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Kedilaya S, Revanth RB, Balije S. Thymic Lymphoepithelial Carcinoma: A Rare Aggressive Mediastinal Mass. Cureus 2024; 16:e64337. [PMID: 39130854 PMCID: PMC11316522 DOI: 10.7759/cureus.64337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2024] [Indexed: 08/13/2024] Open
Abstract
Primary thymic lymphoepithelial carcinoma is a rare neoplasm of the mediastinum. The recognition of clinical, radiologic, and pathologic features can help in making an accurate diagnosis of this aggressive tumor at the earliest.Here, we present the radiologic and pathologic findings of an anterior mediastinal mass in a 44-year-old man, which turned out to be a poorly differentiated squamous cell carcinoma of thymic origin, also known as lymphoepithelioma-like thymic carcinoma.
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Affiliation(s)
- Sumana Kedilaya
- Onco-Imaging, HealthCare Global Enterprises Ltd., Bangalore, IND
| | - R B Revanth
- Onco-Imaging, HealthCare Global Enterprises Ltd., Bangalore, IND
| | - Swetha Balije
- Onco-Imaging, HealthCare Global Enterprises Ltd., Bangalore, IND
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2
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Zhu K, Shi J, Yang R, Zhou C, Liu Z. Identification of cytokines in benign and malignant thymus tumors: based on Mendelian randomization and proteomics. Front Endocrinol (Lausanne) 2024; 15:1390140. [PMID: 38828408 PMCID: PMC11140017 DOI: 10.3389/fendo.2024.1390140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/26/2024] [Indexed: 06/05/2024] Open
Abstract
Objective The aim of this study was to identify potential causal cytokines in thymic malignancies and benign tumors from the FinnGen database using Mendelian randomization (MR). Methods In this study, data from genome-wide association studies (GWAS) of 91 cytokines were used as exposure factors, and those of thymic malignant tumors and thymic benign tumors were the outcome variables. Two methods were used to determine the causal relationship between exposure factors and outcome variables: inverse variance weighting (IVW) and MR-Egger regression. Sensitivity analysis was performed using three methods, namely, the heterogeneity test, the pleiotropy test, and the leave-one-out test. Results There was a causal relationship between the expression of fibroblast growth factor 5, which is a risk factor for thymic malignant tumors, and thymic malignant tumors. C-C motif chemokine 19 expression, T-cell surface glycoprotein CD5 levels, and interleukin-12 subunit beta levels were causally related to thymic malignant tumors and were protective. Adenosine deaminase levels, interleukin-10 receptor subunit beta expression, tumor necrosis factor (TNF)-related apoptosis-inducing ligand levels, and TNF-related activation-induced cytokine levels showed a causal relationship with thymic benign tumors, which are its risk factors. Caspase 8 levels, C-C motif chemokine 28 levels, interleukin-12 subunit beta levels, latency-associated peptide transforming growth factor beta 1 levels, and programmed cell death 1 ligand 1 expression showed a causal relationship with thymic benign tumors, which are protective factors. Sensitivity analysis showed no heterogeneity. Conclusion Cytokines showed a causal relationship with benign and malignant thymic tumors. Interleukin-12 subunit beta is a common cytokine that affects malignant and benign thymic tumors.
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Affiliation(s)
- Kangle Zhu
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Jingwei Shi
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Rusong Yang
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Chu Zhou
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
| | - Zhengcheng Liu
- Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Thoracic Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, Jiangsu, China
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3
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Iori E, Mazzoli M, Ariatti A, Salviato T, Rispoli V, Valzania F, Galassi G. Myasthenia Gravis crossing Parkinson's disease: a 20 year study from single Italian center. Int J Neurosci 2024; 134:429-435. [PMID: 35917141 DOI: 10.1080/00207454.2022.2107517] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/10/2022] [Accepted: 07/15/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE The concomitant diagnosis of Parkinson's disease (PD) and Myasthenia Gravis (MG) is rare. The aim of the study was to report our experience of patients with both diagnoses. MATERIAL AND METHODS We performed a retrospective analysis of patients with MG and PD, seen at Neurology Department, Modena, Italy from 2000 to 2020. We encountered 12 patients with both diagnoses. All had late onset MG (LOMG) and low Myasthenia Gravis Foundation of America (MGFA) severity scores at baseline. In respect of PD assessement, clinical signs were followed and summarized with modified Hoehn and Yahr staging (mHY). Patients were ranked as progressive or non-progressive, according to any change in mHY staging. We compared characteristics and outcome of the patients with age matched myasthenic subjects without PD. RESULTS The male gender significantly prevailed (p < 0.01) as well as the presence of multiple comorbidities (p < 0.001) in patients with MG associated with PD. In respect of clinical course, MG was benign as most of cases remained stable (66.7%). Six cases showed worsening of mHY scores; only one subject became wheelchair bound by the end of follow up. This uneven progression, at least in our hands, might suggest that MG and PD can evolve independently. CONCLUSION Clinicians should be alert about the association of PD and MG since early diagnosis and treatment are essential.
