Update in pulmonary carcinoid tumors: a review article

Visual analysis of lung neuroendocrine tumors based on CiteSpace knowledge graph

Objective

The relevant literatures in the field of pulmonary neuroendocrine tumor were analyzed to understand the lineage, hot spots and development trends of research in this tumor.

Method

The Web of Science core collection was searched for English-language literature about neuroendocrine tumors of the lung published between 2000 and 2022. CiteSpace software was imported for visualization analysis of countries, institutions, co-cited authors and co-cited journals and sorting of high-frequency keywords, as well as co-cited references and keyword co-occurrence, clustering and bursting display.

Results

A total of 594 publications on neuroendocrine tumours of the lung were available, from 2000 to 2022, with an overall upward trend of annual publications in the literature. Authors or institutions from the United States, Italy, Japan and China were more active in this field, but there was little cooperation among the major countries. Co-cited references and keyword co-occurrence and cluster analysis showed that research on diagnostic instruments, pathogenesis, ectopic ACTH signs, staging and prognosis and treatment was a current research hotspot. The keyword bursts suggested that therapeutic approaches might be a key focus of future research into the field for pulmonary neuroendocrine tumors.

Conclusion

Over these 20 years, research related to neuroendocrine tumors of the lung has increased in fervour, with research on diagnostic instruments, pathogenesis, ectopic ACTH signs, staging and prognosis, and treatment being the main focus of research. Therapeutic treatments may be the future research trend in this field.

Proliferation, apoptosis and invasion of human lung cancer cells are associated with NFATc1

The expression of nuclear factor of activated T cells c1 (NFATc1) is closely associated with the progression of numerous types of cancer. When NFATc1 expression becomes dysregulated in some types of cancer, this alteration can promote malignant transformation and thereby progression of cancer. NFATc1 expression has been demonstrated to be upregulated in lung cancer cells. This suggests that knockdown of NFATc1 in lung cancer cells may be a therapeutic marker for the treatment of cancer. In the present study, the effects of NFATc1 on the proliferation, apoptosis, invasion and migration of NCI-H1299 and A549 lung cancer cell lines were explored. Lentivirus infection was used to establish a cell model of NFATc1 knockdown in A549 and NCI-H1299 lung cancer cells. Reverse transcription-quantitative PCR was subsequently performed to detect NFATc1 expression in these human lung cancer cells. MTT, wound healing, colony formation and Transwell invasion assays, and flow cytometry were then performed to measure the proliferation, invasion, apoptosis and cell cycle of the cells. Finally, western blot analysis was performed to investigate the mechanism underlying the involvement of NFATc1 in these processes. NFATc1 knockdown was found to significantly inhibit the proliferation, clone formation, migration and invasion of the cells. Furthermore, the cell cycle was arrested at the G₁ phase and the expression levels of the target proteins located downstream in the signaling pathway, namely CDK4, c-Myc, ERK, p38 and N-cadherin, were decreased. Following NFATc1 knockdown, the percentages of apoptotic cells were increased, and the expression levels of Bax, cleaved caspase-3 and E-cadherin were also increased. Taken together, the results of the present study suggested that NFATc1 serves an oncogenic role in lung cancer. In terms of the underlying mechanism, NFATc1 promoted the proliferation of lung cancer cells by inhibiting the MAPK and epithelial-to-mesenchymal transition signaling pathways, suggesting that NFATc1 may be a novel target for therapeutic intervention for the treatment of lung cancer.

Efficacy and safety of 177Lu-DOTATATE targeted therapy in advanced/metastatic pulmonary neuroendocrine tumors: A systematic review and meta-analysis

Objective

To perform a meta-analysis of the efficacy and safety about ¹⁷⁷Lu-DOTATATE therapy for advanced/metastatic pNETs based on the current clinical evidence.

Methods

This systematic review follows the PRISMA guideline. Search PubMed, Medline, EMBASE and CNKI, VIP, Wanfang databases, from establishment to June 2022, on the study of ¹⁷⁷Lu-DOTATATE for advanced/metastatic pNETs, the primary endpoint was to evaluate the treatment effect through DRRs and DCRs. Secondary endpoint included assessment of OS, PFS, and treatment-related adverse events across all studies. Two researchers conducted literature screening, data extraction and quality evaluation according to the inclusion and exclusion criteria. Meta-analysis was performed using stata16.0 software, and the data were merged and displayed using forest graphs.

Results

A total of 5 studies, 174 patients, on ¹⁷⁷Lu-DOTATATE for advanced/metastatic pNETs were included. The pools of DRRs and DCRs were 24% (95% CI: 15%~32%) and 77% (95% CI: 62%~92%), respectively. The pool of OS was 48.78 months (95% CI: 41~56.57 months) and the pool of PFS was 21.59 months (95% CI: 17.65~25.53 months). In all studies, the most common side effect of treatment was hematological toxicity. In 174 patients, hematological toxicity of grade III accounted for 4.0% (7/174), and only 4.0% (7/174) and 1.0% (2/174) of patients had mild nephrotoxicity and hepatotoxicity. Gastrointestinal adverse reactions in 3% (6/174), nausea in 2% (3/174), superior vena cava occlusion in 0.5% (1/174).

Conclusion

¹⁷⁷Lu-DOTATATE is effective and safe for advanced/metastatic pNETs, which can delay the progression of the disease, may improve patients' survival, and has low treatment-related toxicity and high safety. However, its efficacy and safety need to be further evaluated in high-quality, multicenter randomized controlled trials in the future.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022344436.

