Bronchial Carcinoid Tumor Research Articles

8036 A Rare Case of Cushing’s Syndrome Caused by a Pulmonary Carcinoid Tumor

Abstract Disclosure: A.C. Tep: None. F.M. Wolf: None. Introduction: The most common causes of ectopic ACTH (adrenocorticotropic hormone) syndrome include bronchial carcinoid tumors and other neuroendocrine tumors. Ectopic ACTH syndrome (EAS) can be difficult to diagnose. Differentiating Cushing’s disease and EAS is difficult, as ACTH-secreting tumors are often small and easily missed on imaging. Case Presentation: A 32-year-old male with a history of hypothyroidism presented with a 6-month history of facial rounding. He also noticed a dorsocervical fat pad, muscle weakness in the extremities, easy bruising, and elevated blood pressure progressing over the same period. A 24-hour urine free cortisol was elevated to 1797 mcg. Two salivary cortisol tests performed 1 hour after the patient’s usual bedtime had values of 4.4 ug/dl and > 1.000 ug/dl. Both the urine and salivary cortisol results were exceedingly high. ACTH was elevated (150 pg/ml). An MRI of the pituitary gland was normal without evidence of an adenoma. Frequently, ACTH-secreting pituitary adenomas are small enough that they are missed on MRI; however, given our patient’s rapid clinical presentation, additional imaging was performed to identify an ectopic source. A CT Chest/Abdomen/Pelvis showed a 1.2 cm nodule in the right middle lobe of the lung. The right middle lobe was resected, and pathology revealed a carcinoid tumor. His cortisol levels slowly decreased postoperatively and eventually normalized. At his one-month post-operative visit, his symptoms were all improving but not yet resolved. Discussion: This patient was found to have Cushing's syndrome due to ectopic ACTH production from a pulmonary carcinoid tumor. The patient demonstrated clinical improvement after resection of the tumor. Pulmonary carcinoid tumors are rare neuroendocrine epithelial tumors that account for 2-5% of all lung tumors. The annual incidence of these tumors is 2.3-2.8 cases per million people. Endogenous Cushing's syndrome is either ACTH-dependent or ACTH-independent. In ACTH-dependent Cushing's syndrome, the ACTH can either be from the pituitary or an ectopic source. Once ACTH-dependent disease is confirmed, a pituitary MRI is performed to evaluate for an ACTH-secreting pituitary adenoma; this is called Cushing’s disease. Some patients undergo inferior petrosal sinus sampling to confirm the source is central and to determine laterality before transsphenoidal resection of the adenoma. If the source of ACTH is not from the pituitary, obtaining a CT or MRI of the chest and abdomen locates tumors in most patients. At times a functional study, such as an octreotide or PET-DOTATE scan, is done to confirm the diagnosis before proceeding with surgical resection to avoid unnecessary removal of an incidental tumor. Ectopic ACTH production often causes a more rapid progression of Cushingoid features, which can be a clue to the diagnosis of this condition. Presentation: 6/1/2024

Pneumomediastinum as a manifestation of a bronchial carcinoid tumour: a very rare association of two uncommon diseases

A 29-year-old man presented to the emergency department with haemoptysis and thoracic pain. His vital signs and blood tests were normal, except for increased C-reactive protein levels. Fibrolaryngoscopy and esophagogastroduodenoscopy results were negative. Computed Tomography of the chest revealed abundant pneumomediastinum, air dissection along the peribronchovascular sheaths of the left lower lobe and a vegetating lesion completely occluding the distal extremity of the left main bronchus. After complete bronchoscopic excision of the lesion, histological examination revealed a carcinoid tumour not otherwise specified. After hospital discharge, 18F-fluorodeoxyglucose and 68Ga-DOTANOC positron emission tomographies ruled out distant metastases. A sleeve resection of approximately 20 mm of the distal extremity of the left main bronchus and a circumferential anastomosis between the left main bronchus and ipsilateral lobar bronchi were performed. Several bronchoscopic follow-ups did not show anastomotic dehiscence or tumour relapse.

