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Background: The clinical significance of multifocal pulmonary neuroendocrine proliferation (MNEP), including tumorlets and pulmonary neuroendocrine cell hyperplasia, in association with typical carcinoid (TC), is still debated., Methods: We evaluated a retrospective series of TC with long-term follow-up data prospectively collected from 2 institutions and compared the outcome between TC alone and MNEP plus TC. Several baseline covariates were imbalanced between the MNEP plus TC and TC groups; therefore, we conducted 1:1 propensity score matching and inverse probability of treatment weighting in the full sample. In the matched group, the association of clinical, respiratory, and work-related factors with the group was determined through univariable and multivariable conditional logistic regression analysis., Results: A total of 234 TC patients underwent surgery: 41 MNEP plus TC (17.5%) and 193 TC alone (82.5%). In the MNEP plus TC group, older age (P < .001), peripheral tumors (P = .0032), smaller tumor size (P = .011), and lymph node spread (P = .02) were observed compared with the TC group. Relapses occurred in 8 patients in the MNEP plus TC group (19.5%) and 7 in the TC group (3.6%). After matching, in 36 pairs of patients, a significantly higher 5-year progression-free rate was observed for the TC group (P < .01). Similar results were observed using inverse probability of treatment weighting in the full sample. The odds of being in the MNEP plus TC group was higher for those with work-related exposure to inhalant agents (P = .008), asthma or bronchitis (P = .002), emphysema, fibrosis, and inflammatory status (P = .032), or micronodules on the chest computed tomography scan and respiratory insufficiency (P = .036)., Conclusions: The association with MNEP seems to represent a clinically and prognostic relevant factor in TC. Hence, careful preoperative workup, systematic pathologic evaluation, including nontumorous lung parenchyma, and long-term postoperative follow-up should be recommended in these patients., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The role of sublobar resection in the treatment of pulmonary typical carcinoids is controversial. This study aims to compare long-term outcomes between sublobar and lobar resections in patients with peripheral typical carcinoid., Methods: We retrospectively compared consecutive patients who underwent curative sublobar resection with patients who underwent lobectomy for cT1-3 N0 M0 peripheral pulmonary typical carcinoid in eight centers between 2000 and 2015. Primary outcomes were rates and patterns of recurrence and overall survival. Cox regression modeling was performed to identify factors influencing overall survival and recurrence. Propensity score analysis was done, and overall survival was compared between the two groups., Results: In all, 177 patients were analyzed, consisting of 74 sublobar resections and 103 lobectomies, with a total of 857 person-years of follow-up. The R1 resection rates were 7% and 1% after sublobar resection and lobectomy, respectively (P = .08). One of 5 patients with sublobar R1 resection had recurrence. Recurrence rate was 0.02 (95% confidence interval [CI]: 0.009 to 0.044) per person-year of follow-up after sublobar resection and 0.008 (95% CI: 0.003 to 0.02) after lobectomy (P = .15). Five-year survival rates were 91.7% (95% CI: 78.5% to 96.9%) and 97.4% (95% CI: 90.1% to 99.4%) after sublobar and lobar resection, respectively (P = .08). Extent of resection was not a predictor of recurrence or survival. Propensity score analysis confirmed a similar survival and freedom from recurrence between the two groups., Conclusions: Sublobar resection of peripheral cT1-3 N0 M0 pulmonary typical carcinoid was not associated with worse short- or long-term outcomes compared with lobectomy. In select patients, sublobar resection may be considered for treatment of peripheral typical carcinoids if an R0 resection is obtained., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The optimal extent of lung resection and lymph node (LN) assessment for surgical treatment of clinical stage T1aN0M0 typical carcinoid tumors is unclear. Using a cohort including only these patients, we aimed to determine the impact of extent of lung resection and LN assessment on overall survival., Methods: Patients undergoing lobectomy or sublobar resection for clinical stage T1aN0M0 intraparenchymal typical carcinoid tumor were identified in the National Cancer Data Base from 1998 to 2012. Kaplan-Meier analysis was used to determine overall survival. A multivariable Cox proportional hazards model was used to determine independent predictors of mortality., Results: Of 1,495 patients, 536 (35.9%) had sublobar resection (wedge resection, n = 429; segmentectomy, n = 91) and 959 (64.2%) had lobectomy. There were 366 patients (24.5%) with no LN assessment. As tumor size increased, sublobar resection decreased and LN assessment increased. Overall, 60 patients (4.0%) were upstaged. Fifty-two patients were upstaged because of LN metastases (40 pN1, 11 pN2, and 1 pN3). The 5-year overall survival rate was 87%. It was 88% for lobectomy versus 87% for sublobar resection (p = 0.3), 65% for LN upstaging versus 89% for patients without LN upstaging, and 86% for patients with no LN assessment (p = 0.002). Independent predictors of mortality included LN upstaging, age, male sex, and Charlson comorbidity index., Conclusions: For patients with clinical stage T1aN0M0 typical carcinoid, sublobar resection results in similar overall survival compared with lobectomy. However, regardless of resection type, LN assessment is important to identify LN upstaging, the strongest independent predictor of overall mortality., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The aim of the study was to evaluate the efficacy of a combined approach of endoscopic resection followed by pure bronchoplasty without any pulmonary resection in patients with endobronchial carcinoids., Methods: We applied a two-stage technique, endoscopic resection first followed by pure bronchoplasty, to 25 patients (10 men, 15 women) with endobronchial carcinoid tumors. The median age was 32.4 years (range, 19 to 64). The indications for this technique were pure endobronchial carcinoid without lymph node involvement. Tumor was located on the right side in 18 patients (72%), and on the left in 7 patients (28%). Flexible bronchoscopy was carried out in all patients as the first-stage procedure for debulking and searching for a true pedicle of the tumor. Different types of pure bronchoplasty were performed as the second-stage surgery with systematic mediastinal lymph node dissection., Results: The resection was complete (R0) in all cases. Tumors were pathologically staged as pT1aN0 in 18 patients, pT2N0 in 5, and pT3N0 in 2 patients; 23 tumors were typical and only two were atypical carcinoids. Morbidity was 28.0% (only minor complications), with no mortality. Overall 5-year and 10-year survival was 100.0% and 91.8%, respectively. No recurrence of the primary tumor was observed in any case., Conclusions: Two-stage surgery consisting of endoscopic resection and pure bronchoplasty without lung parenchyma resection is an effective technique for the treatment of endobronchial carcinoid, with an excellent oncologic outcome., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: This study aimed to assess the reliability and the validity of a prognostic model of survival recently developed by the European Society of Thoracic Surgery Neuroendocrine Tumor Working Group to predict 5-year overall survival after surgical resection of pulmonary typical carcinoid., Methods: We retrospectively collected data on 240 consecutive patients (164 men, 76 women; median age, 58 years [interquartile range, 47 to 68]) who underwent curative lung resection for pulmonary typical carcinoid in seven centers between 2000 and 2015. For each patient, we calculated the corresponding risk class (A, B, C, D) using the following variables: male, age, previous malignancy, Eastern Cooperative Oncology Group performance status, peripheral tumor, TNM stage. Kaplan-Meier method, and Cox proportional hazards model were used for the statistical analysis., Results: During a median follow-up of 42 months (interquartile range, 11 to 84), the 5-year overall survival was 94.2% (95% confidence interval [CI]: 90.2% to 98.2%); 15 of 240 patients died. A significantly decreasing rate of survival was observed from class A to class D (p = 0.004) with rates of 100% (95% CI: 100% to 100%), 96.3% (95% CI: 88.6% to 98.8%), 86.7% (95% CI: 63.0% to 95.7%), and 33.3% (95% CI: 0.9% to 77.4%), respectively, for class A, B, C, and D. This difference persisted also using clinical stage as a variable in the risk class calculation (p = 0.006). No differences were observed in term of overall survival among TNM stage I, II, and III patients (p = 0.94)., Conclusions: This prognostic model of survival is easily applicable, it is validated by our independent cohort, and it appears to stratify better than the traditional TNM staging. Therefore, it may be useful in counseling patients about their outcomes from surgical treatment and in tailoring treatment for high-risk patients., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Carcinoid tumor is a rare, slow-growing neuroendocrine tumor that accounts for less than 1% of all lung tumors. It occurs most commonly in the midgut, then the lung, and usually presents as a solid lesion. We report a patient with a typical carcinoid tumor that had undergone cystic degeneration., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We present a very rare case of simultaneous thymic carcinoids with similar size, one of which showed spontaneous regression. A 68-year-old man was admitted to the hospital because of two similar abnormal masses at his anterior mediastinum on chest computed tomography, one of which had decreased from 25 to 16 mm in diameter. A total thymectomy was performed and the pathologic examinations revealed that both tumors were atypical carcinoids. There have been seldom reports of multiple thymic carcinoids, and this case might suggest that total thymectomy is the best way to treat thymic carcinoid because of the possibility of multicentric origins., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Bronchopulmonary carcinoid tumors are considered as a relatively uncommon and less malignant group of lung cancers. However, patients with histologically atypical disease are known to have a worse prognosis. The present study aims to evaluate the long-term outcomes after resection of bronchopulmonary carcinoid tumors according to the new tumor, nodes, metastasis (TNM) staging system., Methods: Patients with histologically proven bronchopulmonary carcinoid tumors who underwent surgery in our thoracic unit over the last 25 years were identified from a prospectively collected database., Results: One hundred and eighty-six patients were identified from our electronic database. Of these, 164 were known to have typical disease, while 22 had atypical disease. Median overall survival was 20.0 years. The mean follow-up was 8.0 years (median 7.0 years). Univariate analysis found age over 60, atypical disease, TNM staging, N status, and M status to have a statistically significant influence on overall survival. Multivariate analysis found age over 60 and atypical histopathology to have a detrimental impact on overall survival. Patients in the atypical subgroup were found to be significantly older, and presented with higher stage disease., Conclusions: It is clear from the current study and previous reports that patients with atypical histopathology have different baseline characteristics, disease behavior, and prognosis compared with patients with typical disease. The proposed TNM staging system appears to be applicable to patients in our surgical experience, and may offer more accurate prognostic information and assist in the management plans for individuals., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Primary bronchopulmonary carcinoids comprise a significant proportion of carcinoid tumors. The clinical presentation allows prediction of the diagnosis and cell type and directs evaluation and treatment. Young age, central tumor, and no nodal enlargement are highly suggestive of typical carcinoid. These patients require no further diagnostic or staging tests beyond chest computed tomography and bronchoscopy before resection using parenchyma-sparing techniques. All bronchopulmonary carcinoids are malignant (though indolent), and surgical intervention is the mainstay of treatment. Mediastinoscopy is suggested when there is moderate suspicion of atypical carcinoid (central cN1 or peripheral cN0), with lobectomy and lymphadenectomy if the mediastinal nodes are benign. For a high suspicion of atypical carcinoid (central cN2, peripheral cN1, 2), imaging for distant metastases and mediastinoscopy is suggested, with multimodality treatment for an atypical carcinoid with N2 involvement., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Stereotactic radiosurgery is being increasingly used to treat patients with early-stage non-small cell lung cancers (NSCLC) who are not candidates for surgical resection. Stereotactic radiosurgery usually needs fiducial markers (FMs) for the tracking process. FMs have generally been placed using percutaneous computed axial tomography scan guidance. We report the results of FM placement using endobronchial ultrasound (EBUS) in 43 patients., Methods: A multidisciplinary tumor board evaluates NSCLC patients before they are offered stereotactic radiosurgery. In patients selected for stereotactic radiosurgery, FMs were inserted into peripheral, central, and mediastinal tumors using EBUS and, in selected patients, navigational bronchoscopy. Patients underwent repeat computed axial tomography chest scans 2 weeks later to ensure stability of the FMs before beginning stereotactic radiosurgery., Results: Included were 43 consecutive patients (21 men, 22 women; mean age, 74.4 years). Forty-two (98%) had NSC carcinomas (5 recurrences); 1 had a carcinoid tumor. Twenty-two tumors were located in the left lung, 19 in the right lung, 1 at the carina, and 1 pretracheal. Two to 5 FMs were placed in and around all tumor masses using EBUS and, for peripheral lesions, EBUS combined with navigational bronchoscopy. Thirty patients had no displacement of FMs. In the 13 who had displaced 1 or more FMs, the ability to use the remaining FMs for stereotactic radiosurgery was unimpaired., Conclusions: EBUS and navigational bronchoscopy are safe and effective methods to position FMs for preparing patients with both central and peripheral lung cancers for stereotactic radiosurgery., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: We describe the first experience of direct bronchial (epi-bronchial) ultrasound to visualize and determine the endobronchial tumor margins for surgical resection., Description: An ultrasound probe was applied onto the membranous portion of the right main bronchus directly over a pedunculated tumor. The tumor was visualized due to the water content, with a total loss of signal (air-tumor interface) at the tumor edge. A sterile marker was used to outline the air-tumor interface., Evaluation: Traditionally, surgical technique involves palpation of the tumor with an incision to inspect the endobronchial lumen determining the position of the pedicle, thus estimating the amount of airway to resect. Using direct bronchial ultrasound, the right main palpated margin was 0.5-cm proximal to the ultrasound margin, which correctly identified the tumor margin. The upper lobe palpated margin was 1 cm proximal to the ultrasound margin, which correctly identified the tumor margin. In the intermediate bronchus, the palpated and ultrasound margin were the same and correct., Conclusions: By using the air-tumor interface, epi-bronchial ultrasound scanning can accurately demarcate the base of endobronchial tumors for surgical resection and reconstruction.