Surgical Principles in the Management of Lung Neuroendocrine Tumors: Open Questions and Controversial Technical Issues

OPINION STATEMENT

Primary neuroendocrine tumors (NETs) of the lung represent a heterogeneous group of malignancies arising from the endocrine cells, involving different entities, from well differentiated to highly undifferentiated neoplasms. Because of the predominance of poorly differentiated tumors, advanced disease is observed at diagnosis in more than one third of patients making chemo- or chemoradiotherapy the only possible treatment. Complete surgical resection, as defined as anatomical resection plus systematic lymphadenectomy, becomes a reliable curative option only for that little percentage of patients presenting with stage I (N0) high-grade NETs. On the other hand, complete surgical resection is considered the mainstay treatment for localized low- and intermediate-grade NETs. Therefore, in the era of the mini-invasive surgery, their indolent behavior has suggested that parenchyma-sparing resections could be as adequate as the anatomical ones in terms of oncological outcomes, leading to discuss about the correct extent of resection and about the role of lymphadenectomy when dealing with highly differentiated NETs.

Bronchial carcinoid tumor managed with bronchial artery embolization before endobronchial resection: A case report

Endobronchial resection using a bronchoscope is often selected as treatment for carcinoid tumors located in the central airways. However, massive bleeding is one of the most serious complications during bronchoscopic surgery. Here, we report the case of a 77‐year‐old female with a typical carcinoid tumor located in the right truncus intermedius who underwent bronchial artery embolization (BAE) one day before endobronchial intervention using a flexible bronchoscope. The tumor was successfully resected without bleeding. BAE prior to endobronchial resection of carcinoid tumors may be useful for reducing the risk of bleeding.

Bronchoscopic diagnosis and treatment of endobronchial carcinoid: case report and review of the literature

Carcinoid tumours are rare neuroendocrine neoplasms that mostly occur in younger adults with low tendencies to metastasise. Based on their histological characteristics, they are divided into typical and atypical subtypes. The most common presenting symptoms are due to central airway obstruction. The first step in the diagnostic assessment should be a computed tomography (CT) scan, as it provides information both for local tumour extent and lymph node involvement. Bronchoscopy is the main tool for histological confirmation, evaluation of bronchial wall invasion and removal of endobronchial manifestation with subsequent resolution of atelectasis. Endobronchial ultrasound may be necessary to rule out lymph node metastasis. Somatostatin receptor scintigraphy in combination with CT can rule out further metastatic disease.Surgical resection using parenchyma-sparing techniques remains the gold standard for treatment. For selected patients, endobronchial therapy could be an alternative for minimal invasiveness. Long-term follow-up is suggested due to the high likelihood of recurrence.Here, we describe our clinical experience in a 35-year-old male patient who originally presented with haemoptysis and a central polypoid tumour in the left main bronchus revealed by a CT scan. The histological characteristics were indicative of a typical carcinoid. The patient was treated using an endobronchial approach only. No complications and no recurrences have been observed in a follow-up of 2 years.

Predictive Indicators of Survival in Patients With Surgically Resected Lung Carcinoid Tumors at a Greek Medical Center

Introduction

Lung carcinoid tumors are neuroendocrine neoplasms, less frequent than other lung tumors. They are subdivided into typical carcinoids (TC) and atypical carcinoids (AC), according to the rate of mitosis and the presence of necrosis. Lung carcinoids are often asymptomatic and only discovered incidentally. They may also present with cough, wheezing, asthma, and chronic obstructive pulmonary disease, chest pain, and hemoptysis depending on the location of the tumor and, less commonly, present with carcinoid syndrome. In our study, we describe the clinical and pathological features of patients with surgically resected lung carcinoids at our institution over a period of 14 years. We also examine if these features, including age, gender, tumor size, type of carcinoid, stage, nodal involvement, and Ki-67 expression are associated with patients' survival.

Materials and methods

We retrospectively reviewed patients that underwent surgery with a final histologic diagnosis of a pulmonary carcinoid tumor from March 2005 to March 2019. The evaluation included history, physical examination, chest radiographs, computerized tomography of the chest, upper abdomen, and brain, and bone scintiscan. All specimens resected during the surgical procedures were sent for pathological examination, including mediastinal and hilar lymph nodes. The patients' age, gender, tumor size, type of carcinoid, nodal involvement, stage, and Ki-67 expression were recorded and correlated to the patients' survival rates.

Results

The study included 108 patients - 52 males and 56 females - with a mean age of 51.5 years (range 11-80 years). Atypical carcinoid was the diagnosis in 28 patients (16 males and 12 females) and 80 patients had the diagnosis of typical carcinoid (36 males and 44 females). Tumor size was ≤3.7 cm in 84 patients (68 with TC and 16 with AC) and >3.7 cm in 22 patients (12 with TC and 10 with AC). Sixteen patients had nodal deposits, 12 in N1 nodes and four in N2 nodes. Eighty patients were classified in stage I, 18 patients in stage II, and 10 patients in stage III. None of the patients had distant metastases. The Ki-67 proliferation index was examined in 84 specimens and Ki-67 was <2.5 in 50 patients and ≥2.5 in 34 patients. Of the 108 patients, eight died, all with disease-related death. According to the Cox regression univariate analysis, four factors were correlated to shorter survival: atypical histology, tumor size >3.7 cm, nodal involvement, and advanced stage

Conclusions

In conclusion, we found that histological type, tumor size, nodal involvement, and stage are associated with survival in patients with surgically resected lung carcinoids without distant metastases. Other parameters, such as age at operation, gender, and Ki-67 index, did not have a role in survival in these patients according to the Cox regression univariate analysis.

Role of wedge resection in bronchial carcinoid (BC) tumors: SEER database analysis

Background

There is a paucity of data regarding the role of wedge resection (WR) in the management of bronchial carcinoid (BC) tumors. In this study, we queried the Surveillance, Epidemiology, and End Results (SEER) database to compare the oncologic outcomes of patients with BC tumors treated with WR or anatomic resection.

Methods

The SEER database was retrospectively reviewed for patients with BC treated with surgical resection between 1973-2013. Patients who underwent WR were compared to those who underwent lobectomy or segmentectomy (Lob/Seg). Patients with multiple primaries and those who underwent pneumonectomy or have an unspecified surgical procedure were excluded. Differences in demographics and clinicopathological data were compared using Chi (χ²) test or Mann Whitney U test. Overall and cancer specific survival (OS, CSS) were estimated using Kaplan-Meier method and differences were compared using log-rank test. Cox-regression multivariable analysis (MVA) was performed to explore factors associated with worse CSS. Propensity-score matching analysis was done to compare survival differences between WR and Lob/Seg.