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Affiliation(s)
- Erika Iori
- Department of Biomedical, Metabolic Neural Sciences, University of Modena, Modena, Italy
| | - Marco Mazzoli
- Department of Biomedical, Metabolic Neural Sciences, University of Modena, Modena, Italy
| | - Alessandra Ariatti
- Department of Biomedical, Metabolic Neural Sciences, University of Modena, Modena, Italy
| | - Tiziana Salviato
- Department of Anatomy Pathology and Legal Medicine, University of Modena, Modena, Italy
| | - Vittorio Rispoli
- Department of Biomedical, Metabolic Neural Sciences, University of Modena, Modena, Italy
| | - Franco Valzania
- Neuro-Motor Department, S. Maria Nuova Hospital, AUSL-IRCSS, Reggio Emilia, Italy
| | - Giuliana Galassi
- Department of Biomedical, Metabolic Neural Sciences, University of Modena, Modena, Italy
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4
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Yavorov B, Aleksiev V, Petrov PP, Stoev H, Vazhev Z. Radical Removal of Low-Differentiation Thymic Squamous Cell Carcinoma: A Rare Clinical Case. Cureus 2024; 16:e56370. [PMID: 38633954 PMCID: PMC11022669 DOI: 10.7759/cureus.56370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/19/2024] Open
Abstract
The presented case report demonstrates the successful operative treatment of a patient with thymic carcinoma located in the anterior mediastinum, infiltrating the vena cava, and affecting the upper lobe of the left lung. Our multidisciplinary approach, incorporating various operative techniques, proved effective in treating this type of pathology. The Clinic for Thoracic Surgery at UMHAT Kaspela, Plovdiv admitted a 72-year-old female patient due to complaints related to her cardiovascular and respiratory systems. The patient presented with symptoms such as chest pain, shortness of breath, cough with expectoration, and the presence of blood in her sputum. Additionally, the patient exhibited an increased temperature and experienced shortness of breath at rest. Extensive imaging and diagnostic studies were performed, including computed axial tomography of the chest with contrast material, echocardiography, functional breathing tests, and laboratory tests. The clinical board unanimously agreed that operative treatment was necessary, and the techniques used included robot-assisted surgery and median sternotomy. A low-differentiated carcinoma was identified during the surgical intervention and confirmed through patho-anatomical examination (frozen section) and permanent histological preparation. Immunohistochemical examination revealed that the immunophenotype of the tumor corresponds to thymic neuroplastic squamous cell carcinoma (poorly differentiated). The patient had a smooth postoperative period and was discharged in a satisfactory general condition.
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Affiliation(s)
- Boyko Yavorov
- Cardiovascular Surgery, Medical University of Plovdiv, Plovdiv, BGR
| | | | - Petar-Preslav Petrov
- Human Anatomy, Histology and Embryology, Medical University of Plovdiv, Plovdiv, BGR
| | - Hristo Stoev
- Cardiovascular Surgery, Medical University of Plovdiv, Plovdiv, BGR
| | - Zaprin Vazhev
- Cardiovascular Surgery, Medical University of Plovdiv, Plovdiv, BGR
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5
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Tanaka K, Suzuki H, Inage T, Ito T, Sakairi Y, Yoshino I. Lobulated tumor contour as a predictor of preoperative tumor invasion of the lung or pericardium in thymoma patients. Surg Today 2024; 54:162-167. [PMID: 37340140 DOI: 10.1007/s00595-023-02719-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/19/2023] [Indexed: 06/22/2023]
Abstract
PURPOSE Preoperative investigations to detect invasion to neighboring organs are important for deciding on the most appropriate surgical approach for thymoma. We evaluated preoperative computed tomography (CT) findings in thymoma patients to identify the CT features associated with tumor invasion. METHODS Clinicopathologic information on 193 patients who underwent surgical resection for thymoma at Chiba University Hospital between 2002 and 2016 was collected retrospectively. The surgical pathology identified invasion of thymoma in 35 patients: in the lung (n = 18), pericardium (n = 11), or both (n = 6). Contact lengths between the tumor contour and lung (CLTL) or pericardium (CLTP) were measured at the maximum section of the tumor on axial CT. Univariate and multivariate analyses were performed to analyze the relationship between pathological invasion of the lung or pericardium and the clinicopathologic features. RESULTS The mean CLTL and CLTP were significantly longer in patients with invasion of the neighboring organs than in those without invasion. A lobulated tumor contour was identified in 95.6% of the patients with invasion of the neighboring organs. A multivariate analysis revealed that a lobulated tumor contour was significantly associated with both lung and pericardial invasion. CONCLUSIONS A lobulated tumor contour was significantly associated with lung and/or pericardial invasion in thymoma patients.