Factors Associated With Long-term Survival in Children With Bronchial and Lung Carcinoid Tumors

Background and aimsBronchial carcinoids are rare in children and the treatment is based on tumor behavior in adults. The purpose of this study was to determine factors and management strategies associated with long-term survival in the pediatric population using a national cohort. MethodsPatients aged ≤20 years with bronchial carcinoid tumors were identified in the 2004–2020 National Cancer Database using ICD-O-3 codes. Tumor characteristics and management were compared among typical (TC) and atypical (AC) histological subtypes using Chi-square and Fisher's exact tests. Kaplan–Meier and univariate Cox proportional hazards analyses were used to assess survival. ResultsOf 273 patients, 251 (92%) had TCs, and 22(8%) had ACs. The median (IQR) age was 18 (16,19) years. Most patients underwent lobectomy or bilobectomy (67%), followed by sublobar resection (17%), no resection or bronchoscopic excision or ablation (8%), and pneumonectomy (7.7%). Margins were negative in 96%. Lymph node (LN) assessment was performed in 216 patients (84%) with a median (IQR) of 7(3,13) LNs, and 50 (23%) had ≥1 positive LN. There was no difference in age, resection, margin status, LN assessment, or positivity between TC and AC (all p > 00.05). Detection of nodal metastasis did not increase beyond the resection of 1–3 LNs (p = 0.72). Ten-year survival was worse for AC than TC (79% (41, 100) vs 98% (95, 100), HR = 6.9 (95% CI: 1.2–38.3, p = 0.03). Ten-year survival among those with and without LN assessment was 97% (94, 100) vs 91% (81, 100), HR = 4.0, 95% CI: 0.8–19.9, p = 0.09). There were no deaths in those with negative LN while 10-year survival was 89% (72, 100) in those with ≥1 positive LN. ConclusionAmong children with bronchial carcinoids, survival is excellent with TC or negative LN. Atypical histology and positive LN have poor survival and should prompt close monitoring. These risk factors may be missed in the absence of surgical resection and lymph node sampling. Level of EvidenceIII. Type of StudyRetrospective Study.

Robotic left upper lobectomy with bronchoplasty in a 54-year-old female with a left mainstem bronchial carcinoid tumor.

Robotic left upper lobectomy with bronchoplasty in a 54-year-old female with a left mainstem bronchial carcinoid tumor.

Distinctive radiological aspects of bronchial carcinoid tumors

Learning objectives: We report in this article the various radiologic features of bronchial carcinoid tumors, as well as their specific distribution within the lung, which could help distinguishing them from other pulmonary tumors and establishing an appropriate therapeutic strategy. Materials and methods: We reviewed the medical records of all patients with bronchial carcinoid tumors diagnosed by biopsy or surgical resection, and that underwent CT scans in the radiology department of university hospital HASSAN II in Fez, for a period of 05 years, from January 2015 up to January 2020. Results: The study group included 24 patients of which 16 were women and eight were men. The average age was 41 years old (range: 18–64 years). The clinical presentation was dominated by hemoptysis in 16 cases. However, 04 patients were asymptomatic. Tumors were predominantly proximal (72%). The mean tumor diameter was 22 mm (range: 05–58 mm); the majority of the tumors (88%) had a lobulated outline, and they were all solid, containing partial calcifications in 26% of cases and significantly enhanced after contrast injection in 61% of cases. 17 of this tumors were typical carcinoids and the seven remaining were atypical. Conclusion: Carcinoid bronchial tumors are known to be low-grade tumors and are classified as lung neuroendocrine tumors. There are two types of carcinoid tumors, typical and atypical, which are different in terms of aggressiveness and prognosis, although they present similar imaging features. the analysis of imaging features allows a better understanding of this type of tumor and a better management

Pneumopathie infectieuse favorisée par un syndrome de Cushing paranéoplasique d’une tumeur carcinoïde pulmonaire