Results

A total of 22,350 patients with BC were identified, of them 4,450 met our inclusion criteria (3,511 Lob/Seg, vs. 939 WR). The median age was 59.0 years [interquartile range (IQR) =49.0-68.0], 67.6% were females and the median tumor size was 2 cm (1.5-3 cm). 4,119 patients had typical carcinoid (TC) and 331 had atypical carcinoid (AC). WR was performed more frequently in elderly patients, females, lower lobe tumors, TC's and in earlier stage disease. For patients with TC, there was no difference in CSS between WR and Lob/Seg in both the entire cohort (P=0.654) and in the propensity matched groups (P=0.900). However, for patients with AC, Lob/Seg was associated with better CSS compared to WR both in the entire cohort (P<0.001) and in the propensity matched groups (P=0.001). On MVA of the entire cohort, elderly patients, males, blacks, AC and advanced stages had worse CSS. While, the type of the procedure (WR vs. Lob/Seg) was not associated with CSS (HR =1.16, 95% CI: 0.85-1.60).

Conclusions

A WR may offer equivalent CSS in well-selected patients with early-stage TC. An anatomic resection appears warranted in AC.

Differential Diagnosis of Asthma

Asthma is one of the most common chronic syndromes worldwide (Moorman et al., Vital Health Stat 3(35), 2012). It is not a diagnosis but a clinical syndrome based on a constellation of signs and symptoms (Li et al., Ann Allergy Asthma Immunol 81:415–420(IIa), 1998). The classic symptoms of asthma include chest tightness, wheeze, cough, and dyspnea (Moorman et al., Vital Health Stat 3(35), 2012). The term asthma encompasses a spectrum of pulmonary diseases sharing the hallmark of reversible airway obstruction and can be classified as allergic or non-allergic (Löwhagen, J Asthma. 52(6):538–44, 2015). Asthma designated allergic is due to an immunoglobulin E (IgE)-mediated process, but as noted not all asthma is allergic in etiology (Romanet-Manent et al., Allergy 57:607–13, 2002). The differential diagnosis for asthma is broad and requires a detailed history with supportive pulmonary function tests to be properly diagnosed.

Complete lung collapse in a young adolescent

Bronchial carcinoid tumours (BCTs) arise from the neuroendocrine cells of the bronchial epithelium known as Kulchitsky cells. They represent ~25% of all carcinoid tumours, usually have a central distribution, and present with features of bronchial obstruction. They are the most common lung malignancy in children. Here we report the case of a 14-year-old girlwith chronic respiratory symptoms and left lung collapse due to bronchial carcinoid. The differential diagnosis of segmental, lobar or total lung collapse in a young person also includes mucus plugging or foreign body aspiration.

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.

A Case of Primary Combined Squamous Cell Carcinoma with Neuroendocrine (Atypical Carcinoid) Tumor in the Floor of the Mouth. Case Rep Dent. 2016;2016:7532805. [PMID: 28116178 PMCID: PMC5223000 DOI: 10.1155/2016/7532805]

The combined squamous cell carcinoma (SCC) with neuroendocrine (atypical carcinoid (AC)) tumor is extremely rare in the head and neck. We present here the first case of SCC with AC arising in the floor of the mouth of 65-year-old man. The tumor is comprised of two components of SCC and AC in the biopsy specimen. Neuroendocrine tumor component was classified as AC from the punctate necrosis and 2–10>/10 HPF. Immunohistochemical staining was HMW-CK/34B (+) and P63 (+) in SCC and synaptophysin (+) and CD56 (+) in AC. The pathological diagnosis of SCC with AC was made from both the morphological and immunological exam. Concurrent chemoradiotherapy was performed with radiotherapy 70.2 Gy and chemotherapy of CDDP and VP-16. Although the treatment effect was complete response both of primary tumor and of neck metastases, the recurrence of the primary tumor was after 6 months. Bilateral modified radical neck dissection and tumor resection of the floor of the mouth with reconstructive surgery of anterior lateral thigh free flap were performed. Although the primary and neck tumor did not recur, the multiple lung metastases and mediastinum lymph node metastases occurred at 6 months after surgery.

Tracheobronchial tumors

Tumors of trachea and bronchi are uncommon and can occur in the form of benign or low- and high-grade malignant tumors. Although tracheobronchial tumors (TBTs) represent only 0.6% of all pulmonary tumors, they are clinically significant. Delays in diagnosis of these tumors commonly occur because the signs and symptoms caused by these tumors are nonspecific and chest radiographs are often considered unremarkable. Therefore, novel radiological techniques and better access to flexible bronchoscopy enable detection of larger number of TBT. The purpose of this article is to provide a review of tracheal and bronchial tumors and discuss significant aspects of the different TBT with focus on clinical manifestations and diagnostic procedures.

Invasive atypical thymic carcinoid: three case reports and literature review

Atypical thymic carcinoid is an extremely rare thymic neuroendocrine tumor derived from the neuroendocrine system. The aims of this paper were to investigate the clinical features of atypical thymic carcinoid and collate information and experience to improve the diagnosis and treatment of this disease. We describe three cases of atypical carcinoid of the thymus; clinical features, pathological data, treatment modalities, and short-term patient outcomes were summarized and analyzed. The initial clinical symptoms and signs of all three patients were nonspecific and an anterior mediastinal mass was found in each patient on chest computed tomography scan. All three patients underwent surgical resection (total thymectomy and complete excision of the tumor), followed by postoperative radiotherapy, with or without chemotherapy. The diagnoses of three patients were confirmed by pathological and immunohistochemical evaluation. We also present a review of the literature to collate as much information as possible and provide a reference for proper diagnosis and treatment of atypical thyroid carcinoid.

