Bronchial carcinoids

Pulmonary neuroendocrine neoplasms: the molecular landscape, therapeutic challenges, and diagnosis and management strategies

Lung neuroendocrine neoplasms are a group of diverse, heterogeneous tumours that range from well-differentiated, low-grade neuroendocrine tumours-such as typical and atypical carcinoids-to high-grade, poorly differentiated aggressive malignancies, such as large-cell neuroendocrine carcinoma (LCNEC) and small-cell lung cancer (SCLC). While the incidence of SCLC has decreased, the worldwide incidence of other pulmonary neuroendocrine neoplasms has been increasing over the past decades. In addition to the standard histopathological classification of lung neuroendocrine neoplasms, the introduction of molecular and sequencing techniques has led to new advances in understanding the biology of these diseases and might influence future classifications and staging that can subsequently improve management guidelines in the adjuvant or metastatic settings. Due to the rarity of neuroendocrine neoplasms, there is a paucity of prospective studies that focus on the lungs, especially in rare, well-differentiated carcinoids and LCNECs. In contrast with the success of targeted therapies in non-small-cell lung cancer (NSCLC), high-grade neuroendocrine carcinomas of the lung often only have a few specific targetable gene alterations. Optimal therapy for LCNECs is not well defined and treatment recommendations are based on extrapolating guidelines for the management of patients with SCLC and NSCLC. This Review explores the epidemiology, diagnosis, and staging of lung neuroendocrine neoplasms to date. In addition, we focus on the evolving molecular landscape and biomarkers, ranging from tumour phenotypes to functional imaging studies and novel molecular biomarkers. We outline the various clinical outcomes, challenges, the treatment landscape, ongoing clinical trials, and future directions.

Video bronchoscopic electrocautery fulguration of endobronchial carcinoids: Case series from an Indian tertiary care center

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.

Low to intermediate grade lung neuroendocrine tumours. A single centre real world experience

INTRODUCTION

Lung neuroendocrine tumours (LNETs) are a rare heterogenous group of tumours whose incidence has been increasing. We investigated the diagnosis, treatment, and survival patterns of patients with low to intermediate grade LNETs.

METHODS

A retrospective chart review of patients with low to intermediate grade LNETs, treated at a Canadian tertiary-level cancer centre was performed.

RESULTS

We identified 59 patients. Most were G1or G2 and well or moderately differentiated. Forty-seven patients presented with local or locally advanced disease, of which 57.4 % received curative intent surgery. The rest were treated with definitive radiation, radical chemoradiation with platinum and etoposide, palliative chemotherapy with doxorubicin, or supportive care. The five-year overall survival (OS) for those treated surgically was 83 % versus 44 % in the non-surgical group. Metastatic disease was seen in 24/59 patients, with a five-year OS in patients with stage IV disease of 39 %. Of those with advanced or unresectable disease (n = 32), 21 received palliative systemic treatment with up to three lines of therapy. First-line treatment was most commonly chemotherapy with platinum/etoposide combination or somatostatin analogue therapy. Second-line treatment involved chemotherapy or targeted everolimus. PRRT was used once as a first-line and once as second-line therapy. Third-line included lanreotide or chemotherapy with capecitabine/temozolomide combination.

CONCLUSION

Overall, patients with surgically resectable disease had a good five-year OS. However, inoperable or more advanced disease was associated with a poorer OS. Despite many treatment options, the sequence of treatments is poorly established. This highlights the need for further development and dissemination of evidence-based guidelines for LNET patients.

Factors Associated With Long-term Survival in Children With Bronchial and Lung Carcinoid Tumors

BACKGROUND AND AIMS

Bronchial carcinoids are rare in children and the treatment is based on tumor behavior in adults. The purpose of this study was to determine factors and management strategies associated with long-term survival in the pediatric population using a national cohort.

METHODS

Patients aged ≤20 years with bronchial carcinoid tumors were identified in the 2004-2020 National Cancer Database using ICD-O-3 codes. Tumor characteristics and management were compared among typical (TC) and atypical (AC) histological subtypes using Chi-square and Fisher's exact tests. Kaplan-Meier and univariate Cox proportional hazards analyses were used to assess survival.

RESULTS

Of 273 patients, 251 (92%) had TCs, and 22(8%) had ACs. The median (IQR) age was 18 (16,19) years. Most patients underwent lobectomy or bilobectomy (67%), followed by sublobar resection (17%), no resection or bronchoscopic excision or ablation (8%), and pneumonectomy (7.7%). Margins were negative in 96%. Lymph node (LN) assessment was performed in 216 patients (84%) with a median (IQR) of 7(3,13) LNs, and 50 (23%) had ≥1 positive LN. There was no difference in age, resection, margin status, LN assessment, or positivity between TC and AC (all p > 00.05). Detection of nodal metastasis did not increase beyond the resection of 1-3 LNs (p = 0.72). Ten-year survival was worse for AC than TC (79% (41, 100) vs 98% (95, 100), HR = 6.9 (95% CI: 1.2-38.3, p = 0.03). Ten-year survival among those with and without LN assessment was 97% (94, 100) vs 91% (81, 100), HR = 4.0, 95% CI: 0.8-19.9, p = 0.09). There were no deaths in those with negative LN while 10-year survival was 89% (72, 100) in those with ≥1 positive LN.