Ectopic Cushing's syndrome (CS) is a rare condition nevertheless well-known to endocrinologists. The pneumologist may be called upon to treat CS not only because bronchial carcinoid tumors are the most frequent source of ectopic ACTH secretion, but also due to the fact that the immunosuppression induced by hypercorticism favors lower respiratory tract infections. We report the case of a female patient presenting with acute respiratory failure secondary to Enterobacter cloacae pneumonia exacerbated by SC. Further investigations confirmed ectopic ACTH secretion and revealed a right upper lobe pulmonary nodule. After appropriate antibiotic therapy, the patient received preoperative adrenolytic treatment. Management by right upper lobectomy resulted in the extraction of a 12mm tumor. Pathological analysis was consistent with the diagnosis of a typical carcinoid tumor. Immunohistochemistry confirmed ACTH secretion by the tumor. Even though the postoperative course showed CS regression, the patient developed adrenal insufficiency. Ectopic CS induces immunosuppression, which aggravates lower respiratory tract infections. Search for a pulmonary neuroendocrine tumor should be systematic. Following control of the secretory syndrome by adrenolytic treatment, and if the diagnosis of carcinoid tumor is confirmed, surgical treatment is the preferred option.

Advances in Endoscopic Management of Endobronchial Carcinoid.

Bronchial carcinoid (BC) tumors represent between 1% and 5% of all lung cancers and about 20-30% of carcinoid tumors; they are classified into two groups: typical and atypical bronchial carcinoids. The aim of the present study was to review the results of endoscopic treatments as an alternative to surgical treatment in selected patients. The present study was a retrospective and multicentric study, in which all data were reviewed for patients with BC in the central airways, referred to the Thoracic Surgery Units of Luigi Vanvitelli University of Naples and Sant'Andrea Hospital in Rome between October 2012 and December 2022 Overall, 35 patients, 13 of whom were female, were included in the study (median age, 53 years; range, 29-75 years). All patients underwent rigid bronchoscopy combined with flexible bronchoscopy. Tumor clearance was mostly performed by use of Argon Plasma Coagulation or Thulep Laser, mechanical debridement and excision with the use of forceps and aspirator through the working channel of the 8.5 mm-sized rigid bronchoscope. There were no complications during the treatment. Endobronchial treatment provided complete tumor eradication in all patients; two patients had controlled bleeding complications; however, bleeding was well controlled without patient desaturation, and only one patient died of renal failure during the follow-up period. We found two recurrences in the left and right main bronchus, in patients with atypical carcinoma during fiberoptic bronchoscopy follow-up. Only one patient died of renal failure. At the first analysis, there were no significant differences between the patients receiving endobronchial treatment and patients receiving surgical treatment in the present study (p-value > 0.05-it means statistically insignificant). Endobronchial treatment is a valid and effective alternative for patients with BC unsuitable for surgery.

Bronchial carcinoid tumors in children and adolescents – A report and management considerations from the German MET studies

ObjectivesBronchial carcinoid tumors (BC) are exceptionally rare in childhood, with an incidence of <0.2/1,000,000 per year. Typical low-grade BCs are distinguished from atypical, intermediate-grade BCs. Little is known about BCs in pediatric patients and management guidelines are missing. In this study, we explored characteristics and outcome of pediatric patients with BC prospectively registered with the Malignant Endocrine Tumor studies. Material and methodsWe performed a retrospective multicenter study in children, adolescents, and young adults (aged 0–20 years) with BC reported to the German MET registry between January 1997 and December 2022. Data were last updated on 28 of February 2023. ResultsThirty-two patients were diagnosed at a median age of 15.0 years (range, 9.8–19.2). Atypical BCs (23.3%) were less frequent than typical, but more common than in adulthood. Lymph node metastases were present in 14.3% of cases (atypical BC: 28.6%, typical BC: 10.5%), distant metastases in one (3.1%) patient with atypical BC. 92.6% of patients were in complete remission after surgical resection (median follow-up: 2.7 years). The patient with metastatic spread and one patient with atypical BC and multiple recurrences were on treatment at last follow-up. 5-year event-free survival of typical BC was 100% and 83.3% in atypical BC. ConclusionsCompletely resected localized BCs in pediatric patients have a favorable outcome also with lung tissue sparing surgery. Atypical BC with risk of metastatic spread and recurrence occurred more frequently compared to adults. Interdisciplinary management and collaborative efforts are needed to improve our understanding and the management of pediatric BC.

Expressions of Cushing's syndrome in multiple endocrine neoplasia type 1.

