Neuroendocrine lung tumor: a clinical case
- Authors: Pegina P.A.1, Likhobabina A.S.1, Arzhanykh A.V.1, Magomedrasulova A.A.1
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Affiliations:
- Voronezh State Medical University named after N.N.Burdenko
- Issue: Vol 13 (2024): Материалы XX Международного Бурденковского научного конгресса 18-20 апреля 2024 года
- Pages: 268-272
- Section: Онкология
- URL: https://www.new.vestnik-surgery.com/index.php/2415-7805/article/view/9380
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Abstract
Abstract.
Introduction. Neuroendocrine tumors (NEO) are a heterogeneous group of neoplasms that originate from neuroendocrine cells of the embryonic intestine that have biologically active properties. Neuroendocrine cells have certain secretory characteristics that cause the development of syndromes of hyperproduction of regulatory peptides, which can lead to the development of corresponding clinical syndromes. NEOS can occur in all organs with neuroendocrine cells. Goal. Conducting an analysis of an atypical clinical case. Materials and methods of research. examination, medical history, laboratory and instrumental studies, surgical, radiation, chemotherapeutic and immunotherapy treatment. The results of the study. A 59-year-old man turned to the VOCODE on 04.09.23 with complaints of shortness of breath during physical exertion, weakness. He considers himself sick since 10.19. During the examination, a brain tumor and a peripheral tumor of the upper right lung were revealed. In the NHO OKB22.11.19, removal of a brain tumor with TMO plastic surgery, according to the results of histological examination, fibrous meningioma. 12/30/19 lumboperitoneal bypass surgery on the left. Conclusions. Carcinoid lung tumors are formed from Kulchitsky neuroendocrine cells located in the mucous membrane of the bronchial tree, and account for 2 to 5% of all primary malignant lung diseases, ectopic ACTH hypersecretion occurs only in 0.5–2% of these neoplasms.
The main method of treatment of localized forms of carcinoid tumors of bronchopulmonary localization is surgical, organ-preserving operations such as segmentectomy, bisegmentectomy, lobectomy, lung resection with bronchoplastic stages are preferred.
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Introduction. Neuroendocrine tumors (NETs) are a heterogeneous group of neoplasms that originate from neuroendocrine cells of the embryonic intestine that have biologically active properties. Neuroendocrine cells have certain secretory characteristics that cause the development of syndromes of hyperproduction of regulatory peptides, which can lead to the development of corresponding clinical syndromes. NETs can occur in all organs that have neuroendocrine cells. The most common locations of tumors are the gastrointestinal tract and lungs.
NETs occur sporadically, smoking and alcohol do not increase the risk of the disease, but in approximately 15–20% of cases, tumors can be found in hereditary syndromes of multiple endocrine neoplasia types 1 and 2 or other hereditary syndromes. This patient has a poorly differentiated malignant carcinoid.
Purpose of the study. Analysis of an atypical clinical case.
Materials and methods of research. : examination, medical history, laboratory and instrumental studies, surgical, radiation, chemotherapy and immunotherapeutic treatment.
Research results. A 59-year-old man came to the BUZ at VOKOD on 09/04/23 with complaints of shortness of breath on exertion and weakness. He considers himself sick since 10:19. The examination revealed a brain tumor and a peripheral tumor of the upper lobe of the right lung. In NHO OKB 22.11.19 removal of a brain tumor with dura mater plastic surgery, according to the results of histological examination, fibrous meningioma. 12/30/19 lumboperitoneal shunting on the left. In the thoracic department of the Regional Clinical Hospital 02/27/20 VATS, upper lobectomy on the right. Carcinoma of a solid structure with invasion into the visceral pleura, along the resection line; there is no tumor growth in the lymph nodes. According to the results of histological examination, small cell neuroendocrine carcinoma G3.
The therapist diagnosed atherosclerotic post-infarction cardiosclerosis on 03/13/20 on 07/19.
X-ray of the chest organs on March 23, 2020 showed the condition after intralobectomy on the right without relapse or metastases. CTA of the abdominal organs 01/24/20 - liver cysts, right kidney stone. ECHO-cardiography 03/23/20 EF 59%.
LCC on 03/24/20 was diagnosed with: Peripheral cancer of the upper lobe of the right lung StIA2 T1вN0M0, after VATS upper lobectomy on 02/27/20. Class group 2.
