Pre-surgical bronchoscopic treatment for typical endobronchial carcinoids

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension with bronchial obstruction by a carcinoid tumor

Pulmonary endarterectomy (PEA) is a standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH combined with bronchial obstruction by a tumor is rare but should be assessed carefully because PEA for obstructed segments can be less therapeutic and make the subsequent surgical resection challenging. This report describes a case of CTEPH with bronchial obstruction by a typical carcinoid tumor in a 75-year-old man. On-site evaluation and removal of the obstructive tumor were performed bronchoscopically, increasing the effectiveness of subsequent PEA for all affected pulmonary segments. This report illustrates a PEA strategy to treat CTEPH with bronchial tumor obstruction.

[Bronchoscopic treatment of malignant central airway obstruction: A cohort study, long-term survival and complications]

INTRODUCTION

Interventional bronchoscopy is now the standard treatment for tracheobronchial narrowing due to tumor. The objective of our study was to analyze long-term survival and complications occurring in patients with malignant airway obstruction.

METHODS

We retrospectively studied the data from 93 patients treated between 2008 and 2019.

RESULTS

One hundred and eleven therapeutic bronchoscopies were performed. Sixty-seven patients had primary lung cancer, in 17 had tumors of another origin and 9 patients had benign or local lung tumors. Thulium laser was frequently used prior to tumor enucleation and to restore hemostasis. Seventy-one silicone stents were inserted. The death rate at the time of the procedure was 1.8% and immediate complication occurred in 9.9% of the patients. Long-term survival was significantly better for patients with cancer from other origins than in those with primary lung cancer (615.5days versus 177.9days). On the other hand, there was no significant difference in long-term survival between patients with locally advanced and metastatic lung cancer with endobronchial lesions treated by stent and those who were not (234.2days versus 164.6days). All patients with benign or with locally malignant tumors were still alive.

CONCLUSION

Therapeutic bronchoscopy increases the long-term survival of patients with malignant airway obstruction. The risk-benefit ratio was favorable.

Bronchial Carcinoids: From Molecular Background to Treatment Approach

A better understanding of the genetic and molecular background of bronchial carcinoids (BCs) would allow a better estimation of the risk of disease progression and the personalization of treatment in cases of advanced disease. Molecular studies confirmed that lungs neuroendocrine tumors (NETs) and neuroendocrine carcinomas (NECs) are different entities; thus, no progression of NET to NEC is expected. In BCs, MEN1 gene mutations and deletions and decreased gene expression have been associated with a poor prognosis. ATRX mutation has also been linked to a shorter disease-specific survival. In terms of therapeutic targets, PI3K/AKT/mTOR pathway mutations have been described in 13% of typical carcinoids (TCs) and 39% of atypical carcinoids (ACs), representing a targetable mutation with kinase inhibitors. Regarding treatment, surgical resection is usually curative in localized BCs and adjuvant treatment is not routinely recommended. Multiple options for systemic therapy exist for patients with advanced BCs, although limited by a heterogeneity in the scientific evidence behind their use recommendation. These options include somatostatin analogues, everolimus, peptide receptor radionuclide therapy, chemotherapy, radiotherapy, antiangiogenic agents, and immunotherapy. In this article, we provide a comprehensive review about the molecular and genetic background of BCs, and about the treatment of local and metastatic disease, as well as the main paraneoplastic syndromes that have been associated with this tumor.

Treatment of Pulmonary Carcinoid Tumors With Bronchoscopic Cryotherapy: A 28-Year Single-center Experience

BACKGROUND

Pulmonary carcinoids are rare tumors originating from neuroendocrine cells in the lungs. Because of their potentially infiltrative nature, surgical resection remains the treatment of choice. However, not all patients with technically resectable disease will be able to undergo surgery, primarily because of poor lung function or medical co-morbidities. Centrally located, intraluminal tumors have been reported to be amenable to bronchoscopic treatment. We specifically examined the role of cryotherapy in the treatment of bronchial carcinoid tumors.

METHODS

Sixty-three patients (52.38% female) who underwent a combined total of 243 cryotherapy procedures for treatment of bronchial carcinoid between 1992 and 2020 in our institution were included in the study. Following discussion in multidisciplinary meetings, patients were considered for first-line cryotherapy when lung resection was deemed not possible or when they had rejected surgery.

RESULTS

Cryotherapy resulted in complete remission in 21 (33.33%) patients with maximum tumor diameter less than 20 mm (mean: 11.08 mm, 95% confidence interval: 8.76-13.40), and allowed 22 (34.92%) patients with larger lesions (mean: 24.04 mm, 95% confidence interval: 18.78-29.30) to proceed with parenchymal sparing resections. Marked symptomatic relief (P<0.001) was reported by 58 (92.06%) patients. The median follow-up was 33 months (range: 0 to 243 mo). One (1.59%) patient was diagnosed with recurrence in a contralateral lobe 3 years after surgery and was treated with radiofrequency ablation.