CONCLUSION

Among children with bronchial carcinoids, survival is excellent with TC or negative LN. Atypical histology and positive LN have poor survival and should prompt close monitoring. These risk factors may be missed in the absence of surgical resection and lymph node sampling.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective Study.

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.

Does 68Ga-DOTA-NOC-PET/CT impact staging and therapeutic decision making in pulmonary carcinoid tumors?

OBJECTIVE

Purpose of this study was to assess the utility of Ga-DOTA-NOC-PET/computed tomography (CT) (Ga-NOC-PET) in tumor detection, pathological differentiation and baseline staging of pulmonary carcinoids as well as to study its impact on therapeutic decision making.

PATIENTS AND METHODS

Patients who underwent a Ga-NOC-PET for initial evaluation of bronchopulmonary carcinoid tumors from August 2014 to December 2019 were included. Detection rate of Ga-NOC-PET for the primary lesion was calculated by visual estimation of tracer uptake as per Krenning score. SUVmax of typical and atypical carcinoid tumors was measured and difference compared using nonparametric statistical tests. Proportion of patients with distant metastases was also calculated and its impact on intended treatment was assessed.

RESULTS

Imaging, histopathology and treatment details of 119 patients were available for analysis. Majority of tumors had an endobronchial location (74.7%) and showed histopathologic features of typical carcinoid (82.3%). Ga-NOC-PET showed a detection rate/sensitivity of 92.4%. Oncocytic variant on histopathology and smaller tumor size accounted for majority of negative results. Typical carcinoids showed significantly higher SUVmax than atypical tumors (median SUVmax 38.4 vs. 15.7, P = 0.002). Metastases to distant sites outside the thorax were seen in 14 patients (11.7%), primarily in liver and bones changing the intent of treatment from surgery to systemic therapy.

CONCLUSION

Ga-NOC-PET detects asymptomatic distant metastatic disease in a sizeable number of patients (11.7%) with pulmonary carcinoid and thus contribute to clinical management by precluding futile surgeries. It shows a high sensitivity for tumor detection and can help differentiate between typical and atypical carcinoid variants by virtue of their variable tracer uptake. PET/CT using Ga-labeled DOTA peptides should be an integral part of diagnostic workup of patients with lung carcinoid.

Huge typical pulmonary carcinoid presented with gigantism syndrome

A 27-year-old male patient presented with cough and right-sided, light thoracic pain. His physical appearance showed typical features of gigantism. Subsequently, further diagnostic work-up showed elevated level of growth hormone and a huge tumor of the right lung, identifying a typical pulmonary carcinoid tumor (TPCT). Curative surgery was performed leading to normalization of the elevated growth hormone levels few days after surgery. Two- and five-year follow-up showed no signs of recurrence. Respected to tumor size, we determined the largest TPCT to be reported in medical literature history.

Diagnostic Yield and Bleeding Complications Associated With Bronchoscopic Biopsy of Endobronchial Carcinoid Tumors

BACKGROUND

Bronchial carcinoid often appears hypervascular on bronchoscopic visualization and may be associated with hemoptysis. The diagnostic yield and bleeding complications associated with bronchoscopic biopsy of bronchial carcinoid tumors remain unclear.

MATERIALS AND METHODS

Patients with bronchial carcinoid tumors that were bronchoscopically visualized and biopsied at our tertiary referral medical center, over an 8-year period from 2010 to 2017, were retrospectively identified and reviewed to assess diagnostic yield and bleeding complications. Correlations with patient characteristics and carcinoid tumor features were analyzed.

RESULTS

Forty-nine patients were included (57% female). Tumors were predominantly (71%) located in proximal airways (mainstem and lobar bronchi). Bronchoscopic biopsy was diagnostic in 45 patients (92%). Thirteen patients (27%) experienced moderate (n=12, 25%) or severe (n=1, 2%) bleeding. Among these, 6 tumors (46%) had a vascular appearance and 4 patients (31%) had experienced recent hemoptysis. However, neither vascularity nor hemoptysis was associated with bleeding at biopsy (P=0.68 and 0.73, respectively). Carcinoid tumors were classified as typical in 79% and atypical in 21% with no difference in diagnostic yield or bleeding risk (P=0.28 and 0.92, respectively). Tumor size was also not associated with increased diagnostic yield or bleeding risk (P=0.54 and 0.39, respectively).

CONCLUSION

Bronchoscopic biopsy of endobronchial carcinoid is associated with a high diagnostic yield and severe bleeding is rarely encountered. Diagnostic yield and bleeding seemed independent of vascular tumor appearance or history of recent hemoptysis.

Neuroendocrine tumors of the lung: A five-year retrospective experience of Egyptian NCI (2010-2014)

BACKGROUND

The spectrum of lung neuroendocrine tumors (NETs) encompasses low grade typical carcinoid (TC), intermediate grade atypical carcionid (AC) and high grade, both large cell neuroendocrine carcinoma (LCNEC) and small cell lung cancer (SCLC), with extreme differences in management and survival.

OBJECTIVE

To study clinicopathologic and prognostic factors affecting survival of lung NETs.