Ectopic acromegaly due to growth hormone-releasing hormone secretion by a bronchial carcinoid is rare. We report a case of bronchial carcinoid presenting with acromegaly due to ectopic growth hormone production. The patient was treated successfully with right pneumonectomy.

Three cases are presented with benign or low-grade malignant bronchial tumors managed by bronchial sleeve resection distal to the main bronchus. Bronchoplasty was accomplished by suturing the two distal bronchi together and then anastomosing them to the proximal bronchus. No pulmonary parenchyma was removed during the course of operation. All patients had excellent results. Bronchial sleeve resection distal to the main bronchus can be successfully performed; this is a safe and effective bronchoplastic technique for benign or low-grade malignant bronchial tumors.

Carcinoid syndrome is quite a rare presentation in bronchial carcinoid. A review of the literature suggests a figure of 2% to 7% in various series. This is usually associated with recurrent carcinoid tumor in the presence of hepatic metastasis. We discuss a patient who presented with flushing attacks 13 years after a left pneumonectomy. Further investigation found that the patient had recurrence at the pneumonectomy stump and in subcarinal lymph nodes.

Bronchopulmonary typical carcinoid tumors (BTCT) are neuroendocrine neoplasms with histologic low grade characteristics considered benign. However, despite reassuring histologic classification, some of them demonstrate an aggressive nature and metastatic behavior. During a not yet concluded study aiming at establishing criteria to predict this metastatic behavior, three uncommon cases were observed. Metastasis occurred despite typical carcinoid microscopic features in 3 female patients of African origin presenting at macroscopic examination as ramifying bronchopulmonary typical carcinoid tumors following the bronchial tree. We suggest that clinical ramifying presentation may be related to metastatic behavior, even for bronchopulmonary typical carcinoid tumors not displaying histologic criteria for atypical carcinoid tumors.

Background: Positron emission tomography (PET) is often used for an indeterminate pulmonary nodule., Methods: This is a prospective study on a consecutive series of patients who had an indeterminate pulmonary nodule that was 2.5 cm or less, underwent integrated positron emission tomography using fluorodeoxyglucose-PET/computed tomographic [FDG-PET/CT] scan with the maximum standardized uptake values (maxSUVs) reported, and who underwent complete resection., Results: There were 585 patients (401 men). A total of 496 patients had a malignant nodule and the median maxSUV was 8.5 (range, 0 to 36). Eighty-nine patients had a benign nodule and the median maxSUV was 4.9 (range, 0 to 28, p < 0.001). If the maxSUV was between 0 and 2.5 there was a 24% chance the nodule was malignant, if between 2.6 and 4.0 it was 80%, and if 4.1 or greater it was 96%. False negative FDG-PET/CT was from bronchoalveolar carcinoma in 11 patients, carcinoid in 4, and renal cell in 2. False positives included fungal infections in 16 patients. Nodal involvement, whether malignant or infectious, was more likely with a pulmonary mass that had a higher maxSUV (8.4 vs 3.8 for nonmalignant lesions, 9.8 vs 4.5 for malignant lesions)., Conclusions: Although integrated FDG-PET/CT is a valuable study for an indeterminate pulmonary nodule, one must be aware of causes of false positives and negatives. There is a 24% chance a suspicious nodule that has a maxSUV of 0 to 2.5 is cancer. The higher the maxSUV of the primary mass the more likely the nodes are to be involved with either malignancy or infection, and this may help direct nodal biopsy instead of pulmonary resection.

Background: Endobronchial carcinoids may recur even if radically resected. This retrospective study investigates the clinical and prognostic relevance of lymph node micrometastasis in these neoplasms., Methods: Fifty-five patients underwent standard anatomic resection (lobectomy or pneumonectomy) with systematic routine (hilar and mediastinal) lymphadenectomy. After an evaluation of conventional prognostic factors, we reanalyzed lymph nodes of pN0 patients for micrometastasis using immunohistochemistry (anti-cytokeratin AE1/AE3 and anti-chromogranin A antibodies)., Results: We performed 9 pneumonectomies, 41 lobectomies, and 5 bilobectomies. Histologic examination showed 47 (85%) typical carcinoid and 8 (14.5%) atypical. Twelve patients were pN1 (8 typical, 4 atypical); after reanalysis another 8 revealed micrometastasis, 6 N1 micrometastasis (5 typical, 1 atypical), and 2 N2 micrometastasis (2 atypical), increasing subjects with nodal involvement (pN1 and N micrometastasis) from 12 (21.8%) to 20 (36.4%; p = 0.01). Micrometastases were more frequent in atypical carcinoids (p = 0.002). Local recurrence developed in 3 (5.4%) patients: 2 pN1 (1 typical, 1 atypical) and 1 N1-micrometastasis (1 typical). Distant relapse occurred in 2 (3.6%) patients, both N2 micrometastasis (2 atypical). After reanalysis, recurrence rate in patients with nodal disease increased from 16.7% to 25% (p = 0.01). All patients with recurrence died: all had pN1 or N micrometastasis. No patient confirmed as N0 had recurrence. Only histologic pattern and node status significantly influenced disease-free (p = 0.002 and p = 0.05) and overall survivals (p = 0.02 and p < 0.001), respectively. Micrometastasis worsen both disease-free (p < 0.0001) and overall (p < 0.001) survival rates at 5 and 10 years., Conclusions: Routine systematic lymphadenectomy with immunohistochemical detection of lymph node micrometastasis contributes to identification of a larger population at risk with a higher recurrence rate, allowing a more accurate staging of endobronchial carcinoids.

