Octreotide alone or with prednisone in patients with advanced thymoma and thymic carcinoma: an Eastern Cooperative Oncology Group Phase II Trial

A phase II study of saracatinib (AZD0530), a Src inhibitor, administered orally daily to patients with advanced thymic malignancies

OBJECTIVES

Thymic malignancies are rare, and options are limited for metastatic disease. Src plays a role in normal thymic epithelial maturation, and its inhibition with the oral compound saracatinib was postulated to be effective in controlling thymic malignancy.

MATERIALS AND METHODS

Patients with unresectable thymic malignancy were treated with saracatinib 175mg by mouth daily in 28 days cycles with radiographic evaluation at cycle 2 day 1 for safety, then cycle 3 day 1 and every 8 weeks thereafter. Response was evaluated by RECIST 1.0. A two-stage optimal design was used, powered to detect a true response rate of 20%.

RESULTS

21 patients were enrolled at two institutions, 12 of them with thymoma, 9 with thymic carcinoma. Thymoma patients received a median of 4.5 cycles and thymic carcinoma patients a median of 1 cycle. There were no responses, so accrual was halted after the first stage per protocol. 9 patients had stable disease beyond the first assessment. Median time to progression was 5.7 months for thymoma patients and 3.6 months for thymic carcinoma patients. Saracatinib was well tolerated.

CONCLUSION

Src inhibition by saracatinib did not produce any radiographic responses, though some patients did experience stable disease. Though negative, this study shows the feasibility of completing a trial in this rare disease, and of accruing reasonably significant numbers of thymic carcinoma patients. More clinical trials are required for this population (NCT00718809).

Thymoma treated with 177Lu DOTATATE induction and maintenance PRRT

A 47-year-old man presented with a recurrent thymoma World Health Organization type A of the anterior chest wall with pleural metastases after failing chemotherapy. The tumor was positive on In-octreotide, and he was referred for peptide receptor radionuclide therapy (PRRT) with Lu DOTATATE. He received 4 induction and 2 maintenance Lu DOTATATE treatments (total dose, 1000 mCi) and reported significant improvement in symptoms. Before the seventh treatment, mild progression was diagnosed on CT, and PRRT was terminated. The use of induction and maintenance Lu DOTATATE PRRT therapy in the management of thymoma warrants further research.

Available evidence and new biological perspectives on medical treatment of advanced thymic epithelial tumors

Thymic epithelial tumors (TETs) are rare primary mediastinal tumors arising from thymic epithelium. Their rarity and complexity hinder investigations of their causes and therapy development. Here, we summarize the existing knowledge regarding medical treatment of these tumors, and thoroughly review the known genetic aberrations associated with TETs and the present status of potential biological treatments. Epidermal growth factor receptor (EGFR), stem-cell factor receptor, insulin-like growth factor-1 receptor (IGF1R), and vascular endothelial growth factors (VEGF-A, VEGF-B, and VEGF-2) are overexpressed in TETs. EGFR overexpression in TETs is associated with higher stage, and IGF1R overexpression has poor prognostic value. Data indicate that anti-IGF1R monoclonal antibodies, and inhibitors of angiogenesis, somatostatin receptors, histone deacetylase, mammalian target of rapamycin, and cyclin-dependent kinases may be active against TETs. Continued investigations in this field could lead to advancement of targeted and biological therapies for TETs.

Capecitabine plus gemcitabine in thymic epithelial tumors: final analysis of a Phase II trial

ABSTRACT 

Background: A multi-institutional Phase II trial was initiated in 2005 to test the combination gemcitabine and capecitabine in patients with thymic epithelial malignancies (TETs). Patients & methods: Patients with histologic confirmation of TET diagnosis by central review who had received >1 systemic chemotherapy treatment were included. Patients received oral capecitabine (650 mg/mq twice daily on days 1–14) and intravenous gemcitabine (1000 mg/mq on days 1 and 8 every 3 weeks). Results: Of the 30 patients included (18 men, 12 women; median age: 57 years, range: 48–61 years), the majority (73%) had thymoma, and the remaining thymic carcinoma. Eight patients developed grade 3–4 neutropenia. A total of 12 patients had a response. Median progression-free survival was 11 months (range: 6.5–16.5). Conclusion: Capecitabine and gemcitabine is highly active in TETs.