PATIENTS AND METHODS

This is a retrospective study evaluating 35 patients with primary lung NETs treated at National Cancer Institute of Egypt (NCI-E) between January 2010 and December 2014. Pathological diagnosis depended on definite morphology and positivity to at least one of the neuroendocrine markers by immunohistochemistry.

RESULTS

The mean age of the patients was 53 ± 11.2 years with male predominance. Performance status (PS) I was encountered in 48.6%. SCLC was the prevalent histology in 68.6%, followed by LCNEC & TC in 20 & 11.4%, respectively. Curative surgery was employed in 100 & 57% of TC & LCNEC patients, respectively. Stage IV was anticipated in 87.5 & 43% of SCLC & LCNEC, respectively. For the entire cohort, the median event-free survival (EFS) and overall survival (OS) were 8.0 and 13.7 months, respectively, whereas the 3-year EFS and OS were 17.8 & 20%, respectively. SCLC patients showed significantly the worst OS compared to other NETs (p = 0.001). Patients who presented with stage IV and PS > I demonstrated significantly shorter OS than those with locoregional and PS I (p = 0.00001 &p = 0.002, respectively).

CONCLUSIONS

SCLC subtype, stage IV and initial PS > I are poor prognostic factors for lung NETs associated with shorter survival. This conclusion needs to be confirmed by larger studies.

Lung and Thymic Carcinoids

Carcinoids of the lung and thymus are rare thoracic cancers. In general, lung carcinoid tumors have a favorable prognosis, particularly when diagnosed at an early stage and treated with surgical resection. Thymic neuroendocrine tumors may be associated with multiple endocrine neoplasia-1 syndrome, tend to have a more aggressive natural history, and relatively frequently secrete ectopic adrenocorticotropic hormone.

Well-Differentiated Neuroendocrine Carcinoma of the Lung: A Case Report

Well-differentiated neuroendocrine carcinoma (WDNC) of the lower respiratory tract displays clinical and radiologic features intermediate between carcinoids and small cell carcinoma and shares some biologic characteristics with both. We describe a case of WDNC resistant to three different treatments. The patient, a 42-year-old woman, received 2 cycles of chemotherapy before coming to our observation, including cyclophosphamide, adriamycin and vincristine, with progression of disease. We administered r-alpha-2a interferon for 2 months, but the patient showed clinical progression. Therefore, streptozotocln associated with epirubicin was utilized, but the patient died of disease progression after 4 cycles and 10 months from the first treatment. The case of WDNC described in this report showed an unusual aggressive clinical course and was refractory to conventional and unconventional treatments. The proper management for WDNC is still unknown. However, according to literature data, the chemotherapeutic schemes employed for small cell lung cancer represent the first treatment choice for WDNC. Further studies are needed to help define treatment strategies according to the biology of the tumor.

Pulmonary Carcinoid Presenting as Multiple Subcutaneous Nodules

A 60-year-old female presented with a one-year history of multiple enlarging tender subcutaneous nodules. Initial biopsy demonstrated a poorly differentiated adenocarcinoma. Mammography showed multiple nodular breast lesions. After the patient failed to respond to tamoxifen, a second biopsy demonstrated a metastatic carcinoid tumor. Further search revealed a single small pulmonary nodule, which on aspiration biopsy proved to be a carcinoid tumor. The patient failed to respond to treatment with streptozotocin and 5'-fluorouracil. Therapy with leucovorin calcium and 5'-fluorouracil then produced a partial response.

When should genetic testing be performed in patients with neuroendocrine tumours?

Neuroendocrine tumours (NETs) are a heterogenous group of tumours arising from neuroendocrine cells in several sites around the body. They include tumours of the gastroenteropancreatic system, phaeochromocytoma and paraganglioma and medullary thyroid cancer. In recent years, it has become increasingly apparent that a number of these tumours arise as a result of germline genetic mutations and are inherited in an autosomal dominant pattern. The number of genes implicated is increasing rapidly. Identifying which patients are likely to have a germline mutation enables clinicians to counsel patients adequately about their future disease risk, and allows for earlier detection of at-risk patients through family screening. The institution of screening and surveillance programmes may in turn lead to a major shift in presentation patterns for some of these tumours. In this review, we examine the features which may lead a clinician to suspect that a patient may have an inherited cause of a NET and we outline which underlying conditions should be suspected. We also discuss what type of screening may be appropriate in a variety of situations.

Management of pulmonary neuroendocrine tumors

Neuroendocrine tumors (NETs) of the lung are divided into 4 major types: small cell lung cancer (SCLC), large cell neuroendocrine carcinoma (LCNEC), atypical carcinoid (AC) or typical carcinoid (TC). Each classification has distinctly different treatment paradigms, making an accurate initial diagnosis essential. The inconsistent clinical presentation of this disease, however, makes this difficult. The objective of this manuscript is to detail the diagnosis and management of the well differentiated pulmonary carcinoid (PC) tumors. A multidisciplinary approach to work up and treatment should be utilized for each patient. A multimodal radiological work-up is used for diagnosis, with contrast enhanced CT predominantly utilized and functional imaging techniques. A definitive diagnosis is based on tissue findings. Surgical management remains the mainstay of therapy and can be curative. In those with advanced disease, medical treatments consist of somatostatin analog (SSA) therapy, targeted therapy, chemotherapy or peptide receptor radionuclide therapy. SSAs are the standard of care in those with metastatic NETs, using either Octreotide long acting repeatable (LAR) or lanreotide as reasonable options, despite a scarcity of prospective data in PCs. Targeted therapies consist of everolimus which is approved for use in PCs, with various studies showing mixed results with other targeted agents. Additionally, radionuclide therapy may be used and has been shown to increase survival and to reduce symptoms in some studies. Prospective trials are needed to determine other strategies that may be beneficial in PCs as well as sequencing of therapy. Successful diagnosis and optimal treatment relies on a multidisciplinary approach in patients with lung NETs. Clinical trials should be used in appropriate patients.

