Long-term survival in thymic epithelial tumors: a single-center experience from China

American Radium Society Appropriate Use Criteria for Radiation Therapy in the Multidisciplinary Management of Thymic Carcinoma

Importance

Thymic carcinoma is rare, and its oncologic management is controversial due to a paucity of prospective data. For this reason, multidisciplinary consensus guidelines are crucial to guide oncologic management.

Objective

To develop expert multidisciplinary consensus guidelines on the management of common presentations of thymic carcinoma.

Evidence Review

Case variants spanning the spectrum of stage I to IV thymic carcinoma were developed by the 15-member multidisciplinary American Radium Society (ARS) Thoracic Appropriate Use Criteria (AUC) expert panel to address management controversies. A comprehensive review of the English-language medical literature from 1980 to 2021 was performed to inform consensus guidelines. Variants and procedures were evaluated by the panel using modified Delphi methodology. Agreement/consensus was defined as less than or equal to 3 rating points from median. Consensus recommendations were then approved by the ARS Executive Committee and subject to public comment per established ARS procedures.

Findings

The ARS Thoracic AUC panel identified 89 relevant references and obtained consensus for all procedures evaluated for thymic carcinoma. Minimally invasive thymectomy was rated as usually inappropriate (regardless of stage) due to the infiltrative nature of thymic carcinomas. There was consensus that conventionally fractionated radiation (1.8-2 Gy daily) to a dose of 45 to 60 Gy adjuvantly and 60 to 66 Gy in the definitive setting is appropriate and that elective nodal irradiation is inappropriate. For radiation technique, the panel recommended use of intensity-modulated radiation therapy or proton therapy (rather than 3-dimensional conformal radiotherapy) to reduce radiation exposure to the heart and lungs.

Conclusions and Relevance

The ARS Thoracic AUC panel has developed multidisciplinary consensus guidelines for various presentations of thymic carcinoma, perhaps the most well referenced on the topic.

Real-world study of treatment and outcome of type B2 + B3 thymoma: The neglected part of thymoma

BACKGROUND

This study aimed to examine the treatment and prognosis of patients with type B2 + B3 thymoma and compare it with those patients with type B2 and B3 thymoma.

METHODS

We conducted a retrospective analysis of the results of 39 patients with type B2 + B3 thymoma, 133 patients with type B2 thymoma, and 64 patients with type B3 thymoma. The Kaplan-Meier technique was used to generate survival curves. For multivariate analysis, the Cox proportional hazard model was applied.

RESULTS

With a median follow-up of 60 months (range: 1-128 months), the percentage of patients with tumor, node, metastasis (TNM) stage III and IV disease gradually increased from 19.5% to 25.6% to 35.9% among those with histological subtypes B2, B2 + B3, and B3, respectively, p = 0.045. Twenty-three patients experienced recurrence or metastasis. The total 10-year progression-free survival (PFS) rates were 86.0% overall (85.0% in type B2, 87.2% in type B2 + B3, and 87.5% in type B3). Age, R0 resection, and Masaoka-Koga stage were found to have a significant on PFS in all patients. There was no statistically significant difference in PFS between different histotypes of thymoma, p = 0.650. PFS was predicted by R0 resection in all histotypes and by the Masaoka-Koga stage in the type B2 subgroup.

CONCLUSION

Combining the two staging methods to guide the diagnosis and treatment of patients with B2 + B3 thymoma is recommended. R0 resection is recommended to reduce recurrence. Patients with B2 + B3 thymoma have a prognosis similar to those with a B2 thymoma or a B3 thymoma alone.

Prognostic CT features in patients with untreated thymic epithelial tumors

To determine the prognostic CT features in patients with untreated thymic epithelial tumors (TETs). Clinical data and CT imaging features of 194 patients with pathologically confirmed TETs were retrospectively reviewed. The subjects included 113 male and 81 female patients between 15 and 78 years of age, with a mean age of 53.8 years. Clinical outcomes were categorized according to whether relapse, metastasis or death occurred within 3 years after the first diagnosis. Associations between clinical outcomes and CT imaging features were determined using univariate and multivariate logistic regression analyses, while the survival status was analyzed by Cox regression. In this study, we analyzed 110 thymic carcinomas, 52 high-risk thymomas and 32 low-risk thymomas. Percentages of poor outcome and patient death in thymic carcinomas were much higher than those in patients with high-risk and low-risk thymomas. In the thymic carcinomas groups, 46 patients (41.8%) experienced tumor progression, local relapse or metastasis and were categorized as having poor outcomes; vessel invasion and pericardial mass were confirmed to be independent predictors by logistic regression analysis (p < 0.01). In the high-risk thymoma group, 11 patients (21.2%) were categorized as having poor outcomes, and the CT feature pericardial mass was confirmed to be an independent predictor (p < 0.01). In survival analysis, Cox regression showed that CT features of lung invasion, great vessel invasion, lung metastasis and distant organ metastasis were independent predictors for worse survival in the thymic carcinoma group (p < 0.01), while lung invasion and pericardial mass were independent predictors for worse survival in high-risk thymoma group. No CT features were related to poor outcome and worse survival in the low-risk thymoma group. Patients with thymic carcinoma had poorer prognosis and worse survival than those with high-risk or low-risk thymoma. CT can serve as an important tool for predicting the prognosis and survival of patients with TETs. In this cohort, CT features of vessel invasion and pericardial mass were related to poorer outcomes in those with thymic carcinoma and pericardial mass in those with high-risk thymoma. Features including lung invasion, great vessel invasion, lung metastasis and distant organ metastasis indicate worse survival in thymic carcinoma, whereas lung invasion and pericardial mass indicate worse survival in high-risk thymoma.