Background: Adrenocorticotropic hormone (ACTH)-secreting pulmonary carcinoid is considered an aggressive variant of carcinoid tumors. Current knowledge is based upon a limited number of reports with few patients., Methods: All patients with Cushing's syndrome (CS) resulting from pulmonary carcinoid (PC) who underwent pulmonary resection at our institution from November 1966 through April 1998 were reviewed., Results: The group studied consisted of 10 males and 13 females. The median age was 39 years (range: 14-71). Pulmonary symptoms were present in 4 patients. Chest radiographs identified an abnormality in 13 patients (57%) and chest computerized tomography (CT) identified an abnormality in all 20 patients examined. Before pulmonary resection, hypophysectomy and bilateral adrenalectomy were performed in 7 patients (30%) each. Median time interval from presentation to pulmonary resection was 17 months (range: 1-228). Lobectomy was performed in 16 patients, segmentectomy was performed in 4 patients, and bilobectomy, pneumonectomy, and wedge excision was performed in 1 patient each. There were no operative deaths. Typical carcinoid was identified in 21 patients (91%) and atypical carcinoid was identified in 2 patients (9%). The median tumor diameter was 1.3 cm (range: 0.3-10). Nineteen patients (83%) underwent mediastinal lymphadenectomy and lymph node metastasis was found in 6 patients (32%) (N1 in 4 patients, N2 in 2 patients). The median follow-up was 78 months (range: 1-432). CS resolved in all of the patients. CS with PC recurred in 4 patients and CS alone recurred in 1 patient. Two patients underwent curative re-resection. Two patients, one with disseminated PC, died at last follow-up., Conclusions: Despite long delays in surgical therapy, pulmonary resection for ACTH-secreting PCs results in a favorable prognosis. Anatomic resection with complete mediastinal lymphadenectomy decreases local recurrence. Although rare these tumors do not seem to be as aggressive a variant of typical carcinoid tumors as previously reported.

We present the case of a 70-year-old man who previously had a left upper lobectomy for nonsmall cell lung carcinoma that subsequently developed into small cell carcinoma, which was successfully treated, and finally he had a right upper lobectomy that revealed three synchronous lung malignancies. We were unable to find a previous case report with a total of five separate lung malignancies with a combination of metachronous and synchronous tumors. This case demonstrates the importance of screening after the diagnosis and treatment of lung carcinoma.

Background: Pulmonary nodules are frequently first diagnosed by frozen section, immediately followed by lobectomy or other procedures. The frozen section diagnosis of pulmonary nodules can be difficult, as inflammatory and fibrotic lesions can be confused for malignancy, creating intraoperative dilemmas for pathologists and thoracic surgeons., Methods: We reviewed our experience at Cedars-Sinai Medical Center with the frozen section diagnoses of 183 consecutive pulmonary nodules smaller than 1.5 cm in diameter and calculated the sensitivity, specificity, and predictive values of this diagnostic procedure., Results: One hundred and seventy four nodules were correctly classified by frozen section as neoplastic or nonneoplastic, six lesions were diagnosed equivocally, and two neoplasms were missed owing to sampling errors. The equivocal frozen section diagnoses included two bronchioloalveolar carcinomas (BAC) interpreted as "atypical hyperplasia, favor BAC," two BAC diagnosed as "alveolar hyperplasia," and two carcinoid tumors labeled as "atypical carcinoma" and "spindle cell lesion, carcinoid versus sclerosing hemangioma," respectively. The sensitivities for a diagnosis of neoplasia were 86.9% and 94.1% for nodules smaller than 1.1 cm in diameter and measuring 1.1 to 1.5 cm, respectively. The diagnostic accuracy of frozen sections was significantly better in nodules larger than 1.0 cm in diameter (p = 0.05). There were no false-positive diagnoses of malignancy, resulting in 100% specificity., Conclusions: Intraoperative consultation with frozen section is a sensitive and specific procedure for the diagnosis of malignancy from small pulmonary nodules. The distinction between BAC and atypical adenomatous hyperplasia, and of small peripheral carcinoid tumors from other lesions, can be difficult by frozen section. Thoracic surgeons need to become aware of these problems and develop appropriate therapeutic strategies.

Background: Bronchial carcinoid tumors show a favorable outcome. We sought to determinate the variables influencing the long-term survival of patients treated for bronchial carcinoid tumors., Methods: We conducted a retrospective single institutional review of 163 patients surgically treated from January 1990 to April 2002. According to 1999 World Health Organization criteria, cases were segregated into typical (<2 mitoses per 2 mm, no necrosis) and atypical carcinoids (2 to 10 mitoses per 2 mm or necrosis)., Results: There were 86 men and 77 women with a mean age of 49.5 +/- 11 years. Symptoms were present in 89 patients (54.6%). Operations included 145 formal lung resections (89%), 9 wedge resections (5.52%), 8 sleeve lobectomies (4.9%), and 1 segmental resection (0.61%) plus radical mediastinal lymphadenectomy in all cases. No operative mortality was reported. Histologic examination showed 121 (74.2%) typical carcinoids (107 N0 and 14 N1), and 42 (25.8%) atypical carcinoids (15 N0, 18 N1, 9 N2). All patients were included in a follow-up (median, 54 months; mean, 58 months; range, 4 to 150 months), which included total body computed tomographic scan and bronchoscopy every year. Overall 5-year survival was 90.3% with a mean survival time of 139 months (95% confidence interval, 133 to 145). In N0 patients with either typical or atypical carcinoid tumors, no disease-related mortality was reported (100% 5-year survival). In N1 patients, 5-year survival was 90.0% for those with typical carcinoids, and 78.8% for those with atypical carcinoids (p = 0.394). In atypical carcinoids with N2 disease, 5-year survival was 22.2%., Conclusions: Prognosis in bronchial carcinoid tumors is more related to nodal status than to histologic subtype. In N0 and N1 patients no statistical significant difference has been found between typical and atypical subtype. However, N2 bronchial carcinoid tumors show a dismal prognosis.

