonary tumourlets, seems to increase chemoresistance markedly. The activity of carboplatin and JM118 is significantly and specifically increased in combination with the apoptosis sensitiser DCA that promotes mitochondrial respiration over aerobic glycolysis. In summary, among the novel platinum drugs satraplatin has the potential for treatment of lung carcinoids and DCA potentiates the cytotoxicity of selected platinum drugs.

[Retrospective study of clinicopathological characteristics in bronchopulmonary carcinoid]

背景与目的

支气管肺类癌（bronchopulmonary carcinoid, BPC）占全部肺原发性恶性肿瘤不到2%，相关研究报道较少，本研究拟分析BPC的总体及其两个亚型——典型类癌（typical carcinoid, TC）和不典型类癌（atypical carcinoid, AC）的临床、病理学特点。

方法

回顾性分析中山大学肿瘤防治中心1994年1月-2009年6月收治的28例BPC的临床资料，调取可再行切片的病理蜡块，重新切片染色及病理玻片会诊，分析BPC的总体及其亚型的临床特征和相关免疫组化指标与预后的关系。

结果

全部28例患者的总体5年生存率为56%，TC的5年生存率为70%，AC为41%，单因素分析示TNM分期（P=0.037)、有无淋巴结转移（P=0.001）、Ki-67核阳性数是否大于5%（P=0.009）是BPC总体的预后因素。相关性分析示BPC亚型与CD99、Bcl-2及Ki-67的表达具有相关性（P值分别0.017、0.043、0.033）。20例行肺癌根治性手术患者的5年生存率为73%，TC的5年生存率为83%，AC为57%。单因素分析示BPC亚型（P=0.013）、术后有无淋巴结转移（P=0.004)、Ki-67核阳性数是否大于5%（P=0.006）、TNM分期（P=0.047）是行肺癌根治性手术患者的预后因素。肿瘤复发（n=4）与Ki-67核阳性的表达和Bcl-2表达具有相关性（P值分别为0.027、0.045）。

结论

BPC是预后较好的肺原发性恶性肿瘤，Ki-67、Bcl-2的高表达是提示BPC复发及预后不良的影响因素，TNM分期是影响预后的独立因素，行根治性手术是主要的治疗手段。

Surgical treatment of bronchial carcinoid tumors: a single-center experience

BACKGROUND

Bronchial carcinoid is an infrequent neoplasm with a neuroendocrine differentiation. Surgical treatment is the gold standard therapy, with procedures varying from sublobar resections to complex lung sparing broncoplastic procedures. This study evaluates the results of surgical treatment of bronchial carcinoids and its prognostic factors.

PATIENTS AND METHODS

Retrospective review of 126 consecutive patients who underwent surgical treatment for bronchial carcinoid tumors between December 1974 and July 2007.

RESULTS

There were 70 females (55%) and the mean age was 46 years, ranging from 17 to 81 years. Upon clinical presentation, 38 patients (30%) have had recurrent respiratory tract infection, 31 (24%) cough, 16 (12%) chest pain and 25 (20%) were asymptomatic. Preoperative bronchoscopic diagnosis was obtained in 74 cases (58.7%). The procedures performed were: 19 sublobar resections (14,9%), 58 lobectomies (46%), 8 bilobectomies (6.3%), 6 pneumonectomies (4.7%), 2 sleeve segmentectomies (1.5%), 26 sleeve lobectomies (20.6%) and 9 bronchoplastic procedures without lung resection (7.1%). Operative mortality was 1.5% (n = 2) and morbidity was 25.8% (n=32), including 12 respiratory tract infections and 4 reinterventions due to bleeding (3) and pleural empyema (1). Among the 112 patients available for follow-up, the overall survival at 3, 5 and 10 years was 89.2%, 85.5% and 79.8%, respectively. Five and 10-year survival for typical and atypical carcinoids were 91, 89% and 56, 47%, respectively. Overall disease-free survival at 5 years was 91.9% Statistical analysis showed that overall disease-free survival correlated with histology--typical vs. atypical--(p = 0.04) and stage (p = 0.02).

CONCLUSION

Surgery provides safe and adequate treatment to bronchial carcinoid tumors. Histology and stage were the main prognostic factors.

