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Background We present here a case series of patients who underwent resection for Masaoka Stage III and IVa Thymic Epithelial Tumors (TETs) with invasion into the superior vena cava. Methods 29 patients with Stage III and IVa TETs were treated surgically in three institutions. Operative resections involved replacing the superior vena cava from one of the innominate veins (n=18) or via reconstruction by truncal replacement (n=2) or patchplasty (n=9). Results Fifteen patients underwent neoadjuvant treatment. Thirty and 90-day mortality rate were 3.4% and 10.3%, respectively. For Stage III patients, the median overall survival and DFS were 39 and 30 months, respectively. The median overall survival and DFS in patients with Masaoka Stage IVa disease were 67 and 21 months, respectively. Undergoing only preoperative chemotherapy (p=0.007) or receiving no chemotherapy (p=0.009) had a disease-free survival that was significantly higher than receiving both pre- and postoperative chemotherapy. Conclusions SVC resection and reconstruction in Masoaka Stage III and IVa TETs can be performed with acceptable morbidity and mortality. Stage IVa patients with SVC involvement can be treated with similar results as Stage III patients with multimodality treatment.

This study was aimed at evaluating the safety and efficacy of hyperthermic intrathoracic chemotherapy in patients with Masaoka stage IVA thymoma. This is a retrospective comparative analysis between two groups of patients who were operated for Masaoka stage IVA thymoma. One group underwent complete parietal pleurectomy whereas other group received hyperthermic intrathoracic chemotherapy after complete pleurectomy. An analysis of all perioperative variables, complications and survival was carried out. A total of 13 patients had stage IVA disease during the study period. Initial 7 patients (March 2012–March 2015) underwent complete parietal pleurectomy, whereas next 6 patients (April 2015–December 2018) had undergone HITHOC after complete parietal pleurectomy. Both groups are comparable in terms of age, co-morbidities, tumor size and duration of symptoms. The duration of surgery and intra-operative blood loss, postoperative ICU stay, duration of ICD and total hospital stay was similar between two groups. The total number of post-operative complications was higher in HITHOC group (5 vs 2), however non-significant (p = 0.10). The median follow-up duration was 63 months in no HITHOC group and 49.5 months in HITHOC group. There was no peri-operative mortality. The overall survival (P = 0.06) and relapse-free survival (P = 0.36) were not significantly different in the both groups. Hyperthermic intrathoracic chemotherapy is a safe and feasible modality with no added morbidity or mortality. Multi-institutional prospective studies with large number of patients are required to accurately assess survival benefit.

A 76-year-old woman with a history of angina pectoris, hypertension and dyslipidemia was pointed out an abnormal opacity in the right hilar region on routine chest X-ray. Chest computed tomography showed masses in the anterior mediastinum with the invasion of the adjacent ascending aorta, right brachiocephalic vein and right pleura. Histologic examination led to a diagnosis of Masaoka stage IVa thymoma. Three courses of chemotherapy were given, but further tumor progression was seen. Thereafter, the patient was followed without aggressive treatments. One year after the initial diagnosis, she presented with dyspnea and right chest pain. Chest CT revealed right massive pleural effusion with pleural dissemination and much further progression of existing tumors. For the purpose of symptom palliation, a low dose (5 mg / day) of prednisolone was commenced, which unexpectedly led to marked alleviation of patient's symptoms and dramatic decrease of pleural effusion. To the best of our knowledge, this is the first report of an invasive thymoma responded to low-dose corticosteroid. The present case suggests that corticosteroids, even at low doses, might be potentially effective for invasive thymoma after failure of surgery, chemotherapy and radiotherapy. J. Med. Invest. 68 : 396-399, August, 2021.

Background and objectives It is unclear if a specific strategy for simultaneous treatment of primary thymic neoplasms and pleural metastases confers benefit for Masaoka stage IVA disease. We reviewed our experience with thymic neoplasms with concurrent pleural metastases to identify factors influencing outcomes. Methods Records of patients who presented with stage IVA thymic neoplasms from 2000 to 2018 were assessed. Multivariate Cox proportional hazards analyses were completed to determine predictors of progression-free and overall survival. Results Forty-eight patients were identified, including 34 (71%) who underwent surgery. Median overall and progression-free survival were 123 and 21 months, respectively. The extent of resection varied, and was most commonly thymectomy plus partial pleurectomy (22, 65%). Median progression-free survival for patients who underwent surgical resection versus those who had not was 24 versus 12 months (P = .018). Following surgical resection, mediastinal recurrence was uncommon (2, 6%, vs 7, 50% nonoperatively). Five-year survival rates in these groups were suggestive of possible benefit to surgery (87% vs 68%). Conclusions Thymic neoplasms with pleural dissemination represents a treatment challenge. As part of a multidisciplinary approach, surgery appears to be associated with more favorable long-term results, although selection bias may account for some of the survival differences observed.

