Bronchial adenoma

Assessment of outcomes in typical and atypical carcinoids according to latest WHO classification

BACKGROUND

Pulmonary carcinoid tumors represent a group of malignant neoplasms comprised of neuroendocrine cells. In 1999, the World Health Organization (W.H.O.) proposed the definitive classification of neuroendocrine tumors based on the criteria from Travis and associates. The W.H.O. described two different groups of carcinoid tumors: typical carcinoids (TC) and atypical carcinoids (AC). Few reports have reviewed their data according to the current classification, and therefore, prognosis and standard therapy for TC and AC are still uncertain.

METHODS

From 1980 to 2001, 98 pulmonary resections have been performed for primary bronchial carcinoid tumors in our Thoracic Department of the University of Milan. We reviewed original histology using the current W.H.O. criteria and identified 88 patients with TC and 10 with AC. We reviewed the outcomes in each group.

RESULTS

The 5 year-overall survival rate was 91.9% for TC and 71% for AC. The 10-year overall survival rate was 89.7% for TC and 60% for AC. The 5-year TNM-related survival rates in the TC group were: IA-B, 100%; IIA-B, 75%; and IIIA, 50%. At 10 years, they were: IA-B, 100%; IIA-B, 75%; and IIIA, 0%. The 5-year survival rates in the AC group were: IA-B, 100%; IIA-B, 100%; and IIIA, 0%. At 10 years, they were: IA-B, 100%; IIA-B, 66%; and IIIA, 0%.

CONCLUSIONS

Prognosis is favorable for both subtypes in the early stage. Advanced stages are related to better prognosis in TC. Recurrences rate is worse in the AC subtype. Our data suggest avoiding limited resections when feasible in AC. Parenchyma-sparing resections should be encouraged in TC.

Carcinoid Tumors of the Gut

BACKGROUND: Carcinoid tumors are the most frequently encountered endocrine tumors of the gastrointestinal tract. They are most often found in the appendix, although they can arise in any location of the gut. Carcinoid tumors may secrete a variety of bioactive substances, which can cause the complex of symptoms associated with the carcinoid syndrome. METHODS: The authors reviewed the pathology, clinical presentation, and management of carcinoid tumors with an emphasis on the surgical management. RESULTS: The primary treatment for a carcinoid tumor located anywhere in the gut is surgical. Those who have widely metastatic disease or who are anatomically unresectable may undergo cytoreductive surgical debulking and/or hepatic arterial embolization followed by palliation of symptoms with octreotide, the long-acting somatostatin analog. CONCLUSIONS: The prognosis for patients with carcinoid tumors that are fully resected is excellent. Those with hepatic metastases and the carcinoid syndrome have a less favorable prognosis.

Benign tumors of the tracheobronchial tree. Endoscopic characteristics and role of laser resection

We conducted a review of all the bronchoscopies performed at our institutions for benign tumors from 1980 to 1991 to determine the endoscopic characteristics of these lesions. We reviewed the charts, the endoscopic characteristics from our video records, and finally the pathologic findings of these cases. We tried to identify the effectiveness of laser resections in each group. Of a total of 3,937 patients, 185 (4.7%) were benign tumors. On these patients, 317 procedures were carried out. There were 3 myoblastomas, 53 papillomas, 1 adenoma, 8 chondromas, 4 fibromas, 45 hamartomas, 15 hamartochondromas, 6 lipomas, 19 angiomas, 5 leiomyomas, 4 schwannomas, 1 neurofibroma, and 21 amyloidomas. Results of laser resection were "very good" in 115 (62%) and "good" in 70 (38%). Complications were minimal: two mediastinal emphysemas, one pneumothorax, and one anesthesia-related cardiac arrest leading to the single death in this series. In general, benign tumors of the proximal endobronchial tree responded well to laser resection when their endoscopic appearance is recognized and prognosis known. Even when recurrent, repeated procedures can be performed easily with good results. This series is probably the largest in the world's literature about endoscopic recognition and the role of laser resection in patients presenting with benign endobronchial tumors.

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.

Nd:YAG laser photoresection of low-grade malignant tumors of the tracheobronchial tree

Nineteen patients with low-grade malignant tumors of the tracheobronchial tree received Nd:YAG laser treatment. They were referred for palliation of symptomatic airway obstruction due to carcinoid (14 cases) or adenocystic carcinoma (five cases). In all patients, laser treatment was followed by symptomatic relief. Fifteen patients have done well and remain in good condition between six months and four years after laser photoresection. Two of the five patients with adenocystic carcinoma died because of hemoptysis at one and 49 months after laser therapy. In the group of 14 patients with carcinoids, two episodes of bleeding (more than 250 ml) occurred that were controlled by tamponade with the tube and coagulation by the laser beam itself. Two patients with carcinoid died of unrelated causes (stroke and gastric carcinoma).

Bronchoplastic procedures in the treatment of endobronchial carcinoid tumors

Pulmonary carcinoid tumor was surgically treated in 33 patients during a 22-year period. The tumor was polypoid and endobronchial in 19 (58%) of the patients. Conventional operation was required in 12 (63%) of the 19, viz. pneumonectomy (1), bilobectomy (1), lobectomy (9) or lingulectomy (1). In one of these 12 patients, metastasis to a salivary gland was found 15 years postoperatively, and to the mediastinum after 16 years. The other seven patients (5 female, 2 male) were treated with bronchoplasty, or with lobectomy and bronchial resection including bronchoplasty, to avoid more extensive pulmonary resection. All seven were recalled for follow-up examination 5 months to 10 years postoperatively. No recurrence or metastasis of the tumor was found, and spirometry and radiospirometry showed that the saved pulmonary tissue was functional.