Endobronchial Treatment for Bronchial Carcinoid: Patient Selection and Predictors of Outcome

Quarter Century PET/Computed Tomography Transformation of Oncology: Neuroendocrine Tumors

Significant improvement in molecular imaging and theranostics in the management of neuroendocrine tumors (NETs) has been made in the last few decades. Somatostatin receptor-targeted PET imaging outperforms conventional, planar, and single-photon emission computed tomography imaging and is indicated in the evaluation of these patients when available, resulting in a significant impact on staging, treatment response assessment, and restaging of these patients. Radionuclide therapy can have an impact on patient outcome in metastatic disease when not many treatment options are available.

[Isolated bronchoplastic procedure for typical carcinoid of the left lung]

Lung carcinoids (LC) comprise neuroendocrine lung tumors of low (typical carcinoid) and intermediate (atypical carcinoid) grade of malignancy accounting for less than 2% of all lung neoplasms. In Europe, annual incidence of LC varies from 0.2 to 2 per 100 000. This value increased dramatically over the past 30 years. One of the causes is improvement of diagnostic methods. Compared to aggressive high-grade neuroendocrine lung cancer, natural course of early-stage LC is usually indolent. Therefore, surgery with preservation of as much normal lung tissue as possible is preferable for resectable tumors. Nevertheless, the number of isolated bronchial resections with preservation of the entire lung tissue is relatively small, and these procedures remain technically complex interventions. We present isolated resection of interlobular spur, lower medial wall of distal part of the left main bronchus and proximal part of the lower lobular bronchus for typical carcinoid with monobronchial anastomosis and preservation of the entire lung parenchyma.

Neuroendocrine neoplasms in the context of inherited tumor syndromes: a reappraisal focused on targeted therapies

PURPOSE

Neuroendocrine neoplasms can occur as part of inherited disorders, usually in the form of well-differentiated, slow-growing tumors (NET). The main predisposing syndromes include: multiple endocrine neoplasias type 1 (MEN1), associated with a large spectrum of gastroenteropancreatic and thoracic NETs, and type 4 (MEN4), associated with a wide tumour spectrum similar to that of MEN1; von Hippel-Lindau syndrome (VHL), tuberous sclerosis (TSC), and neurofibromatosis 1 (NF-1), associated with pancreatic NETs. In the present review, we propose a reappraisal of the genetic basis and clinical features of gastroenteropancreatic and thoracic NETs in the setting of inherited syndromes with a special focus on molecularly targeted therapies for these lesions.

METHODS

Literature search was systematically performed through online databases, including MEDLINE (via PubMed), and Scopus using multiple keywords' combinations up to June 2022.

RESULTS

Somatostatin analogues (SSAs) remain the mainstay of systemic treatment for NETs, and radiolabelled SSAs can be used for peptide-receptor radionuclide therapy for somatostatin receptor (SSTR)-positive NETs. Apart of these SSTR-targeted therapies, other targeted agents have been approved for NETs: the mTOR inhibitor everolimus for lung, gastroenteropatic and unknown origin NET, and sunitinib, an antiangiogenic tyrosine kinase inhibitor, for pancreatic NET. Novel targeted therapies with other antiangiogenic agents and immunotherapies have been also under evaluation.

CONCLUSIONS

Major advances in the understanding of genetic and epigenetic mechanisms of NET development in the context of inherited endocrine disorders have led to the recognition of molecular targetable alterations, providing a rationale for the implementation of treatments and development of novel targeted therapies.

A multidisciplinary approach to the work up and management of pulmonary carcinoid tumors and DIPNECH: a narrative review

Background and Objective

Low and intermediate grade neuroendocrine tumors of the lung are uncommon malignancies representing 2% of all lung cancers. These are termed typical and atypical pulmonary carcinoid tumors. These can arise in the setting of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH). The presentation, workup, management and outcomes of patients with these tumors can overlap with more common lung cancers but differ in that many of these patients have a prolonged clinical course. The objective of this narrative review is to summarize the literature and provide evidence and expert-based algorithms for work up and treatment of pulmonary carcinoids and DIPNECH.

