Argyrophil carcinoid tumors of the lung. Incidence, clinical study, and follow-up of 46 patients

The presentation pattern and surgical strategies in bronchopulmonary carcinoid tumors: a multicenter experience in a low-income country

Background

Bronchopulmonary carcinoid tumors include typical and atypical carcinoids, with typical carcinoids accounting for 80%-90% of these types of tumor. The primary curative treatment for these tumors is surgical resection. To our knowledge, there are limited studies on the presentation patterns and treatment strategies of bronchopulmonary carcinoid tumors in Africa.

Objective

To determine the presentation patterns and surgical strategies in bronchopulmonary carcinoid tumors in patients treated at multicenters in Ethiopia from January 2018 to December 2023.

Materials and methods

A 5-year retrospective cross-sectional study was conducted using medical records and pathology record reviews of patients operated on in Tikur Anbessa Specialized Hospital, Menelik II Hospital, and Saint Peter's Specialized Hospital from 1 January 2018 to 31 December 2023. The completeness of the data was checked before being entered into EpiData version 4.6.1, and analysis was conducted using SPSS version 29. Logistic regression was applied to depict the association of the histological pattern with its predictors. A P-value of <0.05 was considered significant for the association of variables.

Results

A total of 62 patients with bronchopulmonary carcinoid tumors were included in the study with a mean age of 35.29 ± 12.26 years ranging from 14 to 67 years, in which more than half [37 (56.5%)] were females, with a male-to-female ratio of 1:1.3. The majority of the patients were non-smokers (90.3%) and symptomatic (98.4%), with a mean duration of symptoms of 29.7 ± 26 months, ranging from 3 to 156 months. Nearly half of the patients (48.4%) were treated for pulmonary tuberculosis before a diagnosis of carcinoid tumor was made. The majority of the patients underwent surgery by open posterolateral thoracotomy (98.4%), and pneumonectomy was the most common (38.7%) resection performed. Typical carcinoids were observed in 85.5% of patients. Age, smoking history, duration of symptoms, location of tumors, and lymph node status were statistically associated with histological patterns.

Recommendation

Based on our study findings, improving physician awareness on the clinical presentation of carcinoid tumors, training for surgeons in less invasive surgical approaches, and further nationwide studies are recommended.

Pulmonary carcinoid tumors and asbestos exposure

OBJECTIVES

The hypothesis that asbestos exposure may have more specific associations with particular histological types of lung cancer remains controversial. The aim of this study was to analyze the relationships between asbestos exposure and pulmonary carcinoid tumors.

METHODS

A retrospective case-control study was conducted in 28 cases undergoing surgery for pulmonary carcinoid tumors and aged >40 years and in 56 controls with lung cancer of a different histological type, matched for gender and age, from 1994 to 1999, recruited in two hospitals in the region of Paris. Asbestos exposure was assessed via expertise of a standardized occupational questionnaire and mineralogical analysis of lung tissue, with quantification of asbestos bodies (AB).

RESULTS

Definite asbestos exposure was identified in 25% of cases and 14% of controls (ns). Cumulative asbestos exposure was significantly higher in cases than in controls (P < 0.05), and results of the quantification of AB tended to be higher in cases than in controls (24 and 9% had >1000 AB per gram dry lung tissue, respectively, P = 0.09). Mean cumulative smoking was lower in cases than in controls (P < 0.05).

CONCLUSIONS

This study argues in favor of a relationship between asbestos exposure and certain pulmonary carcinoid tumors.

CT features of peripheral pulmonary carcinoid tumors

OBJECTIVE

Pulmonary carcinoid tumors are low-grade malignant neoplasms thought to arise primarily within the central airways in 85% of cases. The CT features of pulmonary carcinoid tumors that arise as solitary pulmonary nodules (SPNs) have not been well elucidated. We reviewed our experience with primary pulmonary carcinoid tumors to determine the distribution of lesions within the lung at diagnosis and to identify CT features that might aid in distinguishing these neoplasms from benign pulmonary nodules.

