Carcinoid syndrome in bronchial adenoma

Lung Carcinoids: A Comprehensive Review for Clinicians

Lung carcinoids are neuroendocrine tumors, categorized as typical or atypical carcinoids based on their histological appearance. While most of these tumors are slow-growing neoplasms, they still possess malignant potential. Many patients are diagnosed incidentally on chest X-rays or CT scans. Presenting symptoms include cough, hemoptysis, wheezing, dyspnea, and recurrent pneumonia. Endocrine symptoms, such as carcinoid syndrome or ectopic Cushing's syndrome, are rare. Surgery is the primary treatment and should be considered in all patients with localized disease, even when thoracic lymph node metastases are present. Patients with distant metastases may be treated with somatostatin analogues, chemotherapy, preferably temozolomide-based, mTOR inhibitors, or peptide receptor radionuclide therapy (PRRT) with 177Lu-DOTATATE. Most patients have an excellent prognosis. Poor prognostic factors include atypical histology and lymph node metastases at diagnosis. Long-term follow-up is mandatory since metastases may occur late.

Carcinoid-syndrome: recent advances, current status and controversies

PURPOSE OF REVIEW

To review recent advances and controversies in all aspects of carcinoid-syndrome.

RECENT FINDINGS

Over the last few years there have been a number of advances in all aspects of carcinoid syndrome as well as new therapies. These include new studies on its epidemiology which demonstrate it is increasing in frequency; increasing insights into the pathogenesis of its various clinical manifestations and into its natural history: definition of prognostic factors; new methods to verify its presence; the development of new drugs to treat its various manifestations, both initially and in somatostatin-refractory cases; and an increased understanding of the pathogenesis, natural history and management of carcinoid heart disease. These advances have generated several controversies and these are also reviewed.

SUMMARY

There have been numerous advances in all aspects of the carcinoid-syndrome, which is the most common functional syndrome neuroendocrine tumors produce. These advances are leading to new approaches to the management of these patients and in some cases to new controversies.

Clinical presentation and evaluation of neuroendocrine tumors of the lung

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

Neuroendocrine carcinomas of the lung: a critical analysis

Neuroendocrine carcinomas represent an important group of primary neoplasms in the lung. During the last decades, the nomenclature of these tumors has evolved and the current use of immunohistochemical and molecular biology studies have, to some extent, expanded the conventional view of these tumors. However, the primary diagnosis of most of these lesions is performed on limited biopsy specimens, which may not translate well when one is confronted with a nomenclature that is based on resected material. In addition, for some of these specific entities, some confusion and controversy apparently remain, allowing for the proliferations of different terms that, although they may be dismissed as "semantics," may have a role in interpretation, further subclassification, and, possibly, treatment. Herein we review current concepts regarding the classification of these neoplasms and the role of this classification in our daily practice and discuss how it may impact treatment.

Facial Flushing Due to Recurrent Bronchial Carcinoid

Carcinoid syndrome is quite a rare presentation in bronchial carcinoid. A review of the literature suggests a figure of 2% to 7% in various series. This is usually associated with recurrent carcinoid tumor in the presence of hepatic metastasis. We discuss a patient who presented with flushing attacks 13 years after a left pneumonectomy. Further investigation found that the patient had recurrence at the pneumonectomy stump and in subcarinal lymph nodes.

Neuroendocrine tumors of the lung: recent developments in histopathology

Lung tumors with neuroendocrine differentiation are made up of several neoplasms with particular epidemiologic, clinical, morphologic, and molecular characteristics. Typical and atypical carcinoid tumors represent low-grade and intermediate-grade carcinomas, respectively, whereas small-cell carcinoma and large-cell neuroendocrine carcinoma are considered high-grade carcinomas. Recent studies support the use of this four-tumor, three-tier classification scheme, but in practice, definitive diagnoses on small tissue samples remain a challenge for even the most experienced lung pathologists.

Pathology of lung cancer

This article reviews current concepts in pathologic classification of lung cancer based on 1999 World Health Organization (WHO)/International Association for the Study of Lung Cancer (IASLC) classification. Preinvasive lesions including squamous dysplasia/carcinoma in situ, atypical adenomatous hyperplasia and diffuse idiopathic pulmonary neuroendocrine cell hyperplasia are discussed in addition to current concepts of bronchioloalveolar carcinoma and neuroendocrine tumors.

Lung tumors with neuroendocrine morphology. A perspective for the new millennium

Pulmonary neuroendocrine cell proliferations represent a spectrum of lesions ranging from reactive processes to highly malignant carcinomas. The histogenesis and classification of these lesions is controversial and confusing. Radiologists are performing many diagnostic fine needle aspirations and biopsies, and must be familiar with these tumors. This article describes the various lesions and provides guidelines for their differential diagnosis.

