Ann Thorac Surg 2004;78:1093-1095
© 2004 The Society of Thoracic Surgeons
Case report
Sleeve resection of a transcarinal bronchial carcinoid after laser debulking
Matthew R. Mulloy, MDa,
Charles Anderson, MDa,
Oliver Lao, MSa,
Darryl Weiman, MDa,*
a Departments of Cardiothoracic Surgery and Surgery, University of Tennessee–Memphis Health Sciences Center, Memphis, Tennessee, USA
Accepted for publication June 25, 2003.
* Address reprint requests to Dr Weiman, Department of Surgery, University of Tennessee–Memphis Health Sciences Center, 956 Court Ave, Suite G212, Memphis, TN, USA 38163
dweiman{at}utmem.edu
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Abstract
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We report a case of a bronchial carcinoid tumor extending from the right upper lobe into the left mainstem bronchus in a 30-year-old woman. Diagnosis was established by preoperative bronchoscopy and biopsy. After extensive debulking with seven sessions of bronchoscopic neodymium:yttrium-aluminum-garnet laser therapy, the tumor was resected by right upper-lobe sleeve lobectomy. Final pathology revealed a typical carcinoid tumor with surgical margins and all lymph nodes free of tumor.
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Introduction
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Bronchial carcinoid tumors are neuroendocrine neoplasms arising from the Kulchitsky cells of the bronchial epithelium. They are uncommon, representing just 2% of all primary lung carcinomas [1]. Bronchial carcinoids are low-grade malignant tumors with an indolent nature and a typically benign course. Although they can be locally invasive and spread to hilar and mediastinal lymph nodes, the incidence of regional lymph node metastases has been reported to be just 10% to 15% [2]. Approximately 90% of bronchial carcinoids arise in the central bronchi and often present with a pattern of postobstructive pneumonia, hemoptysis, and cough.
A 30-year-old nonsmoking woman presented to the emergency room with her third bout of right-sided pneumonia in 12 months and intermittent wheezing. Her prior medical history was unremarkable. Physical examination revealed an ill-appearing young woman who was febrile, tachypnic, and tachycardic. Breath sounds were markedly diminished over the right thorax. A chest roentgenogram revealed a large opacification of the right middle and lower lobes, with an abrupt termination of the right mainstem bronchus and apparent fullness of the right hilum (Fig 1). The patient was admitted and a chest computed tomographic (CT) scan was obtained.
The CT scan demonstrated an obstructive lesion at the level of the bronchus intermedius on the right with no aeration of the right upper lobe, a postobstructive pneumonic process, and subcarinal adenopathy. The patient then underwent flexible bronchoscopy, which revealed a pedunculated 1.5-cm lesion emerging from the right mainstem bronchus and extending to the level of the carina. The lesion occluded 95% of the right mainstem bronchus, and the bronchoscope was passed beyond this level only with difficulty. Copious amounts of thick, purulent secretions were seen distal to the mass. The mass was found to be friable and bled with manipulation. The patient was referred to the cardiothoracic service for intraoperative biopsy.
Repeat bronchoscopy revealed a large tumor mass extending from the right main-stem bronchus over the carina and partially into the left main-stem bronchus. Cold biopsy specimens were obtained, and the mass was treated with neodymium:yttrium-aluminum-garnet (Nd:YAG) laser fulguration. At the conclusion of the procedure, the mass was confined to the right main-stem bronchus, there was no active bleeding, and the carina appeared to be free of tumor. Pathologic examination found the biopsy specimens to be consistent with a bronchial carcinoid. The decision was made to proceed with further bronchoscopic Nd:YAG laser therapy until the obstruction was relieved and the patient's pneumonia cleared.
The patient underwent six additional Nd:YAG laser treatments until the mass was finally confined to the right upper lobe and the distal lung was adequately reexpanded (Fig 2). A right upper lobectomy with sleeve resection was then performed through a right posterolateral thoracotomy. Final pathology revealed a typical carcinoid tumor with surgical margins and hilar and mediastinal lymph nodes free of tumor. The patient had an uneventful postoperative course and was discharged home on the seventh postoperative day with a completely reexpanded right lung. At 1-year follow-up, she was free of any clinical recurrence.
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Fig 2. Preoperative chest roentgenogram after seven neodymium:yttrium-aluminum-garnet laser treatments.