MATERIALS AND METHODS

CT scans, if available, of all patients with a primary pulmonary carcinoid tumor diagnosed by biopsy or surgical resection over the previous 15 years were reviewed. The CT scans were reviewed for the following features: lesion location; order of bronchus involved; lesion size, contour, and density; contrast enhancement; and the presence of peripheral atelectasis, hyperlucency, and bronchiectasis. We defined central lesions as those involved with a segmental or larger bronchus. Subsegmental bronchial involvement and tumors surrounded by lung parenchyma without direct airway involvement were defined as peripheral lesions. The final pathologic diagnosis for all cases was confirmed by review of cytologic or histologic specimens.

RESULTS

Twenty-eight carcinoid tumors were identified in 28 patients: 24 typical carcinoids and four atypical carcinoids. The study group was composed of 23 females and five males with a mean age of 52.4 years (range, 14-83 years). Twelve of the 28 lesions (43%) were central (i.e., involved a segmental or larger bronchus), and the remaining 16 lesions (57%) were peripheral. The mean tumor diameter for the 16 peripheral tumors was 14 mm (range, 9-28 mm); the majority (14/16, 88%) had a lobulated contour. Of six peripheral lesions with unenhanced and contrast-enhanced CT nodule enhancement studies, the mean maximal enhancement was 55.2 HU (range, 34-73 HU). Thirteen of the 16 peripheral carcinoid tumors (81%) involved a subsegmental bronchus, with 10 (63%) showing peripheral hyperlucency, bronchiectasis, or atelectasis.

CONCLUSION

In our series, primary pulmonary carcinoid tumors presenting as peripheral SPNs were more common than central endobronchial lesions in contrast to the published literature. The CT features of peripheral carcinoid tumors presenting as SPNs that suggest the diagnosis include lobulated nodules of high attenuation on contrast-enhanced CT; nodules that densely enhance with contrast administration; the presence of calcification; subsegmental airway involvement on thin-section analysis; and nodules associated with distal hyperlucency, bronchiectasis, or atelectasis.

Respiratory syncytial virus as a cause of pulmonary hemorrhage in a low birth weight infant: strategies for protection and prevention: a case report

INTRODUCTION

Respiratory syncytial virus is a common neonatal pathogen. Here we present a case of a premature, low birth weight infant who contracted respiratory syncytial virus and developed a severe pulmonary hemorrhage.

CASE PRESENTATION

A 12-day-old Asian male, former 30 week premature infant with a birth weight of 1025 grams presented with nasal secretions, episodes of desaturations and increased work of breathing. The infant developed a pulmonary hemorrhage. Secretions during tracheal lavage were positive for respiratory syncytial virus on rapid fluorescence assay. After supportive care, the patient improved. Isolation, cohorting techniques and reinforcement of strict hand-washing guidelines prevented and outbreak to other infants.

CONCLUSION

This original case report presents an uncommon presentation of respiratory syncytial virus infection, a common pediatric pathogen. Neonatologists should consider evaluating patients with pulmonary hemorrhage for respiratory syncytial virus if preceding symptoms are consistent with that infectious illness.

A 35-year retrospective study of carcinoid tumors in Taiwan: differences in distribution with a high probability of associated second primary malignancies

BACKGROUND

A comprehensive study of carcinoid tumors from United States-based databases indicated that the small intestine, colon, rectum, and bronchopulmonary system are common locations for carcinoid tumors. In addition, certain carcinoid tumors, such as rectal carcinoids, appeared to be overrepresented in nonwhite populations in the United States. High frequencies of associated noncarcinoid malignancies were reported in some articles. The objective of the current study was to address the organ distribution, frequency of metastasis, and survival rates of carcinoid tumors and the associated noncarcinoid tumors in Taiwanese, Asian populations.

METHODS

Two hundred twenty-eight patients with carcinoid tumors were identified and evaluated from the surgical pathology files and medical records of the Veterans General Hospital, Taipei, Taiwan from January 1970 to December 2005.

RESULTS

In 228 carcinoid tumors that were analyzed, the rectum (60.5%) was the most common location followed by the lung (20.2%) and the thymus (6.6%). Metastatic lesions were demonstrated in 16.2% of patients. Disease extent was associated with survival. The 5-year survival rates for patients with localized, regional metastatic, and distant metastatic disease were 94.1%, 49.1%, and 0%, respectively (P< .001). Associated noncarcinoid malignancies were noted in 14% of patients with carcinoids, mainly in the gastrointestinal tract (52.9%), lung, and genitourinary system.

