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SURGICAL TREATMENT IN THYMOMAS

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* * * * * * * * * * * * Thymomas are primary tumors of thymic epitheial cells The ... 9:495-515 Thymoma is the most common tumor of the anterior mediastinum. – PowerPoint PPT presentation

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Title: SURGICAL TREATMENT IN THYMOMAS


1
  • SURGICAL TREATMENT IN THYMOMAS
  • ANALYSIS OF 58 CASES
  • Dr. Ertan AYDIN
  • ATATÃœRK CHEST DISEASES and CHEST SURGERY TRAINING
    and RESEARCH HOSPITAL

2
  • Thymomas are primary tumors of thymic epitheial
    cells
  • The incidence of thymomas in the U.S is
    approximately 0.15 per 100.000 person-years
  • Typically slow-growing tumors that spread by
    local extension
  • The distinction between thymomas and thymic
    carcinomas is not as clear, because thymic
    carcinomas have malignant cytologic features,
    whereas thymomas are generally considered
    cytologically benign
  • Engels EA et al.Malignant thymoma in the United
    States demographic patterns in incidence and
    associations with subsequent malignancies.Int J
    Cancer 2003105546-551
  • Levine GD et al. Thymic hyperplasia and
    neoplasia a review of current concepts.Hum
    Pathol 19789495-515

3
  • Thymoma is the most common tumor of the anterior
    mediastinum.
  • 95 of thymomas are located in the anterior
    mediastinum.
  • They most commonly present in adults between
    40-60 ages and there is an equal distribution
    between genders for these tumors.

4
SYMPTOM
  • 30 of patients are asymptomatic
  • 30 of them present with MG
  • chest pain
  • cough
  • dyspnea
  • hoarseness
  • phrenic nerve paralysis
  • pleural effusions
  • weight loss
  • superior vena cava (SVC) syndrome
  • TNM stating system is not particularly useful for
    thymomas as most patients do not have nodal
    disease or metastases
  • It generally exhibits a weak growth pattern but
    malignant because of potential for local
    invasion, pleural dissemination, and even
    systemic metastases

5
  • Extrathoracic metastases are very rare.
    Metastases are usually seen in the pleura,
    pericardium or diaphragm
  • Thymomas have a tendency for late recurrence even
    after complete resection
  • Myasthenia gravis is the most frequent autoimmune
    disease associated with thymoma. In reported
    series, 3065 of patients with thymoma have been
    diagnosed with myasthenia gravis.1015 of
    patients with myasthenia gravis have a thymoma
  • Autoantibodies to neuromuscular antigens, the
    acetylcholine receptor and titin, astriated
    muscle antigen can be produced in patients with
    myasthenia gravis
  • Other immune disorders can occur up to 28 of
    thymoma patients. Pure red cell aplasia, lupus
    erythematosus and hypogammaglobulinemia are the
    most common
  • Gray GF, Gutowski WT3. Thymoma. A
    clinicopathologic study of 54 cases. Am J Surg
    Pathol 1979323549.
  • Regnard JF, Magdeleinat P, Dromer C, et al.
    Prognostic factors and long-term results after
    thymoma resection a
  • series of 307 patients. J Thorac Cardiovasc Surg
    199611237684.
  • Ruf?ni E, Mancuso M, Oliaro A, et al.
    Recurrence of thymoma analysis of
    clinicopathologic features, treatment, and
    outcome. J Thorac Cardiovasc Surg 19971135563.
  • Awad WI, Symmans PJ, Dussek JE. Recurrence of
    stage I thymoma 32 years after total excision.
    Ann Thorac Surg 19986621068.

6
DIAGNOSIS
  • The diagnosis of the thymoma is usually made with
    clinical findings and radiological examinations.
    Computed tomography (CT) mostly shows the
    presence of an anterior mediastinal tumor.
    Thymomas usually appear as well-defined round
    masses on CT scan
  • Calci?cations may be seen in about 15 of the
    patients and a small percentage of them may be
    cystic.
  • The tumor extension into the mediastinal fat and
    surrounding structures (vascular invasion,
    encasement and pleural dissemination ) may be
    suggested by CT. CT scan findings carries a
    false-positive rate of 20 and a false negative
    rate of 7 for these patients
  • Souza CA, Muller NL. Imaging of the
    mediastinum. In Patterson GA, Cooper JD,
    Deslauriers J, Lerut AEM, Luketich JD, Rice TW,
    editors. Pearsons thoracic and oesophageal
    surgery. 3rd edition, Churchill Livingstone
    2008. p. 1477505
  • Jung KJ, Lee KS, Han J, Kim J, Kim TS, Kim EA.
    Malignant thymic epithelial tumors. Am J
    Roentgenol 20011764339.
  • LeBlanc J, Wood DE. Diagnosis of mediastinal
    tumors. In Wood DE, Thomas CR, editors.
    Mediastinal tumors update 1995, medical
    radiology. Diagnostic imaging and radiation
    oncology volume. Heidelberg,
  • Germany Springer-Verlag 1995. p. 110.