Nothing But NET: A Review of Neuroendocrine Tumors and Carcinomas

This review covers the diverse topic of neuroendocrine neoplasms (NENs), a relatively rare and heterogeneous tumor type, comprising ~2% of all malignancies, with a prevalence of <200,000 in the United States, which makes it an orphan disease (Basu et al., 2010).1 For functional purposes, NENs are divided into two groups on the basis of clinical behavior, histology, and proliferation rate: well differentiated (low grade to intermediate grade) neuroendocrine tumors and poorly differentiated (high grade) neuroendocrine carcinoma (Bosman et al., 2010)2; this histological categorization/dichotomization is highly clinically relevant with respect to impact on treatment and prognosis even though it is not absolute since a subset of tumors with a low-grade appearance behaves similarly to high-grade lesions. Given the relative dearth of evidenced-based literature about this orphan disease as a whole (Modlin et al., 2008),3 since the focus of most articles is on particular anatomic subtypes of NENs (i.e., gastroenteropancreatic or pulmonary), the purpose of this review is to summarize the presentation, pathophysiology, staging, current standard of care treatments, and active areas of current research.

Bronchial and Thymic Carcinoid Tumors

Bronchial and thymic carcinoids are rare. We present epidemiologic data and potential risk factors. The approach to bronchial and thymic carcinoid patients is discussed, from the initial diagnosis and evaluations to treatment. These malignancies follow staging systems of their site of origin. Because bronchial and thymic carcinoids are rare, we use many treatment strategies that have been demonstrated in gastrointestinal and pancreatic neuroendocrine tumors. The lack of information regarding efficacy in bronchial and thymic carcinoids, as well as the scarcity of therapeutic options available, demands the importance of clinical trials that include these patients.

Ten-year Single Center Experience of Pulmonary Carcinoid Tumors and Diagnostic Yield of Bronchoscopic Biopsy

PURPOSE

Bronchoscopic biopsy of pulmonary carcinoid tumors has been controversial, and no study to date is dedicated to investigate diagnostic yield or safety. We reviewed our single center experience with pulmonary carcinoid tumors over a 10-year time period and assessed the diagnostic yield and safety of bronchoscopic biopsy of these tumors.

METHODS

A retrospective analysis was conducted of all bronchopulmonary carcinoid tumors from January 2003 through January 2014 for patients treated at or referred to our tertiary care facility, including patient and tumor characteristics, diagnostic yield, and complications of bronchoscopy.

RESULTS

Forty-nine patients with bronchopulmonary carcinoid tumors were identified. 75.5 % of our patients were female, and the median age was 60.7 years. 85.7 % patients were white, and 53.1 % were smokers. 83.7 % had typical carcinoid tumors or tumorlets, and 85.7 % had centrally located tumors. The median tumor size was 2.0 cm. Thirty patients underwent bronchoscopy for diagnostic evaluation. 76.7 % were diagnosed via bronchoscopic biopsy. Bronchoscopic yield was calculated at 65.7 % yield, and two complications of moderate to severe bleeding occurred with no emergent thoracotomies, transfusions, or deaths. No other complications occurred from bronchoscopy.

CONCLUSION

The diagnosis of pulmonary carcinoid tumors via bronchoscopic biopsy is safe and effective, and bronchoscopy is recommended as the initial diagnostic modality for these tumors.

Atypical Carcinoid Tumors of Lung: Clinicopathologic Study of Six Cases

This retrospective study of 6 cases of atypical carcinoid tumor was carried out to highlight their clinicopathological features and behavior. All patients were over 40 years of age and were treated by surgical excision of the tumor. Four tumors were central and 2 were peripherally located in the lung. Grossly, the tumors were large with spotted areas of necrosis. Microscopically, all tumors had a typical carcinoid pattern with spotted areas of necrosis and mitotic activity in the range of 2 to 5 per 10 high-power fields. On immunohistochemistry, the tumors were positive for neuron-specific enolase and cytokeratin. Follow-up ranging from 1 to 5 years was available in 4 patients; 2 are currently alive, 1 with local recurrence and distant metastasis one year postoperatively, the other with no disease after 5 years. Two patients died; one had a local recurrence at 2 years and the other had liver metastasis at 3 years.