CONCLUSIONS

A different organ distribution of carcinoids was observed in Taiwanese patients, who had with significantly more carcinoids located in the rectum and thymus compared with patients in Western countries. The patients with carcinoids in the current study had a high possibility of developing associated, noncarcinoid neoplasms. Surveillance of the colon, stomach, lung, and genitourinary system for second malignant tumors is recommended.

A 5-decade analysis of 13,715 carcinoid tumors

BACKGROUND

Carcinoid tumors represent an unusual and complex disease spectrum with protean clinical manifestations. This compilation of several large United States-based databases comprising patients from 1950 to 1999 examines 13,715 carcinoid tumors and provides epidemiologic information regarding the natural history and evolution of the detection and diagnosis of this entity.

METHODS

The authors evaluated 10,878 carcinoid tumors that were identified by the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute (NCI) from 1973 to 1999 in addition to 2837 carcinoid tumors that were registered previously by two earlier NCI programs. To the authors' knowledge, this represents the largest current epidemiology series addressing carcinoid tumors to date.

RESULTS

Specific trends in incidence for carcinoid tumors of certain sites were identified. Among the most recently collected subset of data, sites that demonstrated the greatest incidence of carcinoids were the gastrointestinal tract (67.5%) and the bronchopulmonary system (25.3%). Within the gastrointestinal tract, most carcinoid tumors occurred in the small intestine (41.8%), rectum (27.4%), and stomach (8.7%). For all sites, age-adjusted incidence rates were highest in black males (4.48 per 100,000 population per year). Associated noncarcinoid tumors were frequent in conjunction with small intestinal (29.0%), gastric (20.5%), colonic (20.0%), and appendiceal (18.2%) carcinoids. The highest percentages of nonlocalized lesions were noted for cecal (81.5-83.2%) and pancreatic (71.9-81.3%) carcinoids, whereas the highest percentage of localized disease was found among rectal (81.7%), gastric (67.5%), and bronchopulmonary (65.4%) carcinoids. The best 5-year survival rates were recorded for patients with rectal (88.3%), bronchopulmonary (73.5%), and appendiceal (71.0%) carcinoids; these tumors exhibited invasive growth or metastatic spread in 3.9%, 27.5%, and 38.8% of patients, respectively.

CONCLUSIONS

Carcinoids appear to have increased in overall incidence over the past 30 years; for some sites, this trend has been evident for nearly half a century. Recent marked increases in gastric and rectal carcinoids and a concomitant decrease in appendiceal carcinoid incidence may be due in part to varying rules of registration among the compiled databases examined in this report or to improvements in diagnostic technology; increased awareness of and about carcinoid tumors also may play a significant role. In 12.9% of all patients with carcinoid, distant metastases already were evident at the time of diagnosis; the overall 5-year survival rate for all carcinoid tumors, regardless of site, was 67.2%. These findings bring into question the widely promulgated relative benignity of carcinoid disease. Certain carcinoid tumors, such as those of the rectum, appear to be over-represented among the black and Asian populations within the United States, suggesting the role of genetics in the development of this intriguing disease.

Heterogeneity of so-called neuroendocrine lung tumors

The diagnosis of neuroendocrine (NE) lung tumor is dependent on a number of observations: organoid structure, dense core granules, and various molecular components, including chromogranin A, neurosecretory enolase, synaptophysin, neural cell adhesion molecules, and others. None of these is specific for lung tumors. The Kulchitsky cell, which has these characteristics, forms a carcinoid, which exemplifies the NE tumor. It is euploid, has few mitoses, no necrosis and a 5- to 10-year survival of over 90%. When carcinoids show malignant characteristics, i.e., increased mitoses and necrosis, they have been labeled atypical and have a survival of 50%. Because all other non-small cell lung tumors, especially large cell tumors, may show one or more of these things because of the inherent heterogeneity of lung tumors, the term NE has been applied to them without real evidence that this affects survival with or without chemotherapy. This is expensive and without clinical significance.

An analysis of 8305 cases of carcinoid tumors

BACKGROUND

Carcinoid tumors are unusual and most reports are anecdotal or limited in number. A series of 2837 cases was published in 1975. No recent large series is available.