Background: Assessment of sentinel nodes to predict metastases in a regional nodal basin is valuable for staging patients with melanoma and breast carcinoma. This study tested whether injection of isosulfan blue and technetium-99 could identify mediastinal sentinel nodes in patients with lung carcinoma and determine whether sentinel node histology predicts distal nodal metastases., Methods: Isosulfan blue and technetium-99 were injected into the tumor and pulmonary resection performed. The hilum and mediastinum were assessed visually and with the gamma probe, and a mediastinal nodal dissection was performed., Results: Thirty-one patients were evaluated. Three patients had positive sentinel nodes and positive distal mediastinal nodes. Twenty-two patients had negative sentinel nodes and negative distal nodes. No sentinel node was identified in 6 patients and 2 patients had two sentinel nodes., Conclusions: These data demonstrate that this rapid, simple technique can identify sentinel nodes in the mediastinum and that the sentinel node is an accurate predictor of distal nodal metastases in patients with lung cancer.

Background: Thoracoscopic lobectomy is emerging as a potential alternative to thoracotomy for early stage lung cancer. The issues of safety and oncologic efficacy should be analyzed before recommending this procedure for widespread use., Methods: Thoracoscopic lobectomy was attempted in 110 consecutive patients (age, 35 to 81 years) with tumors that were judged to be amenable to lobectomy over a 26-month period. Exclusion criteria included tumors greater than 5 cm in diameter, T3 tumors, endobronchial tumors visible at bronchoscopy, the use of induction therapy, extensive N1 disease on computed tomographic scan, and N2 disease at mediastinoscopy. The procedures were performed without rib spreading using two ports and included anatomic hilar dissection and individual vessel stapling., Results: Thoracoscopic lobectomy and mediastinal lymph dissection was successfully performed in 108 patients (98.2%); 2 patients required conversion to thoracotomy to control bleeding in the setting of dense hilar adenopathy. There were no intraoperative deaths and 4 perioperative deaths (3.6%) caused by pneumonia and associated adult respiratory distress syndrome (3 patients) and stroke (1 patient). Major complications included pneumonia (5 patients), stroke (1 patient), and return to the operating room to revise the bronchial closure (1 patient). Minor complications included prolonged air leak (6 patients), atrial fibrillation (4 patients), blood transfusion (2 patients) and ileus (1 patient). Median time to chest tube removal was 3 days, and median length of stay was 3 days., Conclusions: Thoracoscopic lobectomy is a safe and effective strategy for patients with early stage lung cancer. Long-term follow-up is required to determine if recurrence rate and 5-year survival are comparable with thoracotomy for lobectomy.

Background: Sleeve lobectomy is a parenchyma-sparing procedure that is particularly valuable in patients with cardiac or pulmonary contraindications to pneumonectomy. The purpose of this study is to report our experience with sleeve lobectomy for bronchogenic cancer and to investigate factors associated with long-term survival., Methods: Between January 1981 and June 2001, 169 patients underwent sleeve lobectomy for non-small-cell lung cancer (n = 139) or carcinoid tumor (n = 30), including 61 with a preoperative contraindication to pneumonectomy. Mean age was 59 +/- 14 years (range, 19 to 82 years). Vascular sleeve resection was performed in 11 patients. The remaining bronchial stump contained microscopic disease in 7 patients., Results: Major bronchial anastomotic complications occurred in 6 (3.6%) patients: one was fatal postoperatively, three required reoperation, and two were managed conservatively. In the non-small-cell lung cancer group, operative mortality was 2.9% (4 of 139), and overall 5-year and 10-year survival rates were 52% and 28%, respectively. Six patients experienced local recurrence after complete resection. By multivariate analysis, two factors significantly and independently influenced survival: nodal status (N0 or N1 versus N2; p = 0.01) and microscopic invasion of the bronchial stump (p = 0.02). In the carcinoid tumor group, there were no operative deaths, and overall 5-year and 10-year survival rates were 100% and 92%, respectively., Conclusions: Sleeve lobectomy achieves local tumor control and is associated with low mortality and bronchial anastomotic complication rates. Long-term survival is excellent for carcinoid tumors. For patients with non-small-cell lung cancer, N2 disease or incomplete resection is associated with a worse prognosis; outcome is not affected by presence of a preoperative contraindication to pneumonectomy.

Neuroendocrine carcinoma (carcinoid) of the thymus associated with Cushing's syndrome is a rare disease. Recent evidence suggests that these tumors form part of a continuous spectrum ranging from well-differentiated carcinomas to small cell carcinomas. We report two new cases and review the 23 cases reported in the literature since 1972. The different diagnostic modalities are discussed, and an algorithm for the diagnosis of ectopic secretion of adrenocorticotropin (ACTH) is presented. In the future, the advent of radiologic and nuclear imaging as well as more accurate workup should help to diagnose these tumors at an earlier stage and improve the long-term outcome.

Background: Neuroendocrine tumors of the thymus are rare, histologically diverse neoplasms with an unpredictable clinical behavior. This study provides a useful clinicopathological classification and determines the relevance of specific prognostic factors., Methods: Ten neuroendocrine tumors of the thymus were analyzed for specific clinical and pathological features. Prognostic factors of these cases and 71 previously published cases were evaluated by Kaplan-Meier survival curves and Cox multivariate hazard model., Results: There were 7 males and 3 females, with ages ranging from 26 to 77 years. Cases were classified as carcinoid tumor (2), atypical carcinoid tumor (6), and small cell carcinoma (2). An advanced clinical stage was evident in all instances with frequent recurrence (4) and metastases (8), and a short disease-free survival. Overall mortality was 60%. Statistical analysis of current and previously published cases (n = 81 total) revealed that unresectability (p = 0.0001), extent of surgical resection (p = 0.0002), and advanced clinical stage at presentation (p = 0.03) were associated with higher mortality. By multivariate Cox regression analysis, unresectability (p = 0.02) and advanced clinical stage (p = 0.03) were associated with decreased survival., Conclusions: Neuroendocrine tumors of the thymus can be classified into distinct clinicopathological entities, and specific factors have prognostic relevance.

