problems with classifications

[john]

It seems like a lot of people get different diagnosis - sclc, then atypical carcinoid, etc. Here is an article about pathologists not being able to reach agreement on what type of cancer is found

Reproducibility of neuroendocrine lung tumor classification.

Travis WD, Gal AA, Colby TV, Klimstra DS, Falk R, Koss MN.

Department of Pulmonary and Mediastinal Pathology, Armed Forces Institute of Pathology, Washington, DC 20306-6000, USA.

For a tumor classification scheme to be useful, it must be reproducible and it must show clinical significance. Classification of neuroendocrine lung tumors is a difficult problem with little information about interobserver reproducibility. We sought to evaluate the classification of typical carcinoid (TC), atypical carcinoid (AC), large-cell neuroendocrine carcinoma (LCNEC), and small-cell carcinoma (SCC) tumors as proposed by W.D. Travis et al (Am J Surg Pathol 15:529, 1991). Forty neuroendocrine tumors were retrieved from the Armed Forces Institute of Pathology (AFIP) files and independently evaluated by five lung pathologists and classified as TC, AC, LCNEC, or SCC (pure SCC, mixed small cell/large cell, and combined SCC). A single hematoxylin and eosin-stained slide from each case was reviewed. Each participant was provided a set of tables summarizing the criteria for separation of the four major categories. Agreement was regarded as unanimous if all five pathologists agreed, a majority if four agreed, and a consensus if three or more pathologists agreed. The kappa statistic was calculated to measure the degree of agreement between two observers. A consensus diagnosis was achieved in all 40 cases (100%), a majority agreement in 31 of 40 (78%), and unanimous agreement in 22 of 40 (55%) of cases. Unanimous agreement occurred in seven of SCC (70%), seven of TC (58%), four of AC (50%), and four of LCNEC (40%). A majority diagnosis was achieved in 11 of 12 (92%) of TC, 9 of 10 (90%) of SCC, 6 of 8 (75%) of AC, and 5 of 10 (50%) of LCNEC. Most of the kappa values were 0.70 or greater, falling into the substantial agreement category. The most common disagreements fell between LCNEC and SCC, followed by TC and AC, and AC and LCNEC. The highest reproducibility occurred for SCC and TC, with disagreement in 8% and 10% of the diagnoses, respectively. For TC, 10% of the diagnoses rendered were AC. For AC, 15% of the diagnoses were rendered as TC, with 2.5% called LCNEC and 2.5% called SCC. For LCNEC, 18% and 4% of the diagnoses were called SCC and AC, respectively. For SCC, 4% of the diagnoses were called AC and 4% were called LCNEC. Thus, using the classification scheme tested, a consensus diagnosis can be achieved for virtually all neuroendocrine lung tumors with substantial agreement between experienced lung pathologists. Classification of NE tumors is most reproducible for classification of TC and SCC but less reproducible for AC and LCNEC. These results indicate a need for more careful definition and application of criteria for TC versus AC and SCC versus LCNEC.

[teetlee]

Hi John,

This was interesting, but have to admit I didn't understand everything I read.

What is the difference between a carcinoid and a carcinoma? I have noticed that Carleen's husband is dx'd with carcinoma and is being treated like sclc and that your mom had been dx'd with large cell carcinoma. What kind of treatment did she have?

My doctor has told me I am definitely atypical carcinoid. What I have read on the internet is that this type would not be treated with chemo. Yet my onc. says it could be but I have already had the ones that he would use.

I have been currently using sandostatin, 3 shots a day, and will have x-rays, blood work, and 24 hour urinalysis on May 6. These are the first tests since starting the sandostatin.

Teet

[john]

The four (SCLC, Large cell neuroendocrine carcinoma (NCLEC), atypical and typical carcinoids) are all neuroendocrine tumors.

The main difference is the mitotic (cell division) rate of the tumors. SCLC, NCLEC have fast dividing cells. atypical and typical carcinoids are slower growing. Since chemo targets fast dividing cells that is why it does not work as well on carcinoids vs SCLC and NCLEC.

I am not sure why there was a name change (from carcinoma to carcinoid) - maybe just to differentiate the tumors.

Yes, Carleen's husband has atypical carcinoma. I refered her to you.

I am not sure why it is called atypical carcinoma vs atypical carcinoid.

I can't find the reference on PubMed but there was a small study that indicates NCLEC responds better to chemo than even SCLC for some reason.

My mom's tumor was resected. They thought she was Stage I. Nothing showed on the PET. The lymph nodes were tested and positive. So she was re-staged to IIIa.

After surgery, she received radiaiton and a vaccine. The doctors told her that after surgery chemo did not improve outcomes based on current research.

typical and atypical carcinoids have pretty good long term survival rates (up to 90%) for 10 years

[Terrie]

John-

Thank you so much for the explanation. I have to admit, after reading the report I was lost. (AND starting to have CWD - like Katie)

I was originally diagnosed with squamous cell, then after my surgery was changed to neuroendecrine carcinoma. I was told this was a typical carcinoid, so you see I was very interested in this report. Originally, I was to have follow-up chemo, but after the change in diagnosis, was told it was not necessary.

Thanks again for the info.

Terrie

[Carleen]

WOW John,

That was a better explanation than my husband and I got from all three of the oncologists we've seen so far.

I have been pretty confused so far, and up til now I thought it was an Atypical Neuroendocrine Carcinoma. I was told carcinoma and carcinoid were the same thing, just a different terminology.

I saw at the bottom of your post you said that Atypical carcinoma has a long survival rate (90%) for 10 years. That gives me so much hope, you just can't believe.

We were told that his Atypical carcinoma was just slightly less aggressive than SCLC, but chemo only works on roughly 50% of patients. We were thinking that meant we had the worst of both worlds.

[john]

I was told by my Aunt who is a pediatrician. She talked to a bunch of oncologists. She was told Indium-111 may be a treatment for cancer with sandostatin receptors

[john]

oopppss.. I meant somatostatin receptors