TREATMENT
Treatment for bronchial carcinoid is surgical. The few reports of radiation and chemotherapy were as surgical adjuncts in difficult cases.10Surgery is generally geared towards preserving as much lung tissue as possible while still resecting the entire tumor.11,12 A recent article by Jamal looked at the feasibility of conservative resection in a group of 110 patients with bronchial carcinoids.8 These patients ranged in age from 14 to 81. A total of 96 operations were done. Follow up time ranged from 6 months to 12 years. Only 3 pneumonectomies and 3 endobronchial resections were done. The rest of the patients had lobectomies or wedge resections. Although follow-up time was short, the authors concluded that conservative surgery resulted in an overall 96% recurrence free survival. However, endoscopic resection was not recommended as 2 out 3 patients recurred. In this series, nodal involvement and histology did not influence outcome. The need for long term follow-up was stressed as a case of recurrence after 18 years was described.
There are few studies looking at factors that predict recurrence. One study by Musi et al., followed 21 patients for over 5 years.13 Within 4 years 5 patients had recurred. All 3 atypical histology patients and both typical histology patients with nodal involvement recurred. It was concluded that atypical histology predicts recurrence, and in typical histology patients, positive nodal status predicted recurrence.
Martini et al. looked at the effect of nodal status on survival in a group of 25 patients.7 All had nodal involvement, 12 were typical histology and 13 were atypical. They were followed for 5 years. The five-year survival was 92% for the typical patients and only 60% in the atypical patients. Size predicted recurrence in the atypical patients in that only 1 out 6 patients with a tumor less than 3 cm large recurred whereas all 6 of those with tumors larger than 3 cm recurred.
A series of 43 patients, all with typical histology, was examined by Granberg et al. to see what predicted survival in this group.10 They were followed from 14 to 330 months. Overall, 5 patients died and mortality was correlated with nodal involvement. 30% of those with nodes died. 6% of those without nodes died.
Larger
studies have looked at survival of bronchial carcinoid tumors. In the
Modlin & Sandor review over 2000 bronchial carcinoids were included in
the analysis.4 Five-year survival was 80%
for localized disease, 75% for those with nodal involvement and only 14%
when distant metastases were present. This study did not differentiate
between histology. Fortunately most bronchial carcinoids are localized
at presentation. In this same review 66% were localized, 20% had nodal
involvement, 7% had distant spread (6% were not staged). This survival
is better than for other carcinoid tumors with the average localized carcinoid
tumor having only a 50% five-year survival.
In general these studies suggest that survival is good for bronchial carcinoids. Although most of the evidence comes from small studies the literature suggests that poor outcome is associated with atypical histology, atypical histology with a large primary, nodal involvement, and distant spread.
Once a diagnosis is made, it is desirable to determine the extent of tumor spread. Somatostatin is a tetradecapeptide that is produced by neurogenic cells.14 It has a variety of functions including reducing hormone release, immune modulation and inhibition of cell proliferation and angiogenesis. Octreotide is a somatostatin analog that binds to somatostatin receptors. These receptors are present on some malignancies including most bronchial carcinoids. Octreotide thus has diagnostic and therapeutic potential.15 Musi et al. found that in a series of 21 patients, follow-up radiolabelled-octreotide scans in 11 predicted all five recurrences.13 The conclusion form this study was that octreotide scans are useful in detecting both metastases and recurrences.
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