METHODS

The authors evaluated 5468 cases identified by the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute (NCI) from 1973 to 1991 together with 2837 carcinoid cases previously registered by 2 earlier NCI programs. To the authors' knowledge, the 8305 carcinoid tumors analyzed represent the largest current epidemiology series to date.

RESULTS

The most frequent sites for carcinoids were the gastrointestinal (GI) tract (73.7%) and the bronchopulmonary system (25.1%). Within the GI tract, most occurred in the small bowel (28.7%), appendix (18.9%), and rectum (12.6%). For all sites, age-adjusted incidence rates were highest in African American males (2.12 per 100,000 population per year). Associated noncarcinoid tumors were frequent in conjunction with small intestinal (16.6%), appendiceal (14.6%), and colonic carcinoids (13.1%). The highest percentage of nonlocalized lesions were noted for pancreatic (76.1%), colonic (71.2%), and small intestinal carcinoids (70.7%) and this corresponded to their poor 5-year survival rates (34.1%, 41.6%, and 55.4%, respectively). The best 5-year survival rates were recorded for appendiceal (85.9%), bronchopulmonary (76.6%), and rectal carcinoids (72.2%). These exhibited invasive growth or metastatic spread in only 35.4%, 27.2%, and 14.2% of cases, respectively.

CONCLUSIONS

Carcinoids appear to have increased in incidence in the past 20 years. In part, this may be due to different surgical rules of the various registries, improved diagnostic technology, and increased awareness. A cumulative analysis of all types of carcinoid tumors in the SEER group indicates that in 45.3% metastases are already evident at the time of diagnosis. The overall 5-year survival rate of all carcinoid tumors regardless of site was 50.4% +/- 6.4%.

An analysis of 8305 cases of carcinoid tumors

BACKGROUND

Carcinoid tumors are unusual and most reports are anecdotal or limited in number. A series of 2837 cases was published in 1975. No recent large series is available.

METHODS

The authors evaluated 5468 cases identified by the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute (NCI) from 1973 to 1991 together with 2837 carcinoid cases previously registered by 2 earlier NCI programs. To the authors' knowledge, the 8305 carcinoid tumors analyzed represent the largest current epidemiology series to date.

RESULTS

The most frequent sites for carcinoids were the gastrointestinal (GI) tract (73.7%) and the bronchopulmonary system (25.1%). Within the GI tract, most occurred in the small bowel (28.7%), appendix (18.9%), and rectum (12.6%). For all sites, age-adjusted incidence rates were highest in African American males (2.12 per 100,000 population per year). Associated noncarcinoid tumors were frequent in conjunction with small intestinal (16.6%), appendiceal (14.6%), and colonic carcinoids (13.1%). The highest percentage of nonlocalized lesions were noted for pancreatic (76.1%), colonic (71.2%), and small intestinal carcinoids (70.7%) and this corresponded to their poor 5-year survival rates (34.1%, 41.6%, and 55.4%, respectively). The best 5-year survival rates were recorded for appendiceal (85.9%), bronchopulmonary (76.6%), and rectal carcinoids (72.2%). These exhibited invasive growth or metastatic spread in only 35.4%, 27.2%, and 14.2% of cases, respectively.

CONCLUSIONS

Carcinoids appear to have increased in incidence in the past 20 years. In part, this may be due to different surgical rules of the various registries, improved diagnostic technology, and increased awareness. A cumulative analysis of all types of carcinoid tumors in the SEER group indicates that in 45.3% metastases are already evident at the time of diagnosis. The overall 5-year survival rate of all carcinoid tumors regardless of site was 50.4% +/- 6.4%.

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

Atypical carcinoids are an intermediate form of tumor between low-grade malignant typical carcinoid and high-grade malignant small cell carcinoma, which represent the two ends of the spectrum of neuroendocrine bronchopulmonary tumors. Between 1983 and 1993, 27 patients with atypical carcinoids underwent surgical treatment. The histologic diagnosis of an atypical carcinoid was established if the criteria proposed by Arrigoni and associates were fulfilled. Seven pneumonectomies, 16 lobectomies, 2 segmentectomies, and 2 wedge resections were performed. Thirteen patients (48.1%) had regional nodal metastases and 6 patients (22%) had N2 disease at the time of surgical therapy. Distant metastases developed in 5 patients (18.5%) after initial treatment. The 10-year survival in patients with an atypical carcinoid was 49%, versus the 84% 10-year survival rate observed in patients with a typical carcinoid. We conclude that the aggressive behavior of atypical carcinoids precludes the use of limited surgical resection and requires a more aggressive approach, with lobectomy and mediastinal lymph node dissection constituting a minimal procedure. The same criteria used for well-differentiated lung carcinoma should apply to this form of neuroendocrine lung tumor. Adjuvant chemotherapy is recommended for patients with stage III or distant metastases.

