| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 1998;66:1870-1871
© 1998 The Society of Thoracic Surgeons
a Department of Thoracic Surgery, Hôpitaux Universitaires de Strasbourg and, Hopital Sainte Marguerite, Marseille, France
To the Editor
We thank Drs Yildizeli and Yüksel for their kind comments regarding our article [1], and for raising the discussion about endoscopic treatment of bronchial carcinoid tumors. We have to admit that our personal experience is limited to a single case included in the reported series [1]. This particular patient underwent surgical resection early after laser resection, and pathology disclosed residual tumor on the specimen. Despite the advent of various endoscopic tools, such as laser, cryotherapy, brachytherapy, and photodynamic therapy, we would still be reluctant to submit a patient with a curable lesion to exclusive endoscopic treatments.
The first reason is that the typical feature of a carcinoid tumor may well be hypothesized on biopsy specimens, but confirmation relies on pathologic examination of the whole specimen. Patchy areas of increased mitoses, necrosis, or both characterizing atypical carcinoid tumors often evolve within an atmosphere of typical carcinoid differentiation, and need a thorough analysis of the complete resection specimen to be recognized. This is particularly important for prognosis, because atypical carcinoid tumors are known for their aggressive behavior, which requires radical resection as for nonsmall cell lung cancer. Photocoagulation destroys at least a part of the tumor, which is thus lost for pathologic examination. Second, approximately 10% of patients with typical carcinoid tumors are expected to have nodal metastases, which obviously cannot be identified without complete lymph node dissection [1, 2]. Presence of lymph nodes is not correlated with tumor size and may occur together with very small tumors. Given that several evaluations of computed tomographic scanning have concluded that its specificity regarding lymph node status of conventional bronchogenic carcinoma is relatively low, there is no reason why computed tomographic scan should be more reliable to predict lymph node metastases of carcinoid tumors. On the other hand, various reports demonstrate that lymph node metastases are not an adverse prognostic factor, provided that a complete resection has been performed [1, 2]. Therefore, incomplete endoscopic therapy may jeopardize long-term prognosis in these patients. Third, the endobronchial part of a carcinoid tumor is most often the tip of the iceberg, and a large part of the tumor would be inaccessible to endobronchial treatments. Finally, application of endoscopic treatments is limited by anatomic restrictions. We would recommend neither blind laser photocoagulation nor photodynamic therapy achieving coagulation necrosis to a depth of 5 mm in areas where the pulmonary artery crosses the bronchial tree, such as the posterior wall of the left upper lobe or the anterior aspect of the right mainstem bronchus, because of the threat of immediate or delayed bronchoarterial fistula.
A prolonged follow-up period is mandatory to validate any form of treatment for typical carcinoid tumors, because local recurrence and metastases appear generally beyond 5 to 7 years after treatment [1]. Regarding long-term results achieved with endoscopic therapies, Drs Yildizeli and Yüksel refer to a retrospective multicenter study published by Dr Sutedja and colleagues [3]. The latter article summarized the records of 11 patients collected from five centers; at the conclusion of the study, all patients had remained in complete remission. Median follow-up was 54 months; 5 patients were followed up for more than 5 years and only 2 patients were followed up for 10 years or longer. Because 6 patients had undergone surgical resection soon after endoscopic therapy, exclusive endoscopic treatment was applied to 5 patients only; 2 of them were followed up for 5 years and a single patient was followed up for 10 years. We believe that these data are insufficient to draw definitive conclusions. In addition, the authors recommend bronchoscopic follow-up at 3 to 6 month intervals; cost and patient discomfort also should be taken into consideration.
The series of Dr Sutedja and colleagues with excellent long-term results should be counterbalanced with less optimistic reports, concluding that local recurrence rate exceeds 50% in patients managed with exclusive endoscopic therapies [4]. Further, considering that patients with typical carcinoid tumors have an excellent long-term vital prognosis, one should not obscure the risk of median-term bronchial stenosis after endoscopic laser resection, which is quoted from 10% to 50% [5].
Given the low morbidity and excellent long-term results observed with bronchoplastic resections [1, 4, 6], we believe that surgery should still be regarded as the mainstay of curative treatment for typical bronchial carcinoid tumors. In our opinion, endoscopic therapies for otherwise operable patients should be limited to preoperative deobstruction of the airway in patients presenting with tumors close to the tracheobronchial bifurcation, impaired respiratory reserve, or both. When the precise origin of the tumor can not be established by endoscopy and medical imaging, there might be some place for endoscopic debulking before reassessment and subsequent operative management. In conclusion, we would like to return the following question to Drs Yildizeli and Yüksel, and to the thoracic surgical community in general: What would be their decision when caring for a 22-year-old woman presenting with a complete obstruction of the left upper lobe take-off by a carcinoid tumor?
References
This article has been cited by other articles:
|
|
 |
|
  J. Lemaitre, Z. Mansour, E. A. Kochetkova, C. Koriche, X. Ducrocq, J.-M. Wihlm, E. Quoix, and G. Massard Bronchoplastic lobectomy: do early results depend on the underlying pathology? A comparison between typical carcinoids and primary lung cancer. Eur. J. Cardiothorac. Surg., July 1, 2006; 30(1): 168 - 171. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