Background: Bronchial carcinoid tumors account for approximately 2% of all lung tumors. Although they were considered benign lesions, they are now categorized malignant, occasionally with poor prognosis. The clinical symptoms can be highly variable and are often present for many years before diagnosis. Whereas some carcinoids are entirely asymptomatic, others are accompanied by carcinoid or paraneoplastic syndromes., Methods: We describe the multidisciplinary management of a 34-year-old female patient with a massive actively secreting bronchial carcinoid tumor of the right lung. Furthermore, we provide a review of the literature regarding the operative treatment and the perioperative management of pulmonary carcinoid tumors with respect to surgical, anesthetic, radiologic, and pathologic considerations., Results: In the reported case, the first symptoms were chronic watery diarrhea, skin flushing, progressive shortness of breath, and increasing right shoulder pain. When the patient initially presented at our institution, the tumor had already reached an enormous size and it involved the right and left atrium as well as the atrial septum. Using an evidence-based, multidisciplinary approach the patient was treated successfully with extended surgical resection., Conclusions: Carcinoid tumors are potentially curable even if they reach a significant size and thus an aggressive strategy is warranted. The management of such cases requires careful investigation, planning, and treatment with collaborative expertise provided by a multidisciplinary team. We demonstrated that this approach can lead to a favorable outcome in what first appeared to be a formidable and unresectable tumor.

Background: With the increasing use of mass screening programs for lung cancer, and especially the use of sputum cytology, the incidence of roentgenographically occult lung cancer has been increasing. These occult cancers comprise mainly histologically centrally-located early stage lung cancers. This study examined the clinicopathologic characteristics and surgical results of centrally-located early stage lung cancer., Results: From 1980 to 1998, there were 98 patients and 99 lesions of centrally-located early stage lung cancer resected. A total of 64 patients were detected by mass screening. Histologic examination revealed that 96 lesions were squamous cell carcinoma, and in these patients, there were 10 lesions of carcinoma in situ. The 5-year survival rate was 81.4% in all patients, and 88.9% in carcinoma in situ patients. In the postoperative follow-up period, a second lung cancer occurred in 13 patients., Conclusions: The surgical results for centrally-located early lung cancer were good. However, sometimes these cancers are accompanied by a second centrally-located primary lung cancer, so it is necessary to follow-up with sputum cytology to allow early detection of additional centrally-located lung cancer.

Background: This study examines the experience of the Spanish Multicenter Study of Neuroendocrine Tumors of the Lung through the clinical data and behavior of patients treated for this pathologic process., Methods: From 1980 to 1997, 361 cases of neuroendocrine carcinomas (NEC) were treated surgically. Patients were enrolled in a protocol using the pathologic and follow-up reports. According to Dreslers' criteria, the cases were segregated into grade 1 (typical carcinoid), grade 2 (atypical carcinoid), grade 3 large cell type, and grade 3 small cell type. Several variables were reviewed in all patients. Statistical analysis was performed to determine whether clinical characteristics and differentiation were associated with significant differences in the prognosis., Results: A total of 261 cases of NEC were identified with grade 1, 43 with grade 2, and with grade 3: 22 of large and 35 of small cells. Five-year survival for different grades was as follows: grade 1, 96%; 2, 72%; 3 large cell type, 21%; and 3 small cell type, 14%. When a comparative analysis between typical and atypical carcinoids was performed a significant difference for mean age, tumor size, nodal metastases, and recurrence was observed. However, female sex, nodal metastases, and recurrence rate differed between atypical carcinoids and grade 3 NEC of large cells. A difference in recurrence rate was found between patients with both types of grade 3 NEC., Conclusions: The progressive deterioration of tumor organization highlights that neuroendocrine tumors constitute a continuous spectrum. A careful observation of pathologic findings is necessary to individualize their prognostic factors.

Background: Thymic neuroendocrine tumor (carcinoid tumor) is rare, and prognosis for patients with this tumor has been difficult to predict., Methods: The medical records of 15 patients were reviewed, and the patients were classified according to tentative TNM classification and histologic grade., Results: Ten (66.7%) of 15 patients were male. Lymph node metastases were identified in 9 (60%) of 15 patients at the time of resection. There were one grade 1, nine grade 2, and five grade 3 tumors. Total resection was possible in 13 patients. Distant metastases developed in 10 (76.9%) of these 13 patients, although no local recurrence developed. Of these 10 patients, 6 died of distant metastases 5 to 25 months after the recurrence. Three patients are still alive, with metastases to the bone, spleen, and pleura 1 to 24 months after the diagnosis of recurrence. Two patients are presently tumor free (T1N0, grade 3 and T3N2, grade 2), but only 1 has survived beyond 5 years., Conclusions: Thymic neuroendocrine tumor must be regarded as a malignant neoplasm that is prone to metastasize to mediastinal lymph nodes and to distant sites, even after total excision. Neither T and N classification nor histologic grade has been successful in predicting the outcome of a patient with this tumor. More aggressive management, including adjuvant therapies and reexcision of subsequent tumors, may result in increased survival.

Background: This study estimated operative risk and examined factors determining long-term survival after resection of typical carcinoid tumors., Methods: From 1976 to 1996, 139 consecutive patients (66 male and 73 female patients with a mean age of 47 +/- 15 years) underwent thoracotomy for typical carcinoid tumor. The tumors were centrally located in 102 patients (73.4%)., Results: Radical resection was performed in 106 patients (7 pneumonectomies, 13 bilobectomies, and 86 lobectomies) and conservative resection in 33 (3 segmentectomies, 3 wedge resections, 20 sleeve lobectomies, and 7 sleeve bronchectomies). There were no postoperative deaths. Complications occurred in 19 patients (13.7%). The morbidity rate was not increased after bronchoplastic procedures (chi 2 = 0.033, not significant). Staging was pT1 in 107 patients (77.0%) and pT2 in 32 (23.0%); 13 patients (9.4%) had nodal metastases. Seventeen patients have died (12.2%), during follow-up, but only three deaths were related to the disease. The overall survival rate at 5, 10, and 15 years was estimated to be 92.4%, 88.3%, and 76.4%, respectively; estimated disease-free survival was 100% at 5 years and 91.4% at 10 and 15 years. Estimated survival of patients with lymph node metastasis was 100% at 5, 10, and 15 years. Univariate analysis failed to demonstrate any prognostic significance for sex, tumor size (T1 versus T2), tumor location (central versus peripheral), and type of resection., Conclusions: These data confirm an excellent prognosis after complete resection of typical carcinoid tumors, including those with lymph node metastases. Parenchyma-saving resections should be preferred.

