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Complete surgical resection is the main goal in the treatment of thymoma, but is not always achievable in stage III and IVA thymoma because of local invasion of the neighboring organs or the presence of diffuse pleural or pericardial implants. We reviewed our experience in multimodality treatment of advanced stage (III and IVA) thymic tumors to eva...
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... Patients with locally advanced thymomas where a complete resection is not feasible, may benefit from induction chemotherapy, surgery and PORT (62)(63)(64)(65)(66)(67)(68)(69). Table 9 summarizes studies with a multidisciplinary approach of unresectable malignant thymomas. ...
... Hassan et al. (16) performed a study including 9 patients with unresectable (III and IVa) thymic tumors. Patients underwent induction chemotherapy with 3 courses of cisplatin and etoposide (EP). ...
... p= 0.011) (13). Hassan et al. (16) conducted a study to explore the function of induction chemotherapy in locally advanced thymoma patients, 3 cycles of EP were administered before surgery. Of these, only 3 patients presented great vessel invasion before induction chemotherapy, and unfortunately an extensive full-thickness tumor invasion of the vessels was still evident at the time of surgical intervention. ...
Surgery remains cornerstone for the management of thymoma. Complete surgical resection (R0), is recognized as the constant and significant factor for prognosis. However, in locally advanced (Masaoka-Koga stages III-IVa) thymomas, achieving R0 resection remains challenging due to local-regional invasion of the disease. Induction treatment, with the aim of reducing bulky tumor mass, offers new strategy to facilitate totally surgical resection. Herein, we reviewed recent progress and provided a comprehensive overview of induction strategy in locally advance thymoma.
... 128 For locally advanced thymomas, induction chemotherapy is recommended followed by an evaluation for surgery; postoperative RT can be considered after surgical resection of the primary tumor and isolated metastases (see Postoperative Treatment and Management in the algorithm). 133,134 For those with solitary metastasis or ipsilateral pleural metastases, options include: 1) induction chemotherapy followed by surgery for resectable patients; or 2) surgery alone. 128 ...
... There is, in fact, a robust body of evidence [9] of neoadjuvant therapy effectiveness in locally advanced/ biologically aggressive thymomas, as well as in thymic carcinomas [9,10]. ...
There is a certain body of evidence [1,2] suggesting that thymic epithelial tumors (TETs) may be distinguished in different WHO classification subgroups-'low-risk' thy-momas (A, AB, and B1) vs. 'high-risk' thymomas (B2 and B3)-with different prognosis while thymic carcinomas clearly stay as a separate class with poorer prognosis, as clearly emerged in recent meta-analysis [3]. As a consequence of these evidences, the therapeutic strategy may be adapted according to histology by performing (neo) adjuvant chemoradiotherapy in selected high-risk thy-momas and, above all, thymic carcinoma cases. In particular , neoadjuvant chemo(radio)therapy appears as a useful tool to increase the likelihood of a complete resection at the time of surgery [4,5]. The more sophisticated the therapeutic approach, the more necessary is the accuracy of the preoperative identification of the histologic subtype and staging. In this setting, the recent study of Juan et al. [6] points at fluorine -18-fluorodeoxyglucose (18 F-FDG) PET associated with computer tomography (PET/CT) as a potentially useful tool in differentiating TETs histological subgroups. The authors have reported the results of a monocentric retrospective analysis on a large series (#81) of TETs comparing the radiometabolic parameters (SUVmax and the ratio between SUVmax and tumor size) with WHO histology. The Authors observed as both PET parameters were found to be predictive factors that were useful to distinguish thymomas and thymic carcinomas, with a cutoff value for discriminating thymomas and thymic carcinomas of 5.34. However, differently, by previous reports (including our team's experience [7]), SUVmax nor SUVmax/tumor size failed to differentiate low-risk and high-risk thymomas in this cohort of patients. It is not unusual for small-sized studies to report a positive relationship that subsequent larger studies fail to replicate. In this scenario, a few years ago a meta-analysis performed by Treglia and coworkers [8] on this topic has tried to overcome the limited evidences coming from literature.
