The management of malignant thymona with radiation therapy

Malignant thymoma: current status of classification and multimodality treatment

Classification, understanding of the pathophysiology, and treatment options of thymoma have changed during recent years. It is hoped that novel strategies will lead to a survival benefit in these patients. It has become clear that patients with thymoma are best treated with multimodality therapy. In this review, a pathologist, an immunologist, a surgeon, a radiotherapist, a pneumologist, and oncologists discuss the current status of classification and strategies for the treatment of patients with thymoma.

Malignant thymoma: current status and future directions

Malignant thymomas are rare indolent tumours of the anterior superior mediastinum. Despite a benign histologic appearance, some thymomas invade nearby structures or metastasize. Patients are commonly asymptomatic, but some may present with unusual paraneoplastic syndromes such as myasthenia gravis, pure red cell aplasia, or hypogammaglobulinemia. Since tumour biopsy may potentially disrupt the thymic capsule, it is often not performed. Patients are therefore diagnosed and staged at the time of definitive surgery. Thymomas can generally be categorized into two stages: non-invasive and invasive. Prognosis closely parallels the disease stage. Surgery is the principal treatment and is curative in early stage disease. Radiation therapy, either alone or in combination with chemotherapy, is an option for both incompletely or completely resected disease. Chemotherapy is offered to patients with locally advanced, recurrent, or metastatic thymoma, with excellent responses and prolonged survival. Multicentre co-operative group clinical trials are required to assess novel thymoma therapies to maximize patient resources in this uncommon tumour.

High-dose hemithorax irradiation in a patient with recurrent thymoma: a study of pulmonary and cardiac radiation tolerance

Malignancy spread throughout a hemithorax without distant metastasis poses a difficult therapeutic challenge. Irradiation is often not considered because of the risk of pulmonary and cardiac toxicity. We report on a patient with thymoma recurrent throughout the left pleural cavity. Disease progressed despite chemotherapy, and subsequently a radical course of radiotherapy (6,600 cGy) was delivered to the entire hemithorax. Tumor regressed markedly by the completion of radiotherapy. Although tumor regrowth was noted 1 year after radiotherapy, the patient remained markedly improved symptomatically until shortly before her death 2 years after radiotherapy. Pulmonary function tests at 1 year (forced expiratory volume of the first second and forced vital capacity) were similar to pretreatment values, and cardiac function at 2 years remained essentially normal. High-dose hemithorax irradiation may be a consideration in select cases.

Thymoma: state of the art

Thymoma is the most common tumor of the anterior mediastinum. This tumor is associated with unique paraneoplastic syndromes, such as myasthenia gravis, hypogammaglobulinemia, and pure red cell aplasia. The rarity of this tumor, however, has somewhat obscured the optimal treatment for this disease. For the majority of patients who present with localized tumor, surgical extirpation remains the standard of choice. Adjuvant radiotherapy seems to improve local control and survival. In more advanced disease, systemic therapy has been demonstrated to produce a 50% to 80% objective response rate. These observations have led to the development of multimodality therapy for the treatment of patients with advanced thymoma. In this article, we will review the current perspectives on the management of early stage and advanced thymoma.

Multimodality treatment of thymoma: a prospective study

BACKGROUND

Thymomas are a heterogeneous group of tumors. Treatment of invasive lesions is not well standardized. The aim of this study is to propose a clinicopathologically based protocol for multimodality therapy.

METHODS

Between 1965 and 1988, we operated on 83 patients with thymoma who did not receive standardized adjuvant therapy. In 1989, on the basis of the retrospective analysis of the data, we started a multimodality therapy protocol and used it for 65 patients. Twelve patients had medullary thymoma (11 stage I and 1 stage II), 13 had mixed type (6 stage I and 7 stage II), and 40 had cortical thymoma (4 stage I, 11 stage II, 12 stage III, and 13 stage IV). We considered three groups. Group I (n = 18 patients), benign thymoma, included stage I and II medullary and stage I mixed thymomas; radical resection with no adjuvant therapy was performed. Group II (n = 22), invasive thymoma, included stage I and II cortical and stage II mixed thymomas; postoperative chemotherapy plus radiotherapy was always administered. Group III (n = 25), malignant thymoma, comprised stage III and IV cortical thymomas and stage III mixed thymomas; resectable stage III lesions were removed, and highly invasive stage III and stage IV lesions underwent biopsy, neoadjuvant chemotherapy, and surgical resection; postoperative chemotherapy and radiotherapy was administered to all patients.