Prognostic factors for overall survival after surgical resection in patients with thymic epithelial tumors: A systematic review and meta-analysis

BACKGROUND

Thymic epithelial tumors (TETs) originate in the thymic epithelial cell, including thymoma and thymic carcinoma. Surgical resection is the first choice for most patients. However, some studies have shown that the factors affecting the prognosis of these patients are not consistent. To evaluate prognostic factors in patients with surgically resected thymic epithelial tumors, we performed a meta-analysis.

METHODS

We searched the Chinese biomedical literature database, Pubmed, Embase, Cochrane Library and other electronic databases. Studies including postoperative overall survival (OS) and predictors of TETs were included. We made a comprehensive analysis the hazard ratios (HRs) through a single proportional combination. HRs were combined using single proportion combinations.

RESULTS

The meta-analysis included 11,695 patients from 26 studies. The pooled OS was 84% at 5 years and 73% at 10 years after TETs operation. The age as continuous-year (HR 1.04, 95% confidence interval (CI) 1.02-1.04), incomplete resection (HR 4.41, 95% CI 3.32-5.85), WHO histologic classification (B2/B3 vs A/AB/B1 HR 2.76, 95% CI 1.25-6.21), Masaoka Stage (stage III/IV vs I/II HR 2.74, 95% CI 2.12-3.55,) were the poor prognostic factors.

CONCLUSIONS

For patients with TETs after surgical resection, advanced age, incomplete resection, WHO classification B2/B3, and higher Masaoka stage are risk factors for poor prognosis.

Thymoma type B2 progression, due to fear of contamination, in association with hydrocephalus: A case report of avoidant behavior during COVID-19 pandemic

The novel coronavirus pandemic outbreak caused extreme public fear, health concerns, and psychological distress, especially in oncology patients. The presented rare case is of a 40-year-old female with thymoma type B, with rapid progression, due to fear from the COVID-19 pandemic. Biopsy and histological verification of the tumor show a B-type thymoma with a high proliferative index. The fear of infection is causing avoidant behavior and leads to suboptimal therapy in some oncology patients that will have severe consequences. We can conclude that adequate, personalized, and most importantly, active psychological care is necessary and should be implemented for cancer patients. To be prepared for a future lockdown, it may be helpful to urge patients to seek alternative forms of social contact, such as online and mobile communications, to combat depression lockdown effects.

Does size affect the prognosis of resectable thymoma beyond the eighth edition TNM?

Background

Thymoma is a type of rare mediastinal tumor whose clinical characteristics and indicators of prognosis are poorly understood. This single‐institution retrospective study aimed to assess the predictive value of tumor, node, metastasis (TNM) staging incorporating tumor size in predicting the risk of thymoma recurrence after resection.

Methods

Four binary logistic regression models were developed. Models I and II included median tumor size and TNM stage, respectively. Model III included the above two variables. Model IV was model III containing these two variables and their interaction terms. All models were adjusted for WHO histological type, operational time, and adjuvant therapy.

Results

A total of 276 patients with a median age of 51.0, including 21 patients with thymoma recurrence, were included in this study. Models II or III showed a lower ‐2LogL and higher AUC (0.735 and 0.738 vs. 0.576) with significantly better discrimination than model I, and model III and model II shared similar discrimination. In model III, TNM stage was positively correlated with thymoma recurrence. The recurrence risk of patients with TNM stage IV was significantly higher than those with TNM stage I (OR of 11.03, p = 0.022). No significant correlation between the tumor size and recurrence risk (p = 0.779) and no interaction was found between medium tumor size and TNM stage in model IV.

Conclusions

This study suggests that the prediction contribution of the TNM stage combined with tumor size is similar to the TNM stage alone for tumor recurrence in patients with thymoma after surgical resection.

Case Report of Thymoma Tumor Reduction Following Plasmapheresis

For thymoma, multidisciplinary antitumor strategy is composed of surgery, chemotherapy, and radiotherapy. Meanwhile, ~20% to 25% of patients with thymoma have myasthenia gravis and plasmapheresis is recommended for thymoma-associated myasthenia gravis.We report a case that a 40-year-old woman with thymoma experiencing tumor relapse after surgery showed significant response to plasmapheresis.This is the first case of thymoma responded to plasmapheresis, which may guide the study of the etiology and pathogenesis of thymoma.

