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J Thorac Cardiovasc Surg 2003;126:1224-1225
© 2003 The American Association for Thoracic Surgery

Letter to the editor

Possible Tx N2 M0 atypical bronchial carcinoid associated with Cushing syndrome

Department of Thoracic Surgery, San Giovanni Battista Hospital, University of Torino, Torino, Italy

To the Editor:

Although bronchial carcinoids (BCs) account for only 1% of cases of Cushing syndrome (CS),¹ in many cases the ectopic adrenocorticotropic hormone production has a source within the thorax. Usually typical BCs are the cause of ectopic CS, but rarely atypical ones have been described. BCs associated with CS appear more aggressive than others, with high tendency to metastasize.²

The article of Sugawara and colleagues,³ "Successful Localization and Treatment for Ectopic Adrenocorticotrophic Hormone Secretion in a Rare Case of Possible Tx N2 M0 Carcinoid Tumor With Cushing Syndrome," is interesting and highlights the importance of a correct management of a patient with ectopic CS. I have some questions for the authors:

1. Why did they not perform a mediastinoscopy before 2001, rather than video-assisted thoracoscopic lymph nodal resection?
   
2. Why was scintigraphy with indium In-111 pentetreotide (OctreoScan) performed only in 2001 and not earlier?
   
3. Why was the surgical resection was performed by thoracoscopy and not by thoracotomy?
   
4. Was the patient subjected to any adjuvant therapy?
   
5. Was OctreoScan scintigraphic follow-up planned or not?
   

I think that any pulmonary or mediastinal masses should be investigated in case of suspected ectopic adrenocorticotropic hormone production, and OctreoScan scintigraphy represents the most effective diagnostic tool and should be performed early. I think that thoracotomy should have been preferred for mediastinal lymphadenectomy because of the possibility of achieving a radical resection of the nodes and the possibility of an accurate lung palpation to detect possible small pulmonary nodules. Shrager and associates² confirm that the use of video-assisted thoracoscopic resection in BC with CS would be inappropriate. In cases of N2 atypical BC, adjuvant therapy is mandatory because of the risk of local relapses or distant metastases. Marty-Ané and coworkers⁴ suggest chemotherapy, but medical therapy with octreotide could be considered too. Octreotide, in fact, binds with high affinity to subtype 2 somatostatin receptors that are present in neuroendocrine cells surface, exerting a growth inhibitory effect in neuroendocrine tumors. Octreotide could be considered as an effective biologic postoperative therapy, generally well-tolerated and without important side effects. Using the long-acting form of this drug, only a single administration every 28 days is required. Finally OctreoScan scintigraphy is mandatory for the follow-up, because it has been demonstrated to be effective in detecting recurrences earlier than traditional radiologic procedures.⁵

	References

Top References

 

1. Carpenter PC. Diagnostic evaluation of Cushing’s syndrome. Endocrinol Metab Clin North Am. 1988;17:445–472
   
2. Shrager JB, Wright CD, Wain JC, Torchiana DF, Grillo HC, Mathisen DJ. Bronchopulmonary carcinoid tumors associated with Cushing’s syndrome: a more aggressive variant of typical carcinoid. J Thorac Cardiovasc Surg. 1997;114:367–375[Abstract/Free Full Text]
   
3. Sugawara T, Sato M, Itoi K, Sugawara A, Matsuda Y, Shimada K, et al. Successful localization and treatment for ectopic adrenocorticotrophic hormone secretion in a rare case of possible Tx N2 M0 carcinoid tumor with Cushing syndrome. J Thorac Cardiovasc Surg. 2002;124:1237–1238[Free Full Text]
   
4. Marty-Ané C, Costes V, Pujol JL, Alauzen M, Baldet P, Mary H. Carcinoid tumors of the lung: do atypical features require aggressive management? Ann Thorac Surg. 1995;59:78–83[Abstract/Free Full Text]
   
5. Filosso PL, Ruffini E, Oliaro A, Papalia E, Donati G, Rena O. Long-term survival of atypical bronchial carcinoids with liver metastases, treated with octreotide. Eur J Cardiothorac Surg. 2002;21:913–917[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pier Luigi Filosso Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Filosso, P. L. Search for Related Content PubMed PubMed Citation Articles by Filosso, P. L. Related Collections Related Article