Methods

A search of PubMed and Web of Science databases ending April 15, 2022, with the following keywords "lung carcinoid", "DIPNECH", "lung neuroendocrine," and "bronchopulmonary carcinoid".

Key Content and Findings

Pulmonary carcinoid tumors benefit from a multidisciplinary approach. Pre-treatment imaging with contrast-enhanced computed tomography, and DOTATATE positron emission tomography is required. Surgical resection is the gold standard for curative intent, and possibly including sublobar resections. Patients can recur or develop new primaries thus emphasizing the importance of surveillance; national guidelines recommend at least a 10-year follow up. A growing body of literature support the use of endobronchial therapy, with long responses documented. Systemic therapy consists of everolimus, somatostatin analogs, peptide receptor radionuclide therapy, and chemotherapy. Diffuse idiopathic pulmonary neuroendocrine tumor cell hyperplasia is rare, but series suggest somatostatin analogs may confer clinical benefit.

Conclusions

Pulmonary carcinoid tumors and DIPNECH are rare. Despite lack of regulatory approvals for advanced disease, multiple options are available but should be sequenced according to the clinical status and disease biology. Each patient should be discussed in a multidisciplinary setting and clinical trials should be considered if available.

A Multimodal Biomarker Predicts Dissemination of Bronchial Carcinoid

Background: Curatively treated bronchial carcinoid tumors have a relatively low metastatic potential. Gradation into typical (TC) and atypical carcinoid (AC) is limited in terms of prognostic value, resulting in yearly follow-up of all patients. We examined the additional prognostic value of novel immunohistochemical (IHC) markers to current gradation of carcinoids. Methods: A retrospective single-institution cohort study was performed on 171 patients with pathologically diagnosed bronchial carcinoid (median follow-up: 66 months). The risk of developing distant metastases based on histopathological characteristics (Ki-67, p16, Rb, OTP, CD44, and tumor diameter) was evaluated using multivariate regression analysis and the Kaplan−Meier method. Results: Of 171 patients, seven (4%) had disseminated disease at presentation, and 164 (96%) received curative-intent treatment with either endobronchial treatment (EBT) (n = 61, 36%) or surgery (n = 103, 60%). Among the 164 patients, 13 developed metastases at follow-up of 81 months (IQR 45−162). Univariate analysis showed that Ki-67, mitotic index, OTP, CD44, and tumor diameter were associated with development of distant metastases. Multivariate analysis showed that mitotic count, Ki-67, and OTP were independent risk factors for development of distant metastases. Using a 5% cutoff for Ki-67, Kaplan−Meier analysis showed that the risk of distant metastasis development was significantly associated with the number of risk predictors (AC, Ki-67 ≥ 5%, and loss of OTP or CD44) (p < 0.0001). Six out of seven patients (86%) with all three positive risk factors developed distant metastasis. Conclusions: Mitotic count, proliferation index, and OTP IHC were independent predictors of dissemination at follow-up. In addition to the widely used carcinoid classification, a comprehensive analysis of histopathological variables including Ki-67, OTP, and CD44 could assist in the determination of distant metastasis risks of bronchial carcinoids.

[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.

Diagnosis of atypical carcinoid can be made on biopsies > 4 mm2 and is accurate

In the 2021 WHO thoracic tumors, gradation of lung carcinoids in biopsies is discouraged. We hypothesized that atypical carcinoid (AC) could be reliably diagnosed in larger preoperative biopsies. Biopsy-resection paired specimens of carcinoid patients were included, and definitive diagnosis was based on the resection specimen according to the WHO 2021 classification. A total of 64 biopsy-resection pairs (26 typical carcinoid (TC) (41%) and 38 AC (59%)) were analyzed. In 35 patients (55%), tumor classification between the biopsy and resection specimen was concordant (26 TC, 9 AC). The discordance in the remaining 29 biopsies (45%, 29 TC, 0 AC) was caused by misclassification of AC as TC. In biopsies measuring < 4 mm², 15/15 AC (100%) were misclassified compared to 14/23 AC (61%) of biopsies ≥ 4 mm². Categorical concordance of Ki-67 in biopsy-resection pairs at threshold of 5% was 68%. Ki-67 in the biopsy was not of additional value to discriminate between TC and AC, irrespective of the biopsy size. Atypical carcinoid is frequently missed in small bronchial biopsies (< 4 mm²). If the carcinoid classification is clinically relevant, a cumulative biopsy size of at least 4 mm² should be considered. Our study provides strong arguments to make the diagnosis of AC in case of sufficient mitosis for AC on a biopsy and keep the diagnosis "carcinoid NOS" for carcinoids with ≤ 1 mitosis per 2 mm². Ki-67 has a good concordance but was not discriminative for definitive diagnosis.