[Research status of molecular targeted therapy in thymic epithelial tumors]

In recent years, as the study of molecular mechanism and signal transduction pathways of tumors, molecular target therapy in many solid tumors has made great progress. At present, more and more studies focus on molecular target drugs in thymic epithelial tumors and people have got some experience. Molecular target therapy may be a new therapeutic option for patients of thymic epithelial tumor.

Advances in thymic carcinoma diagnosis and treatment: a review of literature

Thymomas account for up to 50 % of anterior mediastinal neoplasms with an incidence of 0.13 per 100,000 person-years in the USA. Thymic carcinoma is a rare malignancy of the thymus gland distinguished from thymomas as it has a more invasive and metastasizing potential conferring poor prognosis. Due to the rarity of thymic carcinoma and the great variety of its histological subtypes, there is no solid evidence on optimal staging, imaging and treatment guidelines. Herein, we systematically review the literature on current clinical practice with regard to diagnostic evaluation, histopathological assessment, management and treatment of squamous thymic carcinoma.

Docetaxel-based chemotherapy as second-line regimen for advanced thymic carcinoma

Thymic carcinoma is an uncommon neoplasm. The efficacy of second-line treatment with docetaxel in advanced thymic carcinoma has not been well studied. Therefore, we conducted a review of the efficacy of docetaxel-based chemotherapy as a second-line regimen for advanced thymic carcinoma. Fifteen patients with advanced thymic carcinoma who received second-line chemotherapy with docetaxel singlet or docetaxel/platinum combination chemotherapy regimens were retrospectively reviewed. There were 11 males and four females, with a median age of 53 years. Squamous cell carcinoma was most common (n = 10), followed by undifferentiated carcinoma (n = 4), and small cell carcinoma (n = 1). Eight patients received docetaxel/platinum combination chemotherapy and seven docetaxel mono-therapy. Four patients showed partial responses, representing a response rate of 26.7%. The median progression-free survival and overall survival in the 15 patients were 4.0 (2.8-5.2) and 22.0 (14.6-29.4) months, respectively. There was no difference in progression-free survival between the docetaxel singlet or docetaxel/platinum combination chemotherapy (3.5 months vs. 4.0 months, P = 0.889). A docetaxel-based regimen could be a potential therapeutic option as a second-line chemotherapy for advanced thymic carcinoma.

Cixutumumab for patients with recurrent or refractory advanced thymic epithelial tumours: a multicentre, open-label, phase 2 trial

BACKGROUND

No standard treatment exists for refractory or relapsed advanced thymic epithelial tumours. We investigated the efficacy of cixutumumab, a fully human IgG1 monoclonal antibody targeting the insulin-like growth factor 1 receptor in thymic epithelial tumours after failure of previous chemotherapy.

METHODS

Between Aug 25, 2009, and March 27, 2012, we did a multicentre, open-label, phase 2 trial in patients aged 18 years or older with histologically confirmed recurrent or refractory thymic epithelial tumours. We enrolled individuals who had progressed after at least one previous regimen of platinum-containing chemotherapy, had an Eastern Cooperative Oncology Group performance status of 0 or 1, and had measurable disease and adequate organ function. Eligible patients received intravenous cixutumumab (20 mg/kg) every 3 weeks until disease progression or development of intolerable toxic effects. The primary endpoint was the frequency of response, analysed on an intention-to-treat basis. We also did pharmacodynamic studies. This trial is registered with ClinicalTrials.gov, number NCT00965250.