CONCLUSIONS

In the absence of a definitive randomized controlled trial comparing bronchoscopic treatment with surgical resection, we provide evidence on the safety and efficacy of cryotherapy and encourage wider adoption of this inexpensive and minimally invasive technique for treatment of bronchial carcinoids.

The Role of Rigid Bronchoscopic Intervention for Bronchial Carcinoid

Bronchial carcinoid is a rare malignant tumor that is categorized as a typical carcinoid or atypical carcinoid. Many institutions use flexible bronchoscopy for diagnosis. However, due to the hemorrhagic nature of the tumor, the amount of specimen obtained is often small, making it difficult to obtain an accurate diagnosis. The use of rigid bronchoscopy may not only contribute to obtaining a diagnosis but also be beneficial in the treatment plan. The aim of this study was to evaluate the efficacy of rigid bronchoscopic interventions for the diagnosis and treatment of bronchial carcinoids. All patients with bronchial carcinoids who underwent rigid bronchoscopic intervention under general anesthesia at our institution between June 2006 and August 2018 were analyzed retrospectively. Eight patients [3 men and 5 women; median age, 71 years (range 45-82 years)] were eligible for the analysis. None of the cases had accurate subtyping preoperatively before intervention. In contrast, all cases were diagnosed as carcinoid with subtypes (5 patients had typical carcinoid and 3 had atypical carcinoid) following rigid bronchoscopic intervention. All respiratory symptoms improved immediately after the procedure. One instance of bleeding occurred, and was easily controlled by argon plasma coagulation and intraluminal administration of epinephrine under flexible and rigid bronchoscopy. Four patients (3 with typical carcinoid and 1 with atypical carcinoid) underwent radical surgery sequentially, and no recurrences were observed. We conclude that rigid bronchoscopic intervention is safe and effective for accurate diagnosis and improvement of respiratory symptoms in patients with bronchial carcinoids.

Bronchoscopic diagnosis and treatment of endobronchial carcinoid: case report and review of the literature

Carcinoid tumours are rare neuroendocrine neoplasms that mostly occur in younger adults with low tendencies to metastasise. Based on their histological characteristics, they are divided into typical and atypical subtypes. The most common presenting symptoms are due to central airway obstruction. The first step in the diagnostic assessment should be a computed tomography (CT) scan, as it provides information both for local tumour extent and lymph node involvement. Bronchoscopy is the main tool for histological confirmation, evaluation of bronchial wall invasion and removal of endobronchial manifestation with subsequent resolution of atelectasis. Endobronchial ultrasound may be necessary to rule out lymph node metastasis. Somatostatin receptor scintigraphy in combination with CT can rule out further metastatic disease.Surgical resection using parenchyma-sparing techniques remains the gold standard for treatment. For selected patients, endobronchial therapy could be an alternative for minimal invasiveness. Long-term follow-up is suggested due to the high likelihood of recurrence.Here, we describe our clinical experience in a 35-year-old male patient who originally presented with haemoptysis and a central polypoid tumour in the left main bronchus revealed by a CT scan. The histological characteristics were indicative of a typical carcinoid. The patient was treated using an endobronchial approach only. No complications and no recurrences have been observed in a follow-up of 2 years.

Commonwealth Neuroendocrine Tumour Research Collaboration and the North American Neuroendocrine Tumor Society Guidelines for the Diagnosis and Management of Patients With Lung Neuroendocrine Tumors: An International Collaborative Endorsement and Update of the 2015 European Neuroendocrine Tumor Society Expert Consensus Guidelines

Lung neuroendocrine tumors (LNETs) are uncommon cancers, and there is a paucity of randomized evidence to guide practice. As a result, current guidelines from different neuroendocrine tumor societies vary considerably. There is a need to update and harmonize global consensus guidelines. This article reports the best practice guidelines produced by a collaboration between the Commonwealth Neuroendocrine Tumour Research Collaboration and the North American Neuroendocrine Tumor Society. We performed a formal endorsement and updating process of the 2015 European Neuroendocrine Tumor Society expert consensus article on LNET. A systematic review from January 2013 to October 2017 was conducted to procure the most recent evidence. The stepwise endorsement process involved experts from all major subspecialties, patients, and advocates. Guided by discussion of the most recent evidence, each statement from the European Neuroendocrine Tumor Society was either endorsed, modified, or removed. New consensus statements were added if appropriate. The search yielded 1109 new publications, of which 230 met the inclusion criteria. A total of 12 statements were endorsed, 22 statements were modified or updated, one was removed, and two were added. Critical answered questions for each topic in LNET were identified. Through the consensus process, guidelines for the management of patients with local and metastatic neuroendocrine tumors have been updated to include both recent evidence and practice changes relating to technological and definitional advances. The guidelines provide clear, evidence-based statements aimed at harmonizing the global approach to patients with LNETs, on the basis of the principles of person-centered and LNET-specific care. The importance of LNET-directed research and person-centered care throughout the diagnosis, treatment, and follow-up journey is emphasized along with directions for future collaborative research.