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.

Endobronchial resection as a bridge to curative resection in patient with poor preoperative lung function secondary to an airway blocking endobronchial carcinoid tumour

We present a 70-year-old gentleman with chronic cough with haemoptysis found to have left lower zone collapse on imaging. The bronchoscopy showed an endobronchial mass histologically of a non-secreting atypical carcinoid. Poor baseline lung function excluded surgical resection, and instead, he successfully underwent a bronchoscopic debulking procedure which improved his FEV1 to 84% and DLCO 83% predicted. Unfortunately, the tumour regrew, but the calculated percentage predicted postoperative for FEV1 (64%), and DLCO (65%) enabled definitive surgical resection to take place. Surgical resection remains the definite curative option for localised endobronchial atypical carcinoid tumours. Achieving this in proximal endobronchial carcinoid tumour is a challenge. We described an endoscopic tumour debulking procedure as a bridge for curative surgical resection in a patient with an inoperable proximal atypical carcinoid tumour due to poor predicted postoperative lung function. We highlighted the need to assess predicted postoperative lung function with functional and quantitative perfusion methods to aid surgical planning. Debulking the tumour by endoscopy can be used as a conduit to curative surgical resection in bronchial carcinoid tumour. The choice of calculating the percentage predicted values by either or both methods must be individualised based on tumour location and the probability of converting a lobectomy to a pneumonectomy. This precautionary approach could evaluate the postoperative lung function and morbidity and mortality risk if considering a pneumonectomy. Endoscopic debulking can be a successful bridge to a curative surgical resection aided by comprehensive preoperative lung function tests to predict postoperative lung values

Atypical carcinoid with multiple central airway metastases: A case report

A 51-year-old man was found to have multiple polypoid tracheal and bilateral main bronchial tumors during postoperative follow-up of atypical carcinoid. He underwent transtracheal biopsy, and was diagnosed as having central airway metastases of the atypical carcinoid. He underwent chemotherapy, but the effects were unfavorable. Owing to the risk of airway obstruction, he was referred to our hospital for interventional bronchoscopy. Carcinoid tumors usually present as peripheral lung lesions or solitary endobronchial abnormalities, but rarely appear as multiple central airway lesions. We present a very rare case of multiple central airway metastases of atypical carcinoid, controlled by bronchoscopic treatment.

Bronchial carcinoid tumor managed with bronchial artery embolization before endobronchial resection: A case report

Endobronchial resection using a bronchoscope is often selected as treatment for carcinoid tumors located in the central airways. However, massive bleeding is one of the most serious complications during bronchoscopic surgery. Here, we report the case of a 77‐year‐old female with a typical carcinoid tumor located in the right truncus intermedius who underwent bronchial artery embolization (BAE) one day before endobronchial intervention using a flexible bronchoscope. The tumor was successfully resected without bleeding. BAE prior to endobronchial resection of carcinoid tumors may be useful for reducing the risk of bleeding.

Right middle lobe obstruction associated with synchronous endobronchial carcinoid and aspergillosis

Pulmonary carcinoids originate from neuroendocrine cells of the lung and comprise 0.5%-5% of all lung malignancies. Endobronchial carcinoids are rare, low-grade malignant tumors that occasionally coexist with other infectious diseases, including tuberculosis and nontuberculous mycobacterial infection. We treated a 63-year-old woman who presented with a right middle lobe obstruction. A chest computed tomography scan demonstrated a mass-like lesion in the right middle lobe with mediastinal lymphadenopathy. She underwent an exploratory operation after 2 weeks of antibiotic treatment. The pathology revealed a right middle lobe bronchial carcinoid tumor and aspergillosis. Chest computed tomography scans have revealed no recurrence of the carcinoid or aspergillosis during the 5-year follow-up.