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Affiliation(s)
- Kazuhisa Tanaka
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, 260-8670, Japan
| | - Hidemi Suzuki
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, 260-8670, Japan.
| | - Terunaga Inage
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, 260-8670, Japan
| | - Takamasa Ito
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, 260-8670, Japan
| | - Yuichi Sakairi
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, 260-8670, Japan
| | - Ichiro Yoshino
- Department of General Thoracic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, 260-8670, Japan
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6
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Suster D, Suster S. On the Histologic Classification of Thymoma. Adv Anat Pathol 2024; 31:22-33. [PMID: 37702296 DOI: 10.1097/pap.0000000000000412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
The classification of thymoma continues to be a source of controversy in pathology. The difficulties in histologic classification are evident from the number of proposals that have been offered over the years, as well as for the continuous changes and modifications introduced by the World Health Organization to their classification system over the past 20 years. We analyze here some of the issues involved in the classification of these tumors and the difficulties encountered for practicing pathologists in deciphering the "letters and numbers" system devised by the World Health Organization. We would like to propose an alternate approach to thymoma histologic classification that capitalizes on the basic observation of their cytologic features and incorporates the pattern of growth resulting from the interplay of the tumor cells with other cellular constituents as a secondary characteristic. The proposed histologic classification provides a simplified, reproducible means of histologically categorizing these tumors and can be easily understood by most practicing pathologists in simple and clear morphologic terms.
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Affiliation(s)
- David Suster
- Department of Pathology, Rutgers University Hospital, Newark, NJ
| | - Saul Suster
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
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7
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Schroder PM, Biesterveld BE, Al-Adra DP. Premalignant Lesions in the Kidney Transplant Candidate. Semin Nephrol 2024; 44:151495. [PMID: 38490902 DOI: 10.1016/j.semnephrol.2024.151495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
End-stage kidney disease patients who are referred for transplant undergo an extensive evaluation process to ensure their health prior to transplant due in part to the shortage of available organs. Although management and surveillance guidelines exist for malignancies identified in the transplant and waitlist populations, less is written about the management of premalignant lesions in this population. This review covers the less common premalignant lesions (intraductal papillary mucinous neoplasm, gastrointestinal stromal tumor, thymoma, and pancreatic neuroendocrine tumor) that can be found in the transplant candidate population. High-level evidence for the management of these rarer premalignant lesions in the transplant population is lacking, and this review extrapolates evidence from the general population and should not be a substitute for a multidisciplinary discussion with medical and surgical oncologists.
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Affiliation(s)
- Paul M Schroder
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Ben E Biesterveld
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - David P Al-Adra
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI.