Aspects on diagnosis and treatment of the foregut carcinoid syndrome

Eight patients with the foregut carcinoid syndrome (two gastric and six bronchial primary tumors) are reported. The patients presented with complex clinical symptoms including ectopic production of adrenocorticotrophic hormone and growth hormone-releasing factors. The most alarming symptoms were facial flush and edema, accompanied by severe bronchoconstriction, which easily was misinterpreted as asthmatic attacks. Conventional bronchodilatory drugs may be potentially dangerous in these patients, in whom combined blockade of histamine receptors and treatment with cortisone and octreotide are recommended. Owing to the patients' age and general condition individualized long-term therapy was instituted. Surgical therapy under optimal protection by drugs can be of substantial value also in patients with advanced disease. One patient with life-threatening hormonal symptoms underwent hyperthermic perfusion of the liver with cytotoxic drugs, resulting in good palliation.

Prealbumin in the diagnosis of bronchopulmonary carcinoid tumours

The reliability of prealbumin as a diagnostic marker was studied in 60 cases of bronchopulmonary carcinoid tumours. There were differences in the incidence of positivity between typical and atypical carcinoids (well differentiated neuroendocrine carcinomas). Seventy five per cent of the carcinoid tumours were positive for prealbumin; (86.7% typical and 63.3% atypical carcinoids). In 15 cases, which were Grimelius negative, 10 were prealbumin positive. Only 8.3% carcinoids were negative with both prealbumin and Grimelius stains. Ten squamous, 10 adeno- and 10 small cell carcinomas showed only occasional scattered prealbumin positive cells. It is concluded that prealbumin is a useful marker for bronchopulmonary carcinoid tumours. It is cheap, readily available, and should be considered part of routine diagnostic procedures for the diagnosis of carcinoid tumours.

Bronchial neuroendocrine (carcinoid) tumor causing unilateral left-sided carcinoid heart disease

A female patient suffering from a bronchial neuroendocrine tumor with unilateral left-sided carcinoid heart disease is reported. Repeated x-ray films of the chest showed a slowly growing lung tumor in the left lower lobe. The patient refused any diagnostic or therapeutic procedure to define the type of the tumor. During the follow-up of 24 years she developed severe mitral and moderate to severe aortic insufficiency, both invasively quantified by thermodilution techniques. During surgery for double valve replacement the patient died from left ventricular heart failure. Necropsy revealed the typical pattern of a bronchial neuroendocrine tumor without metastases. Examination of the heart disclosed the characteristic deposits of fibrous tissue on the cusps of both the mitral and the aortic valves whereas the right heart showed no abnormalities. Review of the literature suggests the unilateral left-sided carcinoid heart disease to be a very rare finding, its pathogenesis remains to be elucidated.

Bronchial carcinoid: a clinical follow-up study of 33 cases

Thirty-three bronchial carcinoid tumours operated on in a 22-year period are reviewed. They were histologically verified as typical carcinoids with Grimelius' argryophilic staining (25 cases), electron microscopy (6) and immunostaining for synaptophysin (4). Nineteen were endobronchial and 14 peripheral, intraparenchymal tumours. Lymph-node metastases were present at operation in two patients. Two tumours, in patients with Cushing's syndrome, were hormonally active (one secreting ACTH and the other ACTH and calcitonin). There was one case of multiple endocrine neoplasia syndrome, but none of carcinoid syndrome. During follow-up for 5-18 (mean 8.2) years five patients died of unrelated causes. Only one patient showed distant metastasis (after 15 years in salivary gland and a year later in mediastinal fat). Extensive clinical re-examination was performed on 20 patients, and six others were interviewed. All were well but one, who died of uterine cancer 8 weeks later. Typical bronchial carcinoid is concluded to be of low-grade malignancy and suitable for limited pulmonary resection.

