Extended surgical resections of advanced thymoma Masaoka stages III and IVa facilitate outcome

The role of surgery in advanced thymic tumors: A retrospective cohort study

Background

There is no definitive and detailed treatment guideline for advanced thymic tumors, thus when lymph node and other organ metastasis are present, clinical guidelines recommend chemotherapy-based multidisciplinary treatment. A consensus has been reached that surgery has beneficial effects on partial patients with stage IVA whose metastatic lesions were isolated and resectable, but because of few cases of advanced thymic tumor s and the scarcity of reports, the role of surgery in stage IVB is still unknown. The current study aimed to systematically analyze the role of surgery in advanced thymic tumors based on the Surveillance, Epidemiology, and End Results (SEER) database, with a sufficient number of cases. A secondary aim was to clarify the prognostic value of surgery in advanced thymic tumors.

Method

Data derived from a total of 979 patients with advanced thymoma or advanced thymic carcinoma were collected from the SEER database. Propensity score matching was performed to eliminate confounding factors, and Cox regression analyses were conducted to assess prognoses.

Results

Patients were assigned to four groups based on pathology and whether surgery was performed; thymoma (surgery), thymoma (no surgery), thymic carcinom a (surgery), and thymic carcinoma (no surgery). Disease-specific survival differed significantly in the thymoma (surgery) and thymoma (no surgery) groups, both before and after propensity score matching (both p < 0.001). Similarly, disease-specific survival differed significantly in the thymic carcinoma (surgery) and the thymic carcinoma (no surgery) groups (p < 0.001 before and p = 0.003 after). No total resection, distant metastasis, and thymic carcinoma were all unfavorable prognostic factors.

Conclusions

In the present study surgery had positive effects on advanced thymoma and advanced thymic carcinoma patients who could undergo surgical resection, significantly improving survival times. Total resection of the primary site was the most advantageous form of surgery. The study provides a reference for the clinical treatment of advanced thymic tumors.

Hypertermic Intrathoracic Chemotherapy (HITHOC) for thymoma: a narrative review on indications and results

Objective

With this narrative review, we retraced the history of hypertermic intrathoracic chemotherapy (HITHOC) since the beginning, analyzing literature on operative technique, feasibility and efficacy of this treatment. Moreover, we report the fifteen-year experience of our center in this relatively new technique, for what concerns both early postoperative results and long-term oncological outcomes.

Background

Thymomas are frequently misdiagnosed and recognized in advanced stage, often with pleural dissemination, especially when not associated to Myasthenia Gravis that allows an early diagnosis during the initial assessment. Moreover, the natural history of locally advanced thymoma is characterized by a high rate of pleural or pericardial relapses. Surgery has always been considered a milestone in thymoma’s treatment, even in case of serous dissemination or relapses, although his role as exclusive therapy does not guarantee an acceptable local disease control. In case of disseminated disease, different multidisciplinary protocols have been experimented, from chemotherapy to radiation therapy, alone or associated to surgery, in order to increase overall and disease-free survival, but the breakthrough happened in the early 90s with the introduction of HITHOC following surgery. Combination of surgery and HITHOC resulted in less toxic than systemic chemotherapy and providing a good local disease control in patients with stage IVa thymomas or thymoma’s pleural recurrences.

Methods

We searched PubMed for relevant literature, up to January 2020, on hypertermic intrapleural chemotherapy for thymomas (TPR or DNT), selecting only those reporting information about HITHOC protocol used, postoperative course and oncological outcomes.

Conclusions

HITHOC is a safe and feasible procedure, with a very low complication rate and negligible systemic effects of chemotherapeutic agents, effective in controlling both TPR and DNT, in particular as regards local disease-free survival.