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Comment
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Bronchial carcinoid tumors are pathologically classified as typical or atypical variants. This classification, with the atypical variant possessing increased mitoses, areas of necrosis, and pleomorphism, provides a pathologic predictor of the biologic and clinical behavior of the tumor. Whereas patients with typical bronchial carcinoid tumors have a 10-year survival rate of 80% to 90%, patients with atypical bronchial carcinoids have a 10-year survival rate of just 40% to 60% [3]. Preoperative pathologic diagnosis is usually attempted on the basis of bronchoscopic biopsy specimens; however, care must be taken, because multiple reports of serious hemorrhage after cold endobronchial biopsy of these lesions exist [4]. Although preoperative pathologic diagnosis is helpful, a definitive diagnosis of typical bronchial carcinoid can not be made until the entire operative specimen is reviewed. As a result, all such tumors have traditionally been approached as if they are pathologically atypical and definitive surgical resection is necessary.
Recent reports have proposed a policy of the conservative resection of bronchial carcinoid tumors, avoiding pneumonectomy whenever distal lung function is conserved and surgical planes of resection are adequate [4, 5]. These reports have demonstrated low recurrence rates and excellent survival among patients treated with parenchyma-sparing techniques at up to 10 years. We agree with these reports, and it is currently our policy that all patients presenting with bronchial carcinoid tumors be evaluated for parenchyma-sparing sleeve resections when anatomically possible. In the past, patients with bulky tumors extending beyond the planes of oncologic resection were not candidates for this type of conservative therapy. However, advances in the use of Nd:YAG laser endobronchial therapy for the resection of such tumors have led us to adopt a policy of aggressive Nd:YAG laser debulking of large tumors in young patients and those unable to tolerate extensive resections. We believe that the indolent nature and low potential for metastases associated with bronchial carcinoids makes them uniquely suitable to Nd:YAG laser debulking, which creates an opportunity for parenchyma-sparing resections in patients with large lesions traditionally relegated to pneumonectomy or, worse, deemed unresectable. The initial Nd:YAG laser treatment enables the immediate restoration of a viable airway, allows for the resolution of atelectatic areas and postobstructive pneumonic processes, provides an opportunity to assess for potential surgical intervention, and—when performed in conjunction with the initial endobronchial biopsy of the lesion—provides a means of controlling any associated hemorrhage. Subsequent sessions serve to debulk the tumor, which creates the opportunity for parenchyma-sparing resections. Although this does leave the possibility of recurrent disease in those sections of the bronchial tree not resected as part of the parenchyma-sparing procedure, the recent success of Nd:YAG laser vaporization as the sole therapy for intraluminal bronchial carcinoids lends support to this approach [6].
In conclusion, Nd:YAG laser therapy is a safe and effective modality for the relief of bronchial carcinoid airway obstruction, the palliation of symptoms, and the control of hemorrhage associated with cold endobronchial biopsy of these lesions. Additionally, the aggressive use of serial Nd:YAG laser sessions to debulk large bronchial carcinoid tumors facilitates the performance of a parenchyma-sparing resection in young patients and older patients who are unfit for more formal resections.
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References
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- Harpole DH, Feldman JM, Buchanen S, Young WG, Wolfe WG. Bronchial carcinoid tumors: a retrospective analysis of 126 patients. Ann Thorac Surg. 1992;54:50–54[Abstract]
- Davila DG, Dunn WF, Tazelaar HD, Pairolero PC. Bronchial carcinoid tumors. Mayo Clin Proc. 1993;68:795–799[Medline]
- Dusmet ME, McKneally MF. Pulmonary and thymic carcinoid tumors. World J Surg. 1996;20:189–195[Medline]
- Jamal ME, Nicholson AG, Goldstraw P. The feasibility of conservative resection for carcinoid tumours: is pneumonectomy ever necessary for uncomplicated cases? Eur J Cardiothorac Surg. 2000;18:301–306[Abstract/Free Full Text]
- Fadel E, Yildizeli B, Chapelier AR, et al. Sleeve lobectomy for bronchogenic cancers: factors affecting survival. Ann Thorac Surg. 2002;74:851–859[Abstract/Free Full Text]
- Boxem T, Venmans B, Mourik J, Postmus P, Stuteja T. Bronchoscopic treatment. Intraluminal typical carcinoid: a pilot study. J Thorac Cardiovasc Surg. 1998;116:402–406[Abstract/Free Full Text]
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Abstract
Introduction