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8
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Wiendl H, Abicht A, Chan A, Della Marina A, Hagenacker T, Hekmat K, Hoffmann S, Hoffmann HS, Jander S, Keller C, Marx A, Melms A, Melzer N, Müller-Felber W, Pawlitzki M, Rückert JC, Schneider-Gold C, Schoser B, Schreiner B, Schroeter M, Schubert B, Sieb JP, Zimprich F, Meisel A. Guideline for the management of myasthenic syndromes. Ther Adv Neurol Disord 2023; 16:17562864231213240. [PMID: 38152089 PMCID: PMC10752078 DOI: 10.1177/17562864231213240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/23/2023] [Indexed: 12/29/2023] Open
Abstract
Myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS), and congenital myasthenic syndromes (CMS) represent an etiologically heterogeneous group of (very) rare chronic diseases. MG and LEMS have an autoimmune-mediated etiology, while CMS are genetic disorders. A (strain dependent) muscle weakness due to neuromuscular transmission disorder is a common feature. Generalized MG requires increasingly differentiated therapeutic strategies that consider the enormous therapeutic developments of recent years. To include the newest therapy recommendations, a comprehensive update of the available German-language guideline 'Diagnostics and therapy of myasthenic syndromes' has been published by the German Neurological society with the aid of an interdisciplinary expert panel. This paper is an adapted translation of the updated and partly newly developed treatment guideline. It defines the rapid achievement of complete disease control in myasthenic patients as a central treatment goal. The use of standard therapies, as well as modern immunotherapeutics, is subject to a staged regimen that takes into account autoantibody status and disease activity. With the advent of modern, fast-acting immunomodulators, disease activity assessment has become pivotal and requires evaluation of the clinical course, including severity and required therapies. Applying MG-specific scores and classifications such as Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, and Myasthenia Gravis Foundation of America allows differentiation between mild/moderate and (highly) active (including refractory) disease. Therapy decisions must consider age, thymic pathology, antibody status, and disease activity. Glucocorticosteroids and the classical immunosuppressants (primarily azathioprine) are the basic immunotherapeutics to treat mild/moderate to (highly) active generalized MG/young MG and ocular MG. Thymectomy is indicated as a treatment for thymoma-associated MG and generalized MG with acetylcholine receptor antibody (AChR-Ab)-positive status. In (highly) active generalized MG, complement inhibitors (currently eculizumab and ravulizumab) or neonatal Fc receptor modulators (currently efgartigimod) are recommended for AChR-Ab-positive status and rituximab for muscle-specific receptor tyrosine kinase (MuSK)-Ab-positive status. Specific treatment for myasthenic crises requires plasmapheresis, immunoadsorption, or IVIG. Specific aspects of ocular, juvenile, and congenital myasthenia are highlighted. The guideline will be further developed based on new study results for other immunomodulators and biomarkers that aid the accurate measurement of disease activity.
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Affiliation(s)
- Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, Münster 48149, Germany
| | - Angela Abicht
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Andrew Chan
- Universitätsklinik für Neurologie, Inselspital Bern, Bern, Switzerland
| | - Adela Della Marina
- Klinik für Kinderheilkunde I, Universitätsklinikum Essen, Essen, Germany
| | - Tim Hagenacker
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | | | - Sarah Hoffmann
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
| | | | - Sebastian Jander
- Klinik für Neurologie, Marien Hospital Düsseldorf, Düsseldorf, Germany
| | - Christian Keller
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Alexander Marx
- Pathologisches Institut, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Arthur Melms
- Facharztpraxis für Neurologie und Psychiatrie, Stuttgart, Germany
| | - Nico Melzer
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Wolfgang Müller-Felber
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU Munich, Munich, Germany
| | - Marc Pawlitzki
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | | | - Benedikt Schoser
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Bettina Schreiner
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Switzerland
| | - Michael Schroeter
- Klinik und Poliklinik für Neurologie, Uniklinik Cologne, Cologne, Germany
| | | | | | - Fritz Zimprich
- Universitätsklinik für Neurologie, AKH-Wien, Wien, Austria
| | - Andreas Meisel
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
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Alqaidy D. Thymoma: An Overview. Diagnostics (Basel) 2023; 13:2982. [PMID: 37761349 PMCID: PMC10527963 DOI: 10.3390/diagnostics13182982] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/15/2023] [Accepted: 09/16/2023] [Indexed: 09/29/2023] Open
Abstract
Thymomas are considered one of the most prevalent types of mediastinal epithelial tumors, which frequently develop in the anterior mediastinum. Due to their rarity, these tumors' nomenclature, classification, and staging are likely to be the subject of debate and argument for most expert pathologists. Furthermore, the significance of thymoma histologic classifications have been debated over the past twenty years. While certain advocates argue that staging at the time of diagnosis is more significant, others believe that histologic subtyping has a significant impact on how patients behave clinically. In this review, we will focus on some of the challenges that diagnostic surgical pathologists may experience while evaluating the histopathology of thymomas and staging these tumors. We will additionally glance over the clinical characteristics of these distinct tumors and the current management strategy.
