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From the Archives of the AFIP¹

Thoracic Carcinoids: Radiologic-Pathologic Correlation

¹ From the Departments of Radiologic Pathology (M.L.R., J.R.G.) and Pulmonary and Mediastinal Pathology (W.D.T.), Armed Forces Institute of Pathology, 6825 16th St NW, Bldg 54, Room M-121, Washington, DC 20306-6000; the Department of Radiology and Nuclear Medicine, Uniformed Services University of the Health Sciences, Bethesda, Md (M.L.R.); the Department of Diagnostic Imaging, Brown University School of Medicine, Rhode Island Hospital, Providence (G.F.A.); the Department of Radiology, New Britain General Hospital, New Britain, Conn (W.M.K.); and the Department of Radiology, University of Maryland Medical System, Baltimore (J.R.G.). Address reprint requests to M.L.R.

	Abstract

Top Abstract INTRODUCTION BRONCHIAL CARCINOID THYMIC CARCINOID CONCLUSIONS References

 
Carcinoids are neuroendocrine neoplasms. Bronchial carcinoids are unusual, malignant primary neoplasms that characteristically involve the central airways and typically exhibit well-defined margins and bronchial-related growth. Bronchial carcinoids include low-grade typical carcinoids and the more aggressive atypical carcinoids. These tumors usually affect patients in the 3rd through 7th decades of life who are often symptomatic with cough, hemoptysis, or obstructive pneumonia. Bronchial carcinoids radiologically manifest as hilar or perihilar masses, with or without associated atelectasis, pneumonia, bronchiectasis, or mucoid impaction. At computed tomography, an anatomic relationship of these tumors to a bronchus is usually seen, and they may show contrast material enhancement or calcification. In rare cases, carcinoids occur in the thymus; when they do, they are aggressive tumors that affect adults who usually present with chest pain, cough, and dyspnea. Thymic carcinoids manifest radiologically as anterior mediastinal masses and may mimic thymomas. Thoracic carcinoids are treated by surgical excision. The prognosis for patients with typical bronchial carcinoids is excellent; patients with atypical bronchial or thymic carcinoids have a worse prognosis.

Index Terms: Lung neoplasms, 60.3111, 60.3117 • Thymus, neoplasms, 675.3111

	INTRODUCTION

Top Abstract INTRODUCTION BRONCHIAL CARCINOID THYMIC CARCINOID CONCLUSIONS References

 
Carcinoids occur most frequently (90% of cases) in the gastrointestinal tract. The second most common location is the respiratory tract. Less commonly, they occur in the thymus, biliary tract, or ovary (1). Other anatomic locations are extremely rare. The majority of thoracic carcinoids behave in an indolent manner. However, all have the potential to metastasize and are considered malignant neoplasms (2,3).

The term carcinoid was coined by Oberndorfer in 1907 as "Karzinoide" to denote its resemblance to carcinoma. In 1930, Kramer classified this tumor among the so-called bronchial adenomas to signify its relatively indolent behavior (4,5). Bronchial carcinoids were initially distinguished from other bronchial neoplasms by Hamperl in 1937 (6).

Today, bronchial carcinoids are thought to derive from the neuroendocrine cells of the bronchial and bronchiolar epithelium, which in turn may derive from pluripotent stem cells (3,7,8). The term neuroendocrine refers to the ability of a cell to synthesize, store, and secrete chemical messenger substances such as neuroamines and neuropeptides (9). Neuroendocrine cells occur as solitary cells along the basement membrane of the bronchial and bronchiolar epithelium or as nodular cell clusters called neuroepithelial bodies. Their neuroendocrine function has been demonstrated by means of ultrastructural studies and immunohistochemical markers, and they form part of the diffuse or dispersed endocrine system, which includes gastrointestinal, thymic, and bronchopulmonary components (3,7,10,11).

Bronchial carcinoids are uncommon pulmonary neoplasms and represent 1%–2% of all lung tumors (3,12). Previously, they were classified along with adenoid cystic carcinomas and mucoepidermoid carcinomas as "bronchial adenomas." Today, that term is considered a misnomer, as it implies that these malignant lesions are benign (8,13). The classification and nomenclature of carcinoids has further evolved with our increased understanding of their biologic and clinical behavior. Bronchial carcinoids display a spectrum of clinical behavior and histologic differentiation, ranging from the low-grade typical carcinoids to the intermediate-grade atypical carcinoids to the high-grade large-cell neuroendocrine carcinomas and small cell carcinomas (3,14).

Thymic carcinoids are unusual primary neoplasms of neuroendocrine origin that manifest as anterior mediastinal masses in adult patients, who may present with a clinically evident hormonal syndrome (11). Thymic carcinoids usually exhibit an aggressive behavior.

