Aggressive Postop Surveillance of Bronchopulmonary Carcinoid Patients May Not Be Worth the Cost

The indolent nature of typical bronchopulmonary carcinoids appears to make close post-resection surveillance unnecessary, reported Cleveland Clinic researchers today at the 95th Annual Meeting of the American Association for Thoracic Surgery (AATS).

“These cancers have a low recurrence rate and low mortality risk independent of smoking status,” says thoracic surgeon Sudish Murthy, MD, PhD. “Therefore, it is hard to justify aggressive surveillance after complete resection.”

How much surveillance is indicated?

Dr. Murthy is principal author of the study presented at the AATS meeting, which reviewed all 709 patients who underwent lung resection for cancer at Cleveland Clinic between January 2006 and January 2013, of which 57 were primary bronchopulmonary carcinoid cases. The goals were to examine the impact of Cleveland Clinic’s standard surveillance routine on patient survival and carcinoid recurrence.

“Patients with typical carcinoid have better post-surgical survival than those with atypical carcinoid, with a five-year survival rate greater than 90 percent and close to 100 percent for completely resected, node-negative cases,” says Dr. Murthy. Long-term survival is common, he notes.

“In the absence of definitive guidelines for post-resection surveillance, however, we have monitored patients rather aggressively with chest CT and bronchoscopy,” he adds. “In light of these patients’ favorable risk profile, we questioned whether this was necessary.”

Key findings: Only one (atypical) carcinoid recurrence

Of the 57 primary carcinoid patients reviewed, 53 (93 percent) had tumors of the typical subtype and four (7 percent) had atypical tumors.

All patients were followed to May 1, 2013, at which point 25 percent had been followed more than 2.7 years, and 10 percent for more than 3.8 years. A total of 31 bronchoscopies were performed in 16 patients with typical carcinoid and revealed no recurrences. Six bronchoscopy studies in three patients with atypical carcinoid revealed one patient with a positive resection margin.

Fifty-three patients underwent a total of 146 chest CT scans, which revealed one recurrence (1.8 percent) of an atypical carcinoid 2.5 years after resection.

Although abnormal findings were identified in the majority of patients (including pulmonary nodules, lymphadenopathy, ground glass opacifications and pleural effusions), no cases of typical carcinoid recurrence were detected by either surveillance technique.

Clinical implications: Consider five-year CT screening instead

This relative lack of findings led the researchers to conclude that bronchopulmonary carcinoids are a different entity from non-small-cell lung cancer and carry low risks of recurrence and death.

They added that since patients with node-negative typical carcinoid appear to be cured after complete resection, subjecting them to post-resection surveillance is of little utility and may in fact be counterproductive. “Unfortunately, diligent surveillance of these patients seems to lead to a surprising number of abnormal findings, which then beget additional follow-up studies,” Dr. Murthy explains.

He notes that Cleveland Clinic has modified its surveillance practice as a result of these findings and has significantly reduced use of postoperative chest CTs for patients with node-negative, completely resected typical carcinoids.

“CT scans at five-year intervals might be a reasonable alternative to aggressive surveillance following complete resection of typical carcinoids — and certainly a more cost-effective one,” he concludes.