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Affiliation(s)
- Doaa Alqaidy
- Department of Pathology, King Abdulaziz University, Jeddah 21589, Saudi Arabia
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10
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Kuhn E, Pescia C, Mendogni P, Nosotti M, Ferrero S. Thymic Epithelial Tumors: An Evolving Field. Life (Basel) 2023; 13:life13020314. [PMID: 36836670 PMCID: PMC9964105 DOI: 10.3390/life13020314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
Despite their rarity, thymic epithelial tumors (TETs) have attracted much interest over the years, leading to an impressive number of histological and staging classifications. At present, TETs are divided by the WHO classification into four main subtypes: type A, type AB, and type B thymomas (subdivided into B1, B2, and B3), and thymic carcinomas, going from the more indolent to the most aggressive ones. Among many debated staging proposals, the TNM and the Masaoka-Koga staging systems have been widely accepted and used in routine practice. The four-tiered histological classification is symmetrically mirrored by the molecular subgrouping of TETs, which identifies an A-like and an AB-like cluster, with frequent GTF2I and HRAS mutations; an intermediate B-like cluster, with a T-cell signaling profile; and a carcinoma-like cluster comprising thymic carcinomas with frequent CDKN2A and TP53 alterations and a high tumor molecular burden. Molecular investigations have opened the way to tailored therapies, such as tyrosine kinase inhibitors targeting KIT, mTOR, and VEGFR, and immune-checkpoints that have been adopted as second-line systemic treatments. In this review, we discuss the crucial events that led to the current understanding of TETs, while disclosing the next steps in this intriguing field.
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Affiliation(s)
- Elisabetta Kuhn
- S.C. Anatomia Patologica, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milano, Italy
- Dipartimento di Scienze Biomediche, Chirurgiche ed Odontoiatriche, Università degli Studi di Milano, 20122 Milano, Italy
- Correspondence: ; Tel.: +39-025-032-0564
| | - Carlo Pescia
- S.C. Anatomia Patologica, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milano, Italy
- Dipartimento di Scienze Biomediche, Chirurgiche ed Odontoiatriche, Università degli Studi di Milano, 20122 Milano, Italy
| | - Paolo Mendogni
- S.C. Chirurgia Toracica e Trapianti di Polmone, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milano, Italy
| | - Mario Nosotti
- S.C. Chirurgia Toracica e Trapianti di Polmone, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milano, Italy
- Dipartimento di Patofisiologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, 20122 Milano, Italy
| | - Stefano Ferrero
- S.C. Anatomia Patologica, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milano, Italy
- Dipartimento di Scienze Biomediche, Chirurgiche ed Odontoiatriche, Università degli Studi di Milano, 20122 Milano, Italy
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11
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Epigenetics of Thymic Epithelial Tumors. Cancers (Basel) 2023; 15:cancers15020360. [PMID: 36672310 PMCID: PMC9856807 DOI: 10.3390/cancers15020360] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 01/08/2023] Open
Abstract
Thymic epithelial tumors (TETs) arise from the epithelial cells of the thymus and consist in the 1% of all adult malignancies, despite the fact that they are the most common lesions of the anterior mediastinum. TETs can be divided mainly into thymomas, thymic carcinomas, and the rarest ad aggressive neuroendocrine forms. Despite the surgical resection is quite resolving, the diagnosis of TETs is complicated by the absence of symptoms and the clinical presentation aggravated by several paraneoplastic disorders, including myasthenia gravis. Thus, the heterogeneity of TETs prompts the search for molecular biomarkers that could be helpful for tumor characterization and clinical outcomes prediction. With these aims, several researchers investigated the epigenetic profiles of TETs. In this manuscript, we narratively review the works investigating the deregulation of epigenetic mechanisms in TETs, highlighting the need for further studies combining genetic, epigenetic, and expression data to better characterize the different molecular subtypes and identify, for each of them, the most relevant epigenetic biomarkers of clinical utility.