Cushing's syndrome (CS) resulting from endogenous hypercortisolism can be sporadic or can occur in the context of familial disease because of pituitary or extra-pituitary neuroendocrine tumors. Multiple endocrine neoplasia type 1 (MEN1) is unique among familial endocrine tumor syndromes because hypercortisolism in this context can result from pituitary, adrenal, or thymic neuroendocrine tumors and can therefore reflect either ACTH-dependent or ACTH-independent pathophysiologies. The prominent expressions of MEN1 include primary hyperparathyroidism, tumors of the anterior pituitary, gastroenteropancreatic neuroendocrine tumors, and bronchial carcinoid tumors along with several common non-endocrine manifestations such as cutaneous angiofibromas and leiomyomas. Pituitary tumors are present in about 40% of MEN1 patients, and up to 10% of such tumors secrete ACTH that can result in Cushing's disease. Adrenocortical neoplasms occur frequently in MEN1. Although such adrenal tumors are mostly clinically silent, this category can include benign or malignant tumors causing hypercortisolism and CS. Ectopic tumoral ACTH secretion has also been observed in MEN1, almost exclusively originating from thymic neuroendocrine tumors. The range of clinical presentations, etiologies, and diagnostic challenges of CS in MEN1 are reviewed herein with an emphasis on the medical literature since 1997, when the MEN1 gene was identified.

Atypical revelation of atypical lung carcinoid; back pain after SARS-COV2 vaccination: A case report

Background: Carcinoids make nearly 2% of all lung tumors, and the typical carcinoid are more frequent than atypical carcinoid (AC). Case presentation: We report a histologically confirmed AC case of a 23-years old male patient; revealed by back chest pain as the first presentation; after a covid vaccination. Past medical history revealed that the patient had received the covid-19 vaccine in the days before the presentation. Contrast-enhanced computed tomography scan of the thorax revealed a tumor mass of the right fowler. Conclusion: To our knowledge; this is the first case in literature. Whether bronchial carcinoid tumors are infrequent; they should be considered as differential diagnosis in patients even younger, with recurrent respiratory symptoms as timely and quick diagnosis is essential for curative intervention. We reported a first a COVID-19 vaccine- revealing symptoms of a bronchial atypical carcinoid, the characteristics that led to this phenomenon stay unclear, more studies are needed.

Typical Carcinoid Tumor Cases Causing Ectopic ACTH Syndrome: Dramatic Response to Surgery.

Although Cushing's Syndrome (CS) is usually caused by pituitary/adrenal adenomas, in the remaining few cases, Adrenocorticotrophic hormone (ACTH) is secreted by extrapituitary neuroendocrine tumors (NET). In typical pulmonary / bronchial carcinoid tumors leading to ectopic ACTH syndrome (EAS). The main principle of treatment is the localization of the ACTH-secreting tumor and its surgical removal. In this case report, we aimed to present two typical carcinoid cases, whose ACTH and cortisol levels returned to normal after lung surgery for ectopic ACTH. One of the cases, a 32-year-old female patient with CS symptoms and signs, was referred to our department after detecting a lesion in the left lower lobe in the thorax CT, which did not show an obvious focus on cranial MRI. The other patient, a 36-year-old male, had previously undergone adrenalectomy for Cushing's syndrome and was admitted to the emergency department due to adrenal insufficiency. The lesion seen in the right lower lobe on thorax CT was evaluated as an ectopic ACTH focus. After the tumors of the patients were resected according to surgical principles, CS clinic regressed, and ACTH and cortisol values returned to normal. Pathological examinations of the surgically resected tumors were reported as typical carcinoid. With surgically removed typical carcinoids tumors, excellent longterm survival results can be achieved and hypercortisolism can be controlled.