Recurrent bronchial carcinoid tumor

Bronchial carcinoid tumors are considered to be of low grade malignancy, and if completely resected, to be cured. A patient with resection of a bronchial carcinoid presented 18 years later with superior vena caval obstruction, and carcinoid syndrome due to a recurrence. There was an excellent response to radiation.

Bronchopulmonary carcinoids in Iceland 1955-1984. A retrospective clinical and histopathologic study

Twenty-two cases of bronchopulmonary carcinoid tumor diagnosed in Iceland in the 30-year period 1955-1984 were analyzed. Carcinoid comprised 2% of all primary lung tumors registered in that period. The crude incidence was 0.36 cases/100,000 population/year. The patients' mean age was 48 years and 68% were female. The most common presenting symptom was recurrent pneumonia; only three patients had hemoptysis. One patient had carcinoid syndrome. Two of the 22 tumors were peripheral. Tumor size was 0.8-9 cm, mean 2.8 cm. Of the resectable bronchial tumors, 80% had invaded the pulmonary parenchyma and 18% had metastasized to lymph nodes. Four carcinoid tumors were atypical and showed more malignant behavior. One of them was originally diagnosed as oat-cell carcinoma. Sixteen patients with resectable carcinoid tumor were alive 3 1/2 to 29 years after removal of the tumor.

Atypical carcinoid of the lung. A distinct clinicopathologic entity

Eleven cases of atypical carcinoid (AC) of the lung were identified during an eight-year period. Their clinical features and treatment responses were contrasted with our experience at Vanderbilt with small cell lung cancer (SCLC) and a literature review of typical bronchial carcinoids (TC). Clinically, there were no features to distinguish AC from TC except for age at diagnosis (59 vs 49 years). Atypical carcinoid was similar to SCLC with respect to many clinical features, although female sex, absence of smoking history and localized disease at presentation were more common in AC. Pathologically, these tumors were distinguished by cellular atypia, necrosis, architectural disorder, or increased mitotic rate in the presence of a recognizable carcinoid pattern. Immunoperoxidase staining revealed no difference between AC and TC or SCLC. Atypical carcinoid of the lung represents a distinct clinicopathologic disease.

Application of Grimelius argyrophil staining to the study of tumour ultrastructure. I. Effects of fixatives

Two methods have so far been proposed for staining samples by the argyrophil technique of Grimelius for electron microscopy. For Håkanson glutaraldehyde prevented argyrophilia, so the author stained sections from samples previously fixed by double formaldehyde/osmium tetroxide treatment and embedding. Vassallo used en bloc staining after fixation with glutaraldehyde-formaldehyde mixtures. We examined each factor which could directly interfere in argyrophil staining en bloc and on section. In the present experiment we compared effects of fixatives after staining en bloc. Glutaraldehyde prevented argyrophilia in 1 case out of 15, that of A-like cells in the oxyntic gland of the rat positivity was maintained in EC-like cells of this gland and adrenalin cells of the adrenal gland contrary to the previous description.

Pulmonary carcinoid tumours: a clinico-pathological study of 35 cases

A clinico-pathological study of 35 bronchial carcinoid tumours was undertaken. Age, T stage, N stage, lymph node involvement, number of lymph nodes involved and number of cigarettes smoked per day were the clinical variables affecting survival. The histological variables related to survival were; mitotic count, necrosis, nuclear pleomorphism, vascular and lymphatic permeation and an undifferentiated growth pattern. All these features could be detected with routine histological stains, whereas immunocytochemical methods for demonstrating neuron specific enolase were of no help in assessing the prognosis. However there was a tendency for a well differentiated neuroendocrine carcinoma to stain strongly in some areas with carcinoembryonic antigen.

Bronchial adenoma: surgical experience with long-term follow-up (4-17 years)

Of 16 patients with bronchial adenoma who were operated on at Beilinson Medical Center from 1967 to 1980, only three presented the "triad" of cough, hemoptysis, and recurrent pulmonary infections. In two patients the tumor was diagnosed incidentally and in five patients histological evidence of adenoma was made during bronchoscopy. One patient died of myocardial infarction following reoperation for bleeding, and one patient was lost to follow-up. The remaining 14 patients were followed for 4 to 17 years without evidence of local recurrence or distant metastases. We conclude that the long-term prognosis of patients with bronchial adenoma is excellent, and limited surgical procedure should be the treatment of choice whenever possible.