RESULTS

The 8-year survival rate for patients in stages I, II, III, and IV was 95%, 100%, 92%, and 68%, respectively. Patients with medullary thymoma had a 92% 8-year survival rate; those with mixed type, 100%; and those with cortical thymoma, 85%. Group I had an 8-year survival rate of 94%; group II, 100%; and group III, 76%. Survival was compared with that of patients operated on before 1989: differences were not significant for group I; survival improved in group II (100% versus 81%; p = not significant); and group III showed significant improvement (76% versus 43%; p < 0.049).

CONCLUSIONS

Multimodality treatment with neoadjuvant chemotherapy and adjuvant chemotherapy plus radiotherapy may improve the results of radical resection and the survival of patients with invasive and malignant thymoma.

Entire hemithorax irradiation following complete resection in patients with stage II-III invasive thymoma

PURPOSE

To evaluate the feasibility and efficacy of prophylactic entire hemithorax irradiation (EH) in addition to mediastinal irradiation (MRT) following a complete resection in Stage II-III invasive thymoma.

METHODS AND MATERIALS

Forty-three patients with invasive thymoma treated with surgery and radiation therapy between 1978 and 1993 were analyzed retrospectively. All 43 patients underwent a complete surgical resection and were judged to have Masaoka's Stage II-III invasive thymoma. Of these, 23 patients received EH and MRT (EH-MRT) and the remaining 20 received MRT. Of the 23 patients with EH-MRT, 11 were Stage II and 12 Stage III. Of the 20 with MRT, 11 were Stage II and 9 Stage III. In most cases, EH was 15 Gy per 15 fractions over 3 weeks (without lung compensation calculation). In both the EH-MRT and MRT group, the total radiation doses to the mediastinum were similar with a median of 40 Gy. The median follow-up time after surgery was 63 months and no patients were lost to follow-up.

RESULTS

Only one of the 23 patients with EH-MRT relapsed. On the other hand, eight of the 20 with MRT relapsed, six of whom died of disease. The pleura was the most common site of failure. At 5 years, the relapse-free rate was 100% for those receiving EH-MRT and 66% for those with MRT (p = 0.03); the overall survival rate was 96% for those with EH-MRT, and 74% for those with MRT (p: not significant). The only significant treatment-related complication was radiation pneumonitis requiring treatment, in one patient who received MRT and three who received EH-MRT, including one death of a 72-year-old man and one 68-year-old woman with severe lung fibrosis.

CONCLUSION

Except for elderly patients, EH-MRT following a macroscopically complete resection appears to be safe and feasible, and can reduce intrathoracic relapses.

Radiotherapy and chemotherapy for invasive thymomas: a multicentric retrospective review of 90 cases. The FNCLCC trialists. Fédération Nationale des Centres de Lutte Contre le Cancer

PURPOSE

Thymoma is a rare disease. The treatment of patients with invasive thymoma remains controversial. The prognosis of such patients is poor, even with the use of postoperative radiation therapy and chemotherapy. We retrospectively reviewed the outcome and prognostic factors in a series of 90 patients presenting with an invasive thymoma treated by partial resection or biopsy and radiation therapy.

METHODS AND MATERIALS

From 1979-1990, 163 patients with the diagnosis of lymphoepithelial thymoma were treated in 10 French cancer centers. Patients were staged using the postoperative "GETT" classification derived from that of Masaoka. Ninety patients who presented with an invasive thymoma, 58 Stage III (21 IIIA: partial resection and 37 IIIB: biopsy) and 32 Stage IVA (intrathoracic thymoma spread), are the subject of this report. Treatment combined surgery and radiation therapy (+/- chemotherapy), with curative intent. Surgery consisted of partial resection in 31 patients (21 Stage III), and biopsy in 55 patients (37 Stage III). The median radiation dose to the tumor was 50 Gy (30-70 Gy). Supraclavicular radiation was performed in 59 patients (median dose 40 Gy). Chemotherapy, combined with radiation in 59 patients, consisted of multidrug regimens, mainly platinum based.