FINDINGS

49 patients were enrolled (37 with thymomas and 12 with thymic carcinomas) who received a median of eight cycles of cixutumumab (range 1-46). At the final actuarial analysis when follow-up data were updated (Nov 30, 2012), median potential follow-up (from on-study date to most current follow-up date) was 24·0 months (IQR 17·3-36·9). In the thymoma cohort, five (14%) of 37 patients (95% CI 5-29) achieved a partial response, 28 had stable disease, and four had progressive disease. In the thymic carcinoma cohort, none of 12 patients (95% CI 0-26) had a partial response, five had stable disease, and seven had progressive disease. The most common grade 3-4 adverse events in both cohorts combined were hyperglycaemia (five [10%]), lipase elevation (three [6%]), and weight loss, tumour pain, and hyperuricaemia (two each [4%]). Nine (24%) of 37 patients with thymoma developed autoimmune conditions during treatment (five were new-onset disorders), the most common of which was pure red-cell aplasia. Two (4%) patients died; one was attributed to disease progression and the other to disease-related complications (respiratory failure, myositis, and an acute coronary event), which could have been precipitated by treatment with cixutumumab.

INTERPRETATION

Cixutumumab monotherapy is well-tolerated and active in relapsed thymoma. Development of autoimmunity during treatment needs further investigation.

FUNDING

Division of Cancer Treatment and Diagnosis at the National Cancer Institute (National Institutes of Health), ImClone Systems.

Thymic neoplasms: an update on the use of chemotherapy and new targeted therapies. A literature review

Thymic malignancies represent a wide range of clinical, histological and molecular entities, with probably considerable heterogeneity even among tumors of the same histotype. Systemic chemotherapy with cisplatin-based regimens continues to represent the standard of care in metastatic or inoperable refractory/recurrent diseases and ADOC regimen (including cisplatin, doxorubicin, vincristine and cyclophosphamide) demonstrated the longer overall response rate and median survival in the first line setting, although no randomized trial is available; and there is still a lack of standard treatment after first-line failure. To date research efforts are focused on translational studies on molecular pathways involved in thymic tumors carcinogenesis, aimed to better understand and predict the efficacy of chemotherapy and targeted therapy. Recent molecular characterization includes identification of a number of oncogenes, tumor suppressor genes, chromosomal aberrations, angiogenic factors, and tumor invasion factors involved in cellular survival and proliferation and in tumor growth. The use of biologic drugs is currently not recommended in a routine practice because there are limited data on their therapeutic role in thymic epitelial tumors. Because of the lack of data from adequate-sized, prospective trials are required for validation and the enrolment of patients with advanced disease into available clinical trials has to be encouraged.

Chemotherapy for thymic carcinoma and advanced thymoma in adults

BACKGROUND

Thymic carcinoma or advanced thymoma is a rare cancer of the thymus gland that tends to be aggressive and infiltrate neighbouring organs, making total resection very difficult. Induction or adjuvant chemotherapy, or both, are often used in a multimodality approach to treat people affected by this condition, but the effectiveness of chemotherapy for thymic carcinoma or advanced thymoma remains uncertain.

OBJECTIVES

To assess the role of chemotherapy in adults with thymic carcinoma or advanced thymoma.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 7), MEDLINE (accessed via Ovid from 1966 to July 2012), EMBASE (accessed via Ovid, from 1980 to July 2012), Latin American and Caribbean Literature on Health Sciences (LILACS), the Chinese Biological Medicine Database (CBM, 1978 to July 2012), China National Knowledge Infrastructure (CNKI, 1980 to July 2012) and the Chinese scientific periodical database VIP Information (VIP, 1989 to July 2012). There was no language restriction in searching for studies.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs) of  trials using chemotherapy (either single-agent or combination chemotherapy plus surgery, radiotherapy or not) for thymic carcinoma and/or advanced thymoma. We planned to include all adults (aged 18 years and over) diagnosed with thymic carcinoma and/or with Masaoka stage III or IV thymic tumours. The intended primary outcomes were overall survival (OS) and progression-free survival (PFS).

DATA COLLECTION AND ANALYSIS

Two review authors independently evaluated the search results according to the inclusion and exclusion criteria. There were no studies identified for inclusion and therefore no data extraction was completed.

MAIN RESULTS

No RCTs were eligible for inclusion in this review. We report details of excluded prospective studies in an additional table and try to provide some useful evidence regarding current practice.