We herein report two cases of Masaoka stage IVa thymoma treated by radical resection via thymothymectomy followed by pleurectomy/decortication (PD). Case 1: a 52-year-old man was diagnosed with a type B1 thymoma. Resection of the right lobe of thymus, dissection of left upper mediastinum, and pleurectomy from anterior chest wall to descending aorta were performed via median sternotomy approach. Pericardial resection followed by decortication of the total visceral pleura was then successfully performed via a posterolateral thoracotomy approach. Case 2: a 48-year-old man was diagnosed with type B2 thymoma. Thymothymectomy and extra-pleural dissection except for the right-side diaphragmatic area were achieved via median sternotomy approach. Resection of the visible disseminated lesions of visceral pleura was performed after pleurectomy of the diaphragmatic area via posterolateral thoracotomy approach. Both patients are disease free at 3 years and 2 years and half, respectively. Extended thymothymectomy followed by PD is a candidate approach for surgical management.

Background Primary localized amyloidosis presenting as an isolated mediastinal mass is extremely rare, especially in the thymus. Sclerosing thymoma is also an extremely rare anterior mediastinal tumor, pathologically characterized by extensive sclerotic lesions with hyalinization and calcification. Only 14 cases of sclerosing thymoma and five cases of thymic amyloidosis have been reported to date. Case presentation A 78-year-old Japanese woman was diagnosed as having sclerosing thymoma (Masaoka stage IVa pericardial dissemination)-like thymic amyloidoma. She was diagnosed as having either lung cancer or mediastinal tumor with pericardial dissemination, and received palliative treatment. Three years later, she was readmitted with a complaint of general malaise. Since minimal change nephrotic syndrome was suspected based on the disease onset and selectivity index of urinary protein, steroid pulse therapy was started. Subsequently, because a marked reduction in tumor size was observed during maintenance treatment with prednisolone, a thoracoscopic needle biopsy was performed for a definitive diagnosis. According to the pathological findings and clinical investigations, a final diagnosis of sclerosing thymoma (Masaoka stage IVa pericardial dissemination)-like thymic amyloidoma was made. Conclusions This is a case report of sclerosing thymoma-like thymic amyloidoma. Both sclerosing thymoma and thymic amyloidoma are extremely rare diseases: only 14 cases of sclerosing thymoma and five cases of thymic amyloidosis have been reported to date. In either diagnosis, our case is the first case in which marked reduction in tumor size was observed with steroid therapy. All reported cases of sclerosing thymomas underwent surgical resection, but steroid therapy to sclerosing thymoma has not been reported. It is still unknown whether steroid therapy is effective or not. The hyalinized components of sclerosing thymoma possibly contain amyloid deposits. The marked reduction in tumor size with steroid therapy may result in amyloid deposits. The association between sclerosing thymoma and thymic amyloidoma remains uncertain. Sclerosing thymoma should be stained with Congo red.

BACKGROUND: Thymic epithelial tumors (TET) are the most common tumors of the anterior mediastinum. Patients with advanced/metastatic disease are usually treated with palliative chemotherapy (CT). Unfortunately, even though various palliative CT regimens have been used for long time, there is a real scarcity of published Indian data regarding the experience of palliative CT in metastatic TET (mTET). MATERIALS AND METHODS: This is a retrospective analysis of mTET patients treated between January 2010 and September 2017. Patients who received at least three cycles of first-line palliative CT were included for analysis of response rates, toxicity, and survival and prognostic factors. RESULTS: Of the 49 mTET patients, 27 (55.1%) were males. The median age at diagnosis was 52 years (range: 25–65). Eighteen patients (36.7%) had Masaoka Stage IVa disease, and the rest of the patients had IVb disease. The most common site of metastasis was pleuropericardium (n = 18), followed by lungs (n = 16) and lymph nodes (n = 9). The median progression-free survival and overall survival (OS) were 11.2 months (95% confidence interval [CI], 8.7–13.6) and 20.2 months (95% CI, 17.1–22.8), respectively, for the whole cohort (n = 49). The median OS of patients with Stage IVa disease was significantly better than that of the patients with Stage IVb disease (log-rank P = 0.000). Moreover, the “responders” to first-line CT had a significantly better median OS than the “nonresponders” (log-rank P = 0.000). Various first-line palliative CT regimens were well tolerated in our patients. CONCLUSION: Adriamycin Cisplatin Vincristine Cyclophosphamide (ADOC), Cyclophosphamide Adriamycin Cisplatin, and paclitaxel + carboplatin all are viable first-line palliative CT options for mTET and showed a comparable survival in Indian patients. The present study suggested that “responders” to first-line CT and those with Stage IVa disease might have a better survival than “nonresponders” and those with Stage IVb disease, respectively.