RESULTS

The median follow-up is 105 months (20-165 months). The 5- and 10-year overall survival rates are 51 and 39%, respectively. There is a great impact of the extent of surgery on survival: the 5- and 10-year survival rates were 64% and 43%, respectively, after partial resection, compared to 39% and 31% after biopsy (p < 0.02). Local control at 8.5 years was obtained in 59 of 90 patients (66%): 40 Stage III, 19 Stage IVA. There is a significant relationship between the extent of surgery and the local control (16% of relapse after partial resection vs. 45% after biopsy, p < 0.05). Seven patients developed significant (grades 3-4 WHO grading system) treatment-induced side effects. Stage, histologic type, and chemotherapy were not prognostic factors.

CONCLUSION

In this large multicentric retrospective study of invasive thymomas (Stage III-IVA) treated by surgery and radiation, results show the importance of loco-regional treatments, such as surgery and radiation therapy. There is also a great impact of radiation on local control. However, the rate of local recurrence (34%) justifies recommending a higher dose of radiation (> 50 Gy) than doses used in this study, for incompletely resected patients. The role of chemotherapy needs to be further assessed.

Treatment of invasive thymoma with pleural dissemination

The outcome of eight patients with invasive thymoma accompanying pleural dissemination was investigated. Only two patients had mediastinal tumor resection and pleural disseminated tumor excision. Seven patients underwent radiotherapy to the mediastinum and/or disseminated tumors. A clinical response to radiotherapy was achieved in the six patients with evaluable lesions (complete response in five patients and partial response in one). The estimated 5-year survival rate was 87.5%. Four patients were alive more than 10 years. So far, the mediastinal tumors of seven patients have been controlled for periods ranging from 42 to 154 months. Recurrence in six patients appeared as pleural tumors. Four out of the six patients had five courses of radiotherapy to the recurrent pleural tumors, four of which achieved complete response. No distant metastases were observed at any time. These observations suggest that radiotherapy should be the primary mode of treatment in cases of invasive thymoma with pleural dissemination.

Treatment and prognosis of primary thymic carcinoma

From 1972 to 1990, we treated eight cases of thymic carcinoma (6 squamous cell and 2 small cell carcinomas). According to the classification by Masaoka et al., they consisted of one stage I, four stage III, one stage IVa, and two stage IVb. A complete resection of the primary tumour could be done in only three patients; the others had diagnostic biopsy and then radiation treatment. Four of five patients had a prolonged regression of the primary tumors after irradiation at 40-61.2 Gy. Six patients suffered from extrathoracic metastases. All patients received systemic chemotherapy with different regimens to counter either metastatic or locally recurrent lesions. Only two patients (with a regimen including cyclophosphamide, doxorubicin, and vincristine) obtained a partial response. The median survival of the eight patients was 70 months after surgical operation. The identification of an effective drug combination may thus improve the long-term prognosis of thymic carcinoma since radiotherapy is able to control primary lesions, even in the case of unresectable advanced disease.

Aggressive treatment of intrathoracic recurrences of thymoma

Between 1974 and 1988, 21 patients with intrathoracic recurrences of thymoma received radiotherapy with radical intent; surgery was always attempted when considered feasible: 11 patients were partially (6 cases) or totally (5 cases) resected before irradiation, while in the other 10 radiotherapy was the only treatment. In 7 cases the recurrence was confined to the anterior mediastinum, 9 had pleural nodules without mediastinal lesions and 5 had both mediastinal and pleural lesions. Mediastinal recurrences were treated by opposed parallel mediastinal fields with 2/3 of the dose delivered through the anterior port: doses ranged between 38 and 44 Gy; a boost of 10-16 Gy was given in patients not radically resected. Pleural nodules were treated with a variety of techniques according to the extent of the lesions. The 7-year survival of the whole group was 70%; 5 patients died: 4 with intrathoracic progression and one with distant metastases. The survival was 74% in the 11 patients having received surgery, either radical or subtotal, and 65% in the 10 patients treated with radiotherapy alone: the difference is not significant. Patients with Karnofsky index greater than 70 had a significantly better survival (100%, versus 28%, p = 0.0015). This is a selected series of patients presenting recurrences still amenable to a radical treatment either by surgery and radiotherapy or by radiotherapy alone: the results confirm that an aggressive approach is warranted in patients in good general conditions with recurrences confined to the mediastinum and/or 1 hemithorax.