AUTHORS' CONCLUSIONS

There were no RCTs eligible for inclusion in this review. In current practice the most common regimen for adult patients with thymic carcinoma or advanced thymoma is cisplatin-based chemotherapy. Considering the condition is rare, it is suggested that an international group is set up to organise and evaluate prospective collection of data from cohorts of patients to inform current clinical practice.

Treatment updates in advanced thymoma and thymic carcinoma

OPINION STATEMENT

Thymomas and thymic carcinomas are rare diseases of the anterior mediastinum. Although some thymomas are quite indolent and able to be resected in a curative fashion, the treatment of metastatic disease remains a challenge, especially for the more aggressive thymic carcinoma histology. Based on the results of single-arm trials, combination chemotherapy is the standard of care in the first-line, and anthracycline-based treatments should be used if patients are reasonably fit. Several single-agent cytotoxic chemotherapy agents have some effectiveness in subsequent lines of therapy, especially pemetrexed and, in octreotide scan-positive patients, octreotide. Prospective trials of new agents are difficult to conduct given the rarity of thymoma, but various targeted therapies do show promise. Greater international research collaboration, as well as modern techniques in molecular and genomic characterization, should help to advance the treatment of thymic malignancies in the near future.

When a thymic carcinoma "becomes" a GIST

Thymic carcinoma (TC) is a rare intrathoracic malignancy that it can be invasive and refractory to conventional treatment. Comprehensive genomic analysis evidenced a molecularly distinct subset of thymic carcinoma with high prevalence of c-kit mutation, which may behave as a gastrointestinal stromal tumor (GIST). Here, we present a case report of TC with c-Kit mutation, who has relapsed after exposure to multiple lines of combination chemotherapy, but he has shown an impressive and long lasting response to sunitinib after imatinib failure.

Thymic neoplasms: a clinical update

Thymoma is a unique neoplasm of the anterior mediastinum that is frequently associated with indolent growth and a variety of paraneoplastic syndromes. One third of cases are detected during the evaluation of myasthenia gravis. Classification systems of thymoma have limited ability in accurately predicting prognosis and course of disease. Thus, staging is the only way to predict clinical behavior. Encapsulated tumors that are surgically resected carry the best prognosis. Adjuvant radiotherapy is recommended for incompletely excised and most invasive thymomas. Chemotherapy in anthracycline-based chemotherapy remains the most effective chemotherapy for neoadjuvant, adjuvant or palliative treatment.

Emerging treatment options for patients with recurrent advanced thymic epithelial tumors

The purpose of this review article is to review recent advances in the treatment of advanced thymic epithelial tumors. These tumors are generally responsive to cytotoxic combination chemotherapy in the first-line setting. While newer agents have shown efficacy in the salvage setting, there is no one standard approach. A multitude of targeted agents have shown promise generally in case reports, though as of yet, nothing has shown consistent benefit. Because of the rarity of thymic epithelial tumors, clinical trial enrollment is difficult but nevertheless essential.

Everolimus plus long-acting somatostatin analogs in thymic epithelial malignancies

Although thymic epithelial tumors (TETs) are rare in the general population, they represent the most frequently diagnosed primary malignant tumor of the anterior mediastinum. Unlike localized disease, metastatic disease is invariably fatal. While several chemotherapy agents have proven to be effective in TETs, somatostatin analogs are the only targeted agents with an established role in this disease. Everolimus is an mTOR inhibitor with multiple application in oncology. In this report, we show for the first time that everolimus was effective in two heavily pretreated patients with advanced TETs, with a progression-free survival longer than 1 year and minimal toxicity.

Efficacy and tolerability of long-acting octreotide in the treatment of thymic tumors: results of a pilot trial

OBJECTIVES

Octreotide is a somatostatin analog, long-acting formulations of which have been used experimentally for the treatment of patients with invasive tumors and/or residual disease after conventional therapies. The objective of this retrospective study was to evaluate the efficacy of long-acting octreotide (Sandostatin LAR) for the treatment of thymic tumors, with a primary efficacy end point of progression-free survival.