Purpose To analyze the role of surgery in patients with Masaoka stage IVa thymoma treated with multimodality therapy. Methods Of 191 patients undergoing surgery for thymoma in our department between January 2002 and December 2015, 39 (20.4%) had Masaoka stage IVa. Histopathological tumor type, myasthenic status of the Osserman-Genkins score, Masaoka stage at the first surgery, neoadjuvant treatment, number and type of surgeries, and survival rates were recorded. Results Thymoma B2 was the most common histopathological tumor type (n = 16, 41%). Twenty-six (66.7%) patients underwent primary surgeries for Masaoka stage IVa thymoma, whereas nine (23.1%) underwent secondary surgeries and four (10.3%) underwent tertiary surgeries for pleural or pericardial recurrences. Median survival was 132 ± 25 (82-181; 95% confidence interval [CI]) months. Overall 3-, 5-, and 10-year survival rates were 93%, 93%, and 56%, respectively. Conclusion Surgical treatment should be considered as a completion modality to oncological therapy and has the potential to provide long-term survival of Masaoka stage IVa in patients with thymoma. The type of surgery should be determined based on the invasiveness of the lesion.

Thymomas are relatively uncommon malignancies of the anterior mediastinum and present with four distinct histological types based on the specific epithelial to lymphocyte ratio: spindle cell, epithelial predominant, lymphocyte predominant, or mixed. Each histologic type of thymoma has a propensity for local invasion and metastasis and can have a wide variety of paraneoplastic manifestations, myasthenia being the most common. We present a unique case of a 34-year-old African-American female who initially presented with a history of profound weakness with repetitive motion, shortness of breath, horizontal nystagmus, persistent anemia, keratoconjunctivitis sicca, and what was initially thought to be azithromycin-induced hepatitis. Upon left anterior thoracotomy with biopsy of the mediastinal mass, pathology yielded a lymphocyte-predominant (B1), Masaoka stage IVA invasive thymoma with pericardial extension. This case illustrates the clinical significance of considering a multitude of extrathymic paraneoplastic manifestations, each with a unique physiological mechanism.

Background Thymoma is a rare mediastinal tumor with relatively slow growth. However, advanced-stage cases with pleural dissemination are occasionally encountered. The outcome of surgical resection for thymomas with pleural dissemination has not been clearly determined. Methods We retrospectively investigated the clinical records of 2,835 patients with thymic epithelial tumors that were treated from 1991 to 2010 in 32 institutions that participated in the Japanese Association for Research on the Thymus. In this study, we analyzed the clinicopathologic factors and prognosis of thymoma patients with pleural dissemination who underwent surgical resection. Results The thymomas with pleural disseminations numbered 148 cases (5.2% in the 2,835 thymic epithelial tumors). Surgical resection was performed in 136 cases. Pathologic Masaoka stages were classified as IVA (n = 118) and IVB (n = 18). In Masaoka stage IVA disease, the small number of disseminated pleural nodules (10 or fewer) was related to the curative resection. The prognosis was also better in these cases than in those with greater than 10 disseminated pleural nodules (certified during the operation; p = 0.0057). Patients who underwent macroscopic total resection of disseminated nodules had a better prognosis than those with residual tumors ( p = 0.037). In stage IVA cases with complete resection (n = 42), the efficacy of adjuvant chemotherapy, radiotherapy, or both was not demonstrated. Conclusions Macroscopic total resection of tumors appears to be a promising prognostic factor in Masaoka stage IVA thymomas. The number of disseminated pleural nodules correlated with resectability.