68Ga-DOTA-NOC: a new PET tracer for evaluating patients with bronchial carcinoid

BACKGROUND

Conventional imaging techniques [computed tomography (CT), ultrasound, magnetic resonance] and somatostatin receptor scintigraphy are often insufficient to make a conclusive diagnosis of bronchial carcinoid (BC). PET is commonly used for the assessment of lung cancer but 18F-fluorodeoxyglucose, the most frequently used PET tracer, presents a low sensitivity for the detection of neuroendocrine tumours (NETs). New PET radiopharmaceuticals such as 68Ga-DOTA peptides, which directly bind to somatostatin receptors and are usually expressed on NET cell surfaces, have been reported to be superior to both morphological and somatostatin receptor scintigraphy imaging for gastroenteropancreatic NETs. However, their role in BC has never been evaluated. Our aim is to evaluate the role of 68Ga-DOTA-NOC (68Ga-labelled [1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid]-1-Nal3-octreotide) PET for the assessment of BC patients.

METHODS

Ten patients with pathologically proven well-differentiated BC and one patient with highly suggestive CT images for BC were studied by 68Ga-DOTA-NOC PET/CT. PET findings were compared with clinical follow-up, pathology and contrast-enhanced CT findings.

RESULTS

68Ga-DOTA-NOC PET/CT detected at least one lesion in nine of 11 patients and was negative in two. PET/CT and contrast-enhanced CT were discordant in eight of 11 patients, whereas in only three patients both provided similar results. PET/CT detected a higher number of lesions in five patients and excluded malignancy at sites considered positive on CT in three of 11; follow-up confirmed PET/CT findings in all patients. In PET/CT-positive patients, the mean maximal standardized uptake value was 25.9 [4.4-60.5]. On a clinical basis, PET/CT provided additional information in nine of 11 patients leading to the changes in the clinical management of three of nine patients.

CONCLUSION

PET/CT with Ga-DOTA-NOC was useful in BC patients because it led to a better evaluation of the extent of the disease.

Carcinoid tumors

Carcinoid tumors are rare, slow-growing neuroendocrine tumors arising from the enterochromaffin cells disseminated throughout the gastrointestinal and bronchopulmonary systems. Though they have been traditionally classified based on embryologic site of origin, morphologic pattern, and silver affinity, newer classification systems have been developed to emphasize the considerable clinical and histopathologic variability of carcinoid tumors found within each embryologic site of origin. These neoplasms pose a diagnostic challenge because they are often innocuous at the time of presentation, emphasizing the need for a multidisciplinary diagnostic approach using biochemical analysis, standard cross-sectional imaging, and newer advances in nuclear medicine. Similarly, treatment of both primary and disseminated carcinoid disease reflects the need for a multidisciplinary approach, with surgery remaining the only curative modality. The prognosis for patients with these tumors is generally favorable; however, it can be quite variable and is related to the location of the primary tumor, extent of metastatic disease at initial presentation, and time of diagnosis.

Bronchopulmonary neuroendocrine tumors

Bronchopulmonary neuroendocrine tumors (BP-NETs) comprise approximately 20% of all lung cancers and represent a spectrum of tumors arising from neuroendocrine cells of the BP-epithelium. Although they share structural, morphological, immunohistochemical, and ultrastructural features, they are separated into 4 subgroups: typical carcinoid tumor (TC), atypical carcinoid tumor (AC), large-cell neuroendocrine carcinoma (LCNEC), and small-cell lung carcinoma (SCLC), which exhibit considerably different biological characteristics. The clinical presentation includes cough, hemoptysis, and obstructive pneumonia but varies depending on site, size, and growth pattern. Less than 5% of BP-NETs exhibit hormonally related symptoms such as carcinoid syndrome, Cushing, acromegaly, and SIADH. SCLC is the most common BP-NET, while LCNEC is rare, approximately 10% and < or =1%, respectively, of all lung cancers. Both SCLC and LCNEC progress rapidly, are aggressively metastatic, and exhibit a poor prognosis. The incidence of BP-carcinoids (TC and AC) in the US was 1.57 of 100,000 in 2003 (an unexplained and substantial increase over the last 30 years, approximately 6% per year). No curative treatment except for radical surgery (almost never feasible) exists. The slow-growing TC exhibit a fairly good prognosis ( approximately 88%, 5-year survival), whereas AC demonstrate a 5-year survival of approximately 50%, and the highly malignant LCNEC and SCLC5-year survival of 15% to 57% and <5%, respectively. This review provides a broad overview on BP-NETs and focuses on the evolution of the disease, general features, and current diagnostic and therapeutic options.