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12
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Kuhara A, Sumi A, Chikasue T, Kawaguchi A, Tanoue S, Nagata S, Koganemaru M, Abe T, Kashihara M, Mitsuoka M, Ishii H, Ohshima K, Leung ANC, Fujimoto K. Utility of non-contrast-enhanced magnetic resonance imaging in predicting preoperative clinical stage and prognosis in patients with thymic epithelial tumor. Jpn J Radiol 2023; 41:302-311. [PMID: 36374474 PMCID: PMC9974725 DOI: 10.1007/s11604-022-01358-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 10/30/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this study was to find useful imaging features on non-contrast-enhanced magnetic resonance imaging (MRI) that can divide patients with thymic epithelial tumor (TET) into clinical stage I-II and III-IV groups under assumption that contrast media are contraindicated. MATERIALS AND METHODS This retrospective study included 106 patients (median age, 60 years; range, 27-82 years; 62 women) with surgically resected TET who underwent MRI between August 1986 and July 2015. All cases were classified according to the 2015 WHO classification and staged using the eighth edition of the TNM system. Two radiologists independently evaluated 14 categories of MRI findings; the findings in patients with stage I-II were compared with those of patients with stage III-IV using a logistic regression model. Disease-specific survival associated with significant findings was calculated using the Kaplan-Meier method. RESULTS Univariate analysis showed that stage III-IV patients were more likely to have tumors with an irregular contour, heterogeneity on T1WI, low-signal intensity on T2WI, irregular border with lung, findings of great vessel invasion (GVI) (hereafter, GVI sign), pericardial thickening/nodule, and lymphadenopathy (all, P < 0.01). On multivariable analysis, only two findings, irregular border between tumor and lung (odds ratio [OR], 272.8; 95% CI 26.6-2794.1; P < 0.001) and positive GVI sign (OR, 49.3; 95% CI 4.5-539.8; P = 0.001) remained statistically significant. Patients with one or both features had significantly worse survival (log-rank test, P < 0.001). CONCLUSION For patients with TET who are unable to receive contrast for preoperative staging, the two image findings of an irregular border between tumor and lung and the positive GVI sign on non-contrast-enhanced MRI could be helpful in determining stage III-IV disease which is associated with a worse survival.
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Affiliation(s)
- Asako Kuhara
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Akiko Sumi
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Tomonori Chikasue
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Atsushi Kawaguchi
- Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Shuichi Tanoue
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Shuji Nagata
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Masamichi Koganemaru
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Toshi Abe
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011 Japan
| | - Masaki Kashihara
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Masahiro Mitsuoka
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Hidenobu Ishii
- Division of Respirology, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Koichi Ohshima
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Ann N. C. Leung
- Department of Radiology, Stanford University, Stanford, CA USA
| | - Kiminori Fujimoto
- Department of Radiology, Kurume University School of Medicine, 67 Asahi-Machi, Fukuoka, Kurume, 830-0011, Japan.
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13
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Alkhotani A, Alrishi N. Severity and antibodies profile of seropositive myasthenia gravis. SAUDI JOURNAL FOR HEALTH SCIENCES 2023. [DOI: 10.4103/sjhs.sjhs_153_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
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14
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Chang CC, Lin CY, Huang LT, Chuang MT, Lu YH, Huang WL, Chen YY, Lai WW, Tseng YL, Yen YT. Diagnostic value of apparent diffusion coefficient in predicting pathological T stage in patients with thymic epithelial tumor. Cancer Imaging 2022; 22:56. [PMID: 36199129 PMCID: PMC9533584 DOI: 10.1186/s40644-022-00495-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/27/2022] [Indexed: 11/10/2022] Open
Abstract
Purposes This study aimed to evaluate the diagnostic capacity of apparent diffusion coefficient (ADC) in predicting pathological Masaoka and T stages in patients with thymic epithelial tumors (TETs). Methods Medical records of 62 patients who were diagnosed with TET and underwent diffusion-weighted imaging (DWI) prior to surgery between August 2017 and July 2021 were retrospectively analyzed. ADC values were calculated from DWI images using b values of 0, 400, and 800 s/mm2. Pathological stages were determined by histological examination of surgical specimens. Cut-off points of ADC values were calculated via receiver operating characteristic (ROC) analysis. Results Patients had a mean age of 56.3 years. Mean ADC values were negatively correlated with pathological Masaoka and T stages. Higher values of the area under the ROC curve suggested that mean ADC values more accurately predicated pathological T stages than pathological Masaoka stages. The optimal cut-off points of mean ADC were 1.62, 1.31, and 1.48 × 10–3 mm2/sec for distinguishing pathological T2-T4 from pathological T1, pathological T4 from pathological T1-T3, and pathological T3-T4 from pathological T2, respectively. Conclusion ADC seems to more precisely predict pathological T stages, compared to pathological Masaoka stage. The cut-off values of ADC identified may be used to preoperatively predict pathological T stages of TETs. Supplementary Information The online version contains supplementary material available at 10.1186/s40644-022-00495-x.