Clinical profile, surgical management and outcome of bronchial carcinoids - a single centre experience

Background and objectives: Bronchial carcinoid tumors are neuroendocrine neoplasms that range from low-grade typical carcinoids to more aggressive atypical carcinoids and, therefore demonstrate a wide spectrum of clinical behaviors, histologic features and outcome. The aim of the present study was to investigate the clinical profile, surgical management and outcome of bronchial carcinoids at a single centre over two years period. Materials and methods: Patients with a final histologic diagnosis of bronchial carcinoid tumor were included in the study. Evaluation comprised of clinical history and physical examination, postero-anterior and lateral chest radiographs, and computed tomographic (CT) scans of the chest and upper abdomen (including liver and adrenal glands). Performance status was assessed by the Karnofsky scale. Pulmonary function tests were performed routinely. Results: A total of 18 patients were included in the study. Out of 18 cases, 10 (55.6%) were female and 8 (44.4%) were males. Sixteen (88.9%) patients had typical carcinoid tumor and 2 (11.1%) had atypical carcinoid tumor. The tumor was located in the right lung in 11 (61.1%) and in the left lung in 7 patients (38.9%). Surgeries included 15 standard lobectomies and 3 bronchial sleeve resection. At one month post surgery, there was 13-22% increase in post operative FEV1 in patients who underwent bronchial sleeve resection while in patients who underwent lobectomy, the post operative FEV1 was 84% of pre-operative FEV1. Post surgery, all patients were in group A as per Karnofsky performance status. Conclusion: Standard care of bronchial carcinoid tumors is surgical resection, and the surgical approach should depend on tumor’s size, location and histology. IMC J Med Sci. 2023; 17(2):003. DOI: https://doi.org/10.55010/imcjms.17.013 *Correspondence: Farooq Ahmad Ganie, Department of Cardiovascular and Thoracic Surgery, SKIMS, Soura, Srinagar, Kashmir, India. Email: farooq.ganie@ymail.com

Endobronchial Small Cell Lung Cancer Masquerading as Carcinoid Tumour in a Young Female: A Case Report

Bronchial Carcinoid Tumours also known as BCTs, are remarkable neuroendocrine malignancies that can denature chemical compounds with biological activity. Bronchial carcinoid tumours are also known as BCTs. The phrase “bronchial adenomas” was once used to refer to BCTs; however, this nomenclature is no longer utilised because BCTs are neither glandular nor invariably benign. Instead, the term “Bronchial Cystic Tumours” is used to refer to BCTs in this context (BCTs). They are normally a neoplasm that expands slowly and displays a variety of behaviours, yet, they are also capable of expanding rapidly and being significantly more aggressive in general. Despite the fact that smoking is a significant risk factor for Small Cell Lung Cancer (SCLC), which is a more severe form of lung cancer than carcinoid. In addition, surgery is still the treatment of choice for carcinoid tumours, although chemoradiation and chemotherapy are the only options for patients with stage four SCLC. Here the authors discuss the case of 30 years old young female patient, who was erroneously diagnosed with endobronchial carcinoid turned out to be a SCLC. Because of the significant connection between smoking and SCLC, malignancies are not usually seen in young females. The relevant patient’s investigations were consistent with a small cell carcinoma of the lung. Immunohistochemistry for CD56 and synaptophysin turned out to be positive. The patient received six cycles of chemotherapy with an injection of Cisplatin and an injection of Etoposide three weekly. She was followed-up after three months and did have symptomatic relief.

Carcinoid tumors outside the abdomen.

Neuroendocrine tumors (NETs) are epithelial malignancies that can arise from multiple tissues. Gastrointestinal (GI) NETs are the most common; in this review of extra-abdominal carcinoid tumors, we focus our discussion on bronchial and thymic carcinoid tumors. Bronchial carcinoid tumors comprise a quarter of all NETs and less than 2% of all lung cancers. Thymic carcinoid tumors are extremely rare, accounting for 5% of thymic tumors. Both bronchial and thymic carcinoid tumors are histologically classified as either typical or atypical based on their mitotic rate (less than 2 or 2-10 mitoses per 10 high-powered fields (HPF), respectively). Both bronchial and thymic carcinoids can present with symptoms of obstruction and potentially carcinoid syndrome. The gold standard of management of bronchial and thymic carcinoid tumors is surgical resection. For patients with advanced disease, first-line systemic therapy is generally somatostatin analog monotherapy with octreotide or lanreotide. In patients with refractory disease, therapy generally involves peptide receptor radioligand therapy, everolimus, or cytotoxic chemotherapy. There are ongoing, prospective trials comparing the mainstays of systemic therapy for these patients, as well as ongoing evaluations of immune checkpoint inhibitors and multi-kinase inhibitors. Prognosis for both bronchial and thymic carcinoid tumors depends on histologic grade, local versus invasive disease, and extent of metastases. Herein we provide a summary of the pathophysiologic and clinical background, the current state of the field in diagnosis and management, and note of key ongoing prospective trials for patients with bronchial and thymic carcinoid tumors.