... Consequently, treatment with multiple modalities such as repeat surgical resection, chemotherapy, and radiotherapy has been attempted but without general consensus on the optimal approach [22]. It is known that most thymic tumors are chemo-and radio-sensitive [23][24][25] and, thus, a multimodality treatment that integrates surgical resection with chemo-and radiotherapy has been advocated for advanced stages with the aim to improve both local and distal control of the disease and prolong survival [26][27][28]. In addition, preoperative (induction or neoadjuvant) chemotherapy has been successfully used to down-stage unresectable tumors for surgical resection and to prevent local and systemic recurrences [24,27,[29][30][31][32][33][34][35][36][37]. ...
... It is known that most thymic tumors are chemo-and radio-sensitive [23][24][25] and, thus, a multimodality treatment that integrates surgical resection with chemo-and radiotherapy has been advocated for advanced stages with the aim to improve both local and distal control of the disease and prolong survival [26][27][28]. In addition, preoperative (induction or neoadjuvant) chemotherapy has been successfully used to down-stage unresectable tumors for surgical resection and to prevent local and systemic recurrences [24,27,[29][30][31][32][33][34][35][36][37]. ...
Malignant thymomas are rare epithelial neoplasms of the anterior superior mediastinum that are typically invasive in nature and have a higher risk of relapse that may ultimately lead to death. Here we report a case of an advanced malignant thymoma that was successfully treated with neoadjuvant chemotherapy followed by surgical resection and subsequently with advanced and novel radiation therapy techniques. A 65-year-old male was diagnosed with a stage IV malignant thymoma with multiple metastatic lesions involving the left peripheral lung and pericardium. Initial neoadjuvant chemotherapy with a cisplatin-based regimen resulted in a partial response allowing the inoperable tumor to become operable. Following surgical resection of the residual disease, the tumor recurred within a year. The patient then underwent a course of targeted three-dimensional intensity modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT). Five years after radiation therapy, the localized soft tissue thickening at the left upper lung anterior pleural space had resolved. Seven years after radiation therapy the tumor mass had completely resolved. No recurrences were seen and the patient is well even 8 years after IMRT/IGRT with a favorable outcome. Chemotherapy with targeted three-dimensional IMRT/IGRT should be considered the primary modality for the management of advanced malignant thymoma patients.
... Therefore, as tru-cut CT-guided biopsy recently substituted the more invasive surgical tumor biopsy (usually through an anterior mediastinotomy) [54], it is conceivable that 18 F-FDG PET/CT could integrate the data coming from biopsy and, accordingly, helping the physicians in the strategy of care, like the decision to start an induction treatment. There is, in fact, a robust body of evidence [55][56][57][58][59][60][61] on neoadjuvant therapy effectiveness in locally advanced/biologically aggressive thymomas, as well as in thymic carcinomas [62,63]. ...
... The role of multimodality therapy in the management of unresectable thymoma could not be fully evaluated in this study because the only description on neoadjuvant treatments for both groups was available in the article of Rea et al. [4] and no neoadjuvant treatments apparently were performed in the other 12 studies. Neoadjuvant chemotherapy or chemoradiotherapy followed by surgery may be promising treatment modalities for locally advanced unresectable thymoma, but the long-term outcomes are pending [31,32]. ...
Observational studies on long-term outcomes following debulking surgery or surgical biopsy for unresectable thymoma showed various results. This meta-analysis was designed to determine the effect of debulking surgery against surgical biopsy on overall survival in patients with unresectable thymoma. The PubMed database was queried for studies published in the English language on unresectable thymoma and overall survival. We compared overall survival following surgery in patients undergoing debulking surgery and patients undergoing surgical biopsy for unresectable thymoma. Meta-analysis was performed using the Mantel-Haenszel method, and potential publication bias was evaluated with a funnel plot of precision. No randomized trials on this topic were identified. Thirteen retrospective observational studies containing a sum of 314 patients with information on the number of deaths and person-years were suitable for analysis. Information on Masaoka stages, World Health Organization histology and indications for debulking surgery versus surgical biopsy was lacking in most studies. Diversity of neoadjuvant and adjuvant treatments was noted among the eligible studies. One hundred and seventy-two (54.8%) patients underwent debulking surgery and 142 (45.2%) underwent surgical biopsy. The pooled hazard ratio was 0.451 (95% confidence interval: 0.336-0.605, P < 0.001), favouring patients undergoing debulking surgery compared with patients undergoing surgical biopsy. The funnel plot of precision demonstrated no important publication bias. Our results suggest that debulking surgery for unresectable thymoma may be associated with improved overall survival and be considered for patients with unresectable thymoma.