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Affiliation(s)
- Chao-Chun Chang
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Chia-Ying Lin
- Department of Medical Imaging, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Li-Ting Huang
- Department of Medical Imaging, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Ming-Tsung Chuang
- Department of Medical Imaging, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Ying-Hung Lu
- Department of Medical Imaging, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Li Huang
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Ying-Yuan Chen
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Wu-Wei Lai
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Yau-Lin Tseng
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Ting Yen
- Division of Thoracic Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan. .,Division of Trauma and Acute Care Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medical College, National Cheng Kung University, Tainan, Taiwan.
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15
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Jimenez JC, Lucas CHG, LaHue SC, Sharpe BA. Giant cell myositis associated with metastatic thymoma and granulomatous hypercalcaemia. BMJ Case Rep 2022; 15:e246688. [PMID: 35667693 PMCID: PMC9171203 DOI: 10.1136/bcr-2021-246688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Giant cell myositis (GCM) is a rare inflammatory myopathy associated with myasthenia gravis and thymoma. Here, we report on a woman in her late 50s with a history of myasthenia gravis, systemic lupus erythematosus and stage IV thymoma with pleural metastases, who presented with proximal weakness, neuromuscular respiratory failure and hypercalcaemia. She was diagnosed with GCM via muscle biopsy and screened for myocarditis but showed no evidence of myocardial involvement. Her hypercalcaemia was consistent with a granulomatous process, likely driven by her GCM. Her strength gradually improved, and her hypercalcaemia did not recur after treatment with high dose steroids, intravenous immune globulin and plasma exchange. Her course was complicated by several opportunistic infections in the setting of her immunosuppression. Despite the high morbidity associated with GCM, she demonstrated clinical improvement after initiating immunosuppressive therapy and continues to be managed in the outpatient setting.
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Affiliation(s)
- Jessica C Jimenez
- Department of Neurology, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Calixto-Hope G Lucas
- Department of Pathology, University of California San Francisco, San Francisco, California, USA
| | - Sara C LaHue
- Department of Neurology, University of California San Francisco School of Medicine, San Francisco, California, USA
- Department of Neurology, University of California San Francisco Weill Institute for Neurosciences, San Francisco, California, USA
| | - Bradley A Sharpe
- Department of Medicine, University of California San Francisco, San Francisco, California, USA
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16
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Isik EG, Kuyumcu S, Ozkan ZG, Has Simsek D, Sanli Y. Intratumoral Heterogeneity in a Patient With Metastatic Thymic Carcinoma on 18F-FDG, 68Ga-DOTATATE, and 68Ga-FAPI04 PET/CT. Clin Nucl Med 2022; 47:e79-e80. [PMID: 34392280 DOI: 10.1097/rlu.0000000000003843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Herein, we present a 72-year-old woman with metastatic thymic carcinoma, referred for salvage peptide receptor radionuclide therapy with 177Lu-DOTATATE after completing all treatment options according to current clinical practice and guidelines. However, the patient was not eligible for 177Lu-DOTATATE peptide receptor radionuclide therapy and underwent 68Ga-FAPI04 PET/CT to assess the potential for a FAP-targeted therapy.