In this article, the clinical and radiologic features of bronchial and thymic carcinoids are presented and correlated with the gross and histologic characteristics of these lesions.

	BRONCHIAL CARCINOID

Top Abstract INTRODUCTION BRONCHIAL CARCINOID THYMIC CARCINOID CONCLUSIONS References

 
Clinical Features
Bronchial carcinoids are unique among primary malignant neoplasms of the lung in that the affected population has a significantly lower male-to-female ratio. In fact, in an extensive literature review of 2,837 patients with bronchial carcinoid, 52% of patients were females and 48% were males (15). Affected individuals display a wide age range with an average age at presentation of 45.5 years (11,16). In general, patients with bronchial carcinoids are younger than those with common primary pulmonary neoplasms such as bronchogenic carcinoma (15). However, the age of patients with atypical carcinoid is 1 decade greater (6th decade of life) than that of those with typical carcinoid (13,16,17). Bronchial carcinoid represents the most common primary pulmonary neoplasm of children, and most pediatric patients present in late adolescence (18). Bronchial carcinoid affects whites more frequently than blacks, and there is no documented association with cigarette smoking or exposure to other carcinogens or environmental agents (11,13,15,17).

Patients with bronchial carcinoids are often symptomatic and present with cough and recurrent pulmonary infection. Hemoptysis is frequent and occurs in approximately 50% of patients (11,13). Chest pain, shortness of breath, and constitutional symptoms also occur. Cough, hemoptysis, fever, dyspnea, chest pain, and obstructive pneumonia may occur as isolated symptoms or in combination. Wheezing localized to one lung and "asthma" of recent onset have been described as characteristic findings (11). However, up to 19%–51% of patients are asymptomatic, and bronchial carcinoid is diagnosed incidentally because of abnormal findings at chest radiography (3,11,19). Interestingly, pediatric patients are rarely asymptomatic, and most present with cough, hemoptysis, or pneumonia. In fact, wheezing, pneumonia, and atelectasis are presenting signs in 50% of pediatric patients with bronchial carcinoids (18).

The high frequency of symptoms in patients with bronchial carcinoids is probably related to the frequent central location of the tumor. However, symptoms may be present for many years before the diagnosis is established (20). Peripheral lesions are reported to produce symptoms less frequently than central tumors (3).

It should be noted that although hormonal products can be demonstrated within cellular neurosecretory granules in all carcinoids, systemic hormonal manifestations are rare. However, a small number of patients present because of symptoms related to Cushing syndrome, which is seen in approximately 2% of cases of bronchial carcinoids. Approximately 1% of cases of Cushing syndrome are secondary to bronchial carcinoid through the ectopic production of adrenocorticotropic hormone (ACTH) or ACTH-releasing hormone. In fact, bronchial carcinoids represent the most common source of ectopic ACTH production (13). It may be difficult to distinguish carcinoid-induced Cushing syndrome from pituitary-dependent Cushing syndrome (13,21). However, carcinoid-induced Cushing syndrome may be clinically suspected because of its acute onset, high ACTH concentration (> 55 pmol/L), and hypokalemia (the latter is uncommon in other forms of Cushing syndrome) (21,22). It is also characterized by its glucocorticoid response to high-dose dexamethasone or metyrapone (22). The causative bronchial carcinoid is frequently radiologically occult and may require advanced imaging for detection (22). Typical, atypical, and metastatic carcinoids have all been reported as causes of Cushing syndrome. The carcinoid syndrome is rarely seen in association with bronchial carcinoid. It is seen in less than 2%–5% of patients with bronchial carcinoid, is usually encountered only in patients carcinoid metastatic to the liver, and rarely if ever in patients with isolated bronchial tumors (13,23).

Histologic Features
Histologically typical carcinoid is composed of uniform cells with an organoid growth pattern in a rich fibrovascular stroma (Fig 1) (3,9). The cells are polygonal with an eosinophilic granular cytoplasm and are arranged in nests or solid sheets. The nuclei are central and rounded and contain a fine stippled chromatin and inconspicuous nucleoli (Fig 1). Typical carcinoids exhibit a wide spectrum of histologic variability including spindle cell, trabecular, palisading, glandular, rosette-like, and sclerosing papillary patterns. Necrosis should be absent, and most tumors exhibit more than one pattern. Mitoses are fewer than two per 2 mm² (3,24–26). Most carcinoids are richly vascular. They may exhibit dystrophic calcification, ossification, or amyloid deposition (13).

View larger version (232K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  Typical carcinoid. (a) Low-power photomicrograph (original magnification, x100; hematoxylin-eosin [H-E] stain) of a typical carcinoid demonstrates uniform cells with an organoid nesting pattern. (b) High-power photomicrograph (original magnification, x400; H-E stain) of a typical carcinoid shows uniform cells with granular cytoplasm and stippled nuclear chromatin growing in an organoid nesting pattern.

