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Eur J Cardiothorac Surg 2003;24:672
© 2003 Elsevier Science NL
Letter to the Editor |
Department of Thoracic Surgery, University of Torino Italy, San Giovanni Battista Hospital, Via Genova, 3, 10126 Turin, Italy
Received 13 June 2003; accepted 21 July 2003.
* Tel.: +39-11-633-6635; fax: +39-11-696-0170
e-mail: pierluigifilosso{at}tiscalinet.it
Key Words: Lung cancer • Neuroendocrine carcinoma • Adjuvant therapy
The paper of Hage et al. [1] is an interesting study about the biology and the management of large-cell neuroendocrine carcinoma (LCNC) of the lung. The Authors emphasize the rarity of this tumour, and its correct inclusion within the neuroendocrine family of lung neoplasms, according to the recent Travis classification [2] and the immunohisyological staining characteristics.
The high mitotic rate, the presence of tumour necrosis and the size of the neoplastic cells allow a correct diagnosis of LCNC. This tumour appears to have an intermediate biological behaviour between atypical carcinoid and small cell carcinoma (SCC).
Correctly the Authors emphasize how in the past some LCNCs had been misdiagnosed as SCCs or squamous cell carcinomas [1], probably because the scarcity of immunohistochemical stainings available.
LCNCs have generally a poor prognosis: in the recent series published (and in my personal experience, too) early distant metastases (liver, brain or adrenal glands) and/or mediastinal lymph node metastases are a common complaint, even in case of an early radical surgical resection.
Furthermore, a correct preoperative diagnosis of LCNC is really difficult to achieve: lung tumours with neuroendocrine features are often diagnosed by bronchial biopsy or transthoracic fine needle aspiration biopsy. Unfortunately a sure differentiation between LCNC and atypical carcinoid, for example, is quite impossible to achieve with these techniques, because the scarcity of tissue sampling. And the management of these two tumours is really different. Even if N2 just at presentation, a bronchial carcinoid (and the atypical form, too) should be resected [3].
But the correct LCNCs management remains a dilemma: the gold standard is, in my opinion, a correct preoperative staging. Mediastinal and/or distant metastases should be excluded in all cases, to avoid uneffective surgical procedures. I generally use 111In-DTPA-Pentetreotide scintigraphy (Octreoscan) for the preoperative assessment of patients with a suspect (or proven) neuroendocrine lung tumour, because of its proven efficacy in detecting metastases, with higher sensitivity rather than traditional radiological procedures, even in absence of clinical symptoms. I believe that Octreoscan should be considered as FDG-PET scan, in neuroendocrine tumours, and should be largely used.
I strongly agree with Authors’ conclusions about the low LCNCs disease free interval survival, even if the tumour had been diagnosed and treated in an early stage [1]. Distant metastases are commonly observed also in case of radically resected tumours.
Again, an adjuvant therapy in LCNCs is not widely defined: as neuroendocrine tumours they are not completely responsive to chemo or radiotherapy. Thus I suggest the use of a biological therapy with octreotide (alone or in combination with other chemotherapic drugs) as adjuvant treatment. Octreotide has been demonstrated to be an effective antigrowth agent in neuroendocrine tumours, well tolerated and with poor side effects for the patient, especially when the long-acting form is administered.
References
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