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 tumors of the lung: a comprehensive overview

A total of 25% of neuroendocrine tumors originate in the lung. Still, typical and atypical carcinoids of the lung are rare, accounting for only 1–2% of all lung cancers. Distant metastases are infrequent, occurring in 2–14% of cases. The mainstay of treatment of local disease is surgery. In advanced disease there are no antiproliferative agents approved for carcinoids of the lung. None of the currently available drugs provide a cure. There are several treatment options, such as somatostatin analogs, mTOR inhibition, inhibitors of angiogenesis, systemic chemotherapy and radiolabeled somatostatin analogs. Interpretation of the data is complicated, since it mainly consists of small (retrospective) Phase II studies. Fortunately, randomized Phase II and III studies are underway. This article emphasizes the specific features of neuroendocrine tumors in the lung and focuses on the treatment in advanced disease.

Analysis on the characteristics and prognosis of pulmonary neuroendocrine tumors

OBJECTIVE

To retrospectively review the clinical characteristics and analyze the prognostic factors of Chinese patients with pulmonary neuroendocrine tumors.

MATERIALS AND METHODS

The clinical data of 176 patients with pulmonary neuroendocrine tumors in Chinese PLA General Hospital from Mar., 2000 to Oct., 2012 were retrospectively analyzed. The parameters were evaluated by univariate and multivariate analysis, including the gender, age, smoking history, family history, TNM staging, localization (central or peripheral), tumor size, nodal status, histological subtype and treatment (operation or non-operation).

RESULTS

There were 23 patients with typical carcinoids (TC) (13.1%), 41 with atypical carcinoids (AC) (23.3%), 10 with large cell neuroendocrine carcinoma (LCNEC) (5.7%) and 102 with small cell lung cancer (SCLC) (57.9%). The median follow-up time was 64.5 months for AC, 38 months for LCNEC and 27 months for SCLC. The typical carcinoid censored data was 18 (more than 50% of the patients), so the median follow-up time was not obtained, and actuarial 5-year survivals for TC, AC, LCNEC and SCLC were 75.1%, 51.7%, 26.7% and 38.8%, respectively. COX univariate analysis revealed that the age (P=0.001), histological subtype (P=0.005), nodal status (P=0.000), treatment (P=0.000) and TNM staging (P=0.000) were the prognostic factors of the patients with pulmonary neuroendocrine tumors, whereas its multivariate analysis showed that only the age(P=0.001), TNM staging (P=0.002) and treatment (P=0.000) were independent prognostic factors.

CONCLUSIONS

Radical surgery remains the treatment of choice, and is the only curative option. The age, TNM staging and treatment are confirmed to be the independent prognostic factors in multivariable models for pulmonary neuroendocrine tumors.

Role of 68Ga-DOTATOC PET/CT in initial evaluation of patients with suspected bronchopulmonary carcinoid

PURPOSE

The objective of this study was to evaluate the role of (68)Ga-DOTATOC positron emission tomography (PET)/CT scan in patients with suspected pulmonary carcinoid tumour and to compare its results with (18)F-fluorodeoxyglucose (FDG) PET/CT scan.

METHODS

In this prospective study, 32 patients (age 34.22 ± 12.03 years; 53.1 % female) with clinical suspicion of bronchopulmonary carcinoid were evaluated with (68)Ga-DOTATOC PET/CT and (18)F-FDG PET/CT. The two imaging modalities were compared, considering the tissue diagnosis as the reference standard.

RESULTS

Based on the reference standard 26 cases were carcinoid tumours [21 typical carcinoids (TC) and 5 atypical carcinoids (AC)] and 6 cases were non-carcinoid tumours. The sensitivity, specificity and accuracy of (68)Ga-DOTATOC PET/CT in the diagnosis of pulmonary carcinoid tumour were 96.15, 100 and 96.87 % respectively, whereas those of (18)F-FDG PET/CT were 78.26, 11.1 and 59.37 % respectively. The maximum standardised uptake value (SUV max) of TC on (68)Ga-DOTATOC PET/CT scan ranged from 3.58 to 55, while that of AC ranged from 1.1 to 32.5. (18)F-FDG PET/CT was true-positive in all cases of AC and false-negative in eight cases of TC (sensitivity for TC 61.9 % and for AC 100 %).

CONCLUSION

(68)Ga-DOTATOC PET/CT is a useful imaging investigation for the evaluation of pulmonary carcinoids. (18)F-FDG PET/CT scan suffers from low sensitivity and specificity in differentiating the pulmonary carcinoids from other tumours.

Primary lung and large airway neoplasms in children: current imaging evaluation with multidetector computed tomography

Multidetector computed tomography (MDCT) offers an important noninvasive imaging modality for confirmation and further characterization of primary lung and large airway neoplasms encountered in pediatric patients. Children represent a unique challenge in imaging, not only because of unique patient factors (eg, inability to follow instructions, motion, need for sedation) but because of the technical factors that must be optimized to reduce radiation dose. This article reviews an MDCT imaging algorithm, up-to-date imaging techniques, and clinical applications of MDCT for evaluating benign and malignant primary neoplasms of lung and large airway in infants and children.

Everolimus plus octreotide long-acting repeatable in patients with advanced lung neuroendocrine tumors: analysis of the phase 3, randomized, placebo-controlled RADIANT-2 study

BACKGROUND

The incidence of neuroendocrine tumors (NETs) has increased approximately fivefold since the 1980s. A similar increase in the incidence of lung NETs has been reported, but therapy has not been optimized.