Thymoma. The prognostic significance of flow cytometric DNA analysis

The clinical course of patients with thymoma varies widely despite its histologically benign appearance. Treatment decisions are based on local invasion and the extent of resection. Because some patients have more aggressive tumors, the prognostic significance of flow cytometric (FCM) analysis of nuclear DNA content was examined. Adequate tissue from paraffin-embedded blocks was available for 25 patients. Using FCM, the percentage of cells in S-phase (%S) and the ploidy, based on the DNA index (DI), were determined. The mean patient age was 52 years, with a female-to-male ratio of 1.3:1 and a median follow-up of 64 months. Seventeen patients underwent total tumor resections, and 12 also received radiation therapy. Eight patients underwent subtotal resections, with five receiving radiation therapy (with or without chemotherapy) and three receiving chemotherapy alone. Based on invasion and intrathoracic dissemination, the tumors were classified into four stages. The mean %S was 5.6. There was no relationship observed between %S and patient outcome. The 5-year disease-free survival rate was 85% for the 16 patients with diploid (DI = 1) tumors and 33% for the 9 patients with aneuploid (DI more than 1) tumors (P less than 0.002). Similar significant differences were observed by stage and extent of surgery. For those who had total resection (n = 17), the disease-free survival rate was 89% when DI equaled 1 and 50% when DI was more than 1 (P = 0.01). Although the numbers studied were small, when stage, histologic findings, and type of surgery were subdivided by DI, a higher incidence of relapse was associated consistently with aneuploidy. The DI appears to be a useful prognostic parameter for identifying patients at high risk of relapse.

Complete excision and panpleuropneumonectomy resulting in long-term survival for a teenager with invasive thymoma: report of a case

An 18-year-old girl with invasive thymoma and pleural dissemination underwent a complete removal of the tumor with combined resection of the pericardium and a panpleuropneumonectomy of the left lung. At the time of writing, 70 months later, she was doing well under the classification of grade I performance status with no signs of recurrence. Thus, complete surgical removal of this tumor can prolong the survival time of patients with invasive thymoma and pleural dissemination.

Thymoma: treatment and prognosis

Thirty-six patients with pathologically confirmed thymoma were treated at M.D. Anderson Cancer Center from 1962 to 1987. The tumors were staged based on invasion and intrathoracic dissemination. Twenty-one patients had total resection, five had subtotal resection, and 10 had biopsy alone. Twenty-two patients had definitive megavoltage radiation therapy with a median dose of 50 Gy. The 5-year, disease-free survival by stage was 74% for Stage I (n = 11), 71% for Stage II (n = 8), 50% for Stage III (n = 10), and 29% for Stage IVA (n = 7) (p less than 0.03). The 5-year, disease-free survival by extent of surgery was 74% for total resection, 60% for subtotal resection and 20% for biopsy only (p = 0.001). There were 15 patients with recurrences: two in Stage I, two in Stage II, five in Stage III, and six in Stage IVA. The median months to relapse, for those who failed treatment, were 46, 36, 2, and 13 for Stages I, II, III, and IVA respectively. Of the patients with recurrences four had a total resection, two subtotal resection, and nine biopsy only. Only one patient had distant metastases as the first site of relapse without intrathoracic relapse. For the eight patients who relapsed following radiation therapy, four were in the radiotherapy field. All four of the in-field failures were in patients who had a partial response. There were insufficient numbers of patients to determine a dose response to radiotherapy. For patients with invasive, incompletely resected disease, a multimodality approach may be necessary for long term, disease-free survival.