METHODS

Between 1994 and 2010, 44 patients with thymic malignancies were evaluated. Twenty-seven patients underwent an OctreoScan, and 12 OctreoScan-positive patients were treated with long-acting octreotide at a dose of 20 mg, given as an intramuscular injection, every 2 weeks.

RESULTS

Treatment with long-acting octreotide gave the following results: 3 cases of partial response (25%), 5 cases of stable disease (42%), and 4 cases of progressive disease (33%), with an average progression-free survival of 8 months (range, 3 to 21). Treatment compliance and tolerability were good for all evaluated patients.

CONCLUSIONS

The results of this study confirm the somatostatin receptor as a valid target for the treatment of thymic malignancies. Overall, therapy with long-acting somatostatin analogs seems to be safe and effective.

Thymoma: from chemotherapy to targeted therapy

Thymic malignancies are rare epithelial tumors that may be aggressive and difficult to treat. Thymomas are frequently eligible for upfront surgical resection. However, nearly 30% of patients present with locally advanced tumor at time of diagnosis, and chemotherapy is then used to reduce the tumor burden-possibly allowing subsequent surgery and/or radiotherapy. Metastatic and recurrent thymic malignancies may be similarly treated with chemotherapy. More recently, the molecular characterization of thymoma led to the identification of potentially druggable targets, laying the foundation to implement personalized medicine for patients.

Thymic malignancies: from clinical management to targeted therapies

PURPOSE

A key challenge in the treatment of thymoma and thymic carcinoma (TC) is in improving our understanding of the molecular biology of these relatively rare tumors. In recent years, significant efforts have been made to dissect the molecular pathways involved in their carcinogenesis. Here we discuss the results of large-scale genomic analyses conducted to date and review the most active chemotherapies and targeted treatments.

METHODS

We reviewed the literature for chemotherapeutic trials in the last 20 years and trials involving targeted therapies between 1999 and 2010. The search was supplemented by a review of abstracts presented at the annual meetings of the American Society of Clinical Oncology (from 1999 to 2010), at the first International Conference on Thymic Malignancies in 2009, and at a follow-up meeting of the newly formed International Thymic Malignancies Interest Group in 2010.

RESULTS

Surgery remains the treatment of choice for operable tumors, whereas chemotherapy is standard in locally advanced and metastatic disease. Thus far, targeted therapies have been developed empirically. Histone deacetylase inhibitors have shown some activity in thymoma whereas sunitinib may be active in TC. There are no data to support the use of HER2- or EGFR-targeted therapies in thymic malignancies.

CONCLUSION

Drug development for the treatment of thymic malignancies is difficult because of the rarity of these tumors. Ethnic differences are becoming apparent, with aggressive subtypes being observed in Asians and African Americans. Incremental improvements in our understanding of tumor biology suggest that molecular profiling-directed therapies may be the preferred route of investigation in the future.

Phase II study of belinostat in patients with recurrent or refractory advanced thymic epithelial tumors

PURPOSE

Thymic epithelial tumors are rare malignancies, and there is no standard treatment for patients with advanced disease in whom chemotherapy has failed. Antitumor activity of histone deacetylase (HDAC) inhibitors in this disease has been documented, including one patient with thymoma treated with the pan-HDAC inhibitor belinostat.

PATIENTS AND METHODS

Patients with advanced thymic epithelial malignancies in whom at least one line of platinum-containing chemotherapy had failed were eligible for this study. Other eligibility criteria included adequate organ function and good performance status. Belinostat was administered intravenously at 1 g/m(2) on days 1 to 5 of a 21-day cycle until disease progression or development of intolerance. The primary objective was response rate in patients with thymoma.

RESULTS

Of the 41 patients enrolled, 25 had thymoma, and 16 had thymic carcinoma; patients had a median of two previous systemic regimens (range, one to 10 regimens). Treatment was well tolerated, with nausea, vomiting, and fatigue being the most frequent adverse effects. Two patients achieved partial response (both had thymoma; response rate, 8%; 95% CI, 2.2% to 25%), 25 had stable disease, and 13 had progressive disease; there were no responses among patients with thymic carcinoma. Median times to progression and survival were 5.8 and 19.1 months, respectively. Survival of patients with thymoma was significantly longer than that of patients with thymic carcinoma (median not reached v 12.4 months; P = .001). Protein acetylation, regulatory T-cell numbers, and circulating angiogenic factors did not predict outcome.