Méthodes diagnostiques et stratégie thérapeutique des TNE pulmonaires (tumeurs carcinoïdes typiques et atypiques)

Les carcinoïdes bronchiques typiques ou atypiques sont des tumeurs rares. La prise en charge des formes localisées repose essentiellement sur la chirurgie, et leur pronostic reste bon. Le traitement des formes métastatiques demeure difficile et repose sur un niveau de preuve faible. De nouveaux traitements émergent (évérolimus, lutathérapie), mais leur place respective dans l’algorithme thérapeutique est à préciser. L’accès à l’expertise et à la recherche clinique via les réseaux RENATEN-TENpath doit être favorisé.

Immune Checkpoint Blockade for Advanced NSCLC: A New Landscape for Elderly Patients

The therapeutic scenario for elderly patients with advanced NSCLC has been limited to radiotherapy and chemotherapy. Recently, a novel therapeutic approach based on targeting the immune-checkpoints has showed noteworthy results in advanced NSCLC. PD1/PD-L1 pathway is co-opted by tumor cells through the expression of PD-L1 on the tumor cell surface and on cells within the microenvironment, leading to suppression of anti-tumor cytolytic T-cell activity by the tumor. The success of immune-checkpoints inhibitors in clinical trials led to rapid approval by the FDA and EMA. Currently, data regarding efficacy and safety of ICIs in older subjects is limited by the poor number of elderly recruited in clinical trials. Careful assessment and management of comorbidities is essential to achieve better outcomes and limit the immune related adverse events in elderly NSCLC patients.

Endoscopic central airway recanalization to enable first line pembrolizumab treatment in a PD-L1 strongly positive non-small cell lung cancer: a case report

Background

Tracheobronchial malignant stenosis is a life-threatening condition which may cause recurrent infections due to lung atelectasis. Despite immunotherapy is less toxic than standard chemotherapy, recurrent lung infections may represent a challenge for this treatment.

We report a clinical case of a patient with metastatic squamous cell carcinoma suffering from pulmonary infections due to central airway obstruction who underwent endoscopic recanalization followed by immunotherapy.

Case presentation

A 64 year-old man was referred to our attention for the management of metastatic squamous cell carcinoma obstructing the right main bronchus with recurrent pulmonary infections. Patient exhibited strong positive PD-L1 expression (> 50%). Advanced disease stage contraindicated surgical treatment. Although therapy with immune check point inhibitors was indicated as first-line treatment, recurrent pulmonary infections made it unfeasible. Therefore, we planned a combined approach including endoscopic recanalization of central airway in order to resolve lung atelectasis, and lung infection followed by immunotherapy treatment with pembrolizumab in order to avoid local and systemic disease progression.

Conclusions

At 16-week follow-up, the patient was alive in stable disease with improvement of clinical condition and no signs of lung infection.

Multimodality multistaged management of large endobronchial carcinoid causing respiratory failure: A case report with review of literature

We report the case of a 58-year-old female presenting with central airway obstruction leading to airway compromise thrice, first two times from endobronchial growth of typical carcinoid tissue and subsequently from granulation tissue at anastomotic site after left carinal pneumonectomy. Bronchoscopic resection of carcinoid tumor and granulation tissue was performed successfully with electrosurgical snaring through rigid bronchoscope. Cryodebridement using flexible cryoprobe of the tumor was done postembolization and of the remnant granulation tissue without any complication. A multimodality approach is required for favorable outcome as observed in this case.

Descending necrotizing mediastinitis in the elderly patients

Descending Necrotizing Mediastinitis (DNM) is a polymicrobic, dangerous and often fatal process, arising from head or neck infections and spreading along the deep fascial cervical planes, descending into the mediastinum. It can rapidly progress to sepsis and can frequently lead to death. It has a high mortality rate, up to 40% in the different series, as described in the literature. Surgical and therapeutic management has been discussed for long time especially in an elderly patient population. The literature has been reviewed in order to evaluate different pathogenesis and evolution and to recognise a correct therapeutic management.

Preoperative high-intensity training in frail old patients undergoing pulmonary resection for NSCLC

Thoracic surgery remains the better therapeutic option for non-small cell lung cancer patients that are diagnosed in early stage disease. Preoperative lung function assessment includes respiratory function tests (RFT) and cardio-pulmonary exercise testing (CPET). Vo2 peak, FEV1 and DLCO as well as recognition of performance status, presence of co-morbidities, frailty indexes, and age predict the potential impact of surgical resection on patient health status and survival risk. In this study we have retrospectively assessed the benefit of a high-intensity preoperative pulmonary rehabilitation program (PRP) in 14 patients with underlying lung function impairment prior to surgery. Amongst these, three patients candidate to surgical resection exhibited severe functional impairment associated with high score of frailty according CHS and SOF index, resulting in a substantial mortality risk. Our observations indicate that PRP appear to reduce the mortality and morbidity risk in frail patients with concurrent lung function impairment undergoing thoracic surgery. PRP produced improvement of VO2 peak degree and pulmonary function resulting in reduced postoperative complications in high-risk patients from our cases. Our results indicate that a preoperative training program may improve postoperative clinical outcomes in fraillung cancer patients with impaired lung function prior to surgical resection.