We report a case of bronchial carcinoid that initially manifested as metastatic tumor in the breast. An exhaustive search for the primary tumor yielded the finding of a large right lung mass. Subsequent histopathologic examination of the resected lung and breast tissues confirmed the lung cancer as a primary tumor and the breast tumor as metastatic disease.

A case of a giant atypical carcinoid tumor is discussed. The tumor occurred in a 33-year-old man who presented with pleuritic chest pain and shortness of breath. Details of his preoperative evaluation, metastatic work-up, and use of tumor embolization are described. The operative procedure and use of cardiopulmonary support to achieve appropriate margins are described as well. Review of the literature and pathologic characteristics of carcinoid tumors and atypical carcinoid tumors are discussed.

Background: The terms large cell and mixed small-large cell neuroendocrine carcinoma (LCNC, MNC) have been proposed to describe distinct types of high-grade neuroendocrine lung tumors. However, cytologic appearance and neuroendocrine immunohistochemical stains cannot uniformly distinguish these from other neuroendocrine tumors, such as typical and atypical carcinoids or small cell carcinoma, or nonendocrine lung cancers such as large cell undifferentiated carcinoma. This study sought to determine the patterns of expression in LCNC and MNC of several molecular markers often abnormally expressed in lung cancers., Methods: Primary lung tumors with neuroendocrine features operated on between 1984 and 1994 were reviewed and classified as typical carcinoid (TC), atypical carcinoid (AC), LCNC, MNC, and small cell lung cancer (SCLC) based on mitotic rate, extent of necrosis, and cytoarchitectural features. Immunohistochemistry was performed using antibodies MIB-1 for Ki67, pAb1801 for p53, OP-66 for Rb, 31G7 for EGFR. Staining was scored as 0 to 4+ (0 = less than 5%, 1+ = 5% to 20%, 2+ = 20% to 50%, 3+ = 50% to 80%, 4+ = more than 80%) for p53, Ki67, and EGFR; and negative, focal, or positive for Rb. Overall survival was calculated by the Kaplan-Meier method and prognostic factors compared by log rank test., Results: Ninety-two tumors were examined: 25 TC, 7 AC, 24 LCNC, 18 MNC, 18 SCLC. The LCNC and MNC presented more frequently as stage II or III tumors (n = 28, 66%) than TC and AC (n = 5, 15%). Median survival for LCNC and MNC was 18.7 months, for SCLC 14.3 months, and has not been reached for TC and AC tumors. TC and AC tumors were uniformly characterized by low proliferative rate, absent p53, and normal Rb staining. LCNC, MNC, and SCLC showed a high proliferative rate, abnormal p53, and absent Rb staining. Overexpression of EGFR was frequent in all five tumor types., Conclusions: (1) Ki67, p53, and Rb help distinguish LCNC and MNC from TC and AC. (2) Small numbers of patients preclude comparison of survival rates, but LCNC/MNC have a median survival similar to comparable early stage SCLC, and clearly worse than TC/AC. These results justify a sharp separation of high-grade neuroendocrine tumors from carcinoids, and suggest a close relationship between LCNC, MNC, and SCLC.

Background: The necessity of an easy and noninvasive technique to evaluate mediastinal node status cytopathologically is considered., Methods: Eighteen cases of clinical N2 primary lung cancer were examined. Under local anesthesia, the lymph node was punctured with a 19-gauge needle using intermittent computed tomographic monitoring, and samples were studied cytologically. Subcarinal (no. 7) nodes and lower paratracheal (no. 4) nodes were sampled using the paraspinal posterior approach. Anterior mediastinal (no. 6) nodes were sampled using the parasternal anterior approach. Node status was diagnosed pathologically at operation., Results: Number 7 nodes were examined in 11 cases, no. 4 nodes in 5 cases, and no. 6 nodes in 2 cases. Malignant cells were detected in 14 cases. Fourteen cases were diagnosed as true positive, 2 cases as true negative, and 2 cases as false negative. The sensitivity, specificity, and accuracy of this method were 88%, 100%, and 89%, respectively. Pneumothorax developed in 4 cases (22%)., Conclusions: Computed tomography-guided percutaneous needle cytology of mediastinal lymph nodes is useful for staging primary lung cancer. Because this is a small series, additional studies are necessary.

Atypical carcinoids are an intermediate form of tumor between low-grade malignant typical carcinoid and high-grade malignant small cell carcinoma, which represent the two ends of the spectrum of neuroendocrine bronchopulmonary tumors. Between 1983 and 1993, 27 patients with atypical carcinoids underwent surgical treatment. The histologic diagnosis of an atypical carcinoid was established if the criteria proposed by Arrigoni and associates were fulfilled. Seven pneumonectomies, 16 lobectomies, 2 segmentectomies, and 2 wedge resections were performed. Thirteen patients (48.1%) had regional nodal metastases and 6 patients (22%) had N2 disease at the time of surgical therapy. Distant metastases developed in 5 patients (18.5%) after initial treatment. The 10-year survival in patients with an atypical carcinoid was 49%, versus the 84% 10-year survival rate observed in patients with a typical carcinoid. We conclude that the aggressive behavior of atypical carcinoids precludes the use of limited surgical resection and requires a more aggressive approach, with lobectomy and mediastinal lymph node dissection constituting a minimal procedure. The same criteria used for well-differentiated lung carcinoma should apply to this form of neuroendocrine lung tumor. Adjuvant chemotherapy is recommended for patients with stage III or distant metastases.

Pulmonary carcinoids are rarely associated with carcinoid syndromes and even less commonly with carcinoid crisis. Somatostatin analogues can control carcinoid syndrome or crisis with tumors of gastrointestinal origin. We report the successful use of a somatostatin analogue in preventing carcinoid crisis at the time of resection of an "active" bronchial carcinoid tumor.

