The Role of Surgical Management in Recurrent Thymic Tumors

doi:10.1016/j.athoracsur.2012.02.092

The Annals of Thoracic Surgery

Volume 94, Issue 1, July 2012, Pages 247-254

Presented at the Fifty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 9–12, 2011.

https://doi.org/10.1016/j.athoracsur.2012.02.092 Get rights and content

Background

There are few data on outcomes after surgical treatment for recurrent thymic tumors. The aim of this study is to analyze and compare long-term outcomes of treatments for recurrent thymic tumors.

Methods

Between January 1956 and December 2009, 344 thymic tumors were surgically resected (309 thymomas, 22 thymic carcinomas, 12 thymic carcinoids, and 1 thymolipoma). There were 48 recurrences (13.9%): 30 thymomas, 9 thymic carcinomas, and 9 thymic carcinoids. There were 27 men and 21 women with a median age of 51 years (range, 27 to 83). Retrospective chart review was performed. Relevant factors for recurrence as well as survival and progression-free interval were analyzed.

Results

The median follow-up interval from the initial operation was 83 months (range, 9 to 515). Recurrence adversely affected overall survival in surgically resected thymic tumors (p = 0.0014). In multivariate analysis, the initial Masaoka stage, incomplete resection, and World Health Organization histology were significant risk factors for recurrence. In multivariate analysis, only surgical management was associated with prolonged survival p = 0.0038) and improved progression-free interval (p = 0.0378) in recurrent thymoma. Five-year survival after recurrent thymoma was 54%. For recurrent thymic carcinoma, surgery did not improve survival. For these patients, chemotherapy was associated with improved progression-free interval after recurrence (p = 0.0295). There were no 5-year survivors of recurrent thymic carcinoma.

Conclusions

Our data suggest that surgical management is associated with better outcome and is the treatment of choice for recurrent thymoma. For recurrent thymic carcinoma, surgical management has a very limited role, and chemotherapy appears to be a more effective treatment modality.

Section snippets

Material and Methods

All patients who underwent resection for a thymic tumor at our institution between January 1, 1956, and December 31, 2009, were identified from a prospectively maintained surgical database. The revised Masaoka staging system was used for staging the thymic tumors in this study [1, 11]. Histologic type was classified according to the 2004 revision of the WHO classification of thymic epithelial tumors [12]. The medical records were retrospectively reviewed for demographic information, presenting

Recurrence Patterns and Treatment

The patients' age, sex, and clinical and pathologic characteristics at the time of the initial diagnosis and thymectomy are shown in Table 1. The characteristics of the 48 patients who had recurrence are shown in Table 2, broken down by the histology of the thymic tumor. The median follow-up interval from the initial operation was 83 months (range, 9 to 515). Follow-up was complete in 44 of 48 (92%). Of the 4 patients lost to follow-up, the median follow-up before they were lost was 55.5

Comment

The aim of this study was to characterize patterns of recurrence in patients with thymic tumors and to compare long-term outcomes of treatments to identify independent predictors of recurrence, survival, and improved progression-free interval. We found that recurrence patterns of thymoma, thymic carcinoma, and thymic carcinoid are quite different. Compared with thymoma, patients with thymic carcinoma and thymic carcinoid have an earlier and higher rate of relapse, more distant metastases, and

References (21)

J.F. Regnard et al.
Prognostic factors and long-term results after thymoma resection: a series of 307 patients
J Thorac Cardiovasc Surg
(1996)
E. Ruffini et al.
Recurrence of thymoma: analysis of clinicopathologic features, treatment, and outcome
J Thorac Cardiovasc Surg
(1997)
J. Huang et al.
Comparison of patterns of relapse in thymic carcinoma and thymoma
J Thorac Cardiovasc Surg
(2009)
C.D. Wright et al.
Predictors of recurrence in thymic tumors: importance of invasion, World Health Organization histology, and size
J Thorac Cardiovasc Surg
(2005)
D. Blumberg et al.
Thymic carcinoma: current staging does not predict prognosis
J Thorac Cardiovasc Surg
(1998)
C.P. Hsu et al.
Thymic carcinoma: ten year's experience in twenty patients
J Thorac Cardiovasc Surg
(1994)
S. Igawa et al.
Efficacy of chemotherapy with carboplatin and paclitaxel for unresectable thymic carcinoma
Lung Cancer
(2010)
J.F. Regnard et al.
Results of re-resection for recurrent thymoma
Ann Thorac Surg
(1997)
A. Masaoka et al.
Follow-up study of thymomas with special reference to their clinical stages
Cancer
(1981)
D. Blumberg et al.
Thymoma: a multivariate analysis of factors predicting survival
Ann Thorac Surg
(1995)

There are more references available in the full text version of this article.