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Affiliation(s)
- Emine Göknur Isik
- From the Department of Nuclear Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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17
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Wang Z, Chen Y, Shi Y, Zhang R, Zhang X, Meng L, Cao W. Effect of Age on the Clinicopathological Characteristics and Survival Outcomes of Thymoma Patients. Health (London) 2022. [DOI: 10.4236/health.2022.146047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Blüthgen C, Patella M, Euler A, Baessler B, Martini K, von Spiczak J, Schneiter D, Opitz I, Frauenfelder T. Computed tomography radiomics for the prediction of thymic epithelial tumor histology, TNM stage and myasthenia gravis. PLoS One 2021; 16:e0261401. [PMID: 34928978 PMCID: PMC8687592 DOI: 10.1371/journal.pone.0261401] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 12/01/2021] [Indexed: 12/21/2022] Open
Abstract
Objectives To evaluate CT-derived radiomics for machine learning-based classification of thymic epithelial tumor (TET) stage (TNM classification), histology (WHO classification) and the presence of myasthenia gravis (MG). Methods Patients with histologically confirmed TET in the years 2000–2018 were retrospectively included, excluding patients with incompatible imaging or other tumors. CT scans were reformatted uniformly, gray values were normalized and discretized. Tumors were segmented manually; 15 scans were re-segmented after 2 weeks by two readers. 1316 radiomic features were calculated (pyRadiomics). Features with low intra-/inter-reader agreement (ICC<0.75) were excluded. Repeated nested cross-validation was used for feature selection (Boruta algorithm), model training, and evaluation (out-of-fold predictions). Shapley additive explanation (SHAP) values were calculated to assess feature importance. Results 105 patients undergoing surgery for TET were identified. After applying exclusion criteria, 62 patients (28 female; mean age, 57±14 years; range, 22–82 years) with 34 low-risk TET (LRT; WHO types A/AB/B1), 28 high-risk TET (HRT; WHO B2/B3/C) in early stage (49, TNM stage I-II) or advanced stage (13, TNM III-IV) were included. 14(23%) of the patients had MG. 334(25%) features were excluded after intra-/inter-reader analysis. Discriminatory performance of the random forest classifiers was good for histology(AUC, 87.6%; 95% confidence interval, 76.3–94.3) and TNM stage(AUC, 83.8%; 95%CI, 66.9–93.4) but poor for the prediction of MG (AUC, 63.9%; 95%CI, 44.8–79.5). Conclusions CT-derived radiomic features may be a useful imaging biomarker for TET histology and TNM stage.
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Affiliation(s)
- Christian Blüthgen
- Institute of Diagnostic and Interventional Radiology, University Hospital of Zurich, Zurich, Switzerland
- * E-mail:
| | - Miriam Patella
- Department of Thoracic Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - André Euler
- Institute of Diagnostic and Interventional Radiology, University Hospital of Zurich, Zurich, Switzerland
| | - Bettina Baessler
- Institute of Diagnostic and Interventional Radiology, University Hospital of Zurich, Zurich, Switzerland
| | - Katharina Martini
- Institute of Diagnostic and Interventional Radiology, University Hospital of Zurich, Zurich, Switzerland
| | - Jochen von Spiczak
- Institute of Diagnostic and Interventional Radiology, University Hospital of Zurich, Zurich, Switzerland
| | - Didier Schneiter
- Department of Thoracic Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital of Zurich, Zurich, Switzerland
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19
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Tseng YC, Hsu HS, Lin YH, Tseng YH, Shu CW, Goan YG, Tseng CJ. Does size affect the prognosis of resectable thymoma beyond the eighth edition TNM? Thorac Cancer 2021; 13:346-352. [PMID: 34931461 PMCID: PMC8807255 DOI: 10.1111/1759-7714.14255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Yen-Chiang Tseng
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Han-Shui Hsu
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yi-Hsuan Lin
- Department of Family Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Public Health, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Yen-Han Tseng
- School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Chest Medicine, Taipei Medical University - Shuang Ho Hospital, Taipei, Taiwan
| | - Chih-Wen Shu
- Institute of Biopharmaceutical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan.,Department of Biomedical Science and Environmental Biology, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yih-Gang Goan
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ching-Jiunn Tseng
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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20
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Prays J, Ortiz-Villalón C. Molecular landscape of thymic epithelial tumors. Semin Diagn Pathol 2021; 39:131-136. [PMID: 34272124 DOI: 10.1053/j.semdp.2021.06.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 06/23/2021] [Accepted: 06/30/2021] [Indexed: 12/28/2022]
Abstract
Thymic epithelial tumors (TETs) are extremely rare and represent the most frequent tumors of the anterior mediastinum originating from epithelial cells in the thymus. Thymic epithelial tumors include thymomas (TM), thymic carcinomas (TC) and thymic neuroendocrine neoplasms (TNEN). Thymomas are the most predominant and are associated with autoimmune diseases. The available data suggests that the different histological subtypes have specific molecular alterations. Thymic carcinoma shows recurrent gene mutations, but further investigations are needed to understand the role of those mutations in the pathogenetic of the TETs. Some of the new emerging identified molecular alterations have the potential to offer new targeted therapies opening new possibilities for the treatment of thymic epithelial tumors.
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Affiliation(s)
- Julia Prays
- Department of Pathology, Karolinska University Hospital, Sweden
| | - Cristian Ortiz-Villalón
- Department of Pathology, Karolinska University Hospital, Sweden; Department of Oncology and pathology (ONKPAT), Karolinska Institute, Sweden.
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