THYMOMA AND THYMIC CARCINOMA- STAGING

Stage Information for Thymoma and Thymic Carcinomas

Computed tomography (CT) with intravenous contrast may be useful in the diagnosis and clinical staging of thymoma, especially for noninvasive tumors. CT is usually accurate in predicting the following:

·         Tumor size.

·         Location.

·         Invasion into vessels, the pericardium, and the lungs.

However, CT cannot predict invasion or resectability with accuracy.[1,2] Appearance of the tumor on CT may be related to the World Health Organization (WHO) histologic type.[3] A retrospective study involving 53 patients who underwent thymectomy for thymic epithelial tumors indicated that smooth contours with a round shape were most suggestive of type A thymomas, and irregular contours were most suggestive of thymic carcinomas. Calcification was suggestive of type B thymomas. In this study, however, CT was found to be of limited value differentiating type AB, B1, B2, and B3 thymomas.[4]

Most patients with thymic carcinomas present initially with any of the following:

·         Cough.

·         Chest pain.

·         Phrenic nerve palsy.

·         Superior vena cava syndrome.

Patients may have evidence of invasion of contiguous mediastinal structures at presentation. Thymic carcinoma can metastasize to any of the following:

·         Regional lymph nodes.

·         Bone.

·         Liver.

·         Lungs.

An evaluation for sites of metastases may be warranted for these patients.

Positron emission tomography of 18-flouro-deoxyglucose (FDG-PET) as well as thallium single-photon emission computed tomography have been reported in small series for diagnosis and evaluation of therapeutic outcomes in thymic carcinoma.[5-8] Two small series reported that FDG uptake was related to the invasiveness of thymic carcinoma.[7,8] This raises the possibility of FDG-PET utilization for diagnosis, treatment planning, and monitoring for recurrence. Sensitivity, specificity impact on clinical therapeutic decisions, remains to be defined.

Histologic classification of thymoma is not sufficient to distinguish biologically benign thymomas from malignant thymomas. The degree of invasion or tumor stage is generally thought to be a more important indicator of overall survival.[1,9,10]

Evaluating the invasiveness of a thymoma involves the use of staging criteria that indicate the presence and degree of contiguous invasion, the presence of implants, and lymph node or distant metastases regardless of histologic type. Although no standardized staging system exists, the one proposed by Masaoka in 1981 is commonly employed.[11] It was revised in 1994 and is shown below.[11]

Enlarge

Thymoma Staging System of Masaoka 1994a
Stage	Description
a[12]
I	Macroscopically, completely encapsulated; microscopically, no capsular invasion.
II	Macroscopic invasion into surrounding fatty tissue or mediastinal pleura; microscopic invasion into capsule.
III	Macroscopic invasion into neighboring organs (pericardium, lung, and great vessels).
IVa	Pleural or pericardial dissemination.
IVb	Lymphogenous or hematogenous metastases.

Application of this staging system to a series of 85 surgically treated patients confirmed its value in determining prognosis, with 5-year survival rates of 96% for stage I disease, 86% for stage II disease, 69% for stage III disease, and 50% for stage IV disease.[11,13] In a large, retrospective study involving 273 patients with thymoma, 20-year survival rates (as defined by freedom from tumor death) according to the Masaoka staging system were reported to be 89% for stage I disease, 91% for stage II disease, 49% for stage III disease, and 0% for stage IV disease.[9]

In a retrospective analysis of 130 resected, thymoma patients, the WHO pathological classification was tightly correlated with stage and by multivariate analysis, tumor size, completeness of resection, histologic subtype, and stage were significant prognostic factors for survival. Of note, only four patients received neoadjuvant cisplatin-based chemotherapy and complete resection was possible in 95% of cases. The 5-year survival rate of the 11 stage IV patients was 47%.[12]

Some investigators maintain that the Masaoka staging system does not accurately predict outcome for thymic carcinoma.[14,15] In one retrospective study evaluating 43 cases of thymic carcinoma, prognosis was found to be dependent solely on tumor invasion of the innominate artery.[15]

References

1. Sperling B, Marschall J, Kennedy R, et al.: Thymoma: a review of the clinical and pathological findings in 65 cases. Can J Surg 46 (1): 37-42, 2003. [PUBMED Abstract]
2. Rendina EA, Venuta F, Ceroni L, et al.: Computed tomographic staging of anterior mediastinal neoplasms. Thorax 43 (6): 441-5, 1988. [PUBMED Abstract]
3. Rosai J: Histological Typing of Tumours of the Thymus. New York, NY: Springer-Verlag, 2nd ed., 1999.
4. Tomiyama N, Johkoh T, Mihara N, et al.: Using the World Health Organization Classification of thymic epithelial neoplasms to describe CT findings. AJR Am J Roentgenol 179 (4): 881-6, 2002. [PUBMED Abstract]
5. Sasaki M, Kuwabara Y, Ichiya Y, et al.: Differential diagnosis of thymic tumors using a combination of 11C-methionine PET and FDG PET. J Nucl Med 40 (10): 1595-601, 1999. [PUBMED Abstract]
6. Kageyama M, Seto H, Shimizu M, et al.: Thallium-201 single photon emission computed tomography in the evaluation of thymic carcinoma. Radiat Med 12 (5): 237-9, 1994 Sep-Oct. [PUBMED Abstract]
7. Adams S, Baum RP, Hertel A, et al.: Metabolic (PET) and receptor (SPET) imaging of well- and less well-differentiated tumours: comparison with the expression of the Ki-67 antigen. Nucl Med Commun 19 (7): 641-7, 1998. [PUBMED Abstract]
8. Kubota K, Yamada S, Kondo T, et al.: PET imaging of primary mediastinal tumours. Br J Cancer 73 (7): 882-6, 1996. [PUBMED Abstract]
9. Okumura M, Ohta M, Tateyama H, et al.: The World Health Organization histologic classification system reflects the oncologic behavior of thymoma: a clinical study of 273 patients. Cancer 94 (3): 624-32, 2002. [PUBMED Abstract]
10. Chen G, Marx A, Wen-Hu C, et al.: New WHO histologic classification predicts prognosis of thymic epithelial tumors: a clinicopathologic study of 200 thymoma cases from China. Cancer 95 (2): 420-9, 2002. [PUBMED Abstract]
11. Masaoka A, Monden Y, Nakahara K, et al.: Follow-up study of thymomas with special reference to their clinical stages. Cancer 48 (11): 2485-92, 1981. [PUBMED Abstract]
12. Nakagawa K, Asamura H, Matsuno Y, et al.: Thymoma: a clinicopathologic study based on the new World Health Organization classification. J Thorac Cardiovasc Surg 126 (4): 1134-40, 2003. [PUBMED Abstract]
13. Cameron RB, Loehrer PJ Sr, Thomas CR Jr: Neoplasms of the mediastinum. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds.: Cancer: Principles and Practice of Oncology. 7th ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 2005, pp 845-58.
14. Ritter JH, Wick MR: Primary carcinomas of the thymus gland. Semin Diagn Pathol 16 (1): 18-31, 1999. [PUBMED Abstract]
15. Blumberg D, Burt ME, Bains MS, et al.: Thymic carcinoma: current staging does not predict prognosis. J Thorac Cardiovasc Surg 115 (2): 303-8; discussion 308-9, 1998. [PUBMED Abstract]