Is endobronchial treatment adequate in endobronchial typical

carcinoids?

YES

JM VERGNON MD, Ph DChief , department of chest diseases And thoracic oncologyUniversity hospitals of St Etienne France

President of the GELF (French Speaking International group on thoracic endoscopy)

The carcinoid tumors

are neuro-endocrine tumors. several classifications:

OMS 1981 3 types: typical, atypical and small cell lung cancer Warren et Gould 1985 4 types Travis 1991 4 types: typical, atypical, large cell NE carcinoma and small cell lung cancer.

Carcinoids are rare tumors (1 to 2% of all bronchial tumors)

typical carcinoid: >5 mm, without necrosis,<2 mitoses on 2 mm2

Atypical carcinoid : mitoses ≥ 2 on 2 mm2 and/or focal necrosis

Location et aspect

In central airways in 70% of cases, and more frequently in the right side (61%) (Hage) The tumor can be strictly endoluminal like a polyp or with an « iceberg » shape through the bronchial wall Biopsies are often « bleeding » and cytological analysis non contributive.. Well limited tumor in typical type

Location and aspect (2) The aspect is less limited with infiltrative component in atypical carcinoids

Local and mediastinal extension

Extension beyond the bronchial wall assessed on CT scan, in depth biopsies ou echoendoscopy

Node extension 8-10% N1,3% N2 for typical carcinoids, 27% N1,14% N2 et 14% N3 for atypical carcinoids

Metastatic extension for atypical carcinoids

Conventional treatment and prognosis

Conventional surgery: lobectomy or more for atypical carcinoids Mediastinal curage +++ Limited surgery (sleeve resection) for typical carcinoids In typical carcinoids : the prognosis is not clearly associated with node invasion. (Hage R et al. Ann Surg Oncol 2003, Ducrocq X, Ann Thorac surg. 1998)

Hage R et al. Ann Surg Oncol 2003

Interventional bronchoscopy role

large sampling to assess the best classification of carcinoids palliative intent:

Debulking treatment hemoptysis control.

Interventional bronchoscopy role

Neo-adjuvant therapy Post-obstructive pneumonia drainage Better analysis of tumor limits for minimal surgical resection

Curative intent on highly selected patients with typical carcinoids .

Conditions to propose curative bronchoscopic resection

Only typical carcinoids strictly endoluminal tumors Tumor accessible with the bronchoscopic tool (rigid or flexible) Thin basis (< 1,5 cm2) Without enlarged lymph nodes on CT scan. Less than 5 cm3

5 similar studies: Sutedja T.: Chest 1995 on 11 patients Van Boxem T.: Journal Thorac Cardiovasc Surg 1998 on 19 patients Cavaliere S.: Journal of Bronchology 2002 on 38 patients (47 in 2005) Luckraz H.: Journal Thorac Cardiovasc Surg 2006 on 28 patients Our team, Bertoletti L.Chest 2006 on 18 patients

Patient selection

For S Cavaliere: 47/176 typical carcinoids (27%) For our team 14/29 typical carcinoids referred for resection

Treatment methods

YAG laser coagulation, mechanical resection, laser coagulation and sterilization of the basis (Cavaliere) YAG laser coagulation,(or HF electrocautery), mechanical resection and cryotherapy of the basis (St Etienne and Montreal) Mechanical resection and as needed diathermy for Luckraz Van Boxem: HF electrocautery, YAG laser or photodynamic therapy

Courtesy: Dr Rita Jean-François

ENDOSCOPIA RESPIRATORIASPEDALI CIVILI - BRESCIA

Results

T van Boxem: cure 14/19 at 29 months. Surgery proposed for the others due to a remaining tumor. S Cavaliere: only 1 recurrence on 47 patients ,treated with lobectomy. Median follow-up: 38 months. L Bertoletti (St Etienne): 1 local recurrence on 18 patients, 7 years after, treated by lobectomy. Median follow-up : 44.5 mois H Luckraz: mean follow-up 8.8 years (105. 6 months) 1 local recurrence at 80 months, treated by lobectomy.

despite the lack of mediastinal curage, no mediastinal recurrence has been observed in these series.

Endoluminal tumor

Tumor resection (large Biopsies)

Atypical carcinoidTypical carcinoid

CT scan

±EchoendoscopySurgical Resection± th. BronchoscopyTo spare lung parenchymaResection margins 5mmMediastinal curage

beyond the lumen or N+

endoluminalTumor < 5cm3

Central airwaysN0

T. Bronchoscopy« curative »

Flexible bronchoscopy + CT scanEach 6 months ,2 yearsthen 1 per year : 5 yearsThen, on demand only

Recurrence

YES

NO

Thanks for your attention