View larger version (212K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  Typical carcinoid. (a) Low-power photomicrograph (original magnification, x100; hematoxylin-eosin [H-E] stain) of a typical carcinoid demonstrates uniform cells with an organoid nesting pattern. (b) High-power photomicrograph (original magnification, x400; H-E stain) of a typical carcinoid shows uniform cells with granular cytoplasm and stippled nuclear chromatin growing in an organoid nesting pattern.

View larger version (229K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  Atypical carcinoid. (a) High-power photomicrograph (original magnification, x200; H-E stain) of an atypical carcinoid shows a characteristic punctate focus of necrosis. (b) High-power photomicrograph (original magnification, x400; H-E stain) of an atypical carcinoid demonstrates one mitotic figure (arrow).

View larger version (214K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  Atypical carcinoid. (a) High-power photomicrograph (original magnification, x200; H-E stain) of an atypical carcinoid shows a characteristic punctate focus of necrosis. (b) High-power photomicrograph (original magnification, x400; H-E stain) of an atypical carcinoid demonstrates one mitotic figure (arrow).

View larger version (201K): [in this window] [in a new window] [Download PPT slide]   Figure 3.  Typical carcinoid. High-power photomicrograph (original magnification, x400) of a typical carcinoid stained with immunohistochemistry for chromogranin A shows cytoplasmic staining.

Gross Pathologic Features
Typical and atypical carcinoids are indistinguishable on the basis of gross pathologic features (24). Tumors are frequently classified according to their location as central or peripheral. However, the definitions of central and peripheral vary greatly in the literature. Central tumors are sometimes defined as those involving the mainstem, lobar, or segmental airways, and peripheral tumors as those that involve subsegmental airways or more distal bronchi (6). Central tumors have also been defined as those located within reach of the bronchoscope, those associated with obstructive features, or those resectable by using bronchoplasty or pneumonectomy; peripheral tumors, by this definition, are not visible with endoscopy and are resectable by using lobectomy (9). In addition, lesion location has also been described on the basis of computed tomographic (CT) findings as central or peripheral. Central lesions have been described as those visualized on CT scans in the medial one-third of the lung and peripheral lesions as those in the outer two-thirds (3,27). A 1976 review of 203 bronchial carcinoids classified the lesions according to their sites of origin and found that 10% occurred in the mainstem bronchi, 75% in the lobar bronchi, and 15% at the level of segmental bronchi and beyond (28). Although the location of carcinoids varies, most investigators agree that the majority are central and are related to an airway and that 16%–40% occur in the lung periphery. Others postulate that carcinoids are evenly distributed throughout the lung, with one-third of lesions located centrally, one-third in the middle portion of the lung, and one-third in the peripheral lung (3,14).

Macroscopically, bronchial carcinoids are well-circumscribed nodules or masses. Central lesions have a red-brown endoluminal polypoid component with a focal or broad attachment to the bronchial wall. The bronchial mucosa is often intact over the lesion and results in a smooth, glistening tumor surface (Fig 4) (3,9,13,29). The cut surface of bronchial carcinoids is yellow-tan or pale pink, depending on the degree of tumor vascularity (Fig 5) (3,20,25). Although some carcinoids grow exclusively within the bronchial lumen, invasion through the bronchial wall and its cartilaginous rings is common (Fig 5) (6). Completely endoluminal carcinoids manifest as polypoid or exophytic masses without gross evidence of extension through the cartilage. However, most carcinoids exhibit a dumbbell shape and have parenchymal (extrabronchial) components of variable size (3,6,20). In these cases, a large parenchymal mass may have a very small endoluminal component (Fig 6). Some lesions simply abut the bronchial lumen without gross endoluminal involvement (Fig 7). Central tumors may partially or completely occlude the bronchus and may produce distal obstruction and inflammation (Fig 8) (9,24).

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 4. Figures 4, 5. (4) Typical carcinoid in a 38-year-old man with a 2-year history of recurrent pneumonia. Photograph of the resected specimen shows a completely endobronchial ovoid tumor in the left mainstem bronchus. A smooth glistening mucosa covers the lesion. (5) Typical carcinoid in a 28-year-old woman with a 6-month history of dyspnea. Photograph of a cut section of the surgical specimen shows a polypoid carcinoid tumor occluding the main bronchus and focally invading the bronchial wall (arrows).

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 5. Figures 4, 5. (4) Typical carcinoid in a 38-year-old man with a 2-year history of recurrent pneumonia. Photograph of the resected specimen shows a completely endobronchial ovoid tumor in the left mainstem bronchus. A smooth glistening mucosa covers the lesion. (5) Typical carcinoid in a 28-year-old woman with a 6-month history of dyspnea. Photograph of a cut section of the surgical specimen shows a polypoid carcinoid tumor occluding the main bronchus and focally invading the bronchial wall (arrows).