Patient: Female, 59 Final Diagnosis: Thymic carcinoma Symptoms: Dyspnea Medication: — Clinical Procedure: Bronchoscopy Specialty: Oncology Objective: Unusual clinical course Background: Endobronchial metastases derived from nonpulmonary tumors are uncommon, although a variety of malignant tumors have been reported to be associated with endobronchial metastasis. We herein report a case of repeated bronchoscopic resection of endobronchial metastasis of a thymic carcinoma. Case Report: A 59-year-old woman was diagnosed with primary thymic carcinoma, Masaoka stage IVA, in May 2009. In June 2013, she developed dyspnea. A chest CT scan revealed left upper lobe atelectasis, and a polypoid lesion was noted in the left upper bronchus on bronchoscopy. A pathological examination of the lesion revealed metastatic thymic carcinoma, and bronchoscopic resection was performed for symptom relief. However, the lesion was partially resected, based on the operative findings, which showed the peripheral part of B3 to be the origin of the polypoid lesion and bronchoscopy could not be used to reach this site. Although the patient underwent repeated partial bronchoscopic resection of the polypoid lesion due to the symptoms of dyspnea caused by regrowth of the polypoid metastatic thymic cancer in the left upper bronchus, she remains alive with an excellent performance status and no evidence of widespread or other metastases for more than 5 years after the initial diagnosis. Conclusions: We speculate that this case was successfully managed with repeated partial bronchoscopic resection because thymic cancer tends to be a slow-growing tumor. Therefore, it is worth resecting endobronchial metastatic thymic carcinoma repeatedly in such cases, even if the resection is partial.

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.

Objective: Because pleuropneumonectomy is associated with a high mortality rate, its indication for the treatment of Masaoka stage IVa thymoma is debated. We reviewed retrospectively our single-center experience in order to determine if the benefits warrant the risk of such procedure. Methods: Between 1970 and 2009, 17 patients (12 men and 5 women) with a mean age of 44 years (range, 25—62 years) underwent a pleuropneumonectomy for a Masaoka stage IVa thymoma in our institution. Eight patients had recurrent thymoma after a mean postoperative period of 47 28 months, and nine patients presented de novo with stage IVa disease. A multimodality treatment including chemotherapy, radiotherapy, or both was performed in 14 (82%) patients. Results: Eight patients (47%) experienced a major postoperative complication, includingfourbroncho-pleuralfistulae(23%). Therewere nooperativedeathsandthe 30-daymortalitywas17.6% (3/17). Buttwo patientsdiedat 2 and 3 months, increasing the postoperative mortality to 29.4% (5/17). Complete resection was achieved in 11 (65%) patients. By univariate analysis, myasthenia gravis was the only risk factor for broncho-pleural fistulae. With a median survival of 76 months and median follow-up of 59 months (range, 1—262 months), 5-year and 10-year survivals were 60% and 30%, respectively. During follow-up, a recurrence occurred in two patients at 26 and 87 months, respectively, which was treated medically without success.Conclusions:Pleuropneumonectomy for Masaoka stage IVa thymoma is associated with a high morbid-mortality rate. However, included in a multimodality strategy and in highly selected patients this procedure may provide good long-term survival. Crown Copyright # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

The optimal treatment for Masaoka stage IVA thymoma remains controversial. Whilst extrapleural pneumonectomy (EPP) has been proposed, we sought to examine the results of our institutional preference for induction chemotherapy, cytoreductive surgery and intraoperative hyperthermic pleural irrigation. We undertook a retrospective study of patients undergoing surgery for Masaoka stage IVA thymoma following induction chemotherapy over a three-year period at our institution. Between February 2007 and February 2010, 42 patients underwent surgery for thymoma. Six patients underwent surgery with intent to perform cytoreductive surgery and intraoperative hyperthermic pleural irrigation. Complete cytoreductive surgery was not feasible in one patient and thymectomy only was performed. One patient had re-operation for recurrent disease 24 months after the first operation and there were therefore seven procedures undertaken in six patients during the study period. There were no in-hospital deaths. Median follow-up was 18.8 months (range 1.5-31.9 months). One patient died 14 months postoperatively from an acute cardiovascular event. The four remaining patients are alive and well with no evidence of disease recurrence. Multimodality therapy consisting of induction chemotherapy and cytoreductive surgery is a safe, feasible treatment for stage IVA thymoma. Our experience suggest that full pleurectomy is an alternative to EPP.