7
WHO PATHOLOGIC CLASSIFICATION (1999)
  • Type Histologic description
    Incidence ()
  • A Medullary thymoma 9
  • AB Mixed thymoma 24
  • B1 Predominantly cortical thymoma 13
  • B2 Cortical thymoma 24
  • B3 Well-differantiated thymic
  • carcinoma 15
  • C Thymic carcinoma 15

8
MASAOKA CLINICAL STAGING (1981)
  • Stage Diagnostic Criteria
  • I Macro- and microscopically completely
    encapsulated
  • (tumor invading into but not through the
    capsule is included)
  • II A. Microscopic transcapsuler invasion
  • B. Macroscopic invasion into surrounding
    fatty tissue or grossly adherent to but not
    through mediastinal pleura or pericardium
  • III Macroscopic invasion into neighboring
    organs
  • ( i.e.,pericardium, great vessels, or lung)
  • A. Without invasion of great vessels
  • B. With invasion of great vessels
  • IV A.Pleural or pericardial dissemination
  • B. Lymphogenous or hematogenous metastases

9
  • The most effective treatment modality for thymoma
    is surgical resection.
  • The principles of successfull surgery include
    careful exploration of the whole mediastinum, en
    bloc thymectomy with removal of all the
    surrounding mediastinal fat, protection the
    phrenic nerve from injury and avoidence of
    intrapleural spread
  • The operative mortality is lower than 2 in most
    of the recent series
  • Port JL, Ginsberg RJ Surgery for thymoma.
    Chest Surg Clinics of NA. 11421-437, 2001
  • Rea F, Marulli G, Girardi R, Bortolotti L,
    Favaretto A, Galligioni A, Sartori F. Long term
    survival and prognostic factors in thymic
    epithelial tumors. Eur J Cardiothorac Surg
    2004264128.
  • Crucitti F, Doglietto GB, Bellantone R, Perri
    V, Tommasini O, Tonali P. Effects of surgical
    treatment in thymoma with myasthenia gravis our
    experience with 103 patients. J Surg Oncol
    199250436.
  • Wilkins EJ, Grillo HC, Scannell JG, Moncure AC,
    Mathisen DJ. Role of staging in prognosis and
    management of thymoma. Ann Thorac Surg
    19915188892.

10
5 year survival
  • Stage I 89-100
  • Stage II 71-97
  • Stage III 68-89
  • Stage IV 47-69
  • Despite reduced survival in advanced disease,
    maximal debulking surgery seems benefical,
    facilitating RT and thereby improving survival
  • Falkson C.B et al. The management of thymoma A
    systematic review and practice guideline.J Thorac
    Oncol 20094911-919
  • Liu H.c et al.Debulking surgery for advanced
    thymoma. Eur J Surg Oncol 2006321000-1005

11
  • Chemotherapy as a single treatment modality
  • Overall response 32-56
  • Complete response 0-38
  • Overall 2-year survival 30-79
  • Progression-free survival 13-56
  • Radiotherapy as a single treatment modality
  • Overall 5-year survival 72
  • Progression-free survival 81
  • Recurrence at 5 years 15
  • Neoadjuvant Chemoradiotherapy
  • Complete response 6-22
  • 5-year survival 31-95
  • Progression-free survival 31-77
  • Falkson C.B et al. The management of thymoma A
    systematic review and practice guideline.J Thorac
    Oncol 20094911-919

12
TREATMENT
  • Stage I Complete resection of the entire thymus
    without neoadjuvant or adjuvant therapy
  • Stage II Complete resection of the entire thymus
    with consideration of adjuvant radiation for
    high-risk tumors
  • Stage IIIASurgery either initially or after
    neoadjuvant therapy,or surgery followed by
    adjuvant therapy
  • Stage IIIBTreatment may include a combination of
    chemotherapy, radiation,and/or surgery, or if
    technically possible,surgery in combination with
    chemoradiotherapy ( cisplatin based).For bulky
    tumors, consideration should be given to
    sequential chemotherapy followed by radiation
  • Stage IVA as per stage III,with surgery only if
    metastases can be resected
  • Stage IVB Treatment based on individual case

13
58 cases ( 1999-2009)
  • Male 35 (60 ),female 23 (40 )
  • Age 22 74 (median50,92)
  • Tumor size 1.5-12 cm (med6,9)
  • Asymptomatic11 (20 )
  • Chest pain 21 (36)
  • Dyspnea 14 (24 )
  • Weakness 6 (10 )
  • Cough3 (5 )
  • Pitosis 3 (5 ).

14
  • Postoperative complications occurred in eight
    patients (13,7)
  • - Pleural effusion
  • Atelectasis
  • Prolonged air leak
  • Arrhythmia

15
SURGERY
  • Three of the cases could not be resected totally(
    5) 55 cases were resected completely (95)
  • Median sternotomy 40 (69)
  • Right thoracotomy 11 (19)
  • Left thoracotomy 7 (12)

16
HISTOPATHOLOGIC CLASSIFICATION NUMBER OF PATIENTS RATIO ()
A 4 7
AB 21 36
B1 6 10
B2 16 28,5
B3 6 10
C 5 8,5
17
STAGE PATIENT 5 -YEAR SURVIVAL
I 26 (44) 93
II 13 (22) 88
III 11 (19) 79
IV 8 (15) 58
  • Overall 5 year survival 87

18
62y, MaleType B2 Thymoma
19
27y,MaleTYpe B1 Thymoma
20
42y, FemaleType B3 Thymoma
21
PROGNOSTIC FACTORS
  • Stage is the most important prognostic factor
  • Others
  • Tumor size
  • Completeness of resection
  • Histologic subtype

22
CONCLUSION
  • Surgery is the best treatment choice
  • Chemoradiation should be considered in all
    medically inoperable and technically inoperable
    patients
  • Recurrent disease- consider surgery,radiation,and/
    or chemoradiation
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