Resection Of Thymoma Research Articles

Postoperative radiation therapy after complete resection of thymoma has little impact on survival

Postoperative radiation therapy for thymoma is widely used, although the clinical benefits are controversial. Furthermore, to the authors' knowledge, the relation between postoperative radiation therapy and cell type classified by the World Health Organization (WHO) is not known. The records of 324 patients (ages 17-83 years; mean, 51 years; 160 males and 164 females) who underwent complete resection of a thymoma between 1970 and 2005 were reviewed. Mediastinum postoperative radiation therapy was performed for 134 patients. Survival rates and patterns of recurrence were determined according to Masaoka stage and WHO cell type. The 10-year disease-specific survival rates for patients with and without postoperative radiation therapy were 92.8% and 94.4%, respectively (P = .22). Subset analyses after stratifying by Masaoka stage and WHO cell type demonstrated that the 10-year disease-specific survival rate for patients without postoperative radiation therapy with Masaoka stage I and II, as well as those with WHO cell types A, AB, or B1, was 100%, which was satisfactory. Furthermore, the rates for patients with Masaoka stage III/IV and those with WHO cell types B2/B3 with or without postoperative radiation therapy were not found to be significantly different. In 24 patients with disease recurrence, pleural dissemination was observed most often, followed by distant metastases; local disease recurrence without other recurrence occurred in 2. The authors concluded that surgical resection alone is sufficient for thymoma patients with Masaoka stage I and II, and those with WHO cell types A, AB, and B1. Furthermore, an optimal treatment strategy should be established for patients with Masaoka stage III/IV and WHO cell type B2/B3 thymomas.

Unilateral thoracoscopic subtotal thymectomy for the treatment of stage I and II thymoma

The purpose of this study was to determine the feasibility of thoracoscopic thymectomy for the treatment of Masaoka stage I and II thymoma. We evaluated the short-term outcomes of 40 patients undergoing surgery for Masaoka stage I and II thymomas without myasthenia gravis between July 2000 and July 2008. Of these, 22 patients underwent complete thymoma resection using unilateral thoracoscopic subtotal thymectomy (UTST group), and 18 patients underwent trans-sternal thymectomy (TST group). Intra-operative blood loss amounts did not differ significantly between the UTST and TST groups (100.6 ml and 208.1 ml, respectively, p=0.0513). The duration of the postoperative hospital stay was significantly shortened in the UTST group (4.6 days vs 11.2 days, p<0.0001). No patient in the UTST group underwent conversion to open surgery. No severe surgical complications, such as bleeding due to injury to the left brachiocephalic vein, and no postoperative complications, were detected in this series. These preliminary results suggest that thoracoscopic thymectomy for Masaoka stage I and II thymoma is technically feasible and safe, and it is less invasive for the patient. Nevertheless, this procedure requires further investigation in a large series with a longer follow-up.

Myasthenia Gravis and Autoimmune Addison Disease in a Patient With Thymoma

The association of thymoma with myasthenia gravis has been well documented. However, the relationship between these two syndromes and Addison disease are very rarely encountered in clinical practice. We report on a 32-year-old man who underwent a resection for thymoma 48 months ago. The diagnosis of Addison disease was made followed by a diagnosis of myasthenia gravis on the basis of a high titer of acetylcholine receptor levels. The treatment of oral prednisolone 7.5 mg/day and oral prostigmine 180 mg/day was initiated. His symptoms and physical signs were improved after this treatment. To our knowledge, this is the fourth reported case of thymoma synchronously associated with myasthenia gravis and Addison disease.