Keywords

Hypertermic intrathoracic chemotherapy (HITHOC); thymoma; intracavitary chemotherapy; hyperthermia; redo-surgery

Heart rupture repair during huge mediastinal mass resection - case report

BACKGROUND

Ventricular rupture is rarely described in the literature outside the context of myocardial infarction, infection or neoplasm. It is associated with a high mortality rate due to late presentation and delayed surgical intervention, which involves sutureless or sutured techniques. Comprehensive literature review failed to identify any case of intra-operative right ventricular heart rupture followed by myocardial repair and a complete recovery after a prolonged intensive care unit (ICU) stay.

CASE PRESENTATION

A 57-year-old previously healthy gentleman presented complaining of a new onset shortness of breath for 2 months. A large mediastinal mass was found on chest imaging and biopsy revealed a thymoma. Patient received a neoadjuvant Cisplatin/Doxorubicin/Cyclophosphamide (CAP) regimen chemotherapy then sternotomy and thymectomy en bloc with anterior pericardium. Post-thymectomy, the patient continued to be hypotensive in recovery despite aggressive fluid resuscitation. He was sent back to theatre, aggressive fluid resuscitation continued, surgical site exploration was done by reopening the sternum, and the bleeding source was identified and controlled, but intraoperative asystole developed. During internal cardiac massage, the right ventricle ruptured with a 3 cm defect which was successfully repaired using a pericardial patch without a bypass machine due to unavailability at our cancer center. The patient remained dependent on mechanical ventilation through tracheostomy for a total of 2 months due to bilateral phrenic nerve paralysis, was discharged from ICU to the surgical floor 66 days after the operation and weaned off ventilator support after 85 days, adequate respiratory and physical rehabilitation followed. Patient is doing very well now with excellent performance, and free of tumor recurrence 30 months after surgery.

CONCLUSION

Right ventricular rupture is rarely described outside the context of myocardial infarction and valvular heart disease. Tumor proximity to the heart and neoadjuvant cardiotoxic chemotherapy are the proposed causes for precipitating the cardiac rupture in our case. Post-surgical patients who receive early physical rehabilitation and respiratory physiotherapy have improved survival and outcome.

Thymomas: five-year outcomes of open surgery and a single centre experience

Objective

To present and discuss the clinical course, management, recurrence and survival of patients with thymoma at a single centre.

Methods

This prospective observational study included patients with confirmed thymoma who were diagnosed and managed over a 10-year period.

Results

The study included 89 patients (mean ± SD age, 48.53 ± 11.60 years). There were 46 (51.7%) males and 43 (48.3%) females. The mean duration of follow-up was 60 months (range, 2 months to 8 years). Stage II was the most common stage (37 [41.6%]), followed by stage I with 30 (33.7%) patients, stage IIIA with 11 (12.4%) patients, stage IVA with six (6.7%) patients and stage IIIB with five (5.6%) patients. Overall (actuarial) 5-year survival was achieved by 84 of 89 patients (94.4%). Stage-specific survival was as follows: 100% in stage I (30 of 30 patients), 100% in stage II (37 of 37 patients), 54.5% in stage IIIA (six of 11 patients), 80.0% in stage IIIB (four of five patients) and 50.0% in stage IVA (three of six patients).

Conclusion

Complete surgical resection is the main modality used for the definitive diagnosis, staging and surgical cure of thymoma.

Optimal management of thymic malignancies: current perspectives

Thymic epithelial tumors (TETs) belong to orphan oncology. The incidence of TETs is about 1.3–3.2 cases per million worldwide. Following pathology, evolution and prognosis are variable. The World Health Organization classification distinguishes thymomas and thymic carcinomas. TETs are composed of thymic epithelial tumoral cells and normal lymphocytes. The mean age at diagnosis is 50–60 years-old. There are no identified risk factors. TETs are frequently associated with paraneoplastic syndromes as myasthenia gravis. The complete R₀ surgical resection is the most significant prognosis factor on survival. In 2010, the French National Institute of Cancer labeled the RYTHMIC network as a specific tumor board including thoracic surgeons, oncologist, and radiation therapist to define standard of care for the management of TETs. The aim of the review was to update knowledge to optimize the standard of care.