Management and outcome of pituitary metastasis from a bronchial carcinoid tumour presenting with ocular symptoms

Management and outcome of pituitary metastasis from a bronchial carcinoid tumour presenting with ocular symptoms

A Multimodal Biomarker Predicts Dissemination of Bronchial Carcinoid.

Simple SummaryEvidence of prediction of disease recurrence after curative surgery in bronchial carcinoid is still limited. The aim of this study was to retrospectively investigate a set of markers as potential predictors of dissemination. This study confirmed that adding OTP, CD44, and Ki-67 to the carcinoid classification improved the identification of patients who are at risk for metastatic disease. Patients who did not develop metastasis in follow-up had typical carcinoids with proliferation index <5% and positive OTP and CD44. Atypical carcinoids with proliferation index ≥5% and loss of OTP and/or CD44 were at high risk for distant metastases. Such patients should be screened for metastatic disease at diagnosis and during follow up.Background: Curatively treated bronchial carcinoid tumors have a relatively low metastatic potential. Gradation into typical (TC) and atypical carcinoid (AC) is limited in terms of prognostic value, resulting in yearly follow-up of all patients. We examined the additional prognostic value of novel immunohistochemical (IHC) markers to current gradation of carcinoids. Methods: A retrospective single-institution cohort study was performed on 171 patients with pathologically diagnosed bronchial carcinoid (median follow-up: 66 months). The risk of developing distant metastases based on histopathological characteristics (Ki-67, p16, Rb, OTP, CD44, and tumor diameter) was evaluated using multivariate regression analysis and the Kaplan–Meier method. Results: Of 171 patients, seven (4%) had disseminated disease at presentation, and 164 (96%) received curative-intent treatment with either endobronchial treatment (EBT) (n = 61, 36%) or surgery (n = 103, 60%). Among the 164 patients, 13 developed metastases at follow-up of 81 months (IQR 45–162). Univariate analysis showed that Ki-67, mitotic index, OTP, CD44, and tumor diameter were associated with development of distant metastases. Multivariate analysis showed that mitotic count, Ki-67, and OTP were independent risk factors for development of distant metastases. Using a 5% cutoff for Ki-67, Kaplan–Meier analysis showed that the risk of distant metastasis development was significantly associated with the number of risk predictors (AC, Ki-67 ≥ 5%, and loss of OTP or CD44) (p < 0.0001). Six out of seven patients (86%) with all three positive risk factors developed distant metastasis. Conclusions: Mitotic count, proliferation index, and OTP IHC were independent predictors of dissemination at follow-up. In addition to the widely used carcinoid classification, a comprehensive analysis of histopathological variables including Ki-67, OTP, and CD44 could assist in the determination of distant metastasis risks of bronchial carcinoids.

Psychotic symptoms in Cushing’s syndrome secondary to ACTH-secreting lung carcinoid tumor: report of a case

IntroductionCushing’s syndrome is a hormonal disorder caused by chronic exposure to excess glucocorticoids, either exogenous or endogenous. The bronchial carcinoid tumor is an extremely rare origin, described in less than 1% of cases. The most frequent psychiatric symptoms are depression and anxiety, with manic and psychotic symptoms being less frequent. Psychotic symptoms are difficult to manage, as they are usually resistant to antipsychotic treatment, which is why it is considered an indication for medical treatment of Cushing’s syndrome.ObjectivesTo give visibility to this type of psychotic disorders of organic origin to deepen their study as well as raise awareness among professionals dedicated to clinical care with the intention of improving their prevention.MethodsA description of a clinical case is made, accompanied by a bibliographic review on psychosis of endogenous corticosteroid origin.ResultsWe describe the case of a 44-year-old woman who was admitted to the charge of Internal Medicine due to Cushing’s syndrome. During her admission, she presented a debut of positive psychotic symptoms, so the liaison psychiatry team followed her up. She was diagnosed with an ACTH-secreting lung carcinoid tumor.ConclusionsThis entity should be taken into account in cases of atypical psychosis in patients with compatible phenotypic characteristics.DisclosureNo significant relationships.

