Extended Surgical Resections of Advanced Thymoma Masaoka Stages III and IVa Facilitate Outcome

Abstract

Objective Extended thymoma resections including adjacent structures and pleurectomy/decortication (P/D) with hyperthermic intrathoracic chemotherapy (HITHOC) perfusion were performed in a multidisciplinary treatment regime.

Patients and Methods Between July 2000 and February 2012, 22 patients with Masaoka stage III (n = 9; 41%) and Masaoka stage IVa (n = 13; 59%) thymic tumors were included.

Results Mean age was 55 years (25–84 years) and 50% (11 out of 22) of patients were female. World Health Organization histological classification was as follows: B2 (n = 15), A (n = 1), B1 (n = 1), B3 (n = 2), and thymic carcinoma (C; n = 3). Radical thymectomy and partial resection of the mediastinal pleura and pericardium were performed. Of the 13, 9 patients with pleural involvement (stage IVa) received radical P/D followed by HITHOC (cisplatin). Macroscopic complete resection (R0/R1) was achieved in 19 (86%) patients. All patients received multimodality treatment depending on tumor stage, histology, and completeness of resection. Thirty-day mortality was 0% and three (13.6%) patients needed operative revision. Recurrence of thymoma was documented in five (22.7%) patients (stage III, n = 1; stage IVa, n = 4). Mean disease-free interval of patients with complete resection (n = 14 out of 22) was 30.2 months. After a mean follow-up of 29 months, 18 out of the 22 (82%) patients are alive. After P/D and HITHOC, 89% (8 out of 9 patients) are alive (current median survival is 25 months) without recurrence.

Conclusions Extended surgical resection of advanced thymic tumors infiltrating adjacent structures (stage III) or with pleural metastases (stage IVa) is safe and feasible. It provides a low recurrence rate and an acceptable survival. Additional HITHOC in patients with pleural thymoma spread seems to offer a better local tumor control.

Keywords

thymoma - thymic carcinoma - pleurectomy/decortication - hyperthermic intrathoracic chemotherapy

Note

Presented at the 21st Annual Meeting of The German Society of Thoracic Surgery in Karlsruhe, Baden-Württemberg, Germany, September 2012.