Thoracotomy versus Video-Assisted Thoracoscopy in Pediatric Empyema

Background

To compare the outcomes of video-assisted thoracoscopic surgery (VATS) in comparison to open thoracic surgery in pediatric patients suffering from empyema.

Methods

A prospective study was carried out in 80 patients referred to the Department of Pediatric Surgery between 2015 and 2018. The patients were randomly divided into thoracotomy and VATS groups (groups I and II, respectively). Forty patients were in the thoracotomy group (16 males [40%], 24 females [60%]; average age, 5.77±4.08 years) and 40 patients were in the VATS group (18 males [45%], 22 females [55%]; average age, 6.27±3.67 years). There were no significant differences in age (p=0.61) or sex (p=0.26). Routine preliminary workups for all patients were ordered, and the patients were followed up for 90 days at regular intervals.

Results

The average length of hospital stay (16.28±7.83 days vs. 15.83±9.44 days, p=0.04) and the duration of treatment needed for pain relief (10 days vs. 5 days, p=0.004) were longer in the thoracotomy group than in the VATS group. Thoracotomy patients had surgical wound infections in 27.3% of cases, whereas no cases of infection were reported in the VATS group (p=0.04).

Conclusion

Our results indicate that VATS was not only less invasive than thoracotomy, but also showed promising results, such as an earlier discharge from the hospital and fewer postoperative complications.

Stage-related outcome for thymic epithelial tumours

BACKGROUND

Thymic epithelial tumours (TETs) are characterized by a wide variety of biological behaviors. Radical resection and stage are strong prognostic factors. Aim of this study is to review our Single Center Experience.

METHODS

One hundred and seventy-seven patients observed in the period from January 2000 to December 2016 were included in the study. Data regarding clinicopathologic features, treatment, and survival were collected. Stage-related clinical standpoints and therapeutic options were also evaluated.

RESULTS

Non-surgical treatment was primarily performed in 15 (8.47%), unresectable disease was intraoperatively found in 12 cases (7.4%). The analysis of 150 patients undergoing curative surgery revealed 70 stage I TET (46.66%), 49 stage II (32.66%), 19 stage III (12.66%), 6 stage IVa (4%) and 6 stage IVb (4%) at the first hospital admission. Histology identified 12 A thymoma (8%), 38 AB (25.33%), 24 B1 (16%), 50 B2 (33.33%), 19 B3 (12.66%) and 7 carcinomas (4.66%). The mean follow up time was 84.14 months (sd = 61.68 months). Disease relapse occurred in 13 patients (8.78%) at a mean period of 78.85 months (sd = 60.87 months) after surgery. Exitus due to thymoma happened in 6 cases (4.05%) after a mean survival of 56.02 months (sd = 25.17 months). The 5-year overall survival rate was 0.94 (95%CI 0.88-0.97) and the 5-year disease-free survival rate was 0.90 (95%CI 0.83-0.94). The 5-year overall survival rates were 96.1% (95% CI, 89.9-98.5%) for the early stages and 87.4% (95% CI, 65.6-95.8%) for the advanced stages (p = 0.670). The 5-year disease-free survival rates resulted being 98.8% (95% CI, 92.3-99.8%) for the early stages and 59.8% (95% CI, 37.8-76.2%) for the advanced stages (p < 0.001).

CONCLUSIONS

Advanced stage TETs are characterized by higher mortality and recurrence rates. Although technically demanding, surgery, as part of multimodality therapy, could prolong survival. Iterative surgical treatment of recurrences is a viable option for selected patients.

TRIAL REGISTRATION

The study was approved by the Institutional Review Board of Perugia and Terni University Hospitals [Code T1003] and was retrospectively registered.