Pulmonary Neuroendocrine Tumors: Part II. Treatment

Pulmonary neuroendocrine tumors that arise from Kulchitzky cells of the bronchial mucosa consist of a spectrum of histologic features leading to a variable prognosis. Although typical carcinoid represents the most benign course, small-cell cancer has the grimmest outcome. Therefore, differentiating the spectrum of neuroendocrine tumors helps one not only to determine the prognosis, but also to guide the treatment options. In this part, we aim to discuss the treatment options in pulmonary neuroendocrine tumors except for small-cell lung cancer.

Outcomes after surgical resection of pulmonary carcinoid tumors

BACKGROUND

Pulmonary carcinoid tumors make up approximately one percent of all pulmonary tumors, and controversy exists regarding management and prognosis. We undertook a retrospective analysis of all patients who underwent surgical resection of pulmonary carcinoid tumors at our institution.

METHODS

From 1992 through 2014, 121 patients who underwent surgical resection of pulmonary carcinoid tumors were retrospectively reviewed. Patient demographics, pathologic data and long-term outcomes were recorded.

RESULTS

There were 96 patients with typical carcinoid tumors and 25 patients with atypical carcinoid tumors. All patients received complete resection of their tumors, with 90 % (109/121) of patients undergoing anatomic resection. There were no peri-operative mortalities. Eighty-one percent (98/121) of patients were female. Mean age was 60.7 years. Five and ten year survival rates were 96 % and 88 % respectively for typical carcinoid tumors, as compared to 87 % and 69 % respectively for atypical carcinoid tumors. Tumor size was not associated with survival (p = 0.98). Nodal metastases were evident in 8 % (8/96) of typical carcinoid tumors and 28 % (7/25) percent of atypical carcinoid tumors. Among typical carcinoid cases, the presence of nodal metastases were not associated with overall survival (p = 0.55). Among atypical carcinoid cases, the presence of nodal metastases also was not associated with survival (p = 0.53). No patients received neoadjuvant or adjuvant chemoradiation treatment.

CONCLUSIONS

Excellent long-term outcomes can be achieved following surgical resection of pulmonary carcinoid tumors. The presence of nodal metastases was not associated with overall survival. Tumor size was not associated with either recurrence rates or survival.

[Metastatic bronchial carcinoid tumors]

Bronchial carcinoids are uncommon pulmonary neoplasms and represent 1 to 2 % of all lung tumors. In early stage of disease, the mainstay and only curative treatment is surgery. Bronchial carcinoids are generally regarded as low-grade carcinomas and metastatic dissemination is unusual. The management of the metastatic stage is not currently standardized due to a lack of relevant studies. As bronchial carcinoids and in particular their metastatic forms are rare, we apply treatment strategies that have been evaluated in gastrointestinal and pancreatic neuroendocrine tumors. However, bronchial carcinoids have their own characteristic. A specific therapeutic feature of these metastatic tumors is that they require a dual approach: both anti-secretory for the carcinoid syndrome, and anti-tumoral.

Atypical Endobronchial Carcinoid with Postobstructive Pneumonia Obscuring the Diagnosis of Granulomatosis with Polyangiitis

Granulomatosis with polyangiitis (GPA), previously termed Wegener's Granulomatosis, is an autoimmune small vessel vasculitis which is highly associated with antineutrophil cytoplasmic antibodies (ANCA) and has varied clinical manifestations. Diagnosis hinges on identifying a combination of clinical features of systemic vasculitis, positive ANCA serology, and histological evidence of necrotizing vasculitis, necrotizing glomerulonephritis, or granulomatous inflammation from a relevant organ biopsy. The American College of Rheumatology has also developed a classification criteria focusing specifically on nasal or oral inflammation, abnormal chest radiograph, and abnormal urinary sediment, along with granulomatous inflammation, which helps to distinguish GPA from other forms of systemic vasculitis. In the case presented below, the diagnosis of GPA was delayed as the patient had a concomitant atypical endobronchial carcinoid which predisposed to postobstructive pneumonia. Fortunately, the papular lesions that developed across her lower limbs prompted further investigations. The return of appropriate serology coincided with progression to alveolar hemorrhage, offering a more complete clinical picture, and when she responded to the combination of steroid, cyclophosphamide, and plasma exchange, the diagnosis of GPA was cinched.

Carcinoid tumours of the lung and the 'PEPPS' approach: evaluation of preoperative bronchoscopic tumour debulking as preparation for subsequent parenchyma-sparing surgery

BACKGROUND

Preoperative bronchoscopic tumour ablation has been suggested as a beneficial treatment for bronchopulmonary carcinoid tumours, although data regarding its effects and long-term outcome are lacking.

METHODS

In our case-matched cohort study with 208 patients with bronchopulmonary carcinoid tumours we investigated the role of preoperative bronchoscopic interventions before subsequent surgery and analysed the safety of this Procedure of Endobronchial Preparation for Parenchyma-sparing Surgery (PEPPS) based on metastasis and recurrence rates as well as survival data from 1991 to 2010. The subsequent surgery was classified into parenchyma-sparing procedures and classical lobectomies, bilobectomies and pneumonectomies. Data were obtained from the tumour registry and medical reports. Outcomes were the frequency of parenchyma-sparing surgery after bronchoscopic treatment as well as rates of metastasis, recurrence and survival.

RESULTS

132 of 208 carcinoids were located centrally. Among them, 77 patients could be recanalised preoperatively. After bronchoscopic preparation, the rate of subsequent parenchyma-sparing surgery methods was higher (p=0.021). The effect was measured by the number of segments removed. The 10-year survival rate was 89% (typical carcinoids) and 68% (atypical carcinoids), respectively. After applying PEPPS, long-term survival was slightly higher (p=0.23). Metastasis and recurrence rates showed no relevant differences between the bronchoscopically treated or non-treated groups, or between the two types of surgery classes or between the PEPPS and non-PEPPS groups.