Treatment is indicated: 4 courses of chemotherapy according to the EU scheme, radiation treatment (mediastinum, brain) 7.04.-9.04.20 1 course of chemotherapy: carboplatin AUC4 (568 mg) IV drop 1d, etoposide 100 mg/m2 (210 mg) IV \in cap 1-3d. Conducted 04/29/05/01/20 2nd course of chemotherapy carboplatin 568 mg 1 day, etoposide 210 mg 1-3 days. Conducted 05/23/05/24/20 3rd course of chemotherapy: cisplatin 75 mg/m2 (157 mg) IV drop 1d, Etoposide 100 mg \m2 (210 mg) intravenously for 1-2 days, tolerated satisfactorily, objectively, without changes. Discharged for family reasons. Conducted 15/06.-17/06.20 4th course of chemotherapy: cisplatin 75 mg/m2 (157 mg) intravenous drops 1 day, etoposide 100 mg/m2 (210 mg) intravenous drops 1-2 days. Handled it satisfactorily. From 09.10.20 to 09.29.20, a course of DHT 42 Gy was administered to the mediastinum. Dynamic observation was carried out. CT scan of the chest 01/20/21 condition after VATS upper lobectomy for peripheral cancer, courses of chemotherapy, radiation therapy, without signs of progression. CT scan of the chest 04/23/21 condition after VATSupernylobectomy for peripheral cancer, courses of chemotherapy, radiation therapy, without dynamics. from 01/20/21 ECHO-cardiography 10/04/21 EF 56%. CT scan of the chest 01.11.21 condition after VATS upper lobectomy for peripheral cancer, courses of chemotherapy, radiation therapy, signs of formation of the upper mediastinum to differentiate a conglomerate of lymph nodes. Received hemostimulating therapy at the place of residence, and therefore the course of chemotherapy was not started on time. Ultrasound of the liver, kidneys 10/29/21 without focal pathology. MRI of the brain on 11/25/21 without focal pathology. Conducted on 12/02/21 1 course of chemotherapy: docetaxel 75 mg/m2 (150g) intravenously 1d, tolerated satisfactorily. From 09/06/21 weakness began to bother me. In the general blood test dated 12/08/21 leukemia 1.6, x109 neutr 0.59.
09.12.21-14.12.21 a course of hemostimulating symptomatic therapy was carried out for grade 3 leukopenia with positive dynamics. 24.12.21 a 2nd course of chemotherapy docetaxel 150 mg IV was carried out. Tolerated it satisfactorily, objectively, without changes. On January 14, 2022, the 3rd course of chemotherapy, docetaxel 150 mg IV, was administered. He endured it satisfactorily, objectively, without changes.
X-ray of the OGK dated January 27, 2022 – condition after resection of the right lung, metastases to the mediastinal lymph nodes. Relapse. Ultrasound of OBP, kidneys, l\u from 01/28/22 - signs of cysts, diffuse changes in the liver, pancreas, cholelithiasis. Calicoectasias on the left, stones in the right kidney, lymphadenopathy of the submandibular region on the right. MSCT of the OGK dated January 30, 22 – condition after upper lobectomy for the upper lobe of the right lung. Signs of continued growth 50x35x48mm. Emphysema. Pleural adhesions in the lungs. Relaxation of the right dome of the diaphragm. Atherosclerosis of the thoracic aorta, calcification of the coronary arteries. Moderate cardiomegaly. About the chest OP. Formations in the liver (most likely cysts). GSD, gallbladder calculus. ICD, right kidney stone. Revision dated 02/03/22 – condition after VATS, upper LE on the right regarding peripheral s-g, after courses of RT. The picture of tumor recurrence along the suture with invasion into the mediastinum is 53x62x46mm, metastases are 13mm, 20x21mm. Single small foci of the left lung - without dynamics (focal pulmonary fibrosis). Cysts of the liver, right kidney. GSD, urolithiasis, concretion of the left jaw on the right. Compared to 11.11.21 – negative dynamics. 02/04/22-02/08/22 1 course of chemotherapy was carried out, 2 lines of topotecan 3 mg IV drops on days 1-5. Tolerated satisfactorily, objectively - no changes ECHO-cardiography 03.03.22 EF 56%
03/04/22-03/08/22 a 2nd course of chemotherapy was carried out, 2 lines of topotecan 3 mg IV drops on days 1-5. He endured it satisfactorily, objectively, without changes. Ultrasound of the liver, kidneys, lymph nodes dated 03/21/22 - signs of diffuse changes in the liver, liver cysts, stones in the right kidney.
MSCT of the OGK dated 03/23/22 - condition after surgical treatment for segmental resection of the upper lobe of the right lung, RT. Relapse 56x88x51mm. Single small lesions in the left lung, 2-4 mm. In comparison with 02/03/22 - progression, negative dynamics.
ECHO-KG from 03/29/22 - EF=55%.
04/01/22, 1 course of chemotherapy, 3 lines, cyclophosphamide 600 mg/m2 (1200 mg) IV drop 1 d, doxorubicin 50 mg/m2 (100 mg) IV drop 1 d, vincristine 1.4 mg/m2 (2 mg) IV was carried out \in cap 1 day. Tolerated it satisfactorily, objectively - without changes.
Consulted by the Federal State Budgetary Institution “N.N. Blokhin" 04/18/22 - recommended: continue CAV up to 2 courses with assessment of dynamics, additional examination.
04/22/22 2nd course of chemotherapy, 3rd line, cyclophosphamide 600 mg/m2 (1200 mg) IV drop 1 d, doxorubicin 50 mg/m2 (100 mg) IV drop 1 d, vincristine 1.4 mg/m2 (2 mg) IV \in cap 1 day. Tolerated it satisfactorily, objectively - without changes.
GI No. 12517\22 dated 04.24.22 - large cell neuroendocrine cancer. PET\CT dated 05.16.22 - picture of the presence of metabolic activity of tumor tissue in the space-occupying formation of the anterior mediastinum on the right with invasion of the parenchyma of the right lung, superior vena cava, right-sided bronchopulmonary lymph nodes, focal formation left adrenal gland. 05/24/22 consultation with the Federal State Budgetary Institution “National Medical Research Center of Oncology named after. Blokhina N.N" Ministry of Health of the Russian Federation - recommended: continue CAV up to 3 courses with subsequent assessment of dynamics. In case of stabilization, continue CAV up to 6 courses, in case of negative - EP, EC. 05/27/22 the 3rd course of chemotherapy, 3 lines, cyclophosphamide 600 mg/m2 (1200 mg) IV drop 1 d, doxorubicin 50 mg/m2 (100 mg) IV drop 1 d, vincristine 1.4 mg/m2 (2 mg) IV was carried out \in cap 1 day. Tolerated satisfactorily. ECHO-cardiography 05/29/22 EF=55%. Ultrasound of the abdominal organs 06/02/22 signs of diffuse changes in the liver, liver cysts. CT scan of the chest 06/01/22 condition after right upper lobectomy for peripheral cancer of the upper lobe of the right lung. In comparison with the CT scan dated 03/23/22, there was a slight increase in the size of the formation of the postoperative zone of the right root (according to RECIST1.1 stabilization) On 06/17/22, a 4th course of chemotherapy of the 3rd line was carried out, cyclophosphamide 600 mg\m2 (1200 mg) intravenous drops 1 d, doxorubicin 50 mg\ m2 (100 mg) IV drop 1 d, vincristine 1.4 mg/m2 (2 mg) IV drop 1 d. Tolerated satisfactorily. ECHO-cardiography 07/05/22 EF = 55%. He received hemostimulating therapy at his place of residence, and therefore the course of chemotherapy was not started on time. On July 12, 2022, the 5th course of chemotherapy, 3rd line, cyclophosphamide 600 mg/m2 (1200 mg) IV drop 1 d, doxorubicin 50 mg/m2 (100 mg) was carried out. IV drop 1 d, vincristine 1.4 mg/m2 (2 mg) IV drop 1 d. Tolerated satisfactorily. 08/02/22 6th course of chemotherapy, 3 lines, cyclophosphamide 600 mg/m2 (1200 mg) IV drop 1 d, doxorubicin 50 mg/m2 (100 mg) IV drop 1 d, vincristine 1.4 mg/m2 (2 mg) IV \in a drop of 1 d. Tolerated satisfactorily.
CT scan of the chest 09/05/22 condition after upper lobectomy on the right for peripheral cancer of the upper lobe of the right lung, chemotherapy courses. CT signs of formation in the postoperative area involving the SVC, right pulmonary artery, and aortic arch. Foci of compaction in the lungs. Consulted with a radiologist 09/06/22: radiation therapy is not indicated. CT scan of the chest 03.11.22 condition after upper lobectomy on the right for peripheral cancer of the upper lobe of the right lung, chemotherapy courses. CT signs of formation in the postoperative area involving the SVC, right pulmonary artery, and aortic arch. Foci of compaction in the lungs - metastases, mediastinal lymphadenopathy - metastases, effusion in the right pleural cavity, foci in the liver. In comparison with the CT scan dated 09/05/22, the dynamics are negative.
Consulted at the National Medical Research Center of Oncology named after N.N. Blokhin 08.11.22, taking into account the progression, courses of chemotherapy are indicated - etoposide 110 mg/m2 (220 mg)1-3, cisplatin 75 mg/m2 (150 mg) intravenously 1 d, course after 21 days. ECHO-cardiography 10.11 .22 EF=58%, myocardial contractility is satisfactory. The dimensions of the cavities and wall thickness are within normal limits. Minor disturbance of the relaxation phase of the left ventricle. 11.11.-13.11.22 1 course of chemotherapy line 5 etoposide 110 mg/m2 (220 mg)1-3, cisplatin 75 mg/m2 (150 mg) intravenously 1 d was administered, tolerated satisfactorily
12/05/22-12/07/22 2nd course of 5th line chemotherapy was carried out, etoposide 110 mg/m2 (220 mg)1-3, cisplatin 75 mg/m2 (150 mg) IV drop 1 d,
MSCT of the OGK dated 12/23/22 - condition after upper right lobectomy for peripheral cancer of the upper lobe of the right lung, courses of PCT. CT scan signs of the formation of a postoperative zone of the right lung, complicated by atelectasis of the middle lobe, spreading into the mediastinum, with the involvement of the great vessels. Foci of compaction in the lungs (metastases). Mediastinal lymphadenopathy (metastases). Effusion in the right pleural cavity. In comparison with CT scan 03.11.22 - a decrease in the size of the tumor formation, a decrease in areas of atelectasis of the middle lobe of the right lung, otherwise without pronounced dynamics. CT scan of the abdominal cavity, retroperitoneal space 12.23.22 picture of liver metastases, cysts. Formation of the left adrenal gland, more data for metastasis. Symptom of “turbid mesentery”, formation of mesentery (enlarged mesenteric node). Formation of the right kidney. ICD, right kidney stones. Restructuring of bone tissue in the left iliac region (suspicion of metastasis). 12/23/22 consulted at the Blokhin National Medical Research Center of Oncology, it was recommended to continue chemotherapy courses according to the EP regimen, PET-CT. 12/27/22-12/29/22 3rd course of 5th line chemotherapy was carried out, etoposide 110 mg/m2 (220 mg)1-3, cisplatin 75 mg/m2 (150 mg) intravenous drops 1 d, tolerated satisfactorily. The next course of chemotherapy was not started on time due to leukopenia. 01/20/23-01/22/23 the 4th course of chemotherapy, line 5, etoposide 110 mg/m2 (220 mg)1-3, cisplatin 75 mg/m2 (150 mg) intravenously 1 day, tolerated satisfactorily. PET-CT 02/14/23 marked increase in formation in the left adrenal gland, moderate increase in nodular formations in the perinephric tissue on the right, moderate increase in foci in the liver parenchyma, tumor formation remains in the right lung, intrathoracic lymph nodes without significant dynamics. According to RECIST criteria, an increase in the length of target lesions by 10% means stabilization of the process. Consulted by phone on 02/17/23 with the National Medical Research Center of Oncology named after Blokhin Markovich A.A. It is recommended to conduct 2 more courses of chemotherapy according to the EP regimen. ECHO-cardiography 02/17/23 EF=59%, myocardial contractility is satisfactory. The dimensions of the cavities and wall thickness are within normal limits. Slight disturbance of the relaxation phase of the left ventricle. 02/21/23-02/23/23 the 5th course of chemotherapy, 5th line, etoposide 110 mg/m2 (220 mg)1-3, cisplatin 75 mg/m2 (150 mg) intravenous drops 1 d was carried out, tolerated satisfactorily
03/15/23-03/17/23 the 6th course of 5th line chemotherapy was carried out: etoposide 110 mg/m2 (220 mg)1-3, cisplatin 75 mg/m2 (150 mg) IV drop 1 d, SCT OGK, OBP, GM 03/23. 2023: no data were received for metastases in the bones and cranial cavity; in comparison with PET-CT from 02/14/2023 - without pronounced dynamics.