Hyperthermic Intrathoracic Chemotherapy (HITHOC) for Pleural Malignancies-Experience from Indian Centers

Hyperthermic intrathoracic chemotherapy (HITHOC) has been used in addition to radical surgery for primary and secondary pleural malignancies to improve local control, prolong survival, and improve the quality of life. This study was performed to study the indications, methodology, perioperative outcomes, and survival in patients undergoing HITHOC at Indian centers. A retrospective analysis of prospectively collected demographic and clinical data, perioperative and survival data of patients undergoing surgery with or without HITHOC was performed. From January 2011 to May 2018, seven patients underwent pleurectomy/decortication (P/D) or extrapleural pneumonectomy (EPP) with HITHOC and four had P/D or EPP alone at three Indian centers. P/D was performed in two and EPP in nine patients. The primary tumor was pleural mesothelioma in eight, metastases from thymoma in one, germ cell tumor in one, and solitary fibrous tumor of the pleura in one. HITHOC was performed using cisplatin. Grade 3-4 complications were seen in one patient in the HITHOC group and none in the non-HITHOC group, and one patient in the non-HITHOC group died of complications. At a median follow-up of 9 months, five patients of the HITHOC group were alive, four without recurrence, and one with recurrence. One patient in the non-HITHOC group was alive and disease-free at 24 months, and two died of progression at 18 and 36 months. HITHOC can be performed without increasing the morbidity of P/D or EPP. Most of these patients require multimodality treatment and are best managed by multidisciplinary teams.

Extended resections of large thymomas: importance of en bloc thymectomy

Background

Primary tumors of the thymus are rare; the most common histologic type is thymoma. Most important prognostic factors are anatomical extent of tumor and completeness of surgical resection. Large size has not been directly associated with survival, but is strongly associated with advanced disease and high rates of incomplete resections.

Methods

A retrospective cohort of patients who underwent thymectomy for thymomas of 5 cm or larger at the National Cancer Institute (INCan) of México from January 2005 to December 2016 was analyzed. Primary end-points were rate of complete resection, morbidity and mortality of thymectomy. Secondary end-points were overall survival (OS) and disease-free survival (DFS).

Results

A total of 25 patients were identified and included in the final analysis. Mean age was 56.6 years (27-82 years). Median size of thymoma was 8.3 cm (5-14 cm). Transesternal approach was used in 72% of cases, most of cases (68%) required an extended resection to achieve negative margins. Complete resection was achieved on 23 cases (92%). A 90-day morbidity of 24% and mortality of 8% was found, with a median follow-up of 34.5 months (1-113 months). The only factor associated with OS was completeness of surgical resection (P<0.0001).

Conclusions

Size of thymomas should not be considered as a contraindication for surgical treatment. Our data suggest that extended surgery is feasible even in advanced cases and provides the best chance for cure. Complete resection remains as one of the most important prognostic factor in thymomas and is associated with prolonged DFS and OS.

Role of Surgery in the Treatment of Masaoka Stage IVa Thymoma

PURPOSE

To analyze the role of surgery in patients with Masaoka stage IVa thymoma treated with multimodality therapy.

METHODS

Of 191 patients undergoing surgery for thymoma in our department between January 2002 and December 2015, 39 (20.4%) had Masaoka stage IVa. Histopathological tumor type, myasthenic status of the Osserman-Genkins score, Masaoka stage at the first surgery, neoadjuvant treatment, number and type of surgeries, and survival rates were recorded.

RESULTS

Thymoma B2 was the most common histopathological tumor type (n = 16, 41%). Twenty-six (66.7%) patients underwent primary surgeries for Masaoka stage IVa thymoma, whereas nine (23.1%) underwent secondary surgeries and four (10.3%) underwent tertiary surgeries for pleural or pericardial recurrences. Median survival was 132 ± 25 (82-181; 95% confidence interval [CI]) months. Overall 3-, 5-, and 10-year survival rates were 93%, 93%, and 56%, respectively.

CONCLUSION

Surgical treatment should be considered as a completion modality to oncological therapy and has the potential to provide long-term survival of Masaoka stage IVa in patients with thymoma. The type of surgery should be determined based on the invasiveness of the lesion.