METHODS

This exploratory subanalysis evaluated the efficacy and safety of everolimus plus octreotide long-acting repeatable (LAR) in a cohort of patients with low- to intermediate-grade advanced lung NET from the phase 3, randomized, placebo-controlled RADIANT-2 (RAD001 in Advanced Neuroendocrine Tumors) study. The primary end point was progression-free survival (PFS). Secondary end points included objective response rate, overall survival, change from baseline in biomarker levels, and safety outcomes.

RESULTS

Patients were randomly assigned to everolimus plus octreotide LAR (n 5 33) or placebo plus octreotide LAR (n 5 11). Median PFS was 13.63 months in the everolimus plus octreotide LAR arm compared with 5.59 months in the placebo plus octreotide LAR arm (relative risk for progression: HR, 0.72; 95% CI, 0.31–1.68; P 5 .228). More patients receiving everolimus plus octreotide LAR (67%) experienced minor tumor shrinkage (not partial response as per RECIST [Response Evaluation Criteria in Solid Tumors]) than those receiving placebo plus octreotide LAR (27%). Most frequently reported adverse events (AEs) included stomatitis, rash, diarrhea, and asthenia. This was consistent with the overall RADIANT-2 trial and the safety profile of everolimus.

CONCLUSIONS

This exploratory subgroup analysis of the RADIANT-2 trial indicates that in patients with advanced lung NET, the addition of everolimus to octreotide LAR improves median PFS by 2.4-fold compared with placebo plus octreotide LAR. These clinically significant observations support the continued evaluation of everolimus treatment regimens in this patient population.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT00412061

Is sublobar resection equivalent to lobectomy for surgical management of peripheral carcinoid?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was: Is sub-lobar resection equivalent to lobectomy in terms of operative morbidity and mortality, long-term survival and disease recurrence in patients with peripheral carcinoid lung cancer? A total of 342 papers were identified using the search as described below. Of these, 10 papers presented the best evidence to answer the clinical question as they presented sufficient data to reach conclusions regarding the issues of interest for this review. Long-term survival, disease recurrence and operative morbidity were included in the assessment. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of the papers are tabulated. A literature search showed that there is a good prognosis after resection of lung carcinoid with the 10-year disease-free survival rate ranging between 77 and 94%, and suggested that sub-lobar resection of a typical carcinoid did not compromise the long-term survival. The proportion of peripheral tumours ranged between 22.6 and 100% and the proportion of patients with a preoperative diagnosis of carcinoid ranged between 51.9 and 86.7%, with many series not providing either or both of these data. As a result, a lobectomy or greater resection was necessary on anatomical or diagnostic grounds and led to a low number of sub-lobar resections. Owing to the high heterogeneity within and between series and small numbers of cases included, it is difficult to draw conclusions on disease recurrence and postoperative morbidity. All studies available retrospectively compared heterogeneous groups of non-matched group of patients, which can bias the outcomes reported. There is a lack of comprehensive randomized studies to compare a lobectomy or greater resection and sub-lobar resection. We conclude that there is little objective evidence to show the equivalence or superiority of lobectomy over sub-lobar resection.

Primary pulmonary carcinoid tumor with metastasis to endometrial polyp

INTRODUCTION

A carcinoid tumor occurring in the endometrium has been documented in the literature, but there is no report in regard to carcinoid tumor metastasis to endometrium.

PRESENTATION OF CASE

We report a case of a malignant carcinoid metastasis to an endometrial polyp. Patient underwent hysteroscopy, and polypectomy. The pathology demonstrated an endometrial polyp containing a 4 mm x 5 mm nodule of metastatic carcinoid tumor, consistent with metastasis from patient's known pulmonary carcinoid. The tumor was morphologically similar to the tumors of the right lung, with similar immune-profile.

DISCUSSION

This patient presented with a suspicious pelvic ultrasound. Due to her age, the first priority was to exclude uterine cancer. The endometrial polyp, which was found, had a small focus of metastatic carcinoid tumor. To the best of our knowledge, this finding has not been previously recorded in the literature. Our patient also had a history of metastatic carcinoid tumor to breast. This finding is also very uncommon.

CONCLUSION

This is the first case in the literature described a malignant carcinoid metastasis to an endometrial polyp.

Treatment of pulmonary neuroendocrine tumours: state of the art and future developments

The current classification of pulmonary neuroendocrine tumours includes four subtypes: low-grade typical carcinoid tumour (TC), intermediate-grade atypical carcinoid tumour (AC), and two high-grade malignancies: large cell neuroendocrine carcinoma and small cell lung cancer (SCLC). Unfortunately, with the exclusion of SCLC, no large phase II and III trials for pulmonary neuroendocrine tumours have been published. Thus, several treatment approaches are available for their treatment but none of them has been validated in appropriately designed and adequately sized clinical trials. The main problem of the published studies is that they include neuroendocrine tumours from various sites of origin with different clinical behaviour. It is important that future studies consider these tumours separately. In this regard, increased awareness and referral of these patients to tertiary centres, in which a multidisciplinary management is available, may be of value. The aim of this review is to evaluate the state of the art and discuss future developments in the management of pulmonary neuroendocrine tumours excluding SCLC which we consider should be addressed in a different issue.

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.