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 6. Figures 6–8. (6) Typical carcinoid in a 36-year-old woman with a 1-year history of recurrent left lower lobe pneumonia. Photograph of a cut section of the surgical specimen shows that although the bulk of the tumor is parenchymal, an endoluminal component is also present (*). (7) Typical carcinoid in a 38-year-old man with recurrent right lower lobe pneumonia. Photograph of a cut section of the surgical specimen shows a well-circumscribed, fleshy, ovoid mass abutting the bronchovascular bundle. A mucus plug is seen adjacent to the tumor (*). (8) Typical carcinoid in a 50-year-old woman with an 8-month history of cough and recurrent pneumonia. Photograph of a cut section of the surgical specimen shows an endobronchial tumor (*) occluding the bronchus intermedius with consolidation and bronchiectasis of the right middle and lower lobes.

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 7. Figures 6–8. (6) Typical carcinoid in a 36-year-old woman with a 1-year history of recurrent left lower lobe pneumonia. Photograph of a cut section of the surgical specimen shows that although the bulk of the tumor is parenchymal, an endoluminal component is also present (*). (7) Typical carcinoid in a 38-year-old man with recurrent right lower lobe pneumonia. Photograph of a cut section of the surgical specimen shows a well-circumscribed, fleshy, ovoid mass abutting the bronchovascular bundle. A mucus plug is seen adjacent to the tumor (*). (8) Typical carcinoid in a 50-year-old woman with an 8-month history of cough and recurrent pneumonia. Photograph of a cut section of the surgical specimen shows an endobronchial tumor (*) occluding the bronchus intermedius with consolidation and bronchiectasis of the right middle and lower lobes.

View larger version (135K): [in this window] [in a new window] [Download PPT slide]   Figure 8. Figures 6–8. (6) Typical carcinoid in a 36-year-old woman with a 1-year history of recurrent left lower lobe pneumonia. Photograph of a cut section of the surgical specimen shows that although the bulk of the tumor is parenchymal, an endoluminal component is also present (*). (7) Typical carcinoid in a 38-year-old man with recurrent right lower lobe pneumonia. Photograph of a cut section of the surgical specimen shows a well-circumscribed, fleshy, ovoid mass abutting the bronchovascular bundle. A mucus plug is seen adjacent to the tumor (*). (8) Typical carcinoid in a 50-year-old woman with an 8-month history of cough and recurrent pneumonia. Photograph of a cut section of the surgical specimen shows an endobronchial tumor (*) occluding the bronchus intermedius with consolidation and bronchiectasis of the right middle and lower lobes.

Central lesions are larger than peripheral tumors, with mean diameters of 3.1 and 2.4 cm, respectively (3). Atypical carcinoids are larger, on average, than typical carcinoids, with mean diameters of 3.6 and 2.3 cm, respectively (3,10). Atypical carcinoids are more likely to exhibit hemorrhage and necrosis. Both typical and atypical carcinoids may metastasize to regional lymph nodes, but atypical tumors do so more frequently (48%) (30). Although both may invade the adjacent lung, atypical tumors do so more aggressively and are more likely to invade vascular or lymphatic structures and to establish distant metastases (10). Metastases occur in 15% of bronchial carcinoids and typically affect the liver, bone, adrenal glands, and brain (20).

Radiologic Features
Radiography.—Typical and atypical bronchial carcinoids share similar imaging features. The most frequent radiographic manifestation of bronchial carcinoid is a hilar or perihilar mass, which may represent an isolated finding or may be associated with distal parenchymal disease (19,31). These lesions may occur in any parenchymal location, and, when they occur distal to the hila, they are generally distributed equally throughout the pulmonary lobes. The mass is characteristically well circumscribed, is rounded or ovoid, and may have a notched or lobulated contour (Fig 9). Masses with irregular or ill-defined margins are rarely seen. These lesions typically range in size from 2 to 5 cm. Atypical carcinoids are reported to be larger on average than typical carcinoids (32). Calcification is rarely visible radiographically. Multifocal tumors have been reported but are also rare. Cavitation has not been reported in bronchial carcinoids (19,33,34). In rare cases, the chest radiographs of patients with bronchial carcinoids are read as normal (19,33).

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.  Typical carcinoid in an asymptomatic 38-year-old woman. (a, b) Posteroanterior (PA) (a) and lateral (b) chest radiographs show a well-circumscribed, spherical left hilar mass. (c) Chest CT scan (lung window) demonstrates the lobular, partially endobronchial mass. Note the convex appearance of the lesion within the bronchial lumen. (d) Photograph of a cut section of the resected left upper lobe demonstrates the relationship of the lesion to the bronchus (arrow). Scale is in centimeters.

