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© 2002 American Society for Clinical Oncology
Unusual Pulmonary LesionsCase 2. Endobronchial Carcinoid of the LungVrije Universiteit Medical Centre, Amsterdam, the Netherlands CASE 2. ENDOBRONCHIAL CARCINOID OF THE LUNG A 20-year-old woman was referred for recurrent lower respiratory tract infections treated with antibiotics over the last 3 months. Physical examination revealed only wheezing of the left upper thorax. Laboratory test results were all normal. Chest x-ray (Fig 1, A and B) showed a small dense lesion in the lumen of the left main bronchus region with no hilar or mediastinal lymph node enlargement. Fiberoptic bronchoscopy showed stenosis of the left main bronchus due to a polypoid cherry-red tumor, with a pedicle from the dorsal wall of left upper lobe bronchus orifice. Rigid bronchoscopy using electrocautery was performed with the patient under general anesthesia, and the tumor was completely removed. The initial histologic classification was typical carcinoid with two mitoses per high-power field, with no apparent necrosis (Fig 2, A and B). High-resolution computed tomography (HRCT) with slice thickness of 2 mm was performed a few days after the rigid bronchoscopy; the scans showed no residual tumor, the bronchial wall appeared normal, and lymph node enlargement was absent. Bronchoscopy and endobronchial ultrasonography (EBUS) did not show any residual tumor, and the bronchial wall layers were normal. Extensive biopsy in the area of the initial tumor localization did not show any residual carcinoid.
Endobronchial obstruction is most frequently seen in lung cancer patients. Less malignant or even benign tumors, eg, carcinoid, hamartoma, lipoma, fibroma, and low-grade sarcoma, may also cause lumen obstruction. Patients often present with hemoptysis, wheezing, or postobstructive pneumonia. Bronchoscopic intervention is indicated to obtain a specimen for proper tumor classification and to improve the presurgical condition by resolving the postobstructive pneumonia. Surgery or surgical bronchoplasty has been accepted as the standard treatment for typical bronchial carcinoid. Bronchoscopic tumor removal of intraluminal typical bronchial carcinoid (ITBC) can be attempted in selected cases.1 Confirmation that no tumor has been left behind, by using advanced imaging techniques (eg, HRCT, bronchoscopy, EBUS and biopsies), justifies a more conservative wait-and-see approach. Minimal residual tumor in the bronchial wall may well be below the detection threshold of the HRCT (  2 mm) and EBUS ( 0.1 mm). However, due to the criteria of Travis et al2 in this particular case, the diagnosis shifted from previously typical into an atypical class, purely because of the two mitoses per high-power field that were seen. However, the survival rate in completely resected, atypical carcinoid, even with five to 10 mitoses per high-power field, is still reported to be 81%. The propensity to metastasize and not cause local tumor recurrence is seen mostly in carcinoid tumors that show a more atypical morphologic pattern.
Our experience in treating patients with ITBC, the excellent survival after complete removal, and our ability to accurately assess local tumor invasion using radiologic and sensitive diagnostic tools in bronchoscopy seem to justify a more conservative approach in this particular case.3,4 ITBC tends to be a slow-growing intraluminal polypoid with a low rate of lymph node invasion and low distant metastasis. Even in N2 cases of typical carcinoid, surgery is still indicated.5 An initial bronchoscopic approach seemed to result in a parenchyma-sparing alternative treatment. The only disadvantage is the regular bronchoscopy examinations required for long-term follow-up of possible residual tumor REFERENCES
1.
van Boxem TJ, Venmans BWJ, van Mourik JC, et al: Bronchoscopic treatment of intraluminal typical carcinoid: A pilot study. J Thorac Cardiovasc Surg 116: 402-406, 1998 2. Travis WD, Rush W, Flieder DB, et al: Survival analysis of 200 pulmonary neuroendocrine tumors with clarification of criteria for atypical carcinoid and its separation from typical carcinoid. Am J Surg Pathol 22: 934-944, 1998[CrossRef][Medline] 3. Sutedja G, Golding RP, Postmus PE: High resolution computed tomography in patients referred for intraluminal bronchoscopic therapy with curative intent. Eur Respir J 9: 1020-1023, 1996[Abstract]
4.
Kurimoto N, Murayama M, Yoshioka S, et al: Assessment of usefulness of endobronchial ultrasonography in determination of tracheobronchial tumor invasion. Chest 115: 1500-1506, 1999
5.
Martini N, Zaman MB, Bains MS, et al: Treatment and prognosis in bronchial carcinoids involving regional lymph nodes. J Thorac Cardiovasc Surg 107: 1-6, 1994
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Copyright © 2002 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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