Haemorrhage post biopsy of a bronchial carcinoid

Background: Bronchial carcinoid tumours are rare, indolent, malignant neuroendocrine tumours derived from Kulchitsky cells and are not related to smoking. As these tumours can be asymptomatic or present with nonspecific symptoms, a high index of suspicion is essential to make an early diagnosis which determines the prognosis. Surgery is curative and remains the mainstay of treatment.&#x0D; Case presentation: A 41-year-old female with no background medical illness first presented with a spontaneous left sided pneumothorax requiring a chest tube insertion. High-resolution CT (HRCT) thorax detected an incidental solitary pulmonary nodule. Bronchoscopy revealed a smooth round tumour sitting at the ostium of the basal right lower lobe bronchus. Endobronchial biopsy was complicated with massive bleeding requiring emergency exploration via rigid bronchoscopy. Multiple attempts to secure haemostasis using Watanabe spigot and argon plasma coagulation failed. She was intubated with a double lumen tube to isolate the healthy left lung. An urgent CT pulmonary angiogram (CTA) was performed to look for collaterals and feasibility of embolization, but no collaterals were seen. She was then referred to the cardiothoracic surgeon for an emergency right lobectomy. Histopathological examination revealed typical carcinoid tumour. She was discharged from the hospital in a stable condition.&#x0D; Discussion: Bronchial carcinoids embryologically originate from the foregut and patients rarely present with features suggestive of carcinoid syndrome and crisis. Mostly are asymptomatic resulting in late presentation and diagnosis. Majority of the typical carcinoids are centrally located and may present with obstructive symptoms and recurrent pneumonia. Bronchoscopists may face massive bleeding following endobronchial biopsy in bronchial carcinoids.&#x0D; Conclusion: Massive bleeding after endobronchial biopsy can occur and therefore the bronchoscopist should have anaesthesia, interventional radiology, and cardiothoracic support to handle this complication. Using tumour markers may obviate the need for biopsy in typical bronchial carcinoids to prevent massive bleeding after endobronchial biopsy.&#x0D;

SURGICAL APPROACH OF LUNG CARCINOID TUMORS.

Bronchial carcinoid tumours (typical and atypical carcinoid) are endobronchial tumours that can benefit from both local endobronchial treatment and surgical treatment. Given their relatively good prognosis compared to the other two forms of pulmonary neuroendocrine tumours, there is a current concern about the implications of lymph node involvement as well as the identification of new prognostic factors to shape the treatment of these patients in the future.

Endobronchial resection as a bridge to curative resection in patient with poor preoperative lung function secondary to an airway blocking endobronchial carcinoid tumour

We present a 70-year-old gentleman with chronic cough with haemoptysis found to have left lower zone collapse on imaging. The bronchoscopy showed an endobronchial mass histologically of a non-secreting atypical carcinoid. Poor baseline lung function excluded surgical resection, and instead, he successfully underwent a bronchoscopic debulking procedure which improved his FEV1 to 84% and DLCO 83% predicted. Unfortunately, the tumour regrew, but the calculated percentage predicted postoperative for FEV1 (64%), and DLCO (65%) enabled definitive surgical resection to take place. Surgical resection remains the definite curative option for localised endobronchial atypical carcinoid tumours. Achieving this in proximal endobronchial carcinoid tumour is a challenge. We described an endoscopic tumour debulking procedure as a bridge for curative surgical resection in a patient with an inoperable proximal atypical carcinoid tumour due to poor predicted postoperative lung function. We highlighted the need to assess predicted postoperative lung function with functional and quantitative perfusion methods to aid surgical planning. Debulking the tumour by endoscopy can be used as a conduit to curative surgical resection in bronchial carcinoid tumour. The choice of calculating the percentage predicted values by either or both methods must be individualised based on tumour location and the probability of converting a lobectomy to a pneumonectomy. This precautionary approach could evaluate the postoperative lung function and morbidity and mortality risk if considering a pneumonectomy. Endoscopic debulking can be a successful bridge to a curative surgical resection aided by comprehensive preoperative lung function tests to predict postoperative lung values