Limited thymectomy for stage I or II thymomas

Background Once an anterior mediastinal tumor has been diagnosed as a thymoma, complete excision including the thymic gland and perithymic fat is currently the procedure of choice. However, little is known about the clinical outcome of grossly encapsulated thymomas excised only with the surrounding tissue while leaving a part of the thymic gland. Methods A retrospective historical comparative study was conducted on 79 patients who had received surgery for stage I ( n = 25) or stage II ( n = 54) thymomas. Total thymectomy was performed in 61 patients (Total Thymectomy Group), whereas resection of tumors with only the surrounding tissue was carried out in 18 (Limited Thymectomy Group). The follow-up interval was longer in the Limited Thymectomy Group because these patients were treated longer ago (104.2 ± 58.1 months vs 67.3 ± 54.8 months, p < 0.05). Results One case in the Limited Thymectomy Group showed postoperative myasthenia gravis (5.6%). Two patients with multiple thymomas (2.5%) were treated with total thymectomy. One case in the Limited Thymectomy Group, which had been diagnosed as Masaoka stage II and WHO type B3 at initial surgery, recurred. None died of tumor progression in this study. Disease free survival rates at 10 years did not differ between the Limited Thymectomy and Total Thymectomy Groups (85.7% and 82.0%, respectively). There were no statistical differences in the incidence of postoperative myasthenia gravis and disease free survival between the two groups. Conclusion Resection of thymomas with surrounding tissue instead of total thymectomy can be indicated for stage I or II thymomas in light of disease free and overall survival, post-operative onset of MG, and the incidence of multiple lesions.

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Lichen planus

Postoperative Radiotherapy After Surgical Resection of Thymoma: Differing Roles in Localized and Regional Disease

To analyze the Surveillance, Epidemiology and End Results (SEER) registry data to determine the impact of postoperative radiotherapy (PORT) for thymoma and thymic carcinoma (T/TC). Patients with surgically resected localized (LOC) or regional (REG) malignant T/TC with or without PORT were analyzed for overall survival (OS) and cause-specific survival (CSS) by querying the SEER database from 1973-2005. Patients dying within the first 3 months after surgery were excluded. Kaplan-Meier and multivariate analyses with Cox proportional hazards were performed. A total of 901 T/TC patients were identified (275 with LOC disease and 626 with REG disease). For all patients with LOC disease, PORT had no benefit and may adversely impact the 5-year CSS rate (91% vs. 98%, p = 0.03). For patients with REG disease, the 5-year OS rate was significantly improved by adding PORT (76% vs. 66% for surgery alone, p = 0.01), but the 5-year CSS rate was no better (91% vs. 86%, p = 0.12). No benefit was noted for PORT in REG disease after extirpative surgery (defined as radical or total thymectomy). On multivariate OS and CSS analysis, stage and age were independently correlated with survival. For multivariate CSS analysis, the outcome of PORT is significantly better for REG disease than for LOC disease (hazard ratio, 0.167; p = 0.001). Our results from SEER show that PORT for T/TC had no advantage in patients with LOC disease (Masaoka Stage I), but a possible OS benefit of PORT in patients with REG disease (Masaoka Stage II-III) was found, especially after non-extirpative surgery. The role of PORT in T/TC needs further evaluation.

Thymoma with Dissemination: Efficacy of Macroscopic Total Resection of Disseminated Nodules

Advanced thymomas with disseminated nodules are difficult to manage, and the treatment strategy remains undefined. A total of 28 thymoma patients with pleural and/or pericardial disseminated nodules were treated at Nagoya City University Hospital. Among them, 21 patients underwent resection of thymoma and pleural disseminated nodules. These patients were reviewed in the present study. Preoperative steroid pulse therapy was performed in 14 patients. Macroscopic total resection of all tumors was achieved in 15 patients. Postoperative adjuvant radiotherapy was performed for the mediastinum in 20 patients and hemithoracic irradiation (HTR) in 11 patients. The overall survival rate of operated 21 patients was 73.1% at 5 years. The patients who underwent resection showed a better prognosis than the patients without resection (p = 0.0006). Relapse was diagnosed in 14 of 21 patients who underwent resection. Disease-free survival was 67.5% at 1 year, 39.8% at 3 years, and 13.3% at 5 years. HTR alone did not improve the disease-free survival. Among the patients who underwent total resection, relapse-free survival was better than in the patients with subtotal resection (p = 0.009). Achievement of a trimodality therapy with preoperative steroid pulse, total resection, and postoperative HTR was associated with prolonged relapse-free survival in the operated patients (p = 0.027, hazard ratio 6.452). Pursuing total resection for thymoma and disseminated nodules may be beneficial for stage IV thymoma. The combination of preoperative steroid pulse therapy, macroscopic total resection, and postoperative HTR may prolong the interval to relapse, but it did not lead to cure.