Almost all series reporting on the results of resection in thymic tumors indicate that the performance of a complete resection is probably the most important prognostic factor. This issue is not a factor in Masaoka stage I and II tumors that are almost always easily completely resected and have an excellent prognosis. Masaoka stage III tumors that invade the pericardium, lungs, or great vessels have relatively higher incomplete resection rates, significantly higher recurrence rates, and thus a worse prognosis. There are several small reports on the efficacy of resection of the great veins when involved by a thymic malignancy with low morbidity and meaningful long-term survival. Superior vena cava reconstruction is commonly performed by a polytetrafluroethylene, venous, or pericardial graft. These cases can usually be identified preoperatively and, thus, considered for induction therapy. Because these types of cases are almost always of marginal respectability in terms of obtaining a true en bloc resection, there is an increasing enthusiasm for offering induction therapy in an effort to enhance resectability. Preliminary results suggest increased R0 resection rates and improved survival with induction therapy for locally advanced tumors. The optimal induction treatment is unknown. The ultimate extended surgery for advanced thymic tumors is an extrapleural pneumonectomy performed for extensive pleural disease (Masaoka stage IVA). These rarely performed operations are done for IVA disease found at initial presentation and for recurrent disease as a salvage procedure. Again these advanced patients are probably best managed by induction chemotherapy followed by resection.

Objective Extended resections for advanced-stage thymomas are not commonly performed because of the potential morbidity in the face of unclear survival or palliative benefit. We reviewed our experience with multimodality treatment for Masaoka stage IVA thymomas for feasibility and outcomes. Methods We conducted a retrospective review of a single-institution surgical database. Data included patient demographics, preoperative staging and treatment, perioperative events, pathologic findings, and postoperative outcomes. Results During the period from 1996 to 2006, 18 patients who had Masaoka stage IVA thymoma underwent surgical resection. All patients received preoperative chemotherapy. Four patients with extensive pleural involvement underwent concomitant extrapleural pneumonectomy and postoperative hemithoracic radiation. Complete resection was achieved in 12 (67%) patients. There was no operative mortality. With a median follow-up of 32.2 months (range 1.4–129.9 months), 3-year, 5-year, and 10-year survivals were 91%, 78%, and 65%, respectively, and median survival has not yet been reached. Conclusion Multimodality therapy including extended surgical resection can be performed in select patients with stage IVA thymoma with low morbidity and mortality and can result in excellent long-term survival.

We present 2 cases of a large thymoma with invasion to the hilum of the lung and pleural dissemination. Case 1: a 47-year-old woman was diagnosed with a type B3 thymoma with abundant left pleural effusion and multiple pleural masses, Masaoka stage IVa. A radical resection was planned after chemical pleurodesis and systemic chemotherapy. The left main pulmonary artery and left upper and inferior veins were dissected and resected in the pericardium, while the left main bronchus was cut behind the pericardium through a median sternotomy. Next, the median incision was closed and a left posterolateral thoracotomy was made, thus allowing the pleuropneumonectomy to be safely performed. Case 2: a 47-year-old woman was diagnosed with a type B3 thymoma with lymph node swelling and multiple pleural masses, indicating Masaoka stage IVb. Following induction chemotherapy, a thymothymectomy combined with a right pleuropneumonectomy was performed under a median sternotomy followed by a right posterolateral thoracotomy. The left brachiocephalic vein (BCV) was reconstructed with a ringed polytetrafluoroethylene (PTFE) graft, followed by resection of the right BCV. Next, the right main pulmonary artery and right upper and inferior veins were resected in the pericardium, and the right main bronchus was cut behind the pericardium, followed by reconstruction of the right BCV. Finally, the median incision was closed and a right posterolateral thoracotomy was made, thus allowing performance of a safe pleuropneumonectomy. The median sternotomy allowed safe dissection of pulmonary vessels surrounding the hilum of the lung and, in combination with a posterolateral thoracotomy, was required for performing a pleuropneumonectomy in patients with a huge thymoma with pleural dissemination. Electronic supplementary material The online version of this article (doi:10.1186/s40792-015-0071-z) contains supplementary material, which is available to authorized users.

