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Unusual Pulmonary Lesions: Endobronchial Carcinoid of the Lung

University of North Carolina Multidisciplinary Thoracic Oncology Program, Chapel Hill, NC

To the Editor:In their article in the June 1, 2002, issue of the Journal of Clinical Oncology, Codrington et al¹ try to convince readers that simple endobronchial resection of an atypical carcinoid is reasonable. I think it is not.

There is only anecdotal published experience regarding simple endobronchial resection of a typical carcinoid. There are no data that actually define the survival and recurrence rates after such treatment. There are a great deal of data that patients with an atypical carcinoid have a much higher propensity for metastases and death than patients with a typical carcinoid. To extrapolate from anecdotal data in typical carcinoid to justify an approach in an atypical carcinoid is not reasonable. The authors question whether the classification of atypical carcinoid is appropriate in this patient. However, this argument is nothing more than speculation, because once again there are no data to corroborate their assertion.

It is crucial that we do not blindly accept established dogma, but continually question and search for new approaches in treating our patients. This is particularly true as new treatments and new technology become available. I fully support the authors in their interest in doing this. However, we must do this in a rational and progressive manner. A planned approach to endobronchial resection of typical carcinoids can be justified using newer technologies. Exploring new treatments cautiously is primarily appropriate in patients who have contraindications to the standard approach. However, the physicians caring for this patient have chosen to explore, all at once, a new treatment (endobronchial resection alone), new methods of surveillance (endobronchial ultrasound and high-resolution computed tomography), and a new definition of what should constitute an atypical carcinoid.

It is difficult to view the approach taken by Drs Codrington et al as a carefully considered, preoperatively planned-out approach when so many leaps of faith are involved. I find their arguments are not convincing, and I do not think the endobronchial resection of atypical carcinoid can be justified.

REFERENCE

1. Codrington H, Sutedja T, Golding R, et al: Unusual pulmonary lesions: Case 2—Endobronchial carcinoid of the lung. J Clin Oncol 20: 2747-2748, 2002[Free Full Text]

Response

Vrije Universiteit Medical Center, Amsterdam, the Netherlands

In Reply:By asking if endobronchial resection should be the treatment of choice for an atypical carcinoid, Dr Detterbeck in fact questions whether the currently used classification¹ is appropriate for carcinoids presenting as endobronchial tumors. The reason for classifying the tumor in our patient² as atypical carcinoid is strictly based on the number of mitoses in 10 high-power fields (2-10/mm² instead of < 2/mm²). In the previously used classification,³ the cutoff point was at five mitoses. The new classification is based on a tumor tissue bank of 200 neuroendocrine pulmonary tumors. From the publication by Travis et al,¹ it is unclear how many, if any, tumors are included in this series that presented in the same way as our patient’s did. Furthermore, in the univariate and multivariate analysis, the clinical presentation was not mentioned as a prognostic factor tested in this population; therefore, there remains uncertainty about whether the very strict cutoff point at two mitosis per 2 mm³ is the only important criterion and as such more important than the clinical presentation in a patient like the one we described.

Based on our series, the clinical behavior of patients presenting with an endobronchially growing neuroendocrine tumor is much more like the behavior of a typical carcinoid, with no tendency to metastasize to regional lymph nodes or distant sites and no invasion of the surrounding tissue. In a series of 37 patients presenting with an endobronchial tumor, 19 patients were successfully treated with endobronchial resection; the mean follow-up of these patients was 5 years (range, 1 to 10 years). Of the remaining 18 resected patients, in 13 patients the invasion into the bronchial wall, measured using high-resolution computed tomography,⁴ was to deep to make cure possible by this endobronchial technique. In four patients, resection was performed because of technical limitations of endobronchial treatment. In only one patient was there doubt about the diagnosis before treatment. Of these 18 patients, only one had a lymph node metastasis.

On the basis of these results, we still think that besides the histologic classification, the clinical presentation should also be taken into account before deciding what the appropriate treatment is for a patient with a neuroendocrine tumor presenting as an endobronchial tumor. Since the ability to evaluate local extension of a tumor is becoming more and more accurate, a local treatment, such as intraluminal therapy, should be taken into consideration for this tumor, with its rather benign behavior, as a possible alternative for the more dogmatic choice of immediate surgical bronchoplasty and bronchotomies.

REFERENCES

1. Travis WD, Rush W, Fkieder 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]

2. Codrington H, Sutedja T, Golding R, et al: Unusual pulmonary lesions: Case 2—Endobronchial carcinoid of the lung. J Clin Oncol 20: 2747-2748, 2002[Free Full Text]

3. Arrigoni MG, Woolner LB, Bernatz PE: Atypical carcinoid tumors of the lung. J Thorac Cardiovasc Surg 64: 313-421, 1972

4. Van Boxem TJ, Golding RP, Venmans BJ, et al: High resolution computed tomography in patients with intraluminal typical bronchial carcinoid treated with bronchoscopic therapy. Chest 117: 125-128, 2000[Abstract/Free Full Text]

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