Aplastic anaemia: autoimmune sequel of thymoma

A 67-year-old male presenting with persistent cough was found to have a large anterior mediastinal tumour (top). He underwent mediastinotomy and resection of a thymic tumour, which was subsequently diagnosed as a benign thymoma (bottom left). Six months post-thymectomy he presented with symptomatic anaemia, with full blood examination revealing severe thrombocytopenia in addition to the anaemia: haemoglobin 66 g/l, white cell count 5AE2 · 10/l, platelet count 8 · 10/l, and neutrophils 1AE5 · 10/l. There had been no recent exposure to drugs or chemicals known to cause marrow aplasia and serology for parvovirus and hepatitis B and C were negative. Bone marrow trephine biopsy showed a markedly hypocellular marrow (cellularity c. 10%) with few haemopoietic elements present, consistent with evolving aplastic anaemia (bottom right); there was no clonal T-cell population or evidence of paroxysmal nocturnal haemoglobinuria detected by flow cytometry. A computed tomography scan showed no evidence of recurrent thymoma. The patient was treated with anti-thymocyte globulin and ciclosporin; the most recent blood tests showed a near complete response at 10 weeks. Aplastic anaemia is a rare complication of thymoma occurring concurrently in c. 1% of cases. Aplastic anaemia following thymectomy is exceedingly rare with only five other cases identified by us in the literature. Thymoma-related aplastic anaemia often fails to respond to thymectomy requiring immunosuppressive therapy for count recovery. Autoreactive T-cell clones generated by the thymoma are postulated to be the cause of aplastic anaemia and other autoimmune manifestations. The occurrence of aplastic anaemia as a late autoimmune complication following resection of thymoma indicates that autoreactive T-cell clones may persist post-thymectomy leading to late rather than concurrent autoimmune haematological manifestations.

Partial Upper Sternotomy for Anterosuperior Mediastinal Surgery: An Institutional Experience

Median sternotomy is the traditional approach used to resect anterior mediastinal masses or access the anterosuperior compartment of the mediastinum. A partial upper sternotomy is an alternative, less invasive technique. Our goal in this study is to analyze the circumstances under which partial upper sternotomy is appropriate and to determine the outcomes of these patients. From January 1994 to July 2008, 35 patients underwent partial upper sternotomy, solely or as part of a larger procedure. We analyzed these patients to determine the utility of this approach, the ability to achieve complete resection, and outcomes. Of the 35 patients, 13 patients underwent resection for thymoma (9 stage I, 4 stage II), 5 for cervical node dissection, 7 for thymic hyperplasia, 3 for thyroid resection, 3 for esophagectomy, 2 for thymic cyst, 1 for bronchogenic cyst, and 1 for thymic cholesterol granuloma. Median age of patients was 51 (range 28-79) years with 54% (n = 19) males. There were no intraoperative complications or deaths within 30 days. Median length of stay was 3 days. Complete resection was possible for all patients who underwent resection for thymic masses, hyperplasia, or cystic mediastinal structures (n = 24). There were no recurrences on long-term follow-up for those with thymomas. Partial upper median sternotomy is a safe and effective means of accessing the anterosuperior mediastinum. It is an alternative to full sternotomy and provides a less invasive means of resecting small anterior mediastinal masses as well as accessing the thoracic inlet.