Bronchopulmonary Kulchitzky cell carcinomas. A new classification scheme for typical and atypical carcinoids

Typical and atypical carcinoids constitute less than 5% of lung tumors. They and small cell undifferentiated lung cancers (SCLC) belong to the same family of apudomas arising from bronchopulmonary Kulchitzky cells. To reflect the overlap among these cancers, the authors suggest calling them Kulchitzky cell carcinomas (KCC); to indicate their spectrum of aggressiveness, the authors suggest calling typical carcinoids KCC-I, atypical carcinoids KCC-II, and small cell cancers KCC-III. One hundred fifty-six KCCs were reviewed: 115 were KCC-I and 41 were KCC-II. The ratio of women to men equals 2:1. At time of initial diagnosis, all patients with KCC-I, except one patient, were in Stage I. Among patients with KCC-II, 16 (39%) were in Stages II or III at time of presentation. The incidence of carcinoid syndrome was 1.9%. Treatment was lobectomy in 112 (72%) of patients, the remainder having lesser resections or pneumonectomy in approximately equal distribution. Our data cannot support the use of radical resection in the treatment of KCC because none of the patients died of local recurrence. The mean diameters of KCC-I and -II tumors were 1.5 and 2.8 cm, respectively. Increased mitotic activity and tumor necrosis were reliable criteria for diagnosing KCC-II. Electron microscopic examination did not help in differentiating KCC-I and KCC-II. Thorough sampling of the entire tumor was found to be mandatory for precise diagnosis and for differentiation from KCC-III (SCLC). Measurement of nuclear DNA was done using integrated optical density (IOD) by image analysis. The IODs of KCC-I, -II and -III were 1.36, 1.55 and 1.94, respectively. These significant differences (P less than 0.001) correlated with the aggressiveness of the cancers. Of patients with KCC-I, 1.7% succumbed to KCC; this included one patient reported to have died of KCC-III (SCLC). Of 41 patients with KCC-II, 11 (27%) died of KCC; this includes at least 3 deaths from KCC-III.

Silver stains and immunocytochemical analysis with monoclonal serotonin antibodies for liver metastases of endocrine tumors. A study on percutaneous biopsy specimens

With the aid of ultrasonography, representative percutaneous biopsy specimens were obtained from 20 of 21 patients (95 percent) with liver metastases of carcinoids and endocrine pancreatic tumors. The specimens were examined with silver stains and immunocytochemically after the application of monoclonal serotonin antibodies. The Grimelius argyrophil silver nitrate stain was positive in all tumor metastases, demonstrating that they were of neurohormonal endocrine type. The argentaffin reaction stained 14 of 15 metastases of small intestinal carcinoids, whereas tumors with other primary sites were unreactive. Immunocytochemical analysis with monoclonal serotonin antibodies stained all metastases of small intestinal carcinoids, and the other endocrine tumor metastases were unreactive. With immunocytochemical analysis, optimal results were obtained in Bouin-fixed tumor specimens, whereas for the argentaffin reaction, formalin was preferable. The results show that silver stains and immunocytochemical analysis with monoclonal serotonin antibodies on small percutaneous biopsy specimens of liver metastases of endocrine tumors and carcinoids are valid for the prediction of the location of the primary tumors.

