In the January 2012 issue of the Journal of Bronchology & Interventional Pulmonology, Dr Neyman and colleagues report on a comparison of endobronchial ablation (EA) to surgical resection (SR) for the management of typical carcinoid tumors. In their study, they looked at 73 patients between 2002 and 2010. Forty-eight patients underwent SR and 25 EA, although some crossover was noted.
The criteria for EA with curative intent were as follows:
- Presumably a typical type of tumor histology.
- Polypoid growth of the tumor.
- Absence of obvious distal metastases.
Lesions were treated using a Nd-YAG laser set to 40 to 45 W. A combination of flexible and/or rigid bronchoscopy with mechanical debulking and balloon dilation was also used. SR was performed through a lateral thoracotomy. The median follow-up was 3 years with a range of 6 months to 8 years. Computed tomographic scan and bronchoscopic surveillance were performed yearly for 5 years after treatment. Those patients who did not fulfill the endoscopic ablation criteria were taken for surgery: 5 of 48 had EA in addition to SR. The overall survival by the end of the study was 94.5% for the SR group and 94.4% for the EA group (P=0.9). Patients with typical and atypical carcinoids had a survival of 96.7% and 81.8%, respectively, (P=0.05). Of the 69 survivors, none had signs of recurrence on computed tomographic or bronchoscopy by the termination of the study.1 Although complications were minimal, there was 1 significant complication reported: an endobronchial fire.
The authors argue that there is a similar survival and recurrence rate with each management option. This is in contrast to a long-held belief that SR is the gold standard of treatment, with a survival rate after SR as high as 95% after 5 years.2
From the oncologic point of view, SR is felt to be the standard approach as removal of the malignant tissue, if possible, is one of the primary tenants. Resection also offers the added advantage of a larger sampling of the lesion and the ability to differentiate with more certainty the typical from the atypical carcinoid as this is an important factor in prognosis. A tissue-sparing approach has been advocated as many features of typical carcinoid appear to be amenable to bronchoscopic treatment. Initial success with a 2-staged procedure involving a bronchoscopic ablation first followed by resection showed evidence that in many cases there was no residual tumor. These findings led to the hypothesis that a carcinoid may be amenable to a bronchoscopic-only management scheme.3 Bronchial carcinoids are unique in that they often display a tendency for polypoid growth in a central airway accessible to a bronchoscope (rigid of flexible). They have a low rate of metastasis and a slow growth rate, yielding a high survival rate. These features make bronchoscopic management attractive.
In 1988, Cavaliere et al4 demonstrated that laser ablation of polypoid bronchial carcinoids could be used to eradicate the tumors successfully, and that most of the patients had no relapse with a follow-up of 10 to 50 months. Later, Cavaliere and colleagues described their experience with Nd:YAG laser application in patients with resectable typical carcinoids. In 38 selected patients with intraluminal tumor with no evidence of lymph node or distant metastasis, they reported a 92% success rate with a median follow-up of 24 months.5 Similar reports with excellent survival were presented by many others.6–9
As endobronchial technologies improve, we have the potential to refine our decision-making process and this may translate to better morbidity and survival. Radial endobronchial ultrasound (R-EBUS) is capable of determining the depth and the extent of tumor invasion in an airway as shown by Kurimoto and colleagues.10,11 This technology may allow for improvement in deciding as to which tumor is “localized” on the basis of the depth of invasion and hence better suited for endobronchial management. Coupling R-EBUS with EBUS trans-bronchial needle aspiration for interrogation of the mediastinum allows for differentiation of isolated versus local or distant spread better than ever before. Autofluorescence, narrow band imaging, or other imaging modalities can also increase our sensitivity and may allow this combination of technologies to show results that are truly comparable or possibly even superior to SR in longer term follow-up.12,13
The focus of this paper and discussion was typical carcinoids as the data suggest that it is more amenable to a less aggressive approach. Recently, a few authors have also extended this thought process to the atypical, with good results.14,15
Combining technologies should not be isolated to cases planned as “endobronchial-only” therapy but rather to all cases to determine which management strategy may be best on an individualized approach.
