A case of invasive thymoma with endotracheal polypoid growth

Intratracheal recurrence of thymoma 7 years after complete resection

A 66-year-old woman with a massive anterior mediastinal tumour was diagnosed with type B2 thymoma. After 2 courses of chemotherapy, extended thymectomy and partial resection of the lung and large vessels were performed, and the tumour was completely resected. The patient received no postoperative therapy. Seven years after the surgery, follow-up chest computed tomography showed a papillary soft tissue tumour in the trachea almost obstructing the airway. Intratracheal tumour resection was performed under rigid bronchoscopy, and the pathological diagnosis of intratracheal recurrence of thymoma was made. The patient received postoperative radiotherapy and has remained alive without disease progression 9 months after the second operation.

How to obtain adequate biopsy specımen in suspected thymic tumors

Pathologic diagnosis of thymic tumors (TTs) can be made by surgical or nonsurgical procedures. About 20% of TTs had been diagnosed by pretreatment biopsy methods while the rest had gone to surgery for diagnosis and treatment. However, in the last two decades there was an increase in pretreatment procedures for optimal management of locally advanced or metastatic TTs. Pretreatment tissue diagnosis of a noninvasive TT is not a standard option but is required if there is suspect or atypical clinical presentation and imaging, an invasive tumor requiring a nonsurgical approach or preoperative chemotherapy or chemo-radiotherapy, strong possibility of lymphoma or unclear differential diagnosis between lymphoma or other solid tumor by imaging studies, or suspicion of a metastatic lesion. In surgical diagnosis anterior mediastinotomy, video-assisted thoracic surgery or mediastinoscopy can be chosen for invasive TTs whereas total resection is performed for small, noninvasive tumors. Nonsurgical diagnosis can be made by transthoracic fine or core needle biopsies (TTFNA, TTCNB), conventional bronchoscopy, endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or medical thoracoscopy depending on procedural amenability according to tumor extension. TTFNA and TTCNB have been the most frequently used nonsurgical methods. However, there is an upward trend in using conventional bronchoscopy, EBUS-TBNA, EUS-FNA and medical thoracoscopy recently. To increase the diagnostic performance of these procedures in TTs, recommendations are (I) obtaining histologic specimens, (II) combining smears or liquid based cytology preparations and cell blocks, (III) obtaining multiple sufficient samples, (IV) combining histologic and cytologic specimens, (V) performing morphologic, immunohistochemical and molecular analyses on all specimens, (VI) using rapid onsite evaluation for cytologic specimens, (VII) correlating pathologic, clinical and radiologic findings, (VIII) consulting experienced pathologists.

A "coughed up" tissue diagnosed as type A thymoma in an 80-year-old man: A case report

RATIONALE

Thymoma is the most common primary tumor in the anterior mediastinum. All major subtypes of thymoma can be clinically aggressive. However, type A thymoma is usually benign and rarely invasive, let alone invasive to the trachea. There are no published reports of thymoma diagnosed in a "coughed up' tissue". Here, we report an 80-year-old man who coughed up a piece of tissue which was histopathologically diagnosed as type A thymoma.

PATIENT CONCERNS

An 80-year-old man who had a history of thymoma for 8 years was admitted in our hospital with his severe cough and dyspnea and his "coughed up" something. He felt much better after coughing up the piece of tissue. He saved the tissue and sent it to the pathology department.

DIAGNOSES

The clinical diagnosis was lung cancer. But the final pathological diagnosis was type A thymoma.

INTERVENTIONS

The patient refused to get chemotherapy, or surgery, and only would like to get the traditional Chinese medicine.

OUTCOMES

The patient is stable for 19 months after he coughed up some of the tumor tissue.

LESSONS

The type A thymoma could be slowly aggressive. If left untreated, it would also invade into the trachea. When treat a patient with history of even a benign tumor, we should always bear the rare possibility in mind to avoid misdiagnosis. For an elderly patient, a "wait and see" policy may be acceptable.