CONCLUSION

Belinostat has modest antitumor activity in this group of heavily pretreated thymic malignancies. However, the duration of response and disease stabilization is intriguing, and additional testing of belinostat in this disease is warranted.

The role of chemotherapy in advanced thymoma

BACKGROUND

Thymoma and thymic carcinomas are rare malignancies. Most thymomas and about one-third of thymic carcinomas can be cured with local therapy. The remainder of will be candidates for systemic therapy. Numerous retrospective trials confirm objective responses to a variety of single-agent and combination chemotherapeutic regimens.

METHODS

No prospective randomized comparison of regimens has been performed because of the rarity of the disease. This paper reviewed the literature of chemotherapy in advanced thymic malignancies.

RESULTS

Existing data suggest that anthracycline plus cisplatin regimens seem to demonstrate higher response rates and perhaps longer median survival times compared with nonanthracycline-containing regimens.

DISCUSSION

Thymic malignancies are sensitive to a broad spectrum of systemic agents. Thymic carcinoma has a distinct clinical presentation and worse therapeutic outcomes than thymoma. Despite reproducible high response rates in thymoma, durable complete remissions are rare. Thus, novel new therapeutic targets need to be identified and appropriate agents developed to have further impact on this disease.

Imaging thymoma

Thymoma is a rare tumor, although it is the most common primary neoplasm of the anterior mediastinum. In the majority of thymoma patients, imaging is requested for investigation of symptoms related to their tumor, although an increasing number of asymptomatic patients are discovered incidentally due to the increased utilization of computed tomography for screening or for imaging of other unrelated diseases. This review will focus on the goals of imaging thymoma, the imaging features of thymoma, as well as the advantages and limitations of each imaging modality in establishing the diagnosis, staging, and prognosis of thymoma.

Targeted therapy for advanced thymic tumors

The use of targeted therapies for the treatment of thymic malignancies is documented in the literature. However, only a few drugs have undergone evaluation in phase II trials. Most of the evidence for the benefit of biologic therapies for thymic malignancies is in the form of case reports and small case series. No major activity has been observed with any agent so far, likely due to the lack of selection of patients for targeted therapies and the small numbers studied. A better understanding of the biology of these tumors will be essential in furthering the field.

Thymoma and paraneoplastic myasthenia gravis

Paraneoplastic autoimmune diseases associate occasionally with small cell lung cancers and gynecologic tumors. However, myasthenia gravis (MG) occurs in at least 30% of all patients with thymomas (usually present at MG diagnosis). These epithelial neoplasms almost always have numerous admixed maturing polyclonal T cells (thymocytes). This thymopoiesis-and export of mature CD4(+)T cells-particularly associates with MG, though there are rare/puzzling exceptions in apparently pure epithelial WHO type A thymomas. Other features potentially leading to inefficient self-tolerance induction include defective epithelial expression of the autoimmune regulator (AIRE) gene and/or of major histocompatibility complex class II molecules in thymomas, absence of myoid cells, failure to generate FOXP3(+) regulatory T cells, and genetic polymorphisms affecting T-cell signaling. However, the strong focus on MG/neuromuscular targets remains unexplained and suggests some biased autoantigen expression, T-cell selection, or autoimmunization within thymomas. There must be further clues in the intriguing serological and cellular parallels in some patients with late-onset MG but without thymomas-and in others with AIRE mutations-and in the contrasts with early-onset MG, as discussed here.