Neoadjuvant chemotherapy, surgery, and postoperative radiation therapy for invasive thymoma

Between January 1988 and June 1990, seven previously untreated patients with histologically confirmed and clinically staged IIIa invasive thymoma (IT) were enrolled in a prospective, single treatment arm study of neoadjuvant chemotherapy (NC) followed by surgery and postoperative radiation therapy (4600 to 6000 cGy). The NC included three cycles of cisplatin (75 mg/m2 on day 1), epirubicin (100 mg/m2 on day 1), and etoposide (120 mg/m2 on days 1, 3, and 5), every 3 weeks. All patients showed a partial response (greater than 50%) and underwent complete (n = 4) or incomplete (gross [n = 1] or microscopic [n = 2] residual tumor) surgical resection. Histologic examination was negative for two completely resected patients. Projected 2-year survival was 80%; all patients but one currently are alive and disease-free. This approach appeared to be feasible and may be a new therapeutic choice in the management of IT, but its use on a regular basis should be reserved until a larger number of patients and longer follow-up are available.

Chemotherapy for invasive thymoma. A 13-year experience

From 1977 to 1990, 37 patients with Stage III or IV invasive thymoma (20 men and 17 women; median age, 40 years of age) were referred for chemotherapy to the Padova Medical Oncology Department. All patients initially received the same regimen (50 mg/m2 of cisplatin and 40 mg/m2 of doxorubicin intravenously (IV) on day 1, 0.6 mg/m2 of vincristine IV on day 3, and 700 mg/m2 of cyclophosphamide IV on day 4 [ADOC]), recycling at monthly intervals. No life-threatening side effects were noted. The overall clinical response rate (complete response plus partial response) was 91.8%, with 43% complete remissions. Median duration of response and survival were 12 months (range, 2 to 96+ months) and 15 months (range, 5 to 96+ months), respectively. Seven of the 16 complete remissions were pathologically confirmed at subsequent thoracotomy. Other chemotherapy combinations and radiation therapy have been applied as second-line treatment, achieving only minimal responses. In the opinion of the authors, such chemotherapy deserves evaluation for adjuvant and neo-adjuvant treatment of invasive (and/or inoperable) thymoma due to the high complete response rate and overall response rate.

Post-operative radiotherapy in invasive thymoma

The experience of a large Cancer Institute in treating invasive thymoma has been reviewed. Twenty-eight patients received radiotherapy following biopsy or incomplete resection of a thymoma. The overall survival was 53% at 5 years and 44% at 10 years. Treatment was generally well tolerated but three patients (11%) developed significant side effects from the radiotherapy and two of these died. Radiotherapy appeared to be more effective in patients who had a small volume of residual disease after surgery. An attempt was made to identify prognostic factors but none reached statistical significance. The radiation dose, field size and the use of systemic treatment are discussed.

Role of radiation therapy in locally advanced thymoma

The records of all patients treated for thymoma in the Department of Radiotherapy of the University of Torino between 1970 and 1988 were reviewed. There were 77 patients in stage III or IVa (59 in stage III and 18 in stage IVa); 74 patients were operated upon before radiotherapy and 3 had a pre-operative irradiation followed by surgery and post-operative boost. Complete resection was possible in 55.9% of cases with stage III and in none with stage IVa. Subtotal resection was done in 35.6% of patients in stage III and 83.3% in stage IVa. 8 patients had only a biopsy: 5 in stage III (8.5%) and 3 in stage IVa (16.6%). Post-operative radiation doses ranged between 39.6 and 46 Gy to the whole mediastinum followed by a 10-16 Gy boost on smaller fields in cases presenting residual disease after surgery. The pre-operative dose was 30 Gy followed by a post-operative boost of 16-24 Gy. Conventional fraction sizes of 1.8-2 Gy were always used. The 10 years survival rate was 58.3%. There was a significant difference between stage III (70.9%) and stage IVa (26.3%) (p less than 0.0004). Survival of patients in stage III was not significantly affected by the type of surgery. No significant difference in survival or recurrence rate was observed in patients with different histologies and in patients with or without myasthenia. Thoracic relapses occurred in 15.2% of patients in stage III and in 50% of patients in stage IVa (p less than 0.01). Only 7 relapses (9.1%) were within the limits of the radiation field.(ABSTRACT TRUNCATED AT 250 WORDS)