CONCLUSIONS

After preoperative bronchoscopic treatment, parenchyma-sparing surgery techniques can be applied more frequently. Furthermore, we detected no negative effects after PEPPS based on metastasis, recurrence and survival rates.

Long-term follow-up after first-line bronchoscopic therapy in patients with bronchial carcinoids

BACKGROUND

Carcinoid of the lung is considered to be a low-grade malignancy. A subgroup presents as an endobronchial tumour. Surgical resection is considered the standard approach because of its metastatic potential and the possibility of an iceberg phenomenon for the endobronchial subgroup. Advances in non-invasive and minimally invasive technologies seem to justify a more lung parenchyma-sparing approach.

METHODS

In patients presenting with bronchial carcinoids, initial bronchoscopic treatment (IBT) is first attempted for complete tumour eradication and sufficient tissue sampling for the proper differentiation of typical (TC) versus atypical (AC) histological type. Furthermore in cases with postobstruction problems the desobstruction is aimed at improving the patient's condition and by that alleviate surgery if that is needed. High resolution CT is performed 6 weeks post IBT to determine local tumour growth. Surgical resection follows in case of extraluminal disease, residual carcinoid inaccessible for IBT, or late recurrences not salvaged by repeat IBT.

RESULTS

Minimum follow-up was 5 years from start of treatment for 112 patients (65 women, 47 men), with a median age of 47 years (range 16-77 years). Eighty-three patients (74%) had TC, and 29 (26%) AC. IBT only was ultimately curative in 42% of the cases (47/112): 42 TC, 5 AC. Disease-specific mortality including surgical mortality has been 2.6% (3/112) in patients with extraluminal carcinoids (3 AC).

CONCLUSIONS

IBT, if with unsuccessful rescue surgery, is justifiable with excellent long-term outcome. IBT made surgery unnecessary in 42% of the cases. Iceberg phenomenon and metastatic potential in this group of patients with bronchial carcinoids are clinically insignificant.

[Paraneoplastic Cushing's syndrome, a real diagnostic and therapeutic challenge: A case report and literature review]

INTRODUCTION

Paraneoplastic Cushing's syndrome is a rare cause of endogenous hypercortisolism attributable to ectopic ACTH secretion by non-pituitary tumors. Imaging and biochemical results are often inconclusive and differential diagnosis with Cushing's disease can then be challenging. Moreover, these tumors may be occult and difficult to find and thus the need of new imaging tools such as (18)FDG-PET scan and (18)DOPA-PET scan.

CASE REPORT

We report a 50-year-old man who presented with very aggressive clinical features related to Cushing's syndrome. Biological work-up confirmed the hypercortisolism and was consistent with an ectopic ACTH secretion. Conventional localization techniques failed to show any tumor and bilateral adrenalectomy was performed because of life-threatening complications. Two years later, thoracic computed tomography reveals an 11 mm mass in the left lower pulmonary lobe, (18)FDG-PET scan found a non-specific mild hypermetabolism of the lung nodule, and the (18)DOPA-PET scan confirmed the high uptake of this nodule suggesting an endocrine carcinoma. Histology confirmed a typical carcinoid tumor. The tumor cells stained positive for ACTH, CD56, chromogranin and synaptophysin.

CONCLUSION

This case illustrates the dilemma between the need for morphological diagnosis of the ectopic ACTH source and control of the life-threatening hypercortisolism. (18)FDG-PET scan and (18)DOPA-PET scan should be considered early as a secondary diagnostic tool when conventional imagery fails to show any tumor.

Combined atypical carcinoid tumour and squamous cell carcinoma of the lung

A 71-year-old man diagnosed with lung cancer in the right lower lobe with invasion to the middle lobe underwent right lower and middle lobectomy with mediastinal lymph node dissection. The cancer was pathologically diagnosed as stage IIB (pT3N0M0) with combined squamous cell carcinoma and an atypical carcinoid tumour. To the best of our knowledge, this is the first report of a combined atypical carcinoid tumour and non-small cell lung cancer. This case further expands the histological spectrum of combined neuroendocrine tumours.

Prognostic and diagnostic value of epithelial to mesenchymal transition markers in pulmonary neuroendocrine tumors

Background

Pulmonary neuroendocrine tumors (Pulmonary NETs) include a wide spectrum of tumors, from the low-grade typical carcinoid (TC) and the intermediate-grade atypical carcinoid (AC), to the high-grade large-cell neuroendocrine carcinoma (LCNEC) and the small-cell carcinoma (SCLC). Epithelial Mesenchymal Transition (EMT) is a process initially recognised during several critical stages of embryonic development, which has more recently been implicated in promoting carcinoma invasion and metastasis. The initial stage of the EMT process begins with the deregulation of adhesion molecules, such as E-cadherin, due to transcriptional repression carried out by factors such as Snail family members, Twist and Foxc2.

Methods

Immunohistochemistry for EMT markers and E-cadherin/ β-catenin complex in 134 patients with pulmonary NETs between 1990 – 2009. Analysis of potential associations with clinicopathological variables and survival.

Results

Pulmonary NETs of high malignant potential (LCNEC and SCLC) had reduced expression of the adhesion molecules and high level expression of transcriptional repressors (Snail1, Snail2, Twist and Foxc2). Snail high expression levels and the loss of E-cadherin/β-catenin complex integrity had the strongest negative effect on the five-year survival rates. E-cadherin/β-catenin complex integrity loss independently predicted lymph node involvement and helped in Atypical Carcinoid (AC) vs Typical Carcinoid (TC) differential diagnosis. Importantly, among the TC group, the loss of E-cadherin/β-catenin complex integrity identified patients with an adverse clinical course despite favourable clinicopathological features.

Conclusion

The immunohistochemical determination of E-cadherin/β-catenin complex integrity loss and EMT markers in the clinical setting might be a potential useful diagnostic and prognostic tool especially among the TC patients.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2407-14-855) contains supplementary material, which is available to authorized users.

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.