55-jährige Patientin mit Thymom und Hypogammaglobulinämie (Good-Syndrom), Colitis ulcerosa sowie CMV-Infektion

The authors report on a 55-year-old female patient after R1 resection of a malignant thymoma with spindle type epithelial cells (WHO type A, Masaoka stage III) referred for further therapy of an ulcerative colitis. At that time, both adjuvant radiation and cytostatic therapy were not applicable due to severe activity of the ulcerative colitis. Under immunosuppressive treatment with azathioprine and steroids, the patient developed cytomegalovirus (CMV) enteritis which was triggered by therapy-induced leukopenia. After a switch from azathioprine to mycophenolatmofetil (MMF) treatment and administration of cidofovir because of nonresponse to ganciclovir and incompatibility of foscarnet sodium (Foscavir), the patient clinically improved. In addition, the patient was treated with immunoglobulins every 3-4 weeks because of antibody deficiency. At present, 3.5 years after R1 resection, the patient still has no clues of a remaining tumor mass under current immunosuppressive therapy. Ulcerative colitis is also in complete remission stage. This case indicates the very rare features of a syndrome with thymoma and antibody deficiency which was first described by Robert Good. Furthermore, the impact of immunosuppressive therapy and management of opportunistic infections on the course of this disease is obvious.

Cellular and humoral immune alterations in thymectomized patients for thymoma

The aim of this study was to analyze the impact of thymectomy on kinetics of the immune reconstitution in thymoma patients. Nine consecutive patients with completely resected thymoma were enrolled. Immunophenotype analysis (total lymphocytes, CD3, CD4, CD8, CD19, NK subsets) and detection of autoantibodies at 6, 12, 18, and 24 months after thymectomy were planned. A prolonged inversion of CD4/CD8 ratio was present, due to a diminished number of CD4+ cells; CD8+ cell numbers remaining constantly normal at different time points; CD19+ cells remained for a long time understatement, achieving almost normal levels at 24 months; and NK cells always showed a normal amount. Autoantibodies against the muscle acetylcholine receptor were detected in four patients (44.4%) at the time of diagnosis, while antinuclear antibody were detected in eight patients (88.8%) at different time points during postthymectomy. A high incidence of multiple primary neoplasms was observed (66.6% of cases). Our study showed that cellular and humoral immune alterations are a common sequelae of postthymectomy. Further studies, a longer surveillance and a cooperative approach, due to the rarity of the disease, are necessary to define eventual implications of immune alterations on patient's outcome.

Management of pleural recurrence after curative resection of thymoma

A complete surgical resection is the cornerstone of therapy of thymic tumors. Unfortunately, there is no standard treatment for pleural recurrence. This article describes our overall experience with the surgical treatment of pleural implants in patients who previously underwent resection of a thymoma. From January 1980 to June 2006, 20 patients previously operated on for a thymoma were operated on for the surgical resection of pleural implants. Patients with the initial Masaoka stage IVA were excluded from our analysis. Our sample comprised 10 male and 10 female patients (12-65 years old). The surgical approach to the resection of the thymoma was as follows: video-assissted thoracic surgery in 2 patients, sternotomy in 13 patients, thoracotomy in 2 patients, and sternothoracotomy in 3 patients. The initial Masaoka stage of the thymoma was IIA in 2 patients, IIB in 7 patients, and III in 11 patients. The interval between resection of the thymoma and pleural implants ranged from 11 to 156 (median 60) months. Fifteen patients had a thymus-related syndrome (in 13 patients it resulted myasthenia gravis), and in 11 patients it improved or remitted after treatment of the pleural recurrence. All the resections were performed through a posterolateral thoracotomy. Three patients underwent an iterative resection of new pleural implants. At the latest follow-up, 10 patients are still alive (8 disease-free) and 10 have died (9 of a relapse and 1 of the complications of red cell aplasia). From the pleural recurrence resection, the overall 5- and 10-year survivals are 43.1% and 25.8%, respectively. Repeat operation on patients with thymoma pleural recurrences is feasible and safe. It can produce satisfactory results in terms of overall survival and paraneoplastic syndrome control. Moreover, the multimodality treatment could improve the results of surgical treatment.