Radiation therapy of invasive thymoma

Between 1978 and 1987, 30 cases of invasive thymomas were treated with radiotherapy after surgery. Surgical therapy consisted of total resection in 15 patients, subtotal resection in 1 patient, and biopsy in 14 patients. Myasthenia gravis (MG) was associated in nine patients (MG(+) group), but in 21 patients there was no evidence of myasthenia gravis (MG(-) group). Irradiation in the dose range of 30 to 58.7 Gy was delivered. The total average 5-year survival rate was 71.8%; it was 39.2% in MG(+) group and 78.3% in MG(-) group, though there was no significant statistical difference. Myasthenia gravis was well controlled by the tumorectomy and associated radiotherapy in 7 of the 9 patients. However, in 3 of 7 patients (42.9%) myasthenia gravis recurred at 2 years, 2 years and 7 months, and 5 years and 8 months after initial therapy. Total body irradiation of 2 Gy with 0.1 Gy fractions was administered for uncontrollable myasthenia gravis in one patient with marked improvement. Radiation therapy is an important therapeutic modality for unresectable malignant thymoma as well as for postoperative combined therapy. Total body irradiation may be an effective method to treat patients with otherwise resistant myasthenia gravis.

The role of preoperative radiotherapy for invasive thymoma

Six patients with large invasive thymomas were treated by preoperative irradiation with 12 to 20 Gy before total or partial resection of the tumor. The responses of these 6 thymomas were estimated on the chest radiograms as follows; complete response in 2 patients, partial response in 3 and no response in one. Although the clinical responses varied, the surgical specimens of all the tumors pronounced severe fibrosis, probably not related to irradiation, and necrotic foci with a few viable tumor cells. Total resection of the thymoma was performed in 3 patients and subtotal resection in 3. Adhered or involved surrounding tissues such as the pericardium, pleura and/or veins were also resected in most patients. Preoperative radiotherapy facilitated total or subtotal resection of the invasive thymoma mass by reducing the tumor volume.

Chemotherapy of invasive thymoma. A retrospective study of 22 cases

The authors report on combination chemotherapy in 22 patients (seven men, 15 women; age 20-67, median 38.5 years) with incompletely resected invasive thymoma. Twelve of 22 patients have had prior radiotherapy of the tumor (four of 12 local failure, eight of 12 remote metastases). By subsequent chemotherapy five of 12 obtained complete remission (CR). One of them died by relapsed tumor, another by an intercurrent infection. At 5 years after diagnosis the survival rate of the 12/22 patients was 33% (Kaplan-Meier). Ten of 22 patients received chemotherapy as primary treatment of incompletely resected thymoma. Four of 10 obtained CR. One of them was lost during follow-up, the others received adjuvant irradiation of the mediastinum and are free of disease. Two of ten obtained partial remission (PR), but relapsed within 6 months after chemotherapy. At 3 years after diagnosis the survival rate of the 10/22 patients was 34%. Thirteen of 22 patients received cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or CHOP/bleomycin as first chemotherapeutic regimen. Five of them achieved CR. Cyclophosphamide, vincristine, and prednisone (COP) or COP plus procarbazine (COPP) was administered to six of 22. Three of them obtained a CR and one a PR. In an alternating manner COPP and Einhorn regimens were given to two of 22, one of which had a CR. In one of 22 the doxorubicin, bleomycin, cisplatin, prednisone (BAPP) regimen was followed by a PR. The authors conclude that combination chemotherapy is effective in the first-line postsurgical treatment of incompletely resected thymoma and also in the treatment of local or metastatic relapses after radiotherapy.