Carcinoids can progress slowly and so yearly follow-up is advised. Because the slow growth and subsequently delayed manifestation of recurrent tumor requires a longer follow-up period than 5 years, some advocate 25 years or more. However, no sound recommendation for follow-up can be given on the basis of the present study. On the basis of this report and the cumulative data, EA can be considered for a typical polypoid carcinoid, in a central airway, with no radiographic evidence of metastasis and a negative R-EBUS of the airway wall and EBUS trans-bronchial needle aspiration of the mediastinal and hilar lymph nodes, provided there is a long-term follow-up. Although complications are rare, an endobronchial fire can lead to devastating long-term issues and care must be taken to avoid this or others as the safety associated with bronchoscopy is a major advantage.
This continues to be an exciting time for interventional pulmonologists as we continue to expand our boundaries. A technique that was originally developed as a purely palliative measure appears to play a curative role. Of course, our excitement must be tempered as until we demonstrate similar findings in randomized, controlled studies with long-term follow-up, we will continue to debate as to which option is superior. This publication by Neyman and colleagues is another step toward a multidisciplinary approach in which individualized care may lead to continued improvement in patient care.
1. Neyman K, Sundset A, Naalsund A, et al. Endoscopic treatment of bronchial carcinoids in comparsion to surgical resection: a retrospective study. J Bronchol Intervent Pulmonol. 2012;19:29–34
2. Rizzardi G, Marulli G, Bortolotti L, et al. Sleeve resections and bronchoplastic procedures in typical central carcinoid tumours. Thorac Cardiovasc Surg. 2008;56:42–45
3. Chhajed PN, Eberhardt R, Dienemann H, et al. Therapeutic bronchoscopy interventions before surgical resection of lung cancer. Ann Thorac Surg. 2006;81:1839–1843
4. Cavaliere S, Foccoli P, Farina PL, et al. Nd:YAG laser bronchoscopy. A five-year experience with 1,396 applications in 1,000 patients. Chest. 1988;94:15–21
5. Cavaliere S, Foccoli P, Toninelli C. Curative bronchoscopic laser therapy for surgically resectable tracheobronchial tumors: personal experience. J Bronchol. 2002;9:90–95
6. Luckraz H, Amer K, Thomas L, et al. Long-term outcome of bronchoscopically resected endobronchial typical carcinoid tumors. J Thorac Cardiovasc Surg. 2006;132:113–115
7. Fuks L, Fruchter O, Amital A, et al. Long-term followup of flexible bronchoscopic treatment for bronchial carcinoids with curative intent. Diagn Ther Endosc. 2009;2009:782961
8. El Jamal M, 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
9. Morandi U, Casali C, Rossi G. Bronchial typical carcinoid tumors. Semin Thorac Cardiovasc Surg. 2006;18:191–198
10. Kurimoto N, Murayama M, Yoshioka S, et al. Assessment of usefulness of endobronchial ultrasonography in determination of depth of tracheobronchial tumor invasion. Chest. 1999;115:1500–1506
11. Herth FJF, Becker HD, LoCicero J III, et al. Endobronchial ultrasound in therapeutic bronchoscopy. Eur Respir J. 2002;20:118–121
12. Herth FJF, Becker HD, LoCicero J III, et al. Endobronchial ultrasound improves classification of suspicious lesions detected by autofluorescence bronchoscopy. J Bronchol. 2003;10:249–252
13. Yasufuku K. Early diagnosis of lung cancer. Clin Chest Med. 2010;31:39–47
14. Brokx HA, Risse EK, Paul MA, et al. Initial bronchoscopic treatment for patients with intraluminal bronchial carcinoids. J Thorac Cardiovasc Surg. 2007;133:973–978
15. Katsenos S, Rojas-Solano J, Schuhmann M, et al. Bronchoscopic long-term palliation of a recurrent atypical carcinoid tumor. Respiration. 2011;81:345–350