Video‐Assisted Thoracoscopic Resection of Noninvasive Thymomas Using One‐Lung Ventilation in Two Dogs

To report the technique and outcome of video-assisted thoracoscopic surgery (VATS) for resection of cranial mediastinal thymoma in 2 dogs. Case report. Eleven-year-old Labrador Retrievers (n=2). Two dogs had VATS resection of thymoma. Preoperative computed tomography (CT) scans revealed well-circumscribed cranial mediastinal masses with dimensions of 4.5 cm x 4.2 cm x 3.7 cm and 2.1 cm x 2.1 cm x 4.1 cm (at the time of resection) without CT evidence of vascular invasion. One-lung ventilation (OLV) was achieved using a bronchoscopically placed double-lumen endobronchial tube. A 3-portal technique was used for VATS access to the thorax. Thymomas were dissected from the tissues of the cranial mediastinum with the aid of a harmonic scalpel and retrieved in specimen retrieval bags. Two cranial mediastinal thymomas were resected successfully, with their capsules intact, using a VATS technique. One dog developed aspiration pneumonia postoperatively which resolved with treatment and remains healthy 18 months postoperatively with no radiographic evidence of tumor recurrence. The second dog was diagnosed with myasthenia gravis, megaesophagus, and aspiration pneumonia preoperatively and despite recovering well from the procedure had a second episode of aspiration pneumonia 5 days postoperatively and was euthanatized. VATS resection of modestly sized noninvasive thymoma is possible in dogs. Careful case selection and preoperative imaging are the keys. Thoracoscopic resection of modestly sized mediastinal masses forms part of an increasingly expansive set of indications for minimally invasive surgery in select veterinary patients.

A Rare Case of Thymoma Associated Autoimmune Enteropathy

Purpose: A 61-year-old female with history of bronchiectasis and resection of benign thymoma presented to The Mount Sinai Hospital with severe weight loss and malnutrition. She reported having chronic watery diarrhea and lower abdominal pain since 2004. A diagnosis of celiac disease was made based on an extensive work up at an outside hospital, which included abnormal small intestinal biopsies, but she had minimal clinical response to a gluten free diet. After a repeat colonoscopy 9 months later, Crohn's disease was diagnosed and she was treated with 4–5 courses of steroid tapering and 6-MP until February 2007, when she was hospitalized twice for severe constipation. On presentation to the Mount Sinai Hospital, she had persistent abdominal pain and reported weight loss of 45 lbs, despite continued gluten restricted diet. On examination, she appeared malnourished and had severe tenderness in left lower quadrant but no palpable mass. Lab data included Hb 10 g/dl, ESR 83, CRP 20.5, albumin 3.5 g/dl and negative HLA-DQ2/DQ8. Immunoglobulin quantitation and absolute T and B cell counts were within normal range. Small bowel series and abdomen CT were normal. On colonoscopy, the colon and terminal ileum appeared normal. Random colonic biopsies revealed loss of goblet cells and Paneth cells, presence of lymphocyte infiltrates in the lamina propria and and multiple apoptotic bodies. The findings were interpreted as autoimmune enteritis (AIE). Indirect immunofluorescence using patient's serum and frozen section of normal small bowel showed linear staining along the gut epithelium, consistent with anti-enterocyte antibodies. The patient resumed a gluten unrestricted diet and started oral prednisone and 6-MP. Her abdominal pain and diarrhea promptly improved and oral prednisone was successfully tapered over the next two months. Clinical remission of GI symptoms was maintained with 6-MP for over 1 year. Worsening bronchiectasis due to recurrent pseudomonas infections resulted in multiple hospitalization and the patient succumbed to respiratory failure in April, 2008. AIE was first described in 1982 by Unsworth and Walker-Smith and characterized by protracted diarrhea, circulating enterocyte antibody and associated autoimmune conditions. Only 3 of 30 reported cases had associated with thymoma. No standard approach for the treatment has not been established and immunosuppressive treatment is required in most cases. 60% of patients respond to steroid and 2/3 of steroid responders require additional immunomodulators for maintenance of remission. AIE should be considered in the differential diagnosis of malabsorption and refractory celiac disease.