The association of a bronchial or thymic carcinoid as a source for the ectopic production of adrenocorticotropic hormone (ACTH) has been reported since 1957, with approximately 72 cases in the literature. These patients are characterized by young age, long duration of Cushing's syndrome because of the inability to find the ectopic source, and a high incidence of hypophysectomy or adrenalectomy without curing the disease. A substantial number of patients, upon discovery of the thoracic ectopic source, are also found to have malignant carcinoid tumors with lymph node metastases. Fifteen patients have been explored for a presumed intrathoracic source of ACTH at our institution since 1983 and 14 carcinoids (13 bronchial, one thymic) have been resected. Seventy-one percent (10/14) of the patients appear cured with normal plasma ACTH levels 5 to 57 months after resection, despite a 50% incidence of positive lymph node disease. Management of these patients demands an aggressive evaluation to prevent unnecessary adrenalectomy or hypophysectomy and to allow earlier resections before these potentially curable malignancies metastasize. When the tumor is discovered, thorough exploration and complete lymph node mapping with resection must be performed.

Carcinoid tumors arising in the thymus are rare. Since Rosai and Higa in 1972 distinguished these neoplasms from thymomas, fewer than 100 cases have been reported in the world literature. In a 38-year review (1950 to 1988) of surgically treated thymic tumors at Henry Ford Hospital, only 7 cases of thymic carcinoids were identified. These 6 men and 1 woman ranged in age from 27 to 70 years (mean, 48 years) at diagnosis. Follow-up was available in all patients with the longest survival being 12 years in 2 patients, and the shortest, 1 year, in 1. Recurrences and/or metastases developed in 4 of 7 patients between 1 and 9 years after initial resection. Recurrences were treated by reexcision in addition to radiation treatment and chemotherapy in 3 patients and reexcision with radiation treatment alone in 1 patient. A review of the literature along with our experience suggests that thymic carcinoids have a biological behavior distinct from thymoma in terms of cell origin, associated syndromes, neoplastic behavior, and prognosis. An aggressive surgical approach with complete initial excision of the tumor and of subsequent recurrences, along with radiation and probably chemotherapy, is the best available treatment today.

The cases of 51 patients with bronchial adenomas were reviewed. There were 43 bronchial carcinoids, 5 adenoid cystic carcinomas, 2 mixed tumors, and 1 mucoepidermoid carcinoma. The carcinoid group was divided into typical (31, 72%) and atypical (12, 28%) subgroups. Nine carcinoids (20%) were categorized as metastasizing adenomas; in this group, 7 lesions were atypical and 2 were typical. Thirty-two lobectomies, 7 bilobectomies, 8 pneumonectomies, 2 sleeve resections, and 2 tracheal resections were performed. Ten-year survival was 88% for patients with typical carcinoids and 59% for those with atypical carcinoids. In the group with adenoid cystic carcinoma, 1 patient died postoperatively, 1 had recurrence of the tumor, 2 were alive and free from disease 16 and 23 years later, and 1 died of heart disease at 11 years. The patient with mucoepidermoid carcinoma was alive without recurrence 15 years after operation. In conclusion, bronchial adenomas of the carcinoid type are potentially malignant. Their prognosis depends on the histology of the tumor, and on the presence of metastasis to the regional lymph nodes and distant organs.

Forty-six patients with bronchial carcinoid tumors were operated on over a 37-year period. The results were reviewed with special reference to presenting complaint, histological diagnosis, location of the tumor, lymphatic involvement, and type of surgical resection. Age at operation ranged from 9 to 86 years (mean, 43.6 years). Presenting symptoms were hemoptysis in 21 instances, chronic cough in 17, and pneumonia in 15. The primary tumor was within the main bronchus in 17 patients. Twenty-one patients required pneumonectomy, and 20 had lobectomy or bilobectomy . Nine of the patients under-going pneumonectomy had severely damaged lung tissue distal to the lesion in the main bronchus. Six patients had metastases to hilar nodes. Four patients died of carcinoid tumor, but none with metastases died of carcinoid tumor. This series confirms the low malignancy potential of bronchial carcinoid tumors, even in the presence of lymphatic involvement. Although conservative resection is an attractive surgical option, only 10 of the 46 (22%) were potential candidates for such intervention. Standard surgical resection resulted in "cure" in 90% of the patients in the series.

Between 1964 and 1986, 19 patients underwent resection of both a primary lung cancer and the associated brain metastasis. One patient underwent resection of 2 separate primary lung cancers and the associated metastases. The 12 men and 7 women ranged in age from 42 to 67 years (mean, 54.6 years). The cell type was adenocarcinoma in 12 tumors, squamous or adenosquamous cell in 5, large cell undifferentiated or anaplastic in 2, and malignant carcinoid in 1 tumor. The types of resection were as follows: lobectomy for 12 neoplasms, pneumonectomy for 5, bilobectomy for 2, and wedge resection for 1 neoplasm. Radiotherapy to the brain was given in connection with sixteen of the twenty craniotomies. The patient with 2 separate primary neoplasms survived 19 years before dying 5 months after the second craniotomy. The mean survival is 8.0 +/- 2.1 years (+/- the standard error), and the median survival is 1.67 years. Survival at 1 year was 65 +/- 10.7% and at 5 years, 45 +/- 11.1%. On univariate analysis, the following factors were found to correlate significantly with longer survival: a lung tumor in Stage I or II; negative mediastinal nodes; curative rather than palliative resection of the lung tumor; and age younger than 55 years. However, on multivariate analysis, only curative resection was a significant factor (p less than 0.01). We believe these results justify continued application of this combined surgical approach to patients having limited-stage lung cancer with a solitary brain metastasis.

Resection of typical bronchial carcinoid was carried out in 203 patients. The average age was 48 years, and the sex distribution was approximately equal. Bronchoscopy was the most definitive diagnostic procedure, even though 15% of the tumors were located in the segmental bronchus or beyond. Conservative resection including local removal of the lesion was the treatment of choice, but distal suppuration and location of the tumor necessitated pneumonectomy in 54 (27%) of the patients. The incidence of metastasis was 5% (11 patients), and the overall hospital mortality was 3%. Of patients who qualified for follow-up, 94% survived 5 years, and of those who were asymptomatic preoperatively, 98% survived 5 years. The 10- and 25-year survival rates for the group as a whole were 87 and 66%, respectively.