... Our data support a multidisciplinary team approach for management of these patients, similar to previously published reports. 9,[24][25][26] In particular, patients with thymoma had excellent results using a trimodality approach. Preoperative chemoradiation has the potential for better preoperative downstaging as has been observed in the treatment of locally advanced lung cancer. ...
: Thymomas are rare neoplasms with variable clinical behavior. Our primary study aim was to analyze treatment practices and outcomes in a population-based cohort of thymoma patients. We hypothesized that stage I and II thymomas would have high cure rates with resection and adjuvant radiation, whereas locally advanced cases would benefit from multimodality therapy.
: All patients, diagnosed with thymoma or thymic carcinoma in British Columbia between 1994 and 2009, were identified using the British Columbia Cancer Agency Registry. Chart review was used to collect demographic and treatment data. Detailed pathology review was performed using the World Health Organization classification.
: One hundred and seventy-one patients were identified for analysis. The 5-year overall survival was 93.3%, 88.7%, 74.6%, 43.4% for stages I, II, III, and IV, respectively. Survival varied significantly among patients with thymoma compared with thymic carcinoma. In patients with stage II disease, adjuvant radiation did not confer an overall survival or recurrence-free survival benefit. Seventy-five patients had locally advanced disease. There was practice variation in treatment of these patients. Patients with thymoma undergoing trimodality treatment had a 5-year median overall survival of 80%, whereas patients with thymic carcinoma had poor outcomes despite aggressive treatment.
: Survival rates in this population-based series were comparable to those in previously published reports. The ideal management of thymic tumors involves a multidisciplinary approach, particularly in locally advanced disease and selection of patients for adjuvant radiation therapy.
... However, multimodal therapy consisting of chemotherapy, radiotherapy, and/or surgery is recommended for any incompletely resected "high-risk" thymoma, locally advanced or metastatic thymoma (Chahinian et al. 1981;Ströbel et al. 2005). It has been shown that multimodal treatment of patients with neoadjuvant chemotherapy, and surgery, followed by additional adjuvant chemotherapy plus radiotherapy, may improve the survival of patients with locally advanced thymoma (Venuta et al. 1997;Hassan & Seoud 2009). In addition, induction chemotherapy may be effective in downstaging thymoma, allowing patients initially thought not to be surgical candidates to undergo resection. ...
Department of 1 Paediatrics, 2 Pathology and 3 Radiology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur ABSTRAK Timoma merangkumi 1% dari keseluruhan kanser mediastinum dan jarang berlaku pada kanak-kanak. Secara tipikal, kanser ini adalah agresif dan kadar sembuh adalah rendah. Rawatan semasa untuk timoma invasif meliputi pelbagai disiplin. Seorang pe-sakit berumur 16 tahun telah di diagnosa dengan kanser timoma invasif. Pesakit ini telah berjaya dirawat dengan kimoterapi di ikuti dengan pembedahan dan radioterapi. Setakat ini, pesakit berada dalam keadaan 'remission' yang berterusan selama 6 ta-hun selepas tamat rawatan. Kata kunci: timoma, kimoterapi, pembedahan, iradiasi ABSTRACT Thymomas comprise about 1% of all mediastinal tumours and are rare in children. Typically, these tumours are aggressive, with a poor outcome. The current treatment of invasive thymoma is often multidisciplinary. We report a 16-year-old boy with invasive thymoma who was successfully treated with systemic chemotherapy, surgical resection and irradiation. The patient has been in continuous remission for 6 years without radiographic evidence of tumour recurrence.
We herein report two cases of Masaoka stage IVa thymoma treated by radical resection via thymothymectomy followed by pleurectomy/decortication (PD). Case 1: a 52-year-old man was diagnosed with a type B1 thymoma. Resection of the right lobe of thymus, dissection of left upper mediastinum, and pleurectomy from anterior chest wall to descending aorta were performed via median sternotomy approach. Pericardial resection followed by decortication of the total visceral pleura was then successfully performed via a posterolateral thoracotomy approach. Case 2: a 48-year-old man was diagnosed with type B2 thymoma. Thymothymectomy and extra-pleural dissection except for the right-side diaphragmatic area were achieved via median sternotomy approach. Resection of the visible disseminated lesions of visceral pleura was performed after pleurectomy of the diaphragmatic area via posterolateral thoracotomy approach. Both patients are disease free at 3 years and 2 years and half, respectively. Extended thymothymectomy followed by PD is a candidate approach for surgical management.