Long-term results after resection of bronchial carcinoid tumour: evaluation of survival and prognostic factors

OBJECTIVES

We retrospectively analysed morbidity, mortality and oncological results of patients who had undergone surgery for bronchial carcinoid tumours.

METHODS

Between 2002 and 2012, 65 patients with bronchial carcinoids underwent lobectomy (n = 34), sublobar resection (segmentectomy/wedge) (n = 18), sleeve lobectomy (n = 5) (reconstruction of the pulmonary artery was associated in 1 case), sleeve resection of the main bronchus (n = 4) or pneumonectomy (n = 4) (reconstruction of the carina was associated in 1 case).

RESULTS

Resection was radical with histologically negative margins in all patients (R0). Histology showed typical carcinoid (TC) in 55 (84.6%) patients and atypical carcinoid (AC) in 10 (15.4%) patients. Final pathological stages were Stage I in 42 (64.6%) patients, Stage II in 18 (27.7%) and Stage III in 5 (7.7%). No postoperative mortality was observed. The postoperative morbidity rate was 15.4% (no bronchial and/or vascular reconstructive-related complications occurred). The median follow-up was 58 (range 2-121) months. The overall recurrence rate was 12.3% (n = 8). The survival rate at 5 years was 100% for TC and 87% for AC. Disease-free survival rates at 3 and 5 years were 95 and 93% for TC and 78 and 44% for AC, respectively (P = 0.004). Pathological nodal involvement (pN1-N2) did not affect overall survival or recurrence.

CONCLUSIONS

The surgical treatment of bronchial carcinoids provides high long-term survival rates. Low postoperative morbidity and mortality can be expected even after bronchial reconstruction. The AC appears to be the main factor that determines the risk of recurrence. Bronchial reconstructive lung sparing operations are not related to an increased recurrence rate.

Carcinoid syndrome caused by a serotonin-secreting pituitary tumour

BACKGROUND

Neuroendocrine tumours are most frequently located in the gastrointestinal organ system or in the lungs, but they may occasionally be found in other organs.

CASE

We describe a 56-year-old woman suffering from a carcinoid syndrome caused by a large serotonin-secreting pituitary tumour. She had suffered for years from episodes of palpitations, dyspnoea and flushing. Cardiac disease had been suspected, which delayed the diagnosis, until blood tests revealed elevated serotonin and chromogranin A in plasma. The somatostatin receptor (SSR) scintigraphy showed a single-positive focus in the region of the pituitary gland and MRI showed a corresponding intra- and suprasellar heterogeneous mass. After pre-treatment with octreotide leading to symptomatic improvement, the patient underwent trans-cranial surgery with removal of the tumour. This led to a clinical improvement and to a normalisation of SSR scintigraphy, as well as serotonin and chromogranin A levels.

CONCLUSION

To our knowledge, this is the first reported case of a serotonin-secreting tumour with a primary location in the pituitary.

Comparative immunohistochemical analysis of pulmonary and thymic neuroendocrine carcinomas using PAX8 and TTF-1

PAX8 is expressed in thymic epithelial neoplasms and a subset of neuroendocrine carcinomas of gastrointestinal origin but not pulmonary neuroendocrine carcinomas. Thyroid transcription factor 1 (TTF-1) is known to be positive in pulmonary neuroendocrine carcinomas, but studies investigating its expression in thymic neuroendocrine carcinomas are lacking. To date, there are no comprehensive studies focusing on the comparative expression of PAX8 or TTF-1 in pulmonary and thymic neuroendocrine carcinoma. Twenty-five cases of low and intermediate grade neuroendocrine carcinomas of pulmonary and thymic origin, respectively, were selected for immunohistochemical studies using antibodies directed against PAX8 and TTF-1. The percentage of positive tumor cells as well as the intensity of staining were evaluated and scored. Twenty-one of the pulmonary neuroendocrine carcinomas were classified as low grade (typical carcinoid) and 4 as intermediate grade (atypical carcinoid) tumors; the thymic tumors consisted of 8 low grade and 17 intermediate grade neuroendocrine carcinomas. Only 2 (8%) of the pulmonary tumors showed nuclear expression of PAX8 while 19 (76%) expressed TTF-1. Of the thymic tumors, 8 (32%) were positive for PAX8 and 2 (8%) showed TTF-1 positivity. Primary neuroendocrine carcinomas of the thymus are rare neoplasms that display a more aggressive clinical course than pulmonary neuroendocrine carcinomas, highlighting the importance of the separation of these tumors. To date, there are no specific immunomarkers to distinguish between neuroendocrine carcinomas of pulmonary and thymic origin. The differential expression of PAX8 and TTF-1 may prove useful in this context as a PAX8+/TTF-1- immunophenotype appears to be more common in thymic neuroendocrine carcinomas, whereas the reverse (PAX8-/TTF-1+) is true for most pulmonary neuroendocrine carcinomas.

A case of presumed choroidal metastasis from carcinoid tumor treated by photodynamic therapy with verteporfin

We report a case of metastatic choroidal carcinoid tumor with favorable outcome after photodynamic therapy. A 75-year-old woman was presumptively diagnosed with bilateral choroidal metastases from carcinoid tumor. Although the tumor in the right eye showed a tendency toward rapid expansion and required aggressive treatment to preserve vision, the size was still small and we hesitated to use external-beam radiotherapy because of the risk of radiation retinopathy. Consequently, photodynamic therapy was performed on the right eye, resulting in drastic reduction of the size and height of the choroidal tumor. Good visual acuity was maintained after photodynamic therapy. Photodynamic therapy may be an effective treatment for choroidal metastasis from carcinoid tumor.

The clinical staging of lung cancer through imaging: a radiologist's guide to the revised staging system and rationale for the changes

In 2009, the International Union Against Cancer and the American Joint Committee on Cancer accepted a revised staging system for the staging of lung cancer. Changes to the staging system were made to correlate patient survival more accurately with characteristics of the primary tumor (T) and presence or extent of nodal (N) and metastatic disease (M). Many changes were made to the staging system, most notably within the tumor (T) and metastases (M) designations. There are many ways to clinical stage lung cancer, but PET-CT remains one of the most accurate noninvasive methods.