Background The treatment of locally advanced Masaoka stage IVA thymoma is not standardized and is problematic. Methods A single-institution retrospective study was made of 5 patients with World Health Organization B3 thymomas who underwent pleuropneumonectomy for locally advanced thymoma. Two patients had recurrent thymoma and 3 presented de novo with stage IVA disease. Patients had a variety of induction and adjuvant treatments. Results There was no operative mortality, and only 1 patient had a major complication. Several patients had relatively prolonged disease-free survival. The median survival was 86 months, and the Kaplan-Meier survival was 75% (95% confidence interval: 53% to 97%) at 5 years and 50% (95% confidence interval: 25% to 75%) at 10 years. Conclusions Pleuropneumonectomy can be performed safely in patients with advanced thymomas and may improve survival. Highly selected patients might be cured with this approach if a complete resection is performed. While the optimal multimodality strategy for these patients is unknown, induction chemotherapy followed by resection then chemoradiotherapy seems promising.

Background: The optimal chemotherapeutic regimens for thymic cancers still remain controversial, although systemic chemotherapy is an important therapeutic modality for unresectable thymic cancer. In general, platinumbased regimens such as CODE and ADOC are widely used. However, several serious side effects of the platinum therapy may significantly restrict its efficacy for clinical application. We herein describe a case with a good response to TS-1 treatment for relapsed thymic cancer in a patient who could not tolerate platinum compounds. Case report: A 73-year-old woman was diagnosed with thymic cancer, Masaoka stage IVa, in May 2009. She underwent the concurrent chemoradiation therapy. In September 2011, lung metastasis of the thymic cancer was noted in the right upper lobe. It was difficult to continue platinum-based chemotherapy due to various life-threatening side effects of the treatment. In June 2013, the chest CT scan revealed the growth of the right upper lobe metastatic tumor and left upper lobe atelectasis due to a metastatic polyploidy lesion in the left upper bronchus. The patient underwent partial resection of the lesion and repeat resections in June and September 2014. At the same time, the right upper lobe metastatic tumor had continued to grow. The patient received chemotherapy with TS-1 monotherapy. There were no severe toxicities and the right upper lobe metastatic tumor showed a marked reduction in size. At present, TS-1 therapy has been continued and the patient remains well with an excellent performance status. Conclusion: TS-1 may be a good alternative treatment for patients who cannot tolerate platinum compounds.

Whole pericardial irradiation may be performed for mediastinal malignancies with pericardial dissemination or malignant pericardial effusion. Case 1 is a 57-year-old woman with a B1 thymoma, Masaoka stage IVa. She underwent whole pericardial irradiation and suffered post-irradiation constrictive pericarditis 3 years later. Diuresis, catecholamine infusions, drainage, and pericardiectomy were performed. However, she died of heart failure after 4 years and 1 month due to constrictive pericarditis. Case 2 is a 56-year-old woman with myasthenia gravis and a B2 thymoma, Masaoka stage III. She underwent an extended thymectomy with partial resection of the lung and pericardium and received adjuvant radiation therapy of the whole pericardium. She was affected by post-irradiation constrictive pericarditis 7 months later, for which she underwent pericardiectomy. However, her constrictive pericarditis remained. In conclusion, we report two advanced thymoma cases with post-irradiation constrictive pericarditis. Indicators for whole pericardial irradiation should be determined strictly and carefully.

Thymomas are rare neoplasms that have an indolent growth with a preferentially intra-thoracic dissemination pattern. Surgery is currently the standard treatment of thymomas; however radiotherapy is often used in an adjuvant setting due to a high sensitivity of these tumors to such treatment. Postoperative entire hemithoracic irradiation has been used in selected Masaoka stage IVa cases after complete surgical excision of metastatic lesions.In the present article, the authors report three cases of Masaoka stage IVa thymoma that underwent entire hemithorax irradiation after surgical excision of metastatic lesions. The first two patients presented as stage IVa thymomas. The third case consisted of a pleural recurrence of a thymoma.Hemithoracic irradiation with low doses has been used by different authors; the available data shows that it is a well-tolerated treatment that could potentially lead to better loco-regional control and increased overall survival.

We report a case of a caucasic woman aged 55, carrying a Masaoka stage IVa thymoma, initially not suitable to surgical treatment. After induction chemotheraphy, she underwent a radical resection of the mediastinal mass combined with left pleuro-pneumonectomy. After being disease-free for 5 years, the patient first developed a splenic recurrence, then an abdominal metastasis, both treated by surgery. To date she is alive and disease-free, 10 years after the first operation. The patient underwent multimodal treatment only after the first surgical operation, while the recurrences were only treated surgically. The exceptional nature of our case lies mainly in the site of the metastases (first the spleen, then the omentum), then in the long disease-free period, and in the final outcome which was beyond all expectations.

Objective 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. Material