Sclerosing thymoma-like thymic amyloidoma with nephrotic syndrome: a case report

Background

Primary localized amyloidosis presenting as an isolated mediastinal mass is extremely rare, especially in the thymus. Sclerosing thymoma is also an extremely rare anterior mediastinal tumor, pathologically characterized by extensive sclerotic lesions with hyalinization and calcification. Only 14 cases of sclerosing thymoma and five cases of thymic amyloidosis have been reported to date.

Case presentation

A 78-year-old Japanese woman was diagnosed as having sclerosing thymoma (Masaoka stage IVa pericardial dissemination)-like thymic amyloidoma. She was diagnosed as having either lung cancer or mediastinal tumor with pericardial dissemination, and received palliative treatment. Three years later, she was readmitted with a complaint of general malaise. Since minimal change nephrotic syndrome was suspected based on the disease onset and selectivity index of urinary protein, steroid pulse therapy was started. Subsequently, because a marked reduction in tumor size was observed during maintenance treatment with prednisolone, a thoracoscopic needle biopsy was performed for a definitive diagnosis. According to the pathological findings and clinical investigations, a final diagnosis of sclerosing thymoma (Masaoka stage IVa pericardial dissemination)-like thymic amyloidoma was made.

Conclusions

This is a case report of sclerosing thymoma-like thymic amyloidoma. Both sclerosing thymoma and thymic amyloidoma are extremely rare diseases: only 14 cases of sclerosing thymoma and five cases of thymic amyloidosis have been reported to date. In either diagnosis, our case is the first case in which marked reduction in tumor size was observed with steroid therapy. All reported cases of sclerosing thymomas underwent surgical resection, but steroid therapy to sclerosing thymoma has not been reported. It is still unknown whether steroid therapy is effective or not. The hyalinized components of sclerosing thymoma possibly contain amyloid deposits. The marked reduction in tumor size with steroid therapy may result in amyloid deposits. The association between sclerosing thymoma and thymic amyloidoma remains uncertain. Sclerosing thymoma should be stained with Congo red.

Polyparaneoplastic Manifestations of Malignant Thymoma: A Unique Case of Myasthenia, Autoimmune Hepatitis, Pure Red Cell Aplasia, and Keratoconjunctivitis Sicca

Thymomas are relatively uncommon malignancies of the anterior mediastinum and present with four distinct histological types based on the specific epithelial to lymphocyte ratio: spindle cell, epithelial predominant, lymphocyte predominant, or mixed. Each histologic type of thymoma has a propensity for local invasion and metastasis and can have a wide variety of paraneoplastic manifestations, myasthenia being the most common. We present a unique case of a 34-year-old African-American female who initially presented with a history of profound weakness with repetitive motion, shortness of breath, horizontal nystagmus, persistent anemia, keratoconjunctivitis sicca, and what was initially thought to be azithromycin-induced hepatitis. Upon left anterior thoracotomy with biopsy of the mediastinal mass, pathology yielded a lymphocyte-predominant (B1), Masaoka stage IVA invasive thymoma with pericardial extension. This case illustrates the clinical significance of considering a multitude of extrathymic paraneoplastic manifestations, each with a unique physiological mechanism.

[Application of vascular repair and reconstruction in surgical treatment of superior vena cava syndrome caused by thoracic tumor]

Objective

To summarize the clinical experience of vascular repair and reconstruction for treating superior vena cava syndrome (SVCS) caused by thoracic tumor.

Methods

Between October 2008 and June 2016, 26 patients with thoracic tumor and SVCS were admitted. There were 18 males and 8 females, aged from 27 to 70 years (mean, 45.9 years). Tumor was typed as B1-B3 thymoma in 13 cases, thymic carcinoma in 6 cases, large B-cell lymphoma in 3 cases, T lymphocytic lymphoma in 1 case, malignant teratoma in 1 case, right lung squamous cell carcinoma in 1 case, and carcinoid in 1 case. The tumor diameter ranged from 8 to 15 cm with an average of 10 cm. The patients had different degrees of neck, face, and upper extremity edema, jugular vein distention, and chest wall collateral venous filling. The superior vena cava pressure was 2.45-5.39 kPa. After excision of tumor and invading superior vena cava, 7 patients underwent superior vena cava reconstruction and 19 patients underwent artificial vascular replacement.