Neuroendocrine tumours--challenges in the diagnosis and classification of pulmonary neuroendocrine tumours

Pulmonary neuroendocrine (NE) proliferations are a diverse group of disorders which share distinct cytological, architectural and biosynthetic features. Tumours composed of NE cells are dispersed among different tumour categories in the WHO classification of tumours and as such do not conform to a singular group with regards to treatment and prognosis. This is reflected by the highly variable behaviour of NE proliferations, ranging from asymptomatic, for instance in diffuse idiopathic pulmonary NE cell hyperplasia and tumourlets, to highly malignant cancers such as small cell lung cancer and large cell NE carcinoma. In this review NE proliferations are described as distinct entities ranging from low grade lesions to high grade cancers. The differential diagnoses are considered with each of the entries. Finally, mention is made of tumours which may show some NE features.

[Bronchial carcinoid tumor: study of 60 patients]

BACKGROUND AND OBJECTIVE

To describe the casuistry of bronchial carcinoid tumor in the last 20 years in our hospital and determine survival after surgical treatment.

PATIENTS AND METHOD

We retrospectively reviewed the medical records from January 1992 to June 2012 of patients diagnosed with carcinoid tumor by the pulmonary service.

RESULTS

Fifty-two patients (87%) had typical carcinoid and 8 (13%) atypical carcinoid. The mean age at diagnosis was 60 years (SD: 14.4). There was no relationship between consumption of tobacco and carcinoid tumor. Twenty-two per cent were asymptomatic radiographic finding (incidental finding) Three patients showed carcinoid syndrome and one patient had Cushing syndrome. There was a right dominance and the mean lesion size was between 2.1 and 5 cm. Nine per cent had lymph node involvement, predominantly in atypical carcinoid. Overall survival at 3.5 and 10 years was 94%, 86% and 82%. Survival at 5 years was 90% for typical and 86% for atypical and survival at 10 years was 85% for typical and 57% for atypical carcinoids.

CONCLUSION

Carcinoid tumors are malignant tumors by their ability to metastasize. In our study, both histological type and staging were predictors of survival.

Pure bronchoplastic resections of the bronchus without pulmonary resection for endobronchial carcinoid tumours

OBJECTIVES

Bronchopulmonary carcinoid tumours are relatively uncommon primary lung neoplasms. A small proportion of these lesions are predominantly endobronchial and do not extend beyond the bronchial wall. Endoscopic resection can be performed, but carries around a one in three risk of local recurrence and, therefore, mandates long-term surveillance. An alternative is complete surgical resection via bronchoplastic resection. We present our experience of surgical resection in patients with endobronchial carcinoids.

METHODS

From 2000 to 2010, 13 patients (age 45±16 years, 10 males) underwent pure bronchoplastic resection, including systematic nodal dissection, for endobronchial carcinoid tumours, without the resection of lung parenchyma.

RESULTS

There was no significant operative morbidity or mortality. This is a retrospective review of a consecutive case series. The last follow-up for all patients was obtained in 2011. The mean maximum tumour size was 18±8 mm. No lymph node invasion was observed. The median follow-up was 6.3±3.3 years, with no regional recurrence. In 1 case, a tumourlet was identified at 5 years in the contralateral airway and viewed as a metachronous new lesion.

CONCLUSIONS

Bronchial sleeve resection is a safe procedure for suitably located endobronchial carcinoid tumours. Endoscopic resection should be reserved for patients who decline, or are unfit, for surgery.

Clinical outcomes of atypical carcinoid tumors of the lung and thymus: 7-year experience of a rare malignancy at single institute

Atypical carcinoid tumors above the diaphragm are extremely rare and are associated with unfavorable clinical outcomes compared to typical carcinoid tumors. We described various clinical and histological features and investigated outcomes in patients with atypical carcinoid tumor of the lung and thymus. Medical records were reviewed in patients diagnosed with atypical carcinoid tumor of the lung or thymus at Samsung Medical Center between December 2003 and April 2010. We reviewed patient characteristics and treatment modalities and analyzed patient outcome in terms of disease-free survival and overall survival. Of the nineteen study patients, there were twelve patients with atypical carcinoid tumors of the lung and seven patients with thymic ones. All patients except one underwent complete resection as the main treatment. All patients who had tumors with lesser mitoses (≤5/10 high-power fields) are presently alive; moreover, they are all free of recurrence except for one patient who is also alive with recurrent tumor without any palliative treatment. Distant metastasis after curative resection developed in six patients and two of them died of progressive disease 25-31 months after recurrence even after palliative systemic chemotherapy. Atypical carcinoid tumor of the lung and thymus was a malignant disease that was prone to metastasize to distant sites even after curative resection and adjuvant treatment. Number of mitosis was a predicting factor for recurrence of disease and death in patients with atypical carcinoid tumor of the lung and thymus.

A case of uncontrolled asthma

A 48-year-old female patient with uncontrolled severe asthma was referred to our hospital for anti-IgE therapy. She was suffering with persistent wheezing and dyspnea after a severe asthma attack that had taken place 5 months previously. Her asthma had not been controlled with adequate asthma treatment, including budesonide at 320 μg + formoterol at 9 μg b.i.d. combination, montelukast at 10 mg/day, and oral steroids (30-40 mg/day of prednisolone), during this period. She was hospitalized for evaluation for anti-IgE therapy. Chest radiography revealed a left-sided hilar opacity. Fiberoptic bronchoscopy was performed and showed an endobronchial lesion obstructing the left lower bronchus lumen. Computed tomography also revealed a nodular lesion at the same location. The patient underwent left lower lobectomy and mediastinal lymph node dissection. Pathological examination concluded the diagnosis of typical carcinoid tumor. After surgery, her symptoms disappeared and she has had no recurrence. In conclusion, a diagnosis of severe asthma requires confirmation of asthma. Uncontrolled symptoms that linger despite aggressive therapy warrant evaluation to rule out other etiologies, such as a carcinoid tumor, before selecting new treatment options.