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.

Recent Advances in the Management of Typical and Atypical Lung Carcinoids

Neuroendocrine neoplasms of the lung represent about 20% to 30% of all neuroendocrine tumors. On the basis of clinical and pathologic characteristics, 2 different categories of tumors may be defined: poorly differentiated neuroendocrine neoplasms, characterized by a high rate of recurrences and poor prognosis, and well-differentiated neuroendocrine neoplasms (typical carcinoids and atypical carcinoids), which generally display an indolent course. Lung carcinoids represent only 1% to 5% of all lung malignancies, but their incidence has significantly increased over the past 30 years. Surgery is the reference standard of treatment for lung carcinoids with locoregional disease. For advanced or unresectable lung carcinoids, several therapeutic options are available, but the choice should be shared within a multidisciplinary team to ensure optimal therapeutic outcomes. We describe the current management of these rare neoplasms.

Preoperative Biopsy Diagnosis in Pulmonary Carcinoids, a Shot in the Dark

INTRODUCTION

The preferred treatment for pulmonary carcinoids (PCs) is lobectomy, and parenchyma-sparing approaches might be considered for typical carcinoids (TCs). Treatment decisions are based on a preoperative biopsy diagnosis. Following the WHO criteria (2015), definitive diagnosis is only feasible postoperatively, thereby hampering preoperative treatment decisions. Here, we determined whether the final carcinoid classification on a resection specimen can be predicted by a preoperative biopsy.

METHODS

We searched all stage I to III patients with a final carcinoid diagnosis who underwent a curative resection and of whom both a preoperative biopsy and paired resection specimen were available (2003-2012) using the Dutch Pathology Registry (PALGA) and the Netherlands Cancer Registry (IKNL). Pathology report conclusions of the biopsy-resection specimen were compared.

RESULTS

Paired biopsy-resection specimens in combination with clinical data were available from 330 patients. 57% (189 of 330) of the patients exhibited discordance between the preoperative biopsy and paired resection diagnosis, including 36% (44 of 121) preoperatively diagnosed TC, 40% (six of 15) atypical carcinoid (AC), and 65% (103 of 158) not-otherwise-specified (NOS) carcinoids. A quarter of preoperatively diagnosed TC and NOS was reclassified as AC on the resection specimen. Preoperatively diagnosed ACs exhibited the highest relapse rates (40%, 6 of 15). Preoperatively diagnosed TC and NOS patients who were reclassified as ACs exhibited higher relapse rates as compared to nonreclassified TCs and NOS (3% versus 1%, and 16% versus 6%).

CONCLUSIONS

We provide evidence that carcinoid classification on preoperative biopsies is imprecise, as is also stated by the current WHO classification. We advise clinicians to interpret the preoperative biopsy diagnosis with caution in deciding the extent of surgery (e.g., parenchyma-sparing versus non-parenchyma-sparing).

Total Lung-sparing Surgery for Tracheobronchial Low-grade Malignancies

BACKGROUND

Total lung-sparing tracheobronchial sleeve resections are a step forward in the treatment of low-grade bronchial tumors in which minimal resection margins are required to achieve complete control of the disease.

METHODS

This study retrospectively collected data on patients who underwent total lung-sparing procedures for low-grade tracheobronchial tumors at 2 thoracic surgical centers from January 1984 to October 2019.

RESULTS

The study included 98 patients, 46 -female (47%) and 52 -male (53%), with a median age of 39 years (range, 7 to 70 years). Thirty-four patients underwent operative endoscopy before surgery (32 had laser treatment, and 2 had endobronchial stenting). The surgical resections were as follows: 9 (9%), tracheal carina; 18 (18%), second carina; 31 (32%), left main bronchi; 25 (26%), right main bronchi; and 15 (15%), intermediate bronchus. The median length of the resected bronchus was 2.2 cm. The median postoperative in-hospital stay was 8 days, and no perioperative mortality was observed. Postoperative complications were recorded in 26-patients (27%). The final histologic classification was as follows: 37 typical carcinoids (38%); 10 atypical carcinoids (10%); 29 adenoid cystic carcinomas (30%); 15 mucoepidermoid carcinomas (15%); 6 inflammatory myofibroblastic tumors (6%); and 1 glomic tumor (1%). Twenty-two patients had positive resection margins and underwent adjuvant radiotherapy. Three patients with adenoid cystic carcinoma had recurrences (1 local and 2 systemic). After a median follow-up time of 54.5 months (range, 4 to 360 months), the overall actuarial 5-year survival was 97%.

