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

doi:10.1016/j.lungcan.2010.01.015

Lung Cancer

Volume 70, Issue 2, November 2010, Pages 158-162

https://doi.org/10.1016/j.lungcan.2010.01.015 Get rights and content

Abstract

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.

Introduction

Bronchial carcinoids (BCs) are well-differentiated neuroendocrine malignant neoplasms, representing only 2–5% of all lung tumors [1]. BC have a spectrum ranging from the indolent neuroendocrine cell hyperplasia to the aggressive small cell carcinoma. Such tumors arise from the Kulchitsky cells, a specialized network of neuroendocrine cells which synthesize a variety of hormones and biogenic amines [2].

According to histology criteria revised by Travis in 1999, BCs are divided into typical and atypical tumors [3]. Typical carcinoids (TCs) are low-grade malignancies with favorable prognosis following complete resection [2]. Due to its predilection for the central bronchial tree, patients usually present with irritative airway bleeding or obstructive symptoms. Atypical carcinoids (ACs) have a more aggressive behavior, with higher rates of metastasis and lower overall survival. ACs are usually located more peripherally and therefore are less symptomatic [4].

Surgery remains the mainstay for the treatment of such tumors and strategy may vary according to histology. Usually lung sparing operations are used for TCs while lobectomy and pneumonectomy are reserved for ACs [5]. This study analyzes the results of surgical treatment of BC in a single institution, with focus on outcome and prognostic factors.

Section snippets

Patients and methods

A retrospective review of the medical charts of 126 consecutive patients diagnosed with BCs who were treated by surgical resection from December 1974 to July 2007 was carried out. All patients were submitted to clinical evaluation and imaging studies. Preoperative staging included chest X-ray, chest computed tomography (CT), cranial and upper abdominal CT. Mediastinoscopy was used selectively for locoregional staging whenever there was a suspicion of bronchogenic carcinoma prior to BC

Results

There were 70 female and 56 male patients, and the mean age was 46 years, ranging from 17 to 81 years. Symptoms were reported on presentation in 101 (80%) patients. The most frequent symptoms were recurrent lower respiratory tract infection in 38 (30%), chronic cough in 31 (24%), chest pain in 16 (12%) and hemoptysis in 15 (11.9%) patients. On chest X-ray examination, 62 (49.2%) patients presented with a central lesion, while atelectasis was present in 54 (42.8%), a pulmonary nodule in 29 (23%)

Discussion

BC affects both genders equally [6], however there are large studies that demonstrate a female preponderance for typical carcinoids [7], [8], [9], while others reveal a male predominance for AC [10], [11]. In our series, atypical carcinoids were more prevalent in women, although such difference has not reached statistical significance. In a large multicentric study, the mean age of TC was 47 years, while the mean age of AC was almost a decade older (56 years) [9]. These findings were also

Conclusion

In summary, the reviewed experience with BC in our institution suggests that surgical resection provides an adequate treatment, with low morbidity and mortality. As reinforced by this work, the modern management of BC should privilege parenchymal-sparing procedures whenever feasible. The most consistent prognostic factors seem to be histology, favouring TC, and pathological stage. Importantly, the performance of both sleeve and sublobar resections have not affected oncological outcome.

Conflict of interest

We have no conflict of interest to declare.

Acknowledgements

The authors would like to thank Mathias Bressel for his support with statisctical analysis.

References (25)

G. Cardillo et al.
Bronchial carcinoid tumors: nodal status and long-term survival after resection
Ann Thorac Surg
(2004)
U. Morandi et al.
Bronchial typical carcinoid tumors
Semin Thorac Cardiovasc Surg
(2006)
W.H. Warren et al.
Well-differentiated neuroendocrine carcinomas: the spectrum of histologic subtypes and various clinical behaviors
Semin Thorac Cardiovasc Surg
(2006)
M. Mezzetti et al.
Assessment of outcomes in typical and atypical carcinoids according to latest WHO classification
Ann Thorac Surg
(2003)
G. Fink et al.
Pulmonary carcinoid: presentation, diagnosis, and outcome in 142 cases in Israel and review of 640 cases from the literature
Chest
(2001)
M. Garcia-Yuste et al.
Prognostic factors in neuroendocrine lung tumors: a Spanish Multicenter Study. Spanish Multicenter Study of Neuroendocrine Tumors of the Lung of the Spanish Society of Pneumonology and Thoracic Surgery (EMETNE-SEPAR)
Ann Thorac Surg
(2000)
C.H. Marty-Ane et al.
Carcinoid tumors of the lung: do atypical features require aggressive management?
Ann Thorac Surg
(1995)
P.L. Filosso et al.
Bronchial carcinoid tumors: surgical management and long-term outcome
J Thorac Cardiovasc Surg
(2002)
T.R. Todd et al.
Bronchial carcinoid tumors: twenty years’ experience
J Thorac Cardiovasc Surg
(1980)
F. Rea et al.
Bronchial carcinoids: a review of 60 patients
Ann Thorac Surg
(1989)

B.L. Pettiford et al.