Alterations of MEN1 and E-cadherin/β-catenin complex in sporadic pulmonary carcinoids

Pulmonary carcinoids, distinct in typical and atypical, represent 2–5% of all primary lung tumors. The aim of this study was to investigate the molecular alterations correlated with the development of this form of neoplasms. A collection of 38 paraffin-embedded apparently sporadic carcinoids was investigated, through a combined study, for protein expression/localization of menin, p53, β-catenin and E-cadherin and for mutational analysis of the MEN1, TP53 and CTNNB1 genes. Menin was expressed in 71% of cases, with a prevalent cytoplasmic (c) localization, β-catenin was expressed in 68.4% of cases, of which 36.8% with a membranous (m) and 31.6% with a cytoplasmic localization. Membranous E-cadherin immunoreactivity was detected in 84.2% cases, nuclear p53 expression in 5.3% of cases. Positive correlation was found between c-menin and c-β-catenin expression (rho=0.439, P=0.008). In addition, m-β-catenin showed a positive correlation with both c-β-catenin and E-cadherin expression (rho=0.380, P=0.022 and rho=0.360, P=0.040, respectively). With regard to the E-cadherin/β-catenin complex, we found also a significant positive correlation between c-menin and ‘disarrayed’ β-catenin expression (rho=0.481, P= 0.007). MEN1 gene variants were characterized in 34% of cases. c-menin was more highly expressed in tumors with MEN1 variants, compared to tumors without MEN1 variants (P=0.023). Three nucleotide variants of TP53 were also detected. This study confirms the involvement of the MEN1 gene in the development of sporadic pulmonary carcinoids, demonstrates the accumulation of menin in the cytoplasm, and indicates that the disarrayed pattern of the complex significantly correlates with c-menin accumulation.

Clinical and Radiological Manifestations of Primary Tracheobronchial Tumours: A Single Centre Experience

Introduction: Tracheobronchial tumours usually cause an airway obstruction and secondary pulmonary infections. Although rare, they are an important differential diagnosis as they may mimic other conditions and diseases. This paper aims to analyse clinical, radiological and histological characteristics of the patients with tracheobronchial tumours diagnosed for a period of 7 years. Materials and Methods: In this retrospective, observational study, we carefully reviewed 65 patients who were diagnosed with tracheal and endobronchial tumours, and performed statistical analysis on the results. Results: Among these 65 patients (36 men and 29 women) with a mean age of 48.8 years (range, 15 to 75), 50 had malignant tumours while 15 had benign ones. The most common symptoms were cough, chest pain and haemoptysis. Cough was a more frequent symptom in patients with benign tumours (P <0.0014). Only 2 patients were asymptomatic. Tumours were predominantly localised in the large airways (46 in large bronchi and 2 in trachea). The most common radiological manifestation of malignant tumours was tumour mass (46%) followed by atelectasis. One third benign tumour caused atelectasis, while tumour mass and consolidation were found in 3 patients each. Computerised tomography revealed endoluminal tumour mass in 29.2% of the cases, which was more frequently found in benign than malignant tumours (47% vs 24%, respectively). On bronchoscopy, tumours were visible in 73% and 70% benign and malignant cases respectively. Conclusion: Tracheobronchial tumours should be ruled as a possible diagnosis in patients with cough, haemoptysis, dyspnoea and chest pain. The imaging techniques and histological examination of the tissue would subsequently lead to correct diagnosis and proper treatment can be administered. Key words: Bronchus, Computerised tomography, Trachea, Tumour, X-ray

Excessive muscle paralysis due to pulmonary carcinoid -a case report

We present the case of a 58-year-old woman with a renin secreting typical bronchopulmonary carcinoid. This patient showed hypotension, constipation and fatigue due to extensive hypokaliemia (K =1.9 meq/L). Aldosterone (102.7 ng/100 mL) and renin (46 ng/mL) were excessively elevated at that time, but cortisol level was normal. Routine chest roentgenography and computed tomography revealed a nodular lesion in the upper left lung lobe, which was suspicious for a neurosecretory pulmonary tumor. The final diagnosis was made by using bronchoscopic procedures and the histologically diagnosis was compatible as a typical pulmonary carcinoid. The tumor was resected curatively, and the renin and aldosterone level became normal. A year after the patient looks healthy.

Phenotyping of pulmonary carcinoids and a Ki-67-based grading approach

Pulmonary carcinoids (PC) are separated into typical (TC) and atypical carcinoids (ATC). However, the biological behavior cannot be reliably predicted, and in small biopsies differential diagnosis can be challenging. To provide a basis for a grading approach, we analyzed mitoses and the proliferative index (PI; Ki-67) of 200 PC specimens (TC: n = 114; ATC: n = 86). To define suitable diagnostic and to screen for putative therapeutic markers, CD56, CD57, CD99, CD117, TTF-1, synaptophysin, chromogranin A, CK 18, KL-1, epidermal growth factor receptor (EGFR), human epidermal growth factor receptor 2 (Her-2/neu), somatostatin receptor subtype 2A (SSTR2A), thymidylate synthase (TS), and excision repair cross-complementation group 1 (ERCC-1) expression was analyzed. A combination of synaptophysin and cytokeratins is the most sensitive marker panel for PC with unclear histomorphology. Predictive phenotyping revealed that SSTR2A is expressed in >80% of all PC and may be used both, as a diagnostic marker for imaging approaches and as a predictive marker for octreotide-based therapies. We introduced a grading system distinguishing between PC with low and highly aggressive biological behavior similar to the grading system for gastrointestinal neuroendocrine tumors. The system is superior to the classical separation into TC and ATC. This study indicates that PI in addition to mitotic count may improve prediction of the biological behavior of PC and should be validated in prospective studies.