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.  Typical carcinoid in an asymptomatic 38-year-old woman. (a, b) Posteroanterior (PA) (a) and lateral (b) chest radiographs show a well-circumscribed, spherical left hilar mass. (c) Chest CT scan (lung window) demonstrates the lobular, partially endobronchial mass. Note the convex appearance of the lesion within the bronchial lumen. (d) Photograph of a cut section of the resected left upper lobe demonstrates the relationship of the lesion to the bronchus (arrow). Scale is in centimeters.

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 9c.  Typical carcinoid in an asymptomatic 38-year-old woman. (a, b) Posteroanterior (PA) (a) and lateral (b) chest radiographs show a well-circumscribed, spherical left hilar mass. (c) Chest CT scan (lung window) demonstrates the lobular, partially endobronchial mass. Note the convex appearance of the lesion within the bronchial lumen. (d) Photograph of a cut section of the resected left upper lobe demonstrates the relationship of the lesion to the bronchus (arrow). Scale is in centimeters.

View larger version (89K): [in this window] [in a new window] [Download PPT slide]   Figure 9d.  Typical carcinoid in an asymptomatic 38-year-old woman. (a, b) Posteroanterior (PA) (a) and lateral (b) chest radiographs show a well-circumscribed, spherical left hilar mass. (c) Chest CT scan (lung window) demonstrates the lobular, partially endobronchial mass. Note the convex appearance of the lesion within the bronchial lumen. (d) Photograph of a cut section of the resected left upper lobe demonstrates the relationship of the lesion to the bronchus (arrow). Scale is in centimeters.

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 10a. Figures 10, 11. (10) Typical carcinoid in a 21-year-old woman who was being evaluated for pyelonephritis. PA (a) and lateral (b) chest radiographs demonstrate atelectasis of the right middle lobe and an incidental right apical pneumothorax. Bronchography revealed a mass obstructing the bronchus intermedius. (11) Typical carcinoid in an 18-year-old man with a 4-month history of recurrent pneumonia. PA chest radiograph demonstrates right middle and lower lobe consolidation, a parapneumonic pleural effusion, and cut-off of the bronchus intermedius (arrow).

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 10b. Figures 10, 11. (10) Typical carcinoid in a 21-year-old woman who was being evaluated for pyelonephritis. PA (a) and lateral (b) chest radiographs demonstrate atelectasis of the right middle lobe and an incidental right apical pneumothorax. Bronchography revealed a mass obstructing the bronchus intermedius. (11) Typical carcinoid in an 18-year-old man with a 4-month history of recurrent pneumonia. PA chest radiograph demonstrates right middle and lower lobe consolidation, a parapneumonic pleural effusion, and cut-off of the bronchus intermedius (arrow).

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 11. Figures 10, 11. (10) Typical carcinoid in a 21-year-old woman who was being evaluated for pyelonephritis. PA (a) and lateral (b) chest radiographs demonstrate atelectasis of the right middle lobe and an incidental right apical pneumothorax. Bronchography revealed a mass obstructing the bronchus intermedius. (11) Typical carcinoid in an 18-year-old man with a 4-month history of recurrent pneumonia. PA chest radiograph demonstrates right middle and lower lobe consolidation, a parapneumonic pleural effusion, and cut-off of the bronchus intermedius (arrow).

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 12a.  Typical carcinoid in a 22-year-old man with a 2-year history of hemoptysis. (a) PA chest radiograph demonstrates a well-marginated, endoluminal mass within the right mainstem bronchus. (b) Chest CT scan (lung window) demonstrates the well-defined, endoluminal tumor.

View larger version (105K): [in this window] [in a new window] [Download PPT slide]   Figure 12b.  Typical carcinoid in a 22-year-old man with a 2-year history of hemoptysis. (a) PA chest radiograph demonstrates a well-marginated, endoluminal mass within the right mainstem bronchus. (b) Chest CT scan (lung window) demonstrates the well-defined, endoluminal tumor.

View larger version (169K): [in this window] [in a new window] [Download PPT slide]   Figure 13a.  Typical carcinoid in a 23-year-old woman with hemoptysis. (a) PA chest radiograph demonstrates left upper lobe atelectasis. (b) Chest CT scan (lung window) helps confirm the left upper lobe collapse and shows a lesion (*) obstructing the left upper lobe bronchus. (c) Photograph of a cut specimen of the resected left upper lobe shows the obstructing endobronchial tumor (*) and the distal bronchiectasis and mucoid impaction.

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 13b.  Typical carcinoid in a 23-year-old woman with hemoptysis. (a) PA chest radiograph demonstrates left upper lobe atelectasis. (b) Chest CT scan (lung window) helps confirm the left upper lobe collapse and shows a lesion (*) obstructing the left upper lobe bronchus. (c) Photograph of a cut specimen of the resected left upper lobe shows the obstructing endobronchial tumor (*) and the distal bronchiectasis and mucoid impaction.