The changing pathology of lung cancer

Lung cancer classification is of paramount importance in determining the treatment for oncologic patients. Most lung cancers are non-small cell lung carcinomas (NSCLC), which are further subclassified into squamous cell carcinoma, adenocarcinoma, and large cell carcinoma. Lung neuroendocrine tumors are subclassified into typical carcinoid, atypical carcinoid, small cell carcinoma, and large cell neuroendocrine carcinoma. In NSCLC in particular, the histologic classification and tumor mutation analysis are central to today's targeted therapy and personalized treatment. This article discusses the current diagnostic criteria for classification of NSCLC and lung neuroendocrine tumors and implications for oncologic treatment.

Growth of a solitary pulmonary nodule after 6years diagnosed as oncocytic carcinoid tumour with a high 18-fluorodeoxyglucose (18F-FDG) uptake in positron emission tomography-computed tomography (PET-CT)

INTRODUCTION

Pulmonary carcinoid tumour is low-grade neuroendocrine malignancy that is seen 1%-2% of all lung neoplasms. Oncocytic carcinoid type is a rarely seen variant of pulmonary carcinoids. As carcinoid tumours have hypometabolic activity, they usually have lower 18-fluorodeoxyglucose (18F-FDG) uptake than expected for lung carcinoma on positron emission tomography (PET).

CASE REPORT

A 45-year-old non-smoking man had a stable solitary pulmonary nodule followed for 6years; the tumour remained the same size (1.5×2.4cm) during this period. The patient was admitted to the hospital with complaints of repetitive sneezing and rhinorrhoea. He also experienced flushing and bronchospasm. His chest X-ray revealed a minimal increase in the size of the solitary pulmonary nodule (2.0×2.8cm). In PET-computed tomography (CT), the parenchymal nodule in the anterior segment of the right lung had a standard uptake value of 38.0mg/mL, which was interpreted as a malignant nodule. He underwent fibre-optic bronchoscopy, but cytology showed no evidence of malignancy. Right upper and middle bilobectomy was performed, and a pulmonary carcinoid tumour with an oncocytic subgroup was diagnosed. The diagnosis of carcinoid syndrome was further confirmed by an elevated 24-h urinary excretion of 5-hydroxyindoleacetic acid.

CONCLUSION

We present a rare case of an oncocytic carcinoid tumour with an increase in the size of a solitary pulmonary nodule after 6years' follow-up. In addition, PET-CT showed a very high 18F-FDG uptake in this patient, which is an unexpected finding with a pulmonary carcinoid tumour.

Advances in neuroendocrine lung tumors

Pulmonary neuroendocrine (NE) tumors include a spectrum of tumors from the low-grade typical carcinoid (TC) and intermediate-grade atypical carcinoid (AC) to the high-grade large-cell neuroendocrine carcinoma (LCNEC) and small-cell carcinoma (SCLC). Nodular NE proliferations ≥ 0.5 cm are classified as carcinoid tumors and smaller ones are called tumorlets. When NE cell hyperplasia and tumorlets are extensive they represent the rare preinvasive lesion for carcinoids known as diffuse idiopathic pulmonary NE cell hyperplasia. Carcinoid tumors have significant clinical, epidemiologic and genetic differences from the high-grade SCLC and LCNEC. Multiple endocrine neoplasia type I can be found in TC and AC patients but not those with LCNEC and SCLC. Also both LCNEC and SCLC can demonstrate histologic heterogeneity with other major histologic types of lung carcinoma such as adenocarcinoma or squamous cell carcinoma, but is not characteristic of TC or AC. Genetic changes are very high in SCLC and LCNEC, but usually low for TC, intermediate for AC. The diagnosis of SCLC, TC and AC can be made by light microscopy without the need for special tests in most cases, but for LCNEC it is required to demonstrate NE differentiation by immunohistochemistry or electron microscopy.

Bronchopulmonary carcinoid tumors: long-term outcomes after resection

BACKGROUND

Bronchopulmonary carcinoid tumors are considered as a relatively uncommon and less malignant group of lung cancers. However, patients with histologically atypical disease are known to have a worse prognosis. The present study aims to evaluate the long-term outcomes after resection of bronchopulmonary carcinoid tumors according to the new tumor, nodes, metastasis (TNM) staging system.

METHODS

Patients with histologically proven bronchopulmonary carcinoid tumors who underwent surgery in our thoracic unit over the last 25 years were identified from a prospectively collected database.

RESULTS

One hundred and eighty-six patients were identified from our electronic database. Of these, 164 were known to have typical disease, while 22 had atypical disease. Median overall survival was 20.0 years. The mean follow-up was 8.0 years (median 7.0 years). Univariate analysis found age over 60, atypical disease, TNM staging, N status, and M status to have a statistically significant influence on overall survival. Multivariate analysis found age over 60 and atypical histopathology to have a detrimental impact on overall survival. Patients in the atypical subgroup were found to be significantly older, and presented with higher stage disease.

CONCLUSIONS

It is clear from the current study and previous reports that patients with atypical histopathology have different baseline characteristics, disease behavior, and prognosis compared with patients with typical disease. The proposed TNM staging system appears to be applicable to patients in our surgical experience, and may offer more accurate prognostic information and assist in the management plans for individuals.