Role of sublobar resection (segmentectomy and wedge resection) in the surgical management of non-small cell lung cancer

Thorac Surg Clin

(2007)

W.D. Travis et al.

Survival analysis of 200 pulmonary neuroendocrine tumors with clarification of criteria for atypical carcinoid and its separation from typical carcinoid

Am J Surg Pathol

(1998)

Cited by (59)

Early-Stage Primary Lung Neuroendocrine Tumors Treated With Stereotactic Body Radiation Therapy: A Multi-Institution Experience
2023, International Journal of Radiation Oncology Biology Physics
Current guidelines recommend surgery as standard of care for primary lung neuroendocrine tumor (LNET). Given that LNET is a rare clinical entity, there is a lack of literature regarding treatment of LNET with stereotactic body radiation therapy (SBRT). We hypothesized that SBRT could lead to effective locoregional tumor control and long-term outcomes.
We retrospectively reviewed 48 tumors in 46 patients from 11 institutions with a histologically confirmed diagnosis of LNET, treated with primary radiation therapy. Data were collected for patients treated nonoperatively with primary radiation therapy between 2006 and 2020. Patient records were reviewed for lesion characteristics and clinical risk factors. Kaplan-Meier analysis, log-rank tests, and Cox multivariate models were used to compare outcomes.
Median age at treatment was 71 years and mean tumor size was 2 cm. Thirty-two lesions were typical carcinoid histology, 7 were atypical, and 9 were indeterminate. The most common SBRT fractionation schedule was 50 to 60 Gy in 5 daily fractions. Overall survival at 3, 6, and 9 years was 64%, 43%, and 26%, respectively. Progression-free survival at 3, 6, and 9 years was 88%, 78%, and 78%, respectively. Local control at 3, 6, and 9 years was 97%, 91%, and 91%, respectively. There was 1 regional recurrence in a paraesophageal lymph node. No grade 3 or higher toxicity was identified.
This is the largest series evaluating outcomes in patients with LNET treated with SBRT. This treatment is well tolerated, provides excellent locoregional control, and should be offered as an alternative to surgical resection for patients with early-stage LNET, particularly those who may not be ideal surgical candidates.
Video bronchoscopic electrocautery fulguration of endobronchial carcinoids: Case series from an Indian tertiary care center
2023, Medical Journal Armed Forces India
Carcinoid tumors are slow-growing tumors noticed in the tracheobronchial tree and pulmonary parenchyma. Generally, these tumors are slow growing with minimum risk of distant metastasis, but the atypical type of carcinoids has greater malignant potential with lower survival rates. The primary and most effective treatment for all pulmonary carcinoid tumors is surgical resection if no contraindications to surgery exist. Compared to surgical resection, bronchoscopic management is minimally invasive and parenchyma sparing. The present case series describes six patients, all young males, diagnosed with typical (n = 4) and atypical (n = 2) carcinoids, and managed with electrocautery fulguration carried out through video bronchoscope. Three cases were suggested pneumonectomy, while the other three cases were suggested for lobectomy by the Hospital Tumour Board. After the electrocautery fulguration procedure, the procedures of lobectomy or pneumonectomy were successfully prevented in all the cases, thereby saving these young males from life-threatening surgeries and permanent disabilities that would have affected their health and career. This is one of its kind case series that shows the importance of bronchoscopic management in carcinoid cases, from developing countries that can help in preserving the lungs.
Neuroendocrine neoplasms of the lung
2022, Practical Pulmonary Pathology: A Diagnostic Approach
The pathologic diagnosis of neuroendocrine tumors of the lung requires integration of histologic and cytologic findings with clinical and radiologic consideration. Despite advances in diagnosis, challenges remain in their accurate classification. A search of relevant literature in PubMed was conducted with terms that included neuroendocrine, lung, and the terms in the chapter subheadings of individual entities combined with lung. In addition, a review of archived cases in the file of Weill Cornell Pathology was conducted.
Neuroendocrine tumors, including preinvasive lesions, were described from the perspective of classification, clinical presentation, pathology, ancillary studies, molecular findings, and treatment impact. New information focused on diagnostic criteria for large cell neuroendocrine carcinoma including overlap with small cell carcinoma and adenocarcinoma, mitotic counting, specificity of CD56, utility of INSM1, and potential diagnostic pitfalls. Molecular advances have led to new insights on the origin and classification of neuroendocrine tumors, especially of neuroendocrine carcinomas. The integration of clinical and radiologic findings to enhance diagnostic certainty was addressed.
Emerging knowledge supports the classification of neuroendocrine tumors into low, intermediate, and high grade categories. Use of Ki-67 to distinguish high from low grade lesions is established but not as a replacement for mitotic counting in well-preserved samples and excisions. Molecular data in large cell neuroendocrine carcinoma show some heterogeneity in this category with potential treatment implications. New data support the observation that most carcinoids and atypical carcinoids do not progress into higher grade lesions; however, this may occur in a small subset of cases. In addition, there appear to be atypical carcinoid tumors with mitotic rates higher than 10 in 2 mm²; their biologic behavior needs to be better defined. The consideration of rare entities in the differential diagnosis of neuroendocrine tumors is prompted by unusual epidemiology, histology, and clinical presentation.