CONCLUSIONS

Total lung-sparing tracheobronchial sleeve resection for low-grade malignant disease requires advanced surgical skills, but the hospital morbidity and mortality are very low. This technique is adequate and safe for highly selected patients with low-grade endobronchial malignant diseases, and its use should be encouraged in experienced centers.

Endobronchial Treatment of Bronchial Carcinoid in the Elderly

Purpose of the Review

Although surgical resection is considered the gold standard of curative treatment for bronchial carcinoid, endobronchial treatment (EBT) can serve as a less invasive curative or palliative treatment in a selection of patients. It is unclear whether elderly patients with bronchial carcinoid should be treated in the same way as younger patients. In order to study the characteristics and treatment of elderly patients with bronchial carcinoid, we analyzed data from a cohort of patients that have been treated for bronchial carcinoid with EBT, surgical resection, or a combination of both. We used our existing database of patients referred for EBT and defined two groups of patients: ≥ 65 and < 65 years. We compared the characteristics, treatment, and causes of death between these groups. Successful EBT was defined as definitive treatment without signs of recurrence during follow-up with CT and bronchoscopy.

Recent Findings

Thirty-five patients (19%) were ≥ 65 years. The incidence of atypical carcinoid was the same in both age groups (31%). Thirty-six of 184 patients (20%) were directly referred for surgical resection and 148 (80%) underwent EBT. There was no significant difference in success of EBT between patients <65 years (58/122, 48%) and patients ≥ 65 years (15/26, 58%) (p = 0.347). Complication rates were similar in both groups. After unsuccessful EBT, only 70% (14/20) of the elderly patients was operated, whereas 93% (85/91) of the patients < 65 years was operated (p = 0.001). Disease specific mortality was 6% (2/35) in the group ≥ 65 years and 2% (3/149) in the group < 65 years.

Summary

The incidence of atypical carcinoid is similar between the elderly and younger patients. Success rate and complication rate of EBT do not differ significantly between the age groups. After unsuccessful EBT, elderly patients were less likely to undergo surgical resection, which does not seem associated with excess disease specific mortality, although the number of events in this study is low.

Advances in the Diagnosis and Management of Well-Differentiated Neuroendocrine Neoplasms

Neuroendocrine neoplasms constitute a diverse group of tumors that derive from the sensory and secretory neuroendocrine cells and predominantly arise within the pulmonary and gastrointestinal tracts. The majority of these neoplasms have a well-differentiated grade and are termed neuroendocrine tumors (NETs). This subgroup is characterized by limited proliferation and patients affected by these tumors carry a good to moderate prognosis. A substantial subset of patients presenting with a NET suffer from the consequences of endocrine syndromes as a result of the excessive secretion of amines or peptide hormones, which can impair their quality of life and prognosis. Over the past 15 years, critical developments in tumor grading, diagnostic biomarkers, radionuclide imaging, randomized controlled drug trials, evidence-based guidelines, and superior prognostic outcomes have substantially altered the field of NET care. Here, we review the relevant advances to clinical practice that have significantly upgraded our approach to NET patients, both in diagnostic and in therapeutic options.

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.

Postpneumonectomy-like syndrome due to bronchial carcinoid: a unique case report

Background

Postpneumonectomy-like syndrome is a rare condition resulting from unilateral lung disease with severe lung volume loss leading to excessive mediastinal shift and herniation of the healthy lung into the contralateral hemithorax, mimicking the mediastinal shift observed in postpneumonectomy syndrome after pneumonectomy. We report a unique case of postpneumonectomy-like syndrome caused by an atypical bronchial carcinoid completely occluding the left main bronchus.