[Epithelial tumours of the thymus]

Epithelial tumours of the thymus include thymomas, thymic carcinomas and neuro-endocrine tumours. Rare, they nevertheless represent 20% of all mediastinal tumours and 50% of those located in the anterior mediastinum. Thymomas, in particular, can be associated to auto-immune disorders, among which predominates myasthenia gravis. Their clinical behaviour varies widely, from a relative indolence to the potential of lymph node and/or systematic metastases. However, even patients with an invasive disease may have a long clinical history, explaining that a 10-year or 20-year survival from diagnosis does not imply a definitive cure. In daily practice, both the clinical Masaoka's staging system and the WHO histological classification condition the treatment strategies and allow to anticipate the prognosis. The initial treatment, as well as that of the recurrence, is based mainly on a complete resection. Postoperative radiotherapy is systematically added to the treatment of invasive tumours and/or to those with an aggressive histological subtype. Inoperable or metastatic tumours require a cisplatine and anthracyclin-based chemotherapy, followed by radical surgery and/or radiotherapy.

Preliminary results of phase II study of capecitabine and gemcitabine (CAP-GEM) in patients with metastatic pretreated thymic epithelial tumors (TETs)

BACKGROUND

No previous prospective trials have been reported with capecitabine and gemcitabine (CAP-GEM) in patients with metastatic thymic epithelial tumors (TETs). We conducted a multicenter study to determine the activity and tolerability of this regimen in pretreated TETs.

PATIENTS AND METHODS

A total of 15 patients were enrolled in the first stage of phase II study. All patients received CAP-GEM every 3 weeks. The primary end point was objective response rate (RR); secondary end points were toxicity, progression-free survival (PFS) and overall survival.

RESULTS

Complete responses (CR) and partial responses were observed in three (20%) and three (20%) patients for a 40% RR, respectively. Grade 1-2 neutropenia, anemia and thrombocytopenia were the most common side-effects, noted in seven (46.7%), five (33.3%) and five (33.3%) patients, respectively. The most common grade 3 toxicity was neutropenia in three patients (20%). Median PFS was 11 months (95% confidence interval 4-17). The 1- and 2-year survival rates were 80% and 67%, respectively.

CONCLUSION

We have decided to publish the preliminary results because this regimen was more active than that expected. Although our results are preliminary, CAP-GEM shows activity and safety in pretreated TETs. Furthermore, multicenter trials, also in first-line setting, are necessary to confirm our results.

The management of thymoma: a systematic review and practice guideline

INTRODUCTION

Thymoma is a rare tumor for which there is little randomized evidence to guide treatment. Because of the lack of high-quality evidence, a formal consensus-based approach was used to develop recommendations on treatment.

METHODS

A systematic refview of the literature was performed. Recommendations were formed from available evidence and developed through a two-round modified Delphi consensus approach.

RESULTS

The treatment recommendations are summarized as follows: Stage I--complete resection of the entire thymus without neoadjuvant or adjuvant therapy. Stage II--complete resection of the entire thymus with consideration of adjuvant radiation for high-risk tumors. Stage IIIA--surgery either initially or after neoadjuvant therapy, or surgery followed by adjuvant therapy. Stage IIIB--treatment may include a combination of chemotherapy, radiation, and/or surgery, or if technically possible, surgery in combination with chemoradiotherapy (concurrent cisplatin based). For bulky tumors, consideration should be given to sequential chemotherapy followed by radiation. Stage IVA--as per stage III, with surgery only if metastases can be resected. Stage IVB--treatment on an individual case basis (no generic recommendations). Recurrent disease--consider surgery, radiation, and/or chemoradiation. Chemoradiation should be considered in all medically inoperable and technically inoperable patients.

CONCLUSION

Consensus was achieved on these recommendations, which serve to provide practical guidance to the physician treating this rare disease.

Refractory recurrent thymoma successfully treated with long-acting somatostatin analogue and prednisolone

The patient was 54-year-old woman diagnosed as recurrent invasive thymoma (type B3; WHO classification). Although partial response was obtained by systemic chemotherapy (PAC: cisplatin, doxorubicin, cyclophosphamide), the tumor started to become enlarged after cessation of chemotherapy. Combined treatment of octreotide and prednisolone was administrated because various chemotherapies, including PAC, were not effective. After seven months, the tumor size was markedly decreased. The combination of octreotide and prednisolone should be considered as one of the choices of treatment in patients with recurrent thymoma.