Epidemiology and outcomes of primary pediatric lung malignancies: Updates from the SEER database
2021, American Journal of Surgery
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.
The SEER 18 database from 1975 to 2016 was analyzed for patients ages 0–19 years with primary lung and/or bronchus neoplasms.
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.
Primary pediatric lung malignancies are rare, long-term survival is favorable but histology-dependent. Surgery continues to be an important treatment modality.
A National Study of Surgically Managed Atypical Pulmonary Carcinoid Tumors
2021, Annals of Thoracic Surgery
Atypical pulmonary carcinoid tumors represent a subset of non-small cell lung cancer; however, their relative infrequency has left prognosis, management and long-term survival associated with atypical carcinoids, incompletely characterized.
Patients aged 18 years or more diagnosed with atypical or typical pulmonary carcinoid between 2010 and 2015 within the National Cancer Database were evaluated. Survival was measured using Kaplan-Meier survival and multivariable Cox proportional hazards regression, adjusting for patient and tumor attributes.
A total of 816 atypical and 5688 typical carcinoid patients were identified in the cohort. Patients with atypical carcinoids tended to be older, have larger tumors, and later stage disease. The unadjusted overall 5-year survival for atypical carcinoid patients was 84%, 74%, 52%, and 51% for stages I, II, III, and IV, respectively. The unadjusted 5-year survival for typical carcinoids was 93%, 93%, 89%, and 87% for stages I, II, III, and IV, respectively. Nodal upstaging (ie, lymph node metastases identified in surgical specimens of clinically staged N0 patients) was seen in 16% of atypical and 7% of typical carcinoid patients. Increasing age, comorbidities, and stage were identified as significant predictors of mortality for atypical patients in multivariable analysis. Extent of surgical resection (lobectomy vs sublobar) was not identified as a predictor of survival for atypical carcinoid.
Atypical carcinoid tumors represent a distinct subset of carcinoid tumors, with a tendency toward more aggressive behavior. Further study of the optimal surgical management is warranted.
Long-term survival and recurrence after resection of bronchopulmonary carcinoids: A single-center cohort study of 236 patients
2021, Lung Cancer
Citation Excerpt :
TC comprise about 90 % of BC and show relatively low malignant behavior with excellent prognosis following complete resection. On the contrary, AC have a more aggressive behavior with a higher rate of metastases and lower overall survival (OS) and recurrence-free survival (RFS) [7–9]. Surgery remains the mainstay of treatment for patients with BC and choice of resection may vary according to tumor histology and stage [10].
The aim of this study was to determine overall survival and recurrence-free survival after resection of bronchopulmonary carcinoids by means of predominantly minimally invasive surgery and lung-sparing resections. In addition, we aimed to identify prognostic factors for overall survival.
Retrospective review of consecutive patients operated for bronchopulmonary carcinoids between January 2009 and October 2020 identified from a prospectively collected database.
A total of 236 patients representing 240 cases of bronchopulmonary carcinoids were included. Of these, 212 (88.3 %) were typical carcinoids, while 28 (11.7 %) were atypical carcinoids. A Video-Assisted Thoracoscopic Surgery (VATS) approach was used in 75 % of cases. There was no 30-day mortality. The median follow-up was 5.6 years for overall survival and 4.7 years for recurrence-free survival. 5- and 10-year overall survival rates were 89 % and 71 %, while 5- and 10-year recurrence-free survival rates were 84 % and 71 %. Patients with atypical carcinoids had significantly reduced overall survival and recurrence-free survival rates (HR 3.4; 95 % CI 1.5–7.6; p = 0.003 and HR 5.4; 95 % CI 2.6–11.4; p < 0.001). Independent predictors of overall survival included atypical carcinoid (HR 2.7; 95 % CI 1.2–6.0; p = 0.018) and age > 60 years (HR 2.9; 95 % CI 1.2–7.3; p = 0.021).
Surgery for bronchopulmonary carcinoids by means of predominantly VATS and lung-sparing resections provides favorable long-term survival. Atypical carcinoids and age > 60 years are independent predictors of poor overall survival.

View all citing articles on Scopus

^☆: This work was presented at the XVI Congress of the Brazilian Society of Thoracic Surgery, Curitiba, PR, Brazil.

View full text

Surgical treatment of bronchial carcinoid tumors: A single-center experience☆

Abstract

Background

Patients and methods

Results

Conclusion

Introduction

Section snippets

Patients and methods

Results

Discussion

Conclusion

Conflict of interest

Acknowledgements

Ann Thorac Surg

Semin Thorac Cardiovasc Surg

Semin Thorac Cardiovasc Surg

Ann Thorac Surg

Chest

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Thorac Surg Clin

Survival analysis of 200 pulmonary neuroendocrine tumors with clarification of criteria for atypical carcinoid and its separation from typical carcinoid

Am J Surg Pathol