Results

There was no perioperative death, and the symptoms of superior vena cava obstruction were eliminated. Postoperative pulmonary infection, respiratory muscle weakness, and right chylothorax occurred in 4 cases, 1 case, and 1 case respectively. Twenty-four patients were followed up 2-92 months (mean, 37 months), and 2 patients failed to be followed up. At 1, 3, and 5 years, the survival rate was 83.3% (20/24), 41.7% (10/24), and 25% (6/24), respectively. In 6 patients with 5-year survival, there were 1 case of type B1 thymoma, 3 cases of type B3 thymoma, and 2 cases of large B-cell lymphoma.

Conclusion

For preoperative evaluation of SVCS caused by resectable thoracic tumors, vascular repair and recons-truction technique can be used to quickly and effectively relieve the clinical symptoms and improve the quality of life.

Pleural recurrence of thymoma: surgical resection followed by hyperthermic intrathoracic perfusion chemotherapy†

OBJECTIVES

Recurrences of thymoma are described in 10-30% of cases up to 10 years after surgical resection. Herein we report our experience with surgical removal of pleural recurrences followed by hyperthermic intrathoracic perfusion chemotherapy (HITHOC).

METHODS

We prospectively collected data of patients with pleural recurrence of thymoma who underwent surgery followed by HITHOC. After thoracotomy had been closed, drainages were connected to a dedicated perfusion machine, pleural space was filled with saline solution, progressively heated up to 42.5°C. At this time, chemotherapeutic agents (Doxorubicin and Cisplatin) were injected and perfusion lasted 60 min.

RESULTS

In the period 2005-2012, 13 consecutive patients have been treated (8 males, 5 females, mean age 46 years). Initial Masaoka-Koga stage was 2 IIa, 5 IIb, 5 III, 1 IVa. Disease-free interval was 47.2 months on average [standard deviation (SD): 25.5]. Nine patients presented paraneoplastic syndromes (8 myasthenia gravis and 1 red cell aplasia). Complete resection was achieved in all cases except one. HITHOC was successfully performed in all cases and no signs or symptoms of toxicity were recorded in the perioperative period. With a mean follow-up period of 64.6 months (SD: 32.5), 1 patient died for toxicity following systemic chemotherapy, another one died disease-free, 4 patients developed pleural relapses (2 ipsilateral, 2 contralateral) and 1 mediastinal and abdominal nodal metastases. Mean survival was 58 months [SD: 34.4), median survival by the Kaplan-Meier method was not reached while 5-year actuarial survival was 92%.

CONCLUSIONS

HITHOC was shown to be feasible and safe. In terms of efficacy, it seems promising but multicentre studies and a longer follow-up period are required to ascertain its effectiveness.

Surgical Approaches for Stage IVA Thymic Epithelial Tumors

Thymic epithelial tumors (TET) are rare mediastinal neoplasms that can metastasize to the pleural space (stage IVA). Complete surgical resection remains the backbone of therapy for patients with early stage TET, however, the role of surgery in the management of patients with stage IVA disease is not fully defined. Published reports in this regard are mainly small, retrospective, and uncontrolled, with unclear inclusion criteria. Surgical options to manage pleural disease include metastasectomy, extrapleural pneumonectomy, and metastasectomy/pleurectomy combined with heated intrapleural chemotherapy. The choice of the most appropriate surgical strategy needs to be individualized according to the quantity and location of disease, the patient’s overall condition, as well as operator and institutional expertise. In the majority of cases, metastasectomy of pleural implants will be sufficient to achieve a complete resection. The available literature suggests that in selected patients with stage IVA TET, delivery of neoadjuvant chemotherapy followed by complete resection is a viable treatment option that can be associated with long-term survival.