Carcinoid tumours of the bronchus: a 33 year experience

The term adenoma of the bronchus is discussed, and 79 cases of bronchial carcinoid seen from 1951 to 1983 are reviewed. The symptoms, radiological findings, and bronchoscopic appearances are described. There was no case of the carcinoid syndrome. In no case did haemorrhage cause any serious problem after biopsy at rigid bronchoscopy. In three patients the tumour was reported to be an oat cell carcinoma-in two on the basis of material obtained at fibreoptic bronchoscopy. Resection was by pneumonectomy in 10 cases, lobectomy in 52, segmentectomy in six, a bronchoplastic procedure without resection of lung in seven cases, enucleation in two, and a wedge resection in one case. There was one case of atypical carcinoid which was found at operation to be unresectable. A 5-30 year follow up in 57 cases revealed a recurrence of tumour in two cases, nine and 16 years after lung resection. No recurrence occurred in the nine cases treated by conservative bronchial resection with conservation of lung tissue. An actuarially assessed life table analysis shows survival rates of 94% after 10 years, 80% after 15 years, and 64% after 25 years without recurrence. The similarity of carcinoid to oat cell carcinoma is noted and the serious clinical implications of this are analysed, especially in view of the increasing use of fibreoptic bronchoscopy. The malignant potential of carcinoid and the extent of pulmonary resection is discussed. It is concluded that a carcinoid tumour of the lung has only slight malignant potential and that it may be treated by bronchotomy or sleeve resection of the bronchus in suitable cases. If serious infective changes have occurred in the lung distal to the tumour or if the tumour has extended into the lung parenchyma (88% of cases in this series) lung resection will be necessary. The follow up period should be for at least 25 years, in view of the incidence of late recurrence.

Immunolocalization of prealbumin as a marker for carcinoid tumours

Using a PAP immunoperoxidase technique, we have demonstrated the plasma protein prealbumin in 92 (87 per cent) out of a series of 106 carcinoid tumours from various sites. The frequency of detection was greater than with the conventional stains; 83 (78 per cent) of the cases were positive for one or more of these stains. The Grimelius technique was by far the most effective of the conventional stains; it was positive in 81 (76 per cent) cases. We were unable to detect prealbumin in a variety of carcinomas. Although prealbumin identification did not appear to have any advantage over the routine stains in midgut-derived carcinoids, it was much more effective in the diagnosis of bronchial (foregut) and rectal (hindgut) carcinoids. We believe that prealbumin staining offers a cheap, reliable and valuable method for the detection of carcinoid tumours in routine histopathology.

Malignancies of the endocrine glands

Patients with malignant tumors of the endocrine system can be effectively treated by surgery, the 5 year survival rate varying between 30-90 per cent, depending on organ involvement. In the Federal Republic of Germany, 1 out every 5 persons dies as a result of malignancy. Less than 1 per cent of the total annual rate of such deaths relates to malignancies originating in the endocrine glands.

Pulmonary carcinoids. Immunohistochemical demonstration of brain-gut peptides

Antisera raised against serotonin, gastrin, somatostastin, motilin, bombesin, calcitonin, secretin, glucagon, ACTH, neurotensin, and pancreatic polypeptide carboxyterminal hexapeptide were employed to immunohistochemically stain seven pulmonary carcinoids. Argentaffin and argyrophil stains were also performed on all cases. Serotonin-like immunoreactivity was present in four tumors, pancreatic polypeptide-like immunoreactivity in four tumors, bombesin-like immunoreactivity in two tumors and ACTH-like immunoreactivity in one tumor. The cells shown to contain neuroendocrine products constituted a minority cell population in all tumors except the ACTH-immunoreactive tumor. This study suggests that pulmonary carcinoids, like their abdominal counterparts, contain a variety of neuroendocrine products, and may produce more than one neuroendocrine product. Serotonin and pancreatic polypeptide-like immunoreactivity were the most prevalent neuroendocrine products demonstrable in this study.

The choice of operation for bronchial carcinoids

In a review of the literature, 1,392 patients with bronchial carcinoids were found. Of these, there were 313 patients for whom individual data with regard to type of operation, follow-up period, and outcome were given. Actuarial curves for proportions of patients who had not died of the disease or who had not undergone reoperation for residual disease were constructed for each type of operation. The prognosis up to 20 years after surgical treatment for bronchial carcinoids is excellent. For 15 to 20 years postoperatively, the prognosis after a lobectomy is excellent and after a pneumonectomy, slightly worse. The prognosis after a lung parenchyma-saving operation (wedge or segmental resection and bronchoplastic procedures) is similar to that after a lobectomy up to 7 years postoperatively. After that, the proportion of disease-free patients declines precipitously. At 20 years the difference in comparison with a lobectomy is statistically significant for both wedge or segmental resections and bronchoplastic procedures. Parenchyma-saving operations cannot therefore be said to be radical. A policy for decision-making at the operating table is formulated.