Bronchial carcinoid--twenty years' experience defines a selective surgical approach

BACKGROUND

The purpose of this study was to look at the clinical behavior of bronchial carcinoids and clarify a surgical approach.

METHODS

Eighty-four patients resected for bronchial carcinoids were retrospectively reviewed for clinicopathologic variables, surgical management, and outcome. Tumors were considered "typical" or "atypical" based on histologic features. "Conservative" surgery signified lung parenchyma-sparing procedures. Survival analysis was performed using standard statistical methods.

RESULTS

Most patients presented with an abnormal routine chest x-ray. One patient had the carcinoid syndrome. Computed tomography scan reliably predicted lymph node status and bronchoscopic biopsy diagnosed carcinoids with 70% success. Fifteen "conservative" procedures were performed. Fifteen percent of patients had atypical carcinoids, 12% presented with lymph node metastases, and 6 patients had tumorlets associated with the primary tumor. Overall survival rates were 93% and 82% at 5 and 10 years, respectively. Significantly decreased disease-free survival was found with atypical histology (p < 0.0001) and the presence of tumorlets (p = 0.02); lymph node involvement strongly tended toward poorer outcome.

CONCLUSIONS

Bronchial carcinoids have a definite malignant potential predicted by atypical histology, presence of tumorlets, and lymph node involvement. These features can be identified with routine bronchoscopic biopsy, computed tomography scanning, and intraoperative assessment including frozen section. In the select group of patients without negative features, strong consideration should be given to performing a conservative resection.

Histopathology and prognostic factors in bronchial carcinoid tumours

Images

Exploration of the pulmonary circulation. Festschrift to Professor Donald Heath

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Carcinoid crisis after biopsy of a bronchial carcinoid

Pulmonary carcinoids are rarely associated with carcinoid syndromes and even less commonly with carcinoid crisis. Somatostatin analogues can control carcinoid syndrome or crisis with tumors of gastrointestinal origin. We report the successful use of a somatostatin analogue in preventing carcinoid crisis at the time of resection of an "active" bronchial carcinoid tumor.

Bronchial carcinoid tumors

Bronchial carcinoid tumors, termed (incorrectly) "bronchial adenomas" in the past, are uncommon pulmonary neoplasms. These tumors are currently classified as neuroendocrine in origin because of their potential to form and sometimes secrete a variety of chemical substances. Overall, approximately 75% of bronchial carcinoid tumors arise in the lobar bronchi, 10% occur in the main-stem bronchi, and 15% originate in the periphery of the lung. Well-differentiated carcinoid tumors constitute almost 90% of all bronchial carcinoids. Atypical carcinoid tumors have a higher malignant potential than do typical bronchial carcinoids. The carcinoid syndrome is rarely, if ever, associated with carcinoids limited to the tracheobronchial tree. Occasionally, Cushing's syndrome due to ectopic hormone production is caused by bronchial carcinoid tumors. More than 75% of bronchial carcinoids are detected on conventional posteroanterior chest roentgenograms. Computed tomography may help disclose small neoplasms that are occult on conventional roentgenography, particularly in the assessment of patients who have Cushing's syndrome due to ectopic hormone production. Pulmonary resection is the treatment of choice for bronchial carcinoids. The prognosis is related to the pathologic grade and stage of the tumor.

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.

Anaesthetic management of a patient with carcinoid tumor undergoing myocardial revascularization

Carcinoid tumors with hepatic involvement can produce intense flushing, tachycardia, hypotension or hypertension and diarrhoea. Patients with limited cardiac reserve may not tolerate these effects under anaesthesia. Valvular heart disease associated with carcinoid tumors has been reported, but there is no record in the literature of such an association with coronary artery disease. This report presents the anaesthetic management of a patient with coronary artery disease and carcinoid tumor undergoing myocardial revascularization. Emphasis is placed on the rational use of anaesthetic and adjunctive agents which will minimize the incidence of carcinoid symptons. The salient features of the management are prevention of release of vasoactive substances by the use of promethazine hydrochloride during operation, the avoidance of stropine, prophylactic administration of corticosteroids and smooth induction of anaesthesia by the use of diazepam and dimethyl-tubocurarine iodide (Metocurine).

Tracheal carcinoids

Three cases of carcinoid tumor arising in the trachea are reported and contrasted with carcinoids arising in bronchi and carcinoids in general. Only eleven other documented examples of tracheal carcinoids are found in the English literature. The true prevalence of carcinoids primary in the trachea cannot be accurately determined from the literature because of imprecise nomenclature or because of the failure to distinguish this tumor from carcinoids primary in the bronchus. Presenting symptoms are hemoptysis, dyspnea and wheezing, often persisting for many years before the correct diagnosis is made. The treatment of choice is surgical resection of the involved segment of trachea and primary reconstruction. The prognosis is generally good. The tumor metastasized in one of our three cases and in none of the eleven cases in the English literature.