Case presentation

A 25-year-old woman presented with symptoms of chronic exertional dyspnea and productive cough. Imaging studies showed complete left lung atelectasis due to a mass occluding the left main bronchus, as well as extreme mediastinal deviation and substantial herniation of the right lung into the left hemithorax. Bronchoscopic biopsy of the tumor and subsequent left pneumonectomy with concurrent lymph node dissection revealed an atypical carcinoid. Sixteen months after surgery the patient has been asymptomatic with repeat imaging studies showing no change in mediastinal shifting.

Conclusion

Bronchial carcinoids are notorious for causing bronchial obstruction. The present case represents an extreme complication of centrally located bronchial carcinoid, resulting in postpneumonectomy-like syndrome with severe mediastinal shift and herniation of the healthy lung into the diseased hemithorax.

Atypical bronchial carcinoid with postobstructive mycobacterial infection: case report and review of literature

BACKGROUND

Pulmonary carcinoids are included in the group of neuroendocrine tumors (NET) and derive from pulmonary neuroendocrine cells. The incidence of these tumors is increasing, but disease awareness remains low among clinicians. The synchronous presentation of lung cancer and mycobacterial infection is well known but the combination of pulmonary carcinoid and mycobacterial infection is rare.

CASE PRESENTATION

We treated a 45-year-old female who presented with recurrent pneumonia. Chest X-ray showed a consolidation in the left upper lobe. The patient was treated with various courses of antibiotics without full recovery after six months. Computed tomography (CT) scan demonstrated a central mass in the left upper lobe. Bronchoscopy revealed an endobronchial, well-defined lesion that totally obstructed the left upper lobe bronchus. Bronchial biopsy showed typical carcinoid tumor. Rigid bronchoscopy with electrocautery was attempted, but we were unable to radically remove the tumor. Therefore lobectomy was performed. The surgical pathology specimen showed atypical bronchial carcinoid and consolidations in the lung parenchyma with granulomatous inflammation distally of the bronchial obstruction. Ziehl-Neelsen staining demonstrated acid fast bacilli indicative of mycobacterial infection.

CONCLUSIONS

This case history illustrates the importance of careful surgical pathologic examination, not only of the resected tumor, but also of the postobstructive lung parenchyma. Specific postobstructive infections such as tuberculosis or nontuberculous mycobacteria (NTM) can have clinical implications.

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.

Lung Carcinoids: Long-Term Surgical Results and the Lack of Prognostic Value of Somatostatin Receptors and Other Novel Immunohistochemical Markers

BACKGROUND/AIMS

Lung carcinoids (LCs) are often diagnosed at an early stage and surgical intervention becomes the next phase of treatment. To date, there is lack of long-term follow-up data after surgery and prognostication based on WHO classification criteria and evolving prognostic markers, particularly the expression of somatostatin receptors (SSR).

METHODS

We included 102 consecutive patients (72 women; age at baseline 51 ± 16 years [mean ± SD]) with LCs, who underwent thoracic surgery (n = 99) and/or laser treatment (n = 8). Hospital charts were reviewed for clinico-pathological parameters. Immunohistochemical (IHC) expression of SSR1-5 and other novel markers were studied with regard to their prognostic value.

RESULTS

Five- and 10-year overall survival (OS) was 96 and 83% respectively; relative survival (RS) was 101 and 93% respectively; and event-free survival (EFS) was 80 and 67% respectively. Independent prognostic factors for OS, RS and/or EFS were age at diagnosis, histopathological type and the presence of ipsilateral mediastinal subcarinal lymph node metastases. Macro-radicality of resective surgery and its extent were associated with increased OS and EFS. The IHC expression of SSR1-5 and other novel markers was not associated with OS or EFS.

CONCLUSION

The long-term outcome of surgically treated patients with LCs is favourable. Age, histopathological type and ipsilateral mediastinal subcarinal lymph node status at baseline were independent prognostic factors for survival and disease recurrence or progression. The extent of surgery and operative macro-radicality also had an impact on prognosis. None of the IHC markers tested appeared to be associated with disease prognosis.