View larger version (96K): [in this window] [in a new window] [Download PPT slide]   Figure 13c.  Typical carcinoid in a 23-year-old woman with hemoptysis. (a) PA chest radiograph demonstrates left upper lobe atelectasis. (b) Chest CT scan (lung window) helps confirm the left upper lobe collapse and shows a lesion (*) obstructing the left upper lobe bronchus. (c) Photograph of a cut specimen of the resected left upper lobe shows the obstructing endobronchial tumor (*) and the distal bronchiectasis and mucoid impaction.

View larger version (106K): [in this window] [in a new window] [Download PPT slide]   Figure 14a. Figures 14, 15. (14) Typical carcinoid in a 35-year-old woman with recurrent pneumonia. (a) PA chest radiograph demonstrates consolidation and volume loss of the left lung. (b) Chest CT scan (lung window) demonstrates marked cystic bronchiectasis of the left lung. A carcinoid of the left mainstem bronchus was treated with pneumonectomy. (15) Typical carcinoid in a 48-year-old woman with recurrent right lower lobe pneumonia. (a) PA chest radiograph demonstrates consolidation of the right lower lobe. (b) Follow-up PA chest radiograph shows partial resolution of the consolidation and visualization of an ovoid mass (arrow) in the bronchus intermedius.

View larger version (105K): [in this window] [in a new window] [Download PPT slide]   Figure 14b. Figures 14, 15. (14) Typical carcinoid in a 35-year-old woman with recurrent pneumonia. (a) PA chest radiograph demonstrates consolidation and volume loss of the left lung. (b) Chest CT scan (lung window) demonstrates marked cystic bronchiectasis of the left lung. A carcinoid of the left mainstem bronchus was treated with pneumonectomy. (15) Typical carcinoid in a 48-year-old woman with recurrent right lower lobe pneumonia. (a) PA chest radiograph demonstrates consolidation of the right lower lobe. (b) Follow-up PA chest radiograph shows partial resolution of the consolidation and visualization of an ovoid mass (arrow) in the bronchus intermedius.

View larger version (151K): [in this window] [in a new window] [Download PPT slide]   Figure 15a. Figures 14, 15. (14) Typical carcinoid in a 35-year-old woman with recurrent pneumonia. (a) PA chest radiograph demonstrates consolidation and volume loss of the left lung. (b) Chest CT scan (lung window) demonstrates marked cystic bronchiectasis of the left lung. A carcinoid of the left mainstem bronchus was treated with pneumonectomy. (15) Typical carcinoid in a 48-year-old woman with recurrent right lower lobe pneumonia. (a) PA chest radiograph demonstrates consolidation of the right lower lobe. (b) Follow-up PA chest radiograph shows partial resolution of the consolidation and visualization of an ovoid mass (arrow) in the bronchus intermedius.

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 15b. Figures 14, 15. (14) Typical carcinoid in a 35-year-old woman with recurrent pneumonia. (a) PA chest radiograph demonstrates consolidation and volume loss of the left lung. (b) Chest CT scan (lung window) demonstrates marked cystic bronchiectasis of the left lung. A carcinoid of the left mainstem bronchus was treated with pneumonectomy. (15) Typical carcinoid in a 48-year-old woman with recurrent right lower lobe pneumonia. (a) PA chest radiograph demonstrates consolidation of the right lower lobe. (b) Follow-up PA chest radiograph shows partial resolution of the consolidation and visualization of an ovoid mass (arrow) in the bronchus intermedius.

View larger version (171K): [in this window] [in a new window] [Download PPT slide]   Figure 16a.  Typical carcinoid in a 20-year-old man with a 3-year history of cough and recurrent pneumonia. (a) PA chest radiograph demonstrates a well-defined, lobular, left hilar mass. Tubular opacities project distal to the lesion. (b, c) Chest CT scans (mediastinal window, with b obtained at a lower level than c) demonstrate the mass, which contains central calcification and produces abrupt bronchial obstruction. Mucoid impaction is seen distal to the lesion in c.

View larger version (111K): [in this window] [in a new window] [Download PPT slide]   Figure 16b.  Typical carcinoid in a 20-year-old man with a 3-year history of cough and recurrent pneumonia. (a) PA chest radiograph demonstrates a well-defined, lobular, left hilar mass. Tubular opacities project distal to the lesion. (b, c) Chest CT scans (mediastinal window, with b obtained at a lower level than c) demonstrate the mass, which contains central calcification and produces abrupt bronchial obstruction. Mucoid impaction is seen distal to the lesion in c.