Cited by (56)

Impact of adjuvant radiotherapy and chemotherapy on thymoma
2024, Cancer/Radiotherapie
Thymoma is a rare tumour. The most common treatment for thymoma is surgical resection, while the use of radiotherapy and chemotherapy remains controversial.
We conducted a monocentric observational study of 31 patients diagnosed with thymoma from June 2004 to July 2020 at cancer centre in Strasbourg, France. We analysed the outcomes of the patients.
The 2- and 5- year locoregional relapse-free survival rates were 96.3% (95% confidence interval [CI]: 76.5–99.5%) and 68.0% (95% CI: 43.8–83.5%), respectively. Radiotherapy and chemotherapy significantly improved local tumour control (P = 0.0008 and 0.04, respectively), while a larger initial tumour size significantly worsened local control rates (P = 0.04). The 5- and 10-year overall survival rates were 87.1% (95% CI: 69.2–95%) and 81.7% (95% CI: 60.3–92.2%), respectively. The median overall survival was not reached, and no favourable factor was retrieved. For relapsed patients, the median overall survival after relapse was 115 months.
Despite the inherent limitations of retrospective studies with a limited patient sample size, we demonstrated that chemotherapy and radiotherapy in addition to surgery were effective in achieving local control and contributed to improving patient outcomes in thymoma. Notably, an aggressive treatment strategy at the time of relapse resulted in favourable outcomes for retreated patients.
Les thymomes sont des tumeurs rares. La résection chirurgicale est le traitement le plus important, alors que l’utilisation de la radiothérapie et de la chimiothérapie restent controversées.
Nous avons réalisé une étude observationnelle monocentrique chez 31 patients atteints de thymome diagnostiqué de juin 2004 à juillet 2020. Nous avons analysé le devenir du patient.
À 2 et 5 ans, les taux de rechute locorégionale étaient respectivement de 96,3 % (IC à 95 % [intervalle de confiance à 95 %] : 76,5–99,5 %) et de 68,0 % (IC à 95 % : 43,8–83,5 %). La radiothérapie et la chimiothérapie ont significativement amélioré le taux de contrôle local (respectivement p = 0,0008 et 0,04) alors que la taille initiale de la tumeur plus grande avait significativement dégradé les taux de contrôle local (p = 0,04). Les taux de survie globale à 5 et 10 ans étaient de 87,1 % (IC à 95 % : 69,2–95 %) et de 81,7 % (IC à 95 % : 60,3–92,2 %). La médiane de survie globale n’a pas été atteinte. Aucun facteur favorable n’a été relevé. Pour les patients en situation de rechute, la médiane de survie globale après la rechute était de 115 mois.
Malgré les inconvénients classiques des études rétrospectives sur un petit nombre de patients, nous avons montré que la chimiothérapie et la radiothérapie complétant la chirurgie étaient efficaces et participaient à l’évolution favorable chez des patients atteints de thymome. Il convient de noter qu’un traitement agressif au moment de la rechute a donné de bons résultats chez les patients retraités.
Atypical type A thymoma component identified by pulmonary metastasectomy 11 years after surgery of type AB thymoma
2023, Respiratory Medicine Case Reports
Atypical type A thymomas exhibit more aggressive features than conventional type A thymomas. Type AB thymomas rarely have atypical type A components. We report a rare case of type AB thymoma with an atypical type A component, that was identified after pulmonary metastasectomy 11 years after the primary surgery and long-term follow-up after recurrence.
A 61-year-old female underwent extended thymectomy for an anterior mediastinal tumor 11 years prior and was diagnosed with type AB thymoma (Masaoka stage II). Five years ago, follow-up computed tomography showed well-circumscribed pulmonary nodules up to 1.0 cm in both lungs. All the pulmonary nodules grew slowly; however, one of the nodules grew to 1.6 cm, and thoracoscopic wedge resection was performed for diagnosis. Pathologically, the pulmonary nodule was consisted of type A thymoma component. Conventional type AB thymomas are usually locally aggressive neoplasms; thus, we reviewed the tissue slides of primary thymomas. Histologically, cytological atypia, hypercellularity, and increased mitosis are observed in the type A component. Consequently, the diagnosis was revised to a type AB thymoma with an atypical type A component. The pulmonary nodule exhibited the same atypical type A features. Pulmonary metastasectomy was performed two more times as volume-reduction surgery. The residual metastasis was located only in the lung with slow growth, 4 years after the first pulmonary resection; therefore, we followed up as an outpatient without treatment.
Tumor size as a prognostic factor in limited-stage thymic epithelial tumors: A multicenter analysis
2021, Journal of Thoracic and Cardiovascular Surgery