After the course, grade 3-4 neutropenia. From March 29, 2023, leucostim was administered m/f at 7:15 p.m. CT scan of the chest 05.05.23: condition after upper lobectomy on the right for peripheral cancer of the upper lobe of the right lung, chemotherapy courses. Signs of formation of a postoperative zone of the right lung, complicated by atelectasis of the middle lobe, spreading to the mediastinum, and involvement of the great vessels. Metastases to the lungs, mediastinal lymph nodes. In comparison with the CT scan dated 03/23/23, the dynamics are negative. ECHO-cardiography 04/18/23: EF=55%, myocardial contractility is not impaired, the heart cavities are not dilated. CT scan of the chest 05.26.23: condition after upper lobectomy on the right for peripheral cancer of the upper lobe of the right lung, relapse of the tumor of the right lung with signs of spread of the process to the mediastinum with involvement of the SVC, metastases to the lymph nodes of the mediastinum, lungs, liver, left adrenal gland, right kidney, structural changes in the 3rd and 4th ribs on the right. In comparison with data from 05.05.23, negative dynamics. MRI of the brain 06/02/23 condition after removal of PCF meningioma. Thickening of the dura mater most likely can be a symptom of intracranial hypotension or pachymeningitis, dyscirculatory dystrophic changes in the brain, postoperative changes in the posterior fossa.
Consulted by phone on 06.06.23 with the National Medical Research Center of Oncology named after Blokhin Markovich A.A. It is recommended to conduct 2 more courses of chemotherapy according to the gemcitabine regimen.
Hospitalized at OU No. 9 for 1 course of chemotherapy line 6.
Conclusion. Lung carcinoid tumors are formed from neuroendocrine Kulchitsky cells located in the mucous membrane of the bronchial tree and account for 2 to 5% of all primary malignant lung diseases; ectopic hypersecretion of ACTH occurs in only 0.5–2% of these neoplasms.
The main method of treatment for localized forms of bronchopulmonary carcinoid tumors is surgical; organ-preserving operations such as segmentectomy, bisegmentectomy, lobectomy, and pulmonary resection with bronchoplastic stages are preferred. Metastasis to group N1 lymph nodes in typical carcinoids can occur in approximately 4–5% of cases, N2 lesions have been noted in isolated cases, but mediastinal lymphadenectomy is mandatory. In addition, some studies indicate the possibility of performing sublobar resections in early forms of NSCLC (the size of the primary lesion is less than 2 cm and the absence of mediastinal lymphadenopathy). Systemic treatments include somatostatin analogs, peptide receptor radionuclide therapy (PRRT), low-dose interferon, sunitinib, bevacizumab, and platinum agents.
The performed surgery, radiation, chemotherapy and immunotherapy slow down the progression of the tumor and prolong the life of the patient.
About the authors
Polina Andreevna Pegina
Voronezh State Medical University named after N.N.Burdenko
Email: lihobabinaanastacia@yandex.ru
Russian Federation, 10 Studentskaya str., Voronezh, 394036, Russia
Anastasia Sergeevna Likhobabina
Voronezh State Medical University named after N.N.Burdenko
Email: lihobabinaanastacia@yandex.ru
ORCID iD: 0009-0007-0845-3521
SPIN-code: 4231-0885
Russian Federation, 10 Studentskaya str., Voronezh, 394036, Russia
Angelica Viktorovna Arzhanykh
Voronezh State Medical University named after N.N.Burdenko
Email: ordinatura@vrngmu.ru
ассистент кафедры онкологии
Russian Federation, 10 Studentskaya str., Voronezh, 394036, RussiaAsiyat Abdulnasirovna Magomedrasulova
Voronezh State Medical University named after N.N.Burdenko
Author for correspondence.
Email: ordinatura@vrngmu.ru
Assistant of the Department of Operative Surgery with Topographic Anatomy
Russian Federation, 10 Studentskaya str., Voronezh, 394036, RussiaReferences
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