A proposal for treatment of invasive thymoma

Eleven patients with invasive thymoma were treated with radiotherapy. All patients had gross anterior mediastinal tumors that invaded the adjacent structures, four of whom showed intrathoracic dissemination. Before radiotherapy, only one had macroscopic complete resection of the tumor, and another had partial resection; the other nine patients underwent biopsy only. All 11 patients achieved complete remission after radiotherapy, eight of whom have been free from relapse for 31 to 202 months. Three patients experienced recurrence within the thorax but outside the radiation fields. Even after whole mediastinal irradiation, recurrence could occur in the pleural cavity. Therefore, extended radiation fields including the entire hemithorax is recommended. Intensive combination chemotherapy was administered for two patients with recurrence and they achieved complete remission. A possible role of intensive chemotherapy in induction phase for invasive thymomas is discussed.

Chemotherapy of malignant thymoma. Case report and review of the literature

The authors report the case of a patient with malignant thymoma unresponsive to combination chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone [CHOP] and cisplatin/VP-16) who subsequently achieved clinical response to continuous daily prednisone. A review of the literature indicates that prednisone and cisplatin are the most active agents in the treatment of malignant thymoma.

Remission of invasive thymoma due to chemotherapy. Two patients treated with cyclophosphamide, doxorubicin, and vincristine

Information regarding the effectiveness of chemotherapy in cases of invasive thymoma is limited. Two patients in whom the combination of cyclophosphamide, doxorubicin, and vincristine produced remission of invasive thymoma are described. The durations of remission were eight and seven months, respectively. In both patients, recurrence was observed at the site of bulky disease, and a secondary complete response continuing for 37 months was achieved in one of them with radiation therapy.

Recurrence of thymoma: clinicopathological features, therapy, and prognosis

Factors influencing the recurrence or persistence of thymoma after therapy were investigated in 127 patients with thymoma, including 75 with thymoma and myasthenia gravis. The rate of recurrence or persistence was 19% (24 of 127 patients) overall, 11% (8 of 75 patients) in myasthenic thymoma, and 31% (16 of 52 patients) in nonmyasthenic thymoma. The more advanced the clinical stage, the higher the rate of recurrence or persistence. The recurrence/persistence rate for patients with the same clinical stage was higher in those with nonmyasthenic thymoma (8% in Stage I, 11% in Stage II, 36% in Stage III, and 75% in Stage IV) than in those with myasthenic thymoma (0 in Stage I, 13% in Stage II, 18% in Stage III, and 20% in Stage IV). The prognosis for patients having subtotal resection of tumor was good in myasthenic thymoma (recurrence/persistence rate, 17%) in contrast with nonmyasthenic thymoma (recurrence/persistence rate, 78%). These results suggest that nonmyasthenic thymoma is more malignant than myasthenic thymoma. Postoperative radiotherapy was effective in preventing the recurrence or persistence of thymoma after therapy.

Invasive thymoma with myasthenia gravis

In 261 surgically treated patients with myasthenia gravis (MG), 26 had an invasive thymoma and 49 had a noninvasive thymoma. Invasive thymoma was seen in 41% of thymomatous MG patients older than 40 years of age, and 28% in patients younger than 40 years of age. Of 19 patients who underwent total or subtotal thymothymomectomy accompanied by irradiation (4000 rad), 17 were still alive on an average 6.5 years after surgery. The deterioration of MG by the irradiation was observed in 7 of 20 irradiated cases. Thus, postoperative irradiation is effective but should be done with attention to the deterioration of MG. The prognosis of MG in patients with an invasive thymoma was poorer than that in patients with a noninvasive thymoma.

Invasive carcinoma of the thymus. A multicenter retrospective review of 56 cases

This multicenter retrospective study included 56 cases of histologically reviewed invasive epithelial thymic tumors. All these patients underwent surgical treatment or exploration and were referred for complementary radiotherapy. The majority received a dose higher than 4000 rad. Twenty-three out of 50 patients (46%) with incomplete resection received some chemotherapy. The local recurrence rate at 2 yr was 34%. The overall 5-yr actuarial survival was 46%. There was no evidence of any relationship between radiation dose and local control. No difference in survival was observed with or without chemotherapy, nor according to histological type or lymphocytic infiltration, except cases with very undifferentiated carcinomas which presented a worse prognosis. Nor was any difference in survival observed between patients benefiting from incomplete resection and those only having undergone exploratory thoracotomy and biopsy. Radiotherapy seems to decrease the rate of local recurrence in invasive carcinoma of the thymus. The role of chemotherapy is still debatable, but it could have a role in decreasing tumor volume before radiotherapy. This study has shown the necessity of histological review by a panel of histopathologists in an attempt to better define terminology and diagnosis. A prospective study is necessary in order to solve the problems of concepts and management in epithelial thymic tumors.