The prognostic significance of tumor size in thymic epithelial tumors (TETs) has not been fully evaluated. We aimed to clarify the prognostic value of tumor size in limited-stage and advanced-stage TETs.
Clinical records of patients with completely resected TETs were retrospectively collected from 4 tertiary centers between January 2000 and February 2013. Information on the Masaoka–Koga stage was available for 1215 patients (M-K group), and 433 patients were classified according to the eighth edition of the Tumor-Node-Metastasis staging system (TNM group). Limited-stage and advanced-stage TETs were defined according to whether they were confined within the surrounding fatty tissues without invasion. The optimal cutoff value was selected using a maximally selected log-rank statistic.
The median tumor size was 6.0 ± 2.8 cm in the M-K group and 6.5 ± 3.0 cm in the TNM group. In the multivariable analysis, tumor size had a significant effect on both overall survival (P = .003) and recurrence-free survival (P < .001) for limited-stage tumors (M-K stage I or II or TNM stage I), but not for advanced-stage tumors (M-K stage III or IV or TNM stage II-IV; P = .349 for overall survival and P = .439 for recurrence-free survival). The optimal cutoff value for tumor size was >5.5 cm for both overall survival and recurrence-free survival in limited-stage TETs.
Tumor size is an independent prognostic factor in patients with completely resected limited-stage TETs and a cutoff value >5.5 cm might help clinicians enact proper treatment strategies and surveillance.
Does Follow-Up Duration Affect the Effectiveness of a Predictive Nomogram Model for Thymic Malignancy Recurrences? Results From an External Validation
2020, Journal of Thoracic Oncology
Prognostic factors after treatment for iterative thymoma recurrences: A multicentric experience
2019, Lung Cancer
Citation Excerpt :
To our knowledge, only Marulli [25] analyzed the role of this parameter in recurrent thymomas, without a significant association to OS. Marulli categorized the DFS as > or < to 60 months, compared to our study with a DFS cut-off > or ≤ to 36 months, which can be defined as early relapse time, considering the mean relapse time for thymoma of 60 months [7,8]. As logical consequence, a shorter DFS may be a direct sign of an aggressive disease, but, in our study, a short DFS was independent of Masaoka-Koga stage, B3 histology, microscopical residual disease of the initial thymectomy and migration in histology.
Thymomas are rare neoplasms with a low recurrence rate, which are preferably surgically treated. Iterative thymoma surgery has not been well investigated yet. Study aim is to analyse prognostic factors after iterative recurrence treatment.
Clinical, pathological and surgical findings of 155 patients, treated for thymoma recurrence in three high-volume centres from 01/01/1990 to 1/07/2017, were retrospectively reviewed. Recurrence patterns/treatment types (surgery or chemotherapy, radiotherapy or combined) were correlated to overall (OS) and disease free survival (DFS).
Myasthenia Gravis was present in 135 (87%) patients. Surgery was performed in 135/155 (87%) patients with 109 (80.7%) complete resections. Sixty (55%)patients experienced a second recurrence surgically treated in 31/60 (52%) cases with 18 (58%) complete resections. Eleven (61%) patients experienced a third recurrence and nine underwent complete resection. Myastenia Gravis (HR: 0.45; 95% CI: 0.20-0.98, p = 0.046), DFS after the initial thymectomy >36 months (HR: 0.9; 95% CI: 0.96-0.99, p = 0.006) and complete second recurrence resection (HR: 1.45; 95% CI 2.07–10.01, p = 0.010) resulted as independent favorable prognostic survival factor. Despite patient selection bias, rewarding long-term survivals was predictable after iterative thymoma surgery (5 and 10 years survival of 79.6% and 64.6%) while a poor prognosis was observed after CT/RT (5 and 10 years OS of 56.7% and 21.5%), Masaoka stage and DFS > 36 months were risk factor for iterative recurrences.
Myasthenia Gravis and long DFS after thymectomy are favorable survival factors for multiple thymoma recurrences. Iterative surgical treatment is a viable therapeutic option associated to long-term survival if technically and clinically feasible.
Perioperative management and postoperative outcomes of locally advanced thymic epithelial tumors: a narrative review
2024, Mediastinum

View all citing articles on Scopus

View full text

Original articleGeneral thoracicThe Role of Surgical Management in Recurrent Thymic Tumors

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Recurrence Patterns and Treatment

Comment

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Lung Cancer

Ann Thorac Surg

Follow-up study of thymomas with special reference to their clinical stages

Cancer

Thymoma: a multivariate analysis of factors predicting survival

Ann Thorac Surg

Original article
General thoracic
The Role of Surgical Management in Recurrent Thymic Tumors