Treatment and survival analyses of completely resected thymic carcinoma patients

PURPOSE

To investigate the impact of chemotherapy and/or radiotherapy on disease-free survival (DFS) and overall survival (OS) rates of patients with thymic carcinoma after complete resection.

METHODS

Between 2001 and 2013, 54 patients with complete resection of thymic carcinoma in Hangzhou Cancer Hospital were retrospectively reviewed. The Kaplan-Meier method was used to evaluate the survival rates. The Cox proportional hazard model was used for multivariate analysis.

RESULTS

Among the 54 patients, Masaoka stage I was observed in seven patients, II in 22 patients, and III in 25 patients. Sixteen patients received adjuvant chemotherapy (six with chemotherapy alone and ten with radiotherapy and chemotherapy), 25 patients received adjuvant radiotherapy, and 13 patients did not receive radiotherapy and/or chemotherapy. The 5-year DFS and OS rates for all patients were 63.0% and 73.4%, respectively. Univariate analysis revealed that radiotherapy was significantly associated with DFS and OS (P=0.014 and P=0.029, respectively), while adjuvant chemotherapy was not (P=0.122 and P=0.373, respectively). Multivariate analysis showed that adjuvant radiotherapy increased DFS (P=0.041), but not OS (P=0.051).

CONCLUSION

Complete resection followed by adjuvant radiotherapy increased disease-free rates of thymic carcinoma patients.

Treatment and prognosis of Masaoka stage 3 thymic carcinoma: a retrospective study of 32 cases

PURPOSE

The aim of this study was to investigate the treatment and prognostic factors in patients with Masaoka stage 3 thymic carcinoma.

METHODS

A retrospective review was conducted of the medical records of patients with Masaoka stage 3 thymic carcinoma between 2000 and 2012 in our institution. Clinical characteristics and prognostic factors were analyzed. Survival curves were plotted using the Kaplan-Meier method. The Cox proportional hazard model was used for multivariate analysis.

RESULTS

Thirty-two patients with Masaoka stage 3 thymic carcinoma, operated on in Zhejiang Cancer Hospital, were identified between 2000 and 2012. Among 32 patients, 24 achieved R0 resection. The most common histological subtypes were squamous cell carcinoma (n=15, 46.8%), followed by undifferentiated carcinoma (n=12, 37.5%), and other tumors (n=5, 15.7%). The 5-year disease-free survival and overall survival rates were 56.8% and 61.5%, respectively. Patients with incomplete resection had a significantly worse disease-free survival and overall survival as compared to complete resection with univariate analyses (P-value 0.006 and 0.034, respectively). Multivariate analysis revealed that complete resection was statistically associated with disease-free survival but not overall survival (P-value 0.025 and 0.076, respectively).

CONCLUSION

Our results indicated that complete resection could impact the disease-free survival of patients with stage 3 thymic carcinoma.

Treatment and prognosis of type B2 thymoma

BACKGROUND

Because of the rarity of thymoma, no randomized trials have prospectively detected the prognosis and optimal treatment for type B2 thymoma. The aim of this study is to investigate the treatment and prognosis for patients with type B2 thymoma.

METHODS

We retrospectively evaluated the outcome of 42 patients with type B2 thymoma who were treated between 1995 and 2010 in Zhejiang Cancer Hospital. Survival curves were plotted using the Kaplan-Meier method. The Cox proportional hazard model was used for multivariate analysis.

RESULTS

The current study included 42 patients. The 5-year disease-free survival and overall survival rates were 62.8% and 84.9%, respectively. There were significant differences in disease-free survival and overall survival among different Masaoka stages (both P<0.001). Univariate and multivariate analysis revealed that Masaoka stage was associated with disease-free survival and overall survival (P=0.00 and 0.001, respectively).

CONCLUSIONS

Our results indicate that Masaoka stage affects disease-free survival and overall survival of patients with type B2 thymoma.

Survival and treatments in patients with incompletely resected thymoma

Objectives

the objective of our study was to clarify survival and treatments in patients with incompletely resected thymoma.

Methods

between January 1991 and December 2012, 156 consecutive patients who underwent thymectomy with curative intent at Kyoto University Hospital, were evaluated retrospectively. Overall survival and progression-free survival were analyzed using the Kaplan-Meier method, comparing the complete resection group ( n = 141) with the incomplete resection group ( n = 15). Potentially relevant factors for overall survival and progression-free survival in patients with incompletely resected thymomas were analyzed using Cox proportional-hazard models.

Results

there was a significant difference in progression-free survival ( p = 0.0012) but not in overall survival ( p = 0.638) following thymectomy in the complete and incomplete resection groups. Adjuvant chemotherapy was performed in 6 (40%) patients and adjuvant radiotherapy in 6 (40%) in the incomplete resection group. In univariate analysis, younger age ( p = 0.073) showed a tendency for better overall survival, and adjuvant chemotherapy ( p = 0.071) showed a tendency for better progression-free survival.

Conclusion

our results suggest that patients with incompletely resected thymomas can achieve comparable overall survival to those with completely resected thymomas. Adjuvant chemotherapy for incompletely resected thymomas tends to improve progression-free survival.