T-cell chronic lymphocytic leukemia in a patient with invasive thymoma in remission with chemotherapy

This is a case report of a patient with invasive thymoma. Subsequently to radiotherapy and steroids, a combination chemotherapy of cis-platinum (CDDP) and doxorubicin was tested with good results. The patient later developed a chronic lymphocytic leukemia (CLL); morphologically and cytochemically a T-CLL with skin localizations, hepatomegaly, and a high leukocyte count.

Syndrome of inappropriate antidiuretic hormone secretion following dis-dichlorodiammineplatinum II in a patient with malignant thymoma

A patient with malignant thymoma is reported, in whom the syndrome of inappropriate antidiuretic hormone secretion (SIADH) occurred 36-48 hours after being given cis-Dichlorodiammineplatinum II (CPPD) with a mannitol diuresis. The SIADH was treated by fluid restriction and demeclocycline and subsided after approximately 72 hours. Subsequent courses of CPPD with mannitol diuresis were given with demeclocycline prophylactically and no untoward effects noted. The precise mechanism for the SIADH following the use of CPPD is unknown, but may be life-threatening, especially since preloading with fluid followed by forced diuresis is used when CPPD is given to avoid nephrotoxicity. The patient has survived 37 months, with 24 months of relapse-free survival following treatment with CPPD, irradiation and surgery.

Metastatic thymoma with myasthenia gravis: complete remission with combination chemotherapy

A 29-year-old male developed myasthenia gravis 29 months after resection of a "benign" mediastinal thymoma. Metastatic thymoma was found in the pleura 45 months after the initial surgical resection. Combination chemotherapy with cyclophosphamide and doxorubicin produced a complete remission of the metastatic thymoma which has continued for 13 months. Concurrently, there has been a marked increase in neuromuscular function.

A complete response in metastatic malignant thymoma to cis-platinum, doxorubicin and cyclophosphamide: a case report

Systemic chemotherapy as a mode of therapy in metastatic malignant thymoma has never been systematically evaluated. Chemotherapeutic agents, including doxorubicin, cyclophosphamide, cis-platinum, nitrogen mustard, prednisone or combination of agents like MOPP have produced tumor remission. A case report of complete remission of malignant thymoma in which the combination of cyclophosphamide, doxorubicin and cis-platinum (CAP) was used is reported.

Treatment of invasive or metastatic thymoma: report of eleven cases

The clinical presentation and therapeutic modalities of 11 patients with invasive or metastatic thymoma are presented. Two patients had myasthenia gravis, and five had extrathoracic metastases. Survival exceeded five years in five patients, and four patients remain free of recurrence between 2.1 and 9.0 years after diagnosis. Surgery, with an attempt at complete resection, is the first step of therapy. A second thoracotomy for local relapse or attempt at curative resection was carried out in four patients. Radiotherapy to the mediastinum and/or metastatic sites was given to ten patients with doses ranging from 3600-6000 rads (median = 4500 rads) in the nine nonmyasthenic patients. Inclusion of supraclavicular fossae in the radiotherapy field is recommended because it was a site of relapse in two patients. Systemic therapies were given to eight patients. Objective responses were seen with two of various chemotherapeutic regimens. A combination of bleomycin, Adriamycin, cisplatin, and prednisone ("BAPP") produced a partial remission in two of five patients, during 12 and 4 months, respectively. Two of three patients responded to maytansine as a single agent after failure of other agents. Immunotherapy with intravenous Corynebacterium parvum or intradermal Methanol-Extraction Residue of bacillus Calmette-Guérin (MER-BCG) was ineffective in one patient each. The importance of combined modalities in the management of the disease is emphasized.