Paraneoplastic pemphigus regression after thymoma resection

BackgroundAmong human neoplasms thymomas are associated with highest frequency with paraneoplastic autoimmune diseases.Case presentationA case of a 42-year-old woman with paraneoplastic pemphigus as the first manifestation of thymoma is reported. Transsternal complete thymoma resection achieved pemphigus regression. The clinical correlations between pemphigus and thymoma are presented.ConclusionOur case report provides further evidence for the important role of autoantibodies in the pathogenesis of paraneoplastic skin diseases in thymoma patients. It also documents the improvement of the associated pemphigus after radical treatment of the thymoma.

Videothoracoscopic Resection of Encapsulated Thymic Carcinoma: Retrospective Comparison of the Results Between Thoracoscopy and Open Methods

Although videothoracoscopic (VTS) resection of thymoma has been reported to be a less invasive technique than open sternotomy, the usefulness of this method in the treatment of encapsulated thymic carcinoma has not yet been evaluated. We retrospectively compared the VTS and open methods (median sternotomy) to investigate whether VTS resection could be performed as successfully as open surgery to treat resectable thymic carcinoma. Between November 2002 and March 2007 a retrospective review was made of eight patients (four women and four men) with Masaoka stage I and II encapsulated thymic tumor. Four patients (the VTS group) underwent tumor resection by means of a three-port endoscopic technique. The other four patients (the open group) underwent tumor excision via a standard sternotomy approach. The resected thymic carcinoma tissues were all confirmed by histopathological examination. No patient died nor did any major morbidity or recurrence occur during the mean follow-up period of 3.76 +/- 1.43 years. The open group sustained more blood loss (246.3 ml more) and pleural drainage time (5.7 days more), and were hospitalized for a longer period (12.5 days more). However in the open group the tumor size was larger (38.6 cm(3 )more ) and the mean follow-up time was longer (1.4 years more). These results have encouraged us to treat more patients with encapsulated thymic carcinoma by means of VTS resection.

Widespread Metastases After Resection of Noninvasive Thymoma

Widespread Metastases After Resection of Noninvasive Thymoma

An Institutional Study on Thymomas and Thymic Carcinomas: Experience in 77 Patients

Thymomas and thymic carcinomas are rare tumors of the anterior mediastinum. A WHO classification was introduced in 1999, which has been updated in 2004. Meanwhile, several retrospective studies have been carried out which have shown the prognostic significance of this classification together with Masaoka's staging system and the extent of surgery. Between 1983 and 2000, 77 patients (37 male, 40 female) underwent resection of thymomas and thymic carcinomas in our institution. Complete resection was achieved in 57 patients. The median follow-up was 72.6 months. The overall 5-year survival rate was 71.4 %. The factors "histology" and "extent of resection" had the most important impact on survival. However, even among the patients with complete resection, 12 of them suffered a relapse. Among this patient group, the most important factors for disease-free survival were "tumor stage" and "histology". Patients with an incomplete resection had a 5-year survival rate of only 29 % in spite of adjuvant radiation and/or chemotherapy. Due to the high rate of relapse, the poor survival rate found in incompletely resected patients as well as the failure of classical chemotherapy regimens, especially in type B2 and type B3 thymomas and thymic carcinomas, the search for new chemotherapeutic schemes is mandatory. Our study shows that there are still encouraging therapeutic options for thymomas and thymic carinomas. Type B2, type B3 thymomas and thymic carcinomas have worse outcomes in spite of adjuvant chemo- and radiotherapies. Especially in patients with incomplete surgical resection the outcome remains poor.

A Case of Type 1 Diabetes Mellitus with Impaired Cell-mediated Immunity After the Resection of Thymoma

A Case of Type 1 Diabetes Mellitus with Impaired Cell-mediated Immunity After the Resection of Thymoma

Metastatic Thymoma of the Breast

Breast metastasis from nonmammary malignant neoplasms is uncommon, and it accounts for approximately 2% of all breast tumors. Distant metastasis of thymoma is very rare, and especially to extrathorcic areas. We report a female who had a metastatic thymoma in her breast 20 years after undergoing resection for a non-invasive thymoma. She presented with a palpable mass in her left breast. Mammography and ultrasonogram showed a lobular mass at the anterior glandular portion. Histological examination after surgical excision revealed a metastatic thymoma.