|LETTER TO THE EDITOR
|Year : 2017 | Volume
| Issue : 1 | Page : 213-214
Atypical lung carcinoid: An unusual presentation
MM Mohapatra1, RC Mulkoju1, J Joseph1, D Gochhait2
1 Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Web Publication||1-Dec-2017|
Dr. M M Mohapatra
Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mohapatra M M, Mulkoju R C, Joseph J, Gochhait D. Atypical lung carcinoid: An unusual presentation. Indian J Cancer 2017;54:213-4
A 48-year-old male, nonsmoker, presented to us with recurrent hemoptysis for 1 year associated with dyspnea of modified Medical Research Council Grade II. He had no fever, chest pain, loss of weight, or appetite, and he had no joint pains. He had no history of pulmonary tuberculosis or bronchial asthma. He was diagnosed with ulcerative colitis 2 years back and was on treatment with mesalazine since then. He was allergic to paracetamol.
On examination, his vitals were normal, and auscultation of lungs revealed normal vesicular breath sounds. His blood parameters were within normal limits. Sputum examination was negative for tuberculosis and fungus. Sputum cytology was negative for malignancy. Chest X-ray did not reveal any abnormality. Contrast-enhanced computed tomography (CT) thorax showed a nonenhancing lobulated lesion in the left upper lobe with a size of 2.32 cm × 1.76 cm, in the corresponding segmental bronchi [Figure 1]. CT pulmonary angiogram was normal. The patient was subjected to bronchoscopy for bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB). BAL fluid for malignancy, fungus, and acid-fast Bacillus were negative. Histopathological report of TBLB specimen was stated as monomorphic tumor cells arranged in trabecular and glandular pattern with small round nucleus and inconspicuous nucleoli suggestive of well-differentiated neuroendocrine tumor, Grade II atypical carcinoid. Immunohistochemistry marker for neuroendocrine marker synaptophysin was diffuse and strongly positive. Thyroid transcription factor-1 and napsin marker were negative. Ki-67 proliferation factor was 5%, and mitosis was 3/10 hpf. The final diagnosis of the specimen was made as Grade II atypical carcinoid [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d. The patient was then referred to oncosurgical unit for further management where lobectomy was done.
|Figure 1: Contrast-enhanced computed tomography thorax showing a nonenhancing lesion in the left upper lobe|
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|Figure 2: (a) Histopathology showing the tumor with monotonous looking cells having stippled chromatin and moderate eosinophilic cytoplasm. (b) Immunohistochemistry showed strong diffuse cytoplasmic positivity for synaptophysin. (c) The marker Ki-67 – around 5%. (d) The adenocarcinoma marker thyroid transcription factor-1 was negative in the tumor cells ruling out the possibility of adenocarcinoma|
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Bronchial carcinoid arises from neuroendocrine cells and constitutes 2.5% of lung cancers. The prevalence of bronchial carcinoid has increased in past 30 years up to 6%/year. Females are affected more than males and bronchial carcinoid occurs mostly during fourth–fifth decades. Typical carcinoid is central carcinoid and may present with persistent cough, wheezing, chest pain, hemoptysis, and obstructive pneumonitis. Atypical carcinoids are mostly peripheral carcinoid with lymphatic invasion and rarely present with any symptoms. Contrast-enhanced CT thorax demonstrates an endobronchial lesion associated with atelectasis or bronchiectasis in typical carcinoid whereas atypical carcinoids present as solitary pulmonary nodule or mass lesion. With the evolution of endobronchial ultrasound in various centers, the diagnostic evaluation of solitary pulmonary nodule has increased dramatically with 70% diagnostic yield in peripheral lesion of diameter <2 cm.
This report highlights the presence of symptomatic atypical carcinoid in a central location. Since atypical carcinoids are involved in lymphatic invasion in contrast to typical carcinoids which are confined locally, it becomes necessary for the pulmonologist to be aware of a central presentation of an atypical carcinoid. In such a situation, surgical resection needs to be followed with radiotherapy to prevent lymphatic invasion. In literature search, very few case reports have been published, being a rare entity.
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