Neuroendocrine tumors of the lung: an update

CONTEXT

The 2004 World Health Organization (WHO) classification recognizes 4 major types of lung neuroendocrine tumors: typical carcinoid, atypical carcinoid, small cell lung cancer, and large cell neuroendocrine carcinoma. Markedly different prognostic implications and treatment paradigms for these tumors underscore the importance of accurate pathologic diagnosis.

OBJECTIVE

To detail the clinical and pathologic features of lung neuroendocrine tumors, with emphasis on diagnostic criteria, differential diagnoses, and application of immunohistochemistry. The emerging evidence for the utility of Ki-67 (MIB1) in the diagnosis of lung neuroendocrine tumors, particularly in small biopsy and cytology, is emphasized.

DATA SOURCES

The 2004 WHO classification, other published literature, and primary material from the author's institution.

CONCLUSIONS

The current WHO classification of neuroendocrine tumors is based on morphologic features in combination with precisely defined mitotic rate and absence or presence of necrosis. Ki-67 (MIB1) is emerging as a useful ancillary tool in the diagnosis of these tumors. Continued research efforts are needed to identify additional immunohistochemical and molecular biomarkers that can serve as ancillary diagnostic tools and as potential therapeutic targets for these diseases.

Chromosomal instability is more frequent in metastasized than in non-metastasized pulmonary carcinoids but is not a reliable predictor of metastatic potential

Pulmonary carcinoids are infrequent neoplasms of the lung that normally display a less aggressive biological behavior compared to small cell and non-small cell lung cancers. Approximately 15-25% of carcinoids, in particular atypical carcinoids, show lymph node metastasis and have a worse prognosis than their non-metastasized counterparts. To date, there is no morphological or molecular marker that may help to differentiate between carcinoids that metastasize and carcinoids of identical differentiation that show only local tumor growth. In this study, we analyzed 7 metastasized and 10 non-metastasized pulmonary carcinoids for chromosomal and microsatellite instability in order to determine whether microsatellite instability or chromosomal imbalances are associated with metastasis. Due to the rare occurrence of metastasized carcinoids we compared our results of chromosomal instability with the hitherto published comparative genomic hybridization (CGH) profiles of pulmonary carcinoids, for which information about the absence or presence of metastasis was available. While microsatellite instability was not detected we found chromosomal instability as a common event in pulmonary carcinoids with an increase of frequency and extent of chromosomal alterations in atypical and metastasized carcinoids. These findings are in accordance with the collected and herein compiled data of previous studies and indicate increasing numbers of chromosomal imbalances to play a role in the sequential process of tumor development and metastasis.

68Ga-DOTA-NOC: a new PET tracer for evaluating patients with bronchial carcinoid

BACKGROUND

Conventional imaging techniques [computed tomography (CT), ultrasound, magnetic resonance] and somatostatin receptor scintigraphy are often insufficient to make a conclusive diagnosis of bronchial carcinoid (BC). PET is commonly used for the assessment of lung cancer but 18F-fluorodeoxyglucose, the most frequently used PET tracer, presents a low sensitivity for the detection of neuroendocrine tumours (NETs). New PET radiopharmaceuticals such as 68Ga-DOTA peptides, which directly bind to somatostatin receptors and are usually expressed on NET cell surfaces, have been reported to be superior to both morphological and somatostatin receptor scintigraphy imaging for gastroenteropancreatic NETs. However, their role in BC has never been evaluated. Our aim is to evaluate the role of 68Ga-DOTA-NOC (68Ga-labelled [1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid]-1-Nal3-octreotide) PET for the assessment of BC patients.

METHODS

Ten patients with pathologically proven well-differentiated BC and one patient with highly suggestive CT images for BC were studied by 68Ga-DOTA-NOC PET/CT. PET findings were compared with clinical follow-up, pathology and contrast-enhanced CT findings.

RESULTS

68Ga-DOTA-NOC PET/CT detected at least one lesion in nine of 11 patients and was negative in two. PET/CT and contrast-enhanced CT were discordant in eight of 11 patients, whereas in only three patients both provided similar results. PET/CT detected a higher number of lesions in five patients and excluded malignancy at sites considered positive on CT in three of 11; follow-up confirmed PET/CT findings in all patients. In PET/CT-positive patients, the mean maximal standardized uptake value was 25.9 [4.4-60.5]. On a clinical basis, PET/CT provided additional information in nine of 11 patients leading to the changes in the clinical management of three of nine patients.

CONCLUSION

PET/CT with Ga-DOTA-NOC was useful in BC patients because it led to a better evaluation of the extent of the disease.

Lung tumors with neuroendocrine morphology: essential radiologic and pathologic features

CONTEXT

Tumors with neuroendocrine morphology are a distinct subset of lung neoplasms sharing characteristic histologic, immunohistochemical, ultrastructural, and molecular features.

OBJECTIVE

To review the current histologic classification and the diagnostic criteria for the major categories of neuroendocrine tumors of the lung.

DATA SOURCES

Published classification systems from the World Health Organization and pertinent peer-reviewed articles indexed in PubMed (National Library of Medicine) form the basis of this review.

CONCLUSIONS

Accurate classification of the neuroendocrine tumors of the lung requires knowledge of specific criteria separating the major categories, which is essential for determining prognosis and treatment.