• References

• 1 Detterbeck FC, Parsons AM. Thymic tumors. Ann Thorac Surg 2004; 77 (5) 1860-1869
• 2 Masaoka A, Monden Y, Nakahara K, Tanioka T. Follow-up study of thymomas with special reference to their clinical stages. Cancer 1981; 48 (11) 2485-2492
• 3 Rosai J, Sobin L. Histological typing of tumours of the thymus. In: World Health Organization, ed. International Histological Classification of Tumours. Heidelberg, Germany: Springer; 1999: 1-16
• 4 Margaritora S, Cesario A, Cusumano G , et al. Thirty-five-year follow-up analysis of clinical and pathologic outcomes of thymoma surgery. Ann Thorac Surg 2010; 89 (1) 245-252 , discussion 252
• 5 Venuta F, Anile M, Diso D , et al. Thymoma and thymic carcinoma. Eur J Cardiothorac Surg 2010; 37 (1) 13-25
• 6 Ried M, Guth H, Potzger T , et al. Surgical resection of thymoma still represents the first choice of treatment. Thorac Cardiovasc Surg 2012; 60 (2) 145-149
• 7 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 1996; 112 (2) 376-384
• 8 Wright CD. Extended resections for thymic malignancies. J Thorac Oncol 2010; 5 (10) (Suppl. 04) S344-S347
• 9 Rajan A, Giaccone G. Treatment of advanced thymoma and thymic carcinoma. Curr Treat Options Oncol 2008; 9 (4-6) 277-287
• 10 Cardillo G, Carleo F, Giunti R , et al. Predictors of survival in patients with locally advanced thymoma and thymic carcinoma (Masaoka stages III and IVa). Eur J Cardiothorac Surg 2010; 37 (4) 819-823
• 11 Marulli G, Lucchi M, Margaritora S , et al. Surgical treatment of stage III thymic tumors: a multi-institutional review from four Italian centers. Eur J Cardiothorac Surg 2011; 39 (3) e1-7
• 12 Marienhagen J, Schalke B, Aebert H, Held P, Eilles C, Bogdahn U. Somatostatin receptor scintigraphy in thymoma imaging method and clinical application. Pathol Res Pract 1999; 195 (8) 575-581
• 13 Ried M, Potzger T, Braune N , et al. Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion for malignant pleural tumors: perioperative management and clinical experience. Eur J Cardiothorac Surg 2013; 43 (4) 801-807
• 14 Yellin A, Simansky DA, Paley M, Refaely Y. Hyperthermic pleural perfusion with cisplatin: early clinical experience. Cancer 2001; 92 (8) 2197-2203
• 15 Rea F, Marulli G, Girardi R , et al. Long-term survival and prognostic factors in thymic epithelial tumours. Eur J Cardiothorac Surg 2004; 26 (2) 412-418
• 16 Hosaka Y, Tsuchida M, Toyabe S, Umezu H, Eimoto T, Hayashi J. Masaoka stage and histologic grade predict prognosis in patients with thymic carcinoma. Ann Thorac Surg 2010; 89 (3) 912-917
• 17 Chen G, Marx A, Chen WH , et al. New WHO histologic classification predicts prognosis of thymic epithelial tumors: a clinicopathologic study of 200 thymoma cases from China. Cancer 2002; 95 (2) 420-429
• 18 Spaggiari L, Casiraghi M, Guarize J. Multidisciplinary treatment of malignant thymoma. Curr Opin Oncol 2012; 24 (2) 117-122
• 19 Giaccone G, Wilmink H, Paul MA, van der Valk P. Systemic treatment of malignant thymoma: a decade experience at a single institution. Am J Clin Oncol 2006; 29 (4) 336-344
• 20 Ruffini E, Van Raemdonck D, Detterbeck F, Rocco G, Thomas P, Venuta F. European Society of Thoracic Surgeons Thymic Questionnaire Working Group. Management of thymic tumors: a survey of current practice among members of the European Society of Thoracic Surgeons. J Thorac Oncol 2011; 6 (3) 614-623
• 21 Rena O, Mineo TC, Casadio C. Multimodal treatment for stage IVA thymoma: a proposable strategy. Lung Cancer 2012; 76 (1) 89-92
• 22 Wright CD. Pleuropneumonectomy for the treatment of Masaoka stage IVA thymoma. Ann Thorac Surg 2006; 82 (4) 1234-1239
• 23 Ishikawa Y, Matsuguma H, Nakahara R , et al. Multimodality therapy for patients with invasive thymoma disseminated into the pleural cavity: the potential role of extrapleural pneumonectomy. Ann Thorac Surg 2009; 88 (3) 952-957
• 24 Yang HC, Yoon YS, Kim HK , et al En bloc extended total thymectomy and extrapleural pneumonectomy in Masaoka stage IVA thymomas. J Cardiothorac Surg 2011; 6: 28
• 25 Hofmann HS, Wiebe K. [Cytoreductive surgery and hyperthermic intrathoracic chemotherapy perfusion]. Chirurg 2010; 81 (6) 557-562
• 26 Refaely Y, Simansky DA, Paley M, Gottfried M, Yellin A. Resection and perfusion thermochemotherapy: a new approach for the treatment of thymic malignancies with pleural spread. Ann Thorac Surg 2001; 72 (2) 366-370
• 27 de Bree E, van Ruth S, Baas P , et al. Cytoreductive surgery and intraoperative hyperthermic intrathoracic chemotherapy in patients with malignant pleural mesothelioma or pleural metastases of thymoma. Chest 2002; 121 (2) 480-487
• 28 Yellin A, Simansky DA, Ben-Avi R , et al. Resection and heated pleural chemoperfusion in patients with thymic epithelial malignant disease and pleural spread: a single-institution experience. J Thorac Cardiovasc Surg 2013; 145 (1) 83-87 , discussion 87–89
• 29 Utsumi T, Shiono H, Matsumura A , et al. Stage III thymoma: relationship of local invasion to recurrence. J Thorac Cardiovasc Surg 2008; 136 (6) 1481-1485
• 30 Lucchi M, Mussi A. Surgical treatment of recurrent thymomas. J Thorac Oncol 2010; 5 (10) (Suppl. 04) S348-S351