View larger version (109K): [in this window] [in a new window] [Download PPT slide]   Figure 16c.  Typical carcinoid in a 20-year-old man with a 3-year history of cough and recurrent pneumonia. (a) PA chest radiograph demonstrates a well-defined, lobular, left hilar mass. Tubular opacities project distal to the lesion. (b, c) Chest CT scans (mediastinal window, with b obtained at a lower level than c) demonstrate the mass, which contains central calcification and produces abrupt bronchial obstruction. Mucoid impaction is seen distal to the lesion in c.

View larger version (148K): [in this window] [in a new window] [Download PPT slide]   Figure 17a.  Typical carcinoid in an asymptomatic 68-year-old woman. (a) PA chest radiograph shows an ovoid, solitary, lingular nodule (arrow). (b) Chest CT scan (lung window) demonstrates the sharply marginated, ovoid, lobular pulmonary nodule. (c) Photograph of a cut specimen of the resected lung demonstrates a well-circumscribed, fleshy tumor nodule.

View larger version (134K): [in this window] [in a new window] [Download PPT slide]   Figure 17b.  Typical carcinoid in an asymptomatic 68-year-old woman. (a) PA chest radiograph shows an ovoid, solitary, lingular nodule (arrow). (b) Chest CT scan (lung window) demonstrates the sharply marginated, ovoid, lobular pulmonary nodule. (c) Photograph of a cut specimen of the resected lung demonstrates a well-circumscribed, fleshy tumor nodule.

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 17c.  Typical carcinoid in an asymptomatic 68-year-old woman. (a) PA chest radiograph shows an ovoid, solitary, lingular nodule (arrow). (b) Chest CT scan (lung window) demonstrates the sharply marginated, ovoid, lobular pulmonary nodule. (c) Photograph of a cut specimen of the resected lung demonstrates a well-circumscribed, fleshy tumor nodule.

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 18a.  Typical carcinoid in a 35-year-old man with a 3-month history of recurrent pneumonia. (a, b) Contrast-enhanced chest CT scans (lung [a] and mediastinal [b] windows) demonstrate an endobronchial mass in the posterior segmental bronchus of the right lower lobe with a distal tubular mucus plug. The mass enhances and is distinct from the low-attenuation mucus plug. (c) Photograph of a cut specimen of the resected right upper lobe shows the central tumor (*) and distal mucoid impaction.

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 18b.  Typical carcinoid in a 35-year-old man with a 3-month history of recurrent pneumonia. (a, b) Contrast-enhanced chest CT scans (lung [a] and mediastinal [b] windows) demonstrate an endobronchial mass in the posterior segmental bronchus of the right lower lobe with a distal tubular mucus plug. The mass enhances and is distinct from the low-attenuation mucus plug. (c) Photograph of a cut specimen of the resected right upper lobe shows the central tumor (*) and distal mucoid impaction.

View larger version (128K): [in this window] [in a new window] [Download PPT slide]   Figure 18c.  Typical carcinoid in a 35-year-old man with a 3-month history of recurrent pneumonia. (a, b) Contrast-enhanced chest CT scans (lung [a] and mediastinal [b] windows) demonstrate an endobronchial mass in the posterior segmental bronchus of the right lower lobe with a distal tubular mucus plug. The mass enhances and is distinct from the low-attenuation mucus plug. (c) Photograph of a cut specimen of the resected right upper lobe shows the central tumor (*) and distal mucoid impaction.

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 19a.  Typical carcinoid in a 35-year-old man with a 1-year history of fever, hemoptysis, and pneumonia. (a) PA chest radiograph demonstrates a lobular, right perihilar mass. (b, c) Chest CT scans (lung window, with b obtained at a slightly higher level than c) demonstrate the partially endobronchial mass. The bulk of the mass is extraluminal with a smaller intraluminal component. (d) Photograph of the bisected specimen demonstrates the ovoid, lobular, endoluminal mass with focal hemorrhage. Note the adjacent bronchial wall (arrow).

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 19b.  Typical carcinoid in a 35-year-old man with a 1-year history of fever, hemoptysis, and pneumonia. (a) PA chest radiograph demonstrates a lobular, right perihilar mass. (b, c) Chest CT scans (lung window, with b obtained at a slightly higher level than c) demonstrate the partially endobronchial mass. The bulk of the mass is extraluminal with a smaller intraluminal component. (d) Photograph of the bisected specimen demonstrates the ovoid, lobular, endoluminal mass with focal hemorrhage. Note the adjacent bronchial wall (arrow).

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 19c.  Typical carcinoid in a 35-year-old man with a 1-year history of fever, hemoptysis, and pneumonia. (a) PA chest radiograph demonstrates a lobular, right perihilar mass. (b, c) Chest CT scans (lung window, with b obtained at a slightly higher level than c) demonstrate the partially endobronchial mass. The bulk of the mass is extraluminal with a smaller intraluminal component. (d) Photograph of the bisected specimen demonstrates the ovoid, lobular, endoluminal mass with focal hemorrhage. Note the adjacent bronchial wall (arrow).

