(Chest. 2000;117:125-128.)
© 2000
American College of Chest Physicians
High-Resolution CT in Patients With Intraluminal Typical Bronchial Carcinoid Tumors Treated With Bronchoscopic Therapy*
Ton J. van Boxem, MD;
Richard P. Golding, MD;
Ben J. Venmans, MD;
Pieter E. Postmus, MD, PhD, FCCP and
Tom G. Sutedja, MD, PhD, FCCP
*
From the Departments of Pulmonary Medicine (Drs. van Boxem, Venmans, Postmus, and Sutedja) and Radiology (Dr. Golding), University Hospital Vrije Universiteit Amsterdam, Amsterdam, the Netherlands.
Correspondence to: Tom G. Sutedja, MD, PhD, FCCP, Department of Pulmonary Medicine, University Hospital Vrije Universiteit Amsterdam, PO Box 7057, 1007 MB Amsterdam, the Netherlands; e-mail: tg.Sutedja{at}AZVU.NL
 |
Abstract
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Study objective: To evaluate the extent to which
high-resolution CT (HRCT) can predict the clinical outcome of
bronchoscopic treatment with curative intent in patients with
intraluminal typical bronchial carcinoid tumors.
Design: An observational study.
Setting:
Bronchoscopy unit and radiology department of a university
hospital.
Patients and interventions: Eighteen
patients with intraluminal typical bronchial carcinoid tumors in the
absence of nodal and distant disease were treated with bronchoscopic
electrocautery or Nd-YAG laser as an alternative to surgical resection.
Prior to treatment, HRCT was performed.
Results: In 10
patients, HRCT showed no peribronchial tumor extension, and 9 of these
patients were found to be tumor free after bronchoscopic treatment. So
far during follow-up, none of these patients has had a recurrence of
the tumor. The median duration of follow-up was 33 months (range, 13 to
68 months). In five patients, HRCT showed signs of peribronchial tumor
extension. In three of these patients, specimens taken from biopsies
performed after bronchoscopic treatment showed residual tumors, and
salvage surgery was carried out. In three patients, HRCT was unable to
assess peribronchial tumor extension: in two because of insufficient
connective tissue contrast between the hilar structures and in one
patient because of suboptimal scan technique.
Conclusion: HRCT findings were complementary but not
conclusive in patients with intraluminal typical bronchial carcinoid
tumors treated with bronchoscopic therapy. However, in a category of
patients in whom HRCT showed strictly intraluminal tumors,
bronchoscopic resection as an alternative for surgical resection seems
justified.
Key Words: bronchoscopic treatment • high-resolution CT • intraluminal typical bronchial carcinoid
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Introduction
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Bronchoscopic
treatment has a curative potential in patients with centrally located,
intraluminal, early-stage lung cancer.1
2
3
4
5
The absence of
extraluminal tumor, lymph node metastasis, and distant metastasis is
crucial to achieving complete tumor eradication.6
7
8
The
success of bronchoscopic treatment also is strongly related to tumor
size and location. The accurate assessment of tumor extension prior to
bronchoscopic treatment is essential to properly select candidates for
this alternative to surgery and to provide an accurate prediction of
treatment efficacy. Conventional radiologic examinations and standard
CT have been reported to be relatively inaccurate in assessing tumor
extension.9
10
11
High-resolution CT (HRCT) provided more
accurate information in patients with early-stage squamous cell lung
cancer who were referred for bronchoscopic treatment.12
The same may apply for a subgroup of patients with intraluminal typical
bronchial carcinoid (ITBC) tumors. We have reported
previously13
that in patients with ITBC tumors,
bronchoscopic treatment resulted in the histologically confirmed
disappearance of tumors in patients who underwent surgery after
bronchoscopic treatment. Recently, we have confirmed the curative
potential of bronchoscopic treatment for ITBC tumors as an alternative
to surgical resection in a pilot study.14
In the present
study, the predictive value of HRCT for the clinical outcome of
bronchoscopic treatment in patients with ITBC tumors was examined.
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Materials and Methods
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Eighteen patients, 11 men and 7 women, with a median age of 44
years (range, 20 to 74 years) with ITBC tumors were treated
bronchoscopically with curative intent. Patients were referred from
other hospitals in the Netherlands to our department for bronchoscopic
treatment. Tumors were accessible for the fiberoptic bronchoscope, and
conventional CT showed no signs of extraluminal tumor extension or
nodal enlargement (> 1 cm).14
Patients underwent
additional HRCT scanning (Somaton Plus(R); Siemens; Erlangen, Germany).
Data acquisition was obtained with the spiral technique using the
following factors: mA, 145; kilovolt, 137; table feed, 2 mm; and slice
thickness and reconstruction, 2 mm (pitch, 1 mm). Further
details about the scan technique have been described
elsewhere.12
Images were reevaluated by an experienced
radiologist without knowledge of the bronchoscopic treatment outcome.
The radiologist described tumors as being invisible, strictly
intraluminal, or partly extraluminal. An extraluminal tumor was thought
to be present in the case of bronchial wall irregularities or with the
presence of extraluminal tissue with the same density and contrast
enhancement as the intraluminal tissue. Extraluminal tissue that showed
the same degree of enhancement as intraluminal tumor was considered to
have an identical vascular pattern with regard to contrast access to
both the capillary network and the extracapillary interstitial space.
Nodal enlargement was described when present. Bronchoscopy was
performed prior to treatment, and tumors were assessed in terms of
location and size.
Bronchoscopic treatment was carried out using Nd-YAG laser,
electrocautery, or both. No more than two bronchoscopic treatment
sessions were carried out within a maximum period of 2 months. Surgical
resection was performed without delay in cases in which the tumor
persisted after two bronchoscopic treatment sessions or after 2 months.
A complete response was defined when bronchoscopy, histology specimen,
and radiologic examinations showed no signs of tumor persistence or
recurrence during follow-up. Postbronchoscopic treatment evaluations
consisted of bronchoscopy, chest radiograph, and CT. Follow-up
bronchoscopies were carried out once at 3 to 4 weeks after
bronchoscopic treatment, at 3-month intervals during the first year
after bronchoscopic treatment, and every 6 months thereafter. HRCT
findings prior to treatment with and after the outcome of
bronchoscopic treatment, with a minimum follow-up of 12 months, were
compared.
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Results
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Locations of tumors are shown in Table 1
. Mean tumor size was 1.4 cm (range, 0.4 to 2.0 cm). The results of HRCT
and bronchoscopic treatment are shown in Table 1
. Overall, the success
rate for bronchoscopic treatment was 72% (95% confidence interval, 47
to 90%). None of the HRCT scans showed lymph nodes that were > 1 cm
in diameter. In 10 patients, HRCT showed no signs of peribronchial
tumor extension, and in this subgroup the success rate of bronchoscopic
treatment was 90% (95% confidence interval, 56 to 100%). Median
follow-up after bronchoscopic treatment has been 33 months (range, 13
to 68 months). The tumor was invisible on HRCT scan in four of these
patients. In only one patient with no signs of extraluminal tumor did
bronchoscopic treatment fail to achieve a complete response. In that
case, the tumor was located in a segmental bronchus, and the distal
tumor margin was difficult to assess bronchoscopically. In five
patients, HRCT showed signs of extraluminal tumor extension.
Bronchoscopic treatment could not achieve a complete response in three
of these patients, and salvage surgery was necessary. The sign of
extraluminal tumor extension in these three patients was extraluminal
tissue with the same density and contrast enhancement as the
intraluminal tumor. In one of the three patients, the definite
diagnosis after surgery proved to be atypical carcinoid tumor, which
contrasted with the diagnosis prior to resection. In three patients,
HRCT was not able to assess peribronchial tumor extension: in two
patients because of insufficient connective tissue contrast between the
hilar structures, and in the other patient because of suboptimal scan
technique. Tumor location and tumor size were also predictors of
successful bronchoscopic treatment. In all five patients in whom
bronchoscopic treatment failed, the tumor was located in a
segmental bronchus, and the distal tumor margin was difficult to
assess. Of eight patients who had tumors that were 
1 cm in
diameter, bronchoscopic treatment failed to achieve complete
response in only one patient. Of 10 patients who had tumors that were
> 1 cm in diameter, bronchoscopic treatment failed to achieve
complete response in 4 patients.
View this table:
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Table 1.. Patient Characteristics, Tumor Localization, Tumor
Size, HRCT Findings, Treatment Outcome, and Follow-up*
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Discussion
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This study confirms the assumption that HRCT findings predict
clinical outcome of bronchoscopic treatment in patients with ITBC
tumors. When HRCT showed a strictly intraluminal tumor, bronchoscopic
treatment could achieve clinical complete response in all cases except
one. In this subject, the tumor was located in a segmental bronchus and
the distal tumor margin was difficult to assess. However, HRCT was not
conclusive when signs of extraluminal tumor were found. In two
patients, bronchoscopic treatment achieved complete response despite
signs of extraluminal tumor on HRCT. CT with the high-resolution
technique provided additional information regarding tumor extension. In
five patients in whom conventional CT showed no extraluminal tumor,
HRCT showed signs of extraluminal tumor. However, in all these cases,
the radiologist had difficulty in distinguishing the tumor from
atelectasis. This is understandable since both atelectasis and tumor
can be indistinguishable even on HRCT. Complete response could only be
achieved in two of the five patients with signs of extraluminal tumor
on HRCT.
Accurate assessment of tumor extension is crucial in selecting patients
with ITBC tumors who would be suitable for bronchoscopic treatment and
in properly determining its effectiveness compared to standard
treatment. HRCT provides a better spatial resolution in part by using a
different reconstruction algorithm. The optimal judgment of
extraluminal tumor growth requires an experienced radiologist with
knowledge of the technique and this specific indication. The
indications for and limitations of bronchoscopic treatment with
curative intent have been addressed before.15
The success
rate of bronchoscopic treatment depends not only on the peribronchial
extension of the tumor, but also on its malignant behavior, location,
and size. Early-stage squamous cell lung cancer tumors that are 3
mm thick and have a longitudinal axis 20 mm have been shown not to
have lymph node metastasis.6
7
8
Therefore, bronchoscopic
treatment has been proposed as a "tissue-sparing" treatment
alternative to surgical resection in this category of patients.
Regardless of the technique of choice, eg,
photodynamic therapy, brachytherapy, Nd-YAG laser, or
electrocautery, complete tumor eradication is the ultimate
goal.15
This goal also may apply to a subgroup of patients
with ITBC tumors in whom the tumor is strictly intraluminal, mural,
pedunculated, or sessile and is easily accessible for the bronchoscope,
as has been reported recently.14
In our present series,
the inclusion criteria for bronchoscopic treatment were similar to
those used in early-stage squamous cell lung cancer; ie,
tumors were intraluminal without signs of peribronchial tumor on
conventional CT and never exceeded 2 cm in diameter.
In-depth necrosis of several millimeters can be obtained by endoscopic
techniques such as Nd-YAG laser or bronchoscopic electrocautery. These
techniques have been proven to be potentially curative in patients with
early-stage squamous cell lung cancer and ITBC
tumors.14
16
Longer follow-up is necessary to determine
whether this technique is as effective as surgical resection in a
subgroup of patients with ITBC tumors, as the typical carcinoid tumor
is very slow growing. Nevertheless, the time of survival after
bronchoplastic surgery, together with the low rate of lymph node
invasion and metastasis of the typical carcinoid tumor, the central
localization, and the tendency for endobronchial polypoid growth within
the large airways justify consideration of bronchoscopic treatment as a
potentially tissue-sparing alternative for surgery.17
18
19
In our opinion HRCT should be performed in patients with ITBC tumors to
assess the tumor more accurately and to estimate the likelihood of
achieving complete tumor eradication with bronchoscopic treatment.
Slight signs of peribronchial tumor should not automatically
exclude a patient from bronchoscopic treatment with curative intent,
especially when bronchoscopic accessibility is excellent and tumor
debulking is initially acceptable before the final decision to proceed
to surgical resection.
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Footnotes
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Abbreviations: HRCT = high-resolution CT;
ITBC = intraluminal typical bronchial carcinoid
Received for publication February 22, 1999.
Accepted for publication July 15, 1999.
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TOP
Abstract
Introduction