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 19d.  Typical carcinoid in a 35-year-old man with a 1-year history of fever, hemoptysis, and pneumonia. (a) PA chest radiograph demonstrates a lobular, right perihilar mass. (b, c) Chest CT scans (lung window, with b obtained at a slightly higher level than c) demonstrate the partially endobronchial mass. The bulk of the mass is extraluminal with a smaller intraluminal component. (d) Photograph of the bisected specimen demonstrates the ovoid, lobular, endoluminal mass with focal hemorrhage. Note the adjacent bronchial wall (arrow).

View larger version (116K): [in this window] [in a new window] [Download PPT slide]   Figure 20.  Atypical carcinoid in a 54-year-old man with a 2-month history of cough. Thin-section chest CT scan (lung window) demonstrates a well-marginated, spherical pulmonary nodule that is partially endobronchial.

View larger version (156K): [in this window] [in a new window] [Download PPT slide]   Figure 21a.  Typical carcinoid in a 46-year-old man with a 2-month history of hemoptysis and shortness of breath. (a) PA chest radiograph shows a masslike consolidation in the superior segment of the right lower lobe. (b) Contrast-enhanced chest CT scan (mediastinal window) demonstrates mass effect on the lateral wall of the bronchus intermedius with dense distal consolidation. The mass (arrows) enhances minimally with contrast material and can thus be distinguished from the adjacent consolidated lung. (c) Photograph of a cut section of the surgical specimen shows the peribronchial neoplasm with endobronchial extension (arrow) surrounded by consolidated lung.

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 21b.  Typical carcinoid in a 46-year-old man with a 2-month history of hemoptysis and shortness of breath. (a) PA chest radiograph shows a masslike consolidation in the superior segment of the right lower lobe. (b) Contrast-enhanced chest CT scan (mediastinal window) demonstrates mass effect on the lateral wall of the bronchus intermedius with dense distal consolidation. The mass (arrows) enhances minimally with contrast material and can thus be distinguished from the adjacent consolidated lung. (c) Photograph of a cut section of the surgical specimen shows the peribronchial neoplasm with endobronchial extension (arrow) surrounded by consolidated lung.

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 21c.  Typical carcinoid in a 46-year-old man with a 2-month history of hemoptysis and shortness of breath. (a) PA chest radiograph shows a masslike consolidation in the superior segment of the right lower lobe. (b) Contrast-enhanced chest CT scan (mediastinal window) demonstrates mass effect on the lateral wall of the bronchus intermedius with dense distal consolidation. The mass (arrows) enhances minimally with contrast material and can thus be distinguished from the adjacent consolidated lung. (c) Photograph of a cut section of the surgical specimen shows the peribronchial neoplasm with endobronchial extension (arrow) surrounded by consolidated lung.

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 22a.  Atypical carcinoid in a 25-year-old woman. (a) Chest CT scan (lung window) demonstrates an endoluminal mass (*) completely occluding the lumen of the left lower lobe bronchus. Note the overinflation of the left lower lobe secondary to obstruction. A pneumomediastinum is also present. (b) Photograph of the resected endobronchial lesion shows the fleshy, spherical, homogeneous, soft-tissue mass that straddled the left main and left lower lobe bronchi at the time of surgery.

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 22b.  Atypical carcinoid in a 25-year-old woman. (a) Chest CT scan (lung window) demonstrates an endoluminal mass (*) completely occluding the lumen of the left lower lobe bronchus. Note the overinflation of the left lower lobe secondary to obstruction. A pneumomediastinum is also present. (b) Photograph of the resected endobronchial lesion shows the fleshy, spherical, homogeneous, soft-tissue mass that straddled the left main and left lower lobe bronchi at the time of surgery.

View larger version (124K): [in this window] [in a new window] [Download PPT slide]   Figure 23a.  Typical carcinoid in a 34-year-old woman with a 2-year history of wheezing, shortness of breath, and recurrent bronchitis. (a) Chest CT scan (lung window) demonstrates a well-marginated, ovoid, completely endoluminal nodule in the left mainstem bronchus. (b) Photograph of a cut specimen from a sleeve resection shows the fleshy tumor within the bronchial lumen.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 23b.  Typical carcinoid in a 34-year-old woman with a 2-year history of wheezing, shortness of breath, and recurrent bronchitis. (a) Chest CT scan (lung window) demonstrates a well-marginated, ovoid, completely endoluminal nodule in the left mainstem bronchus. (b) Photograph of a cut specimen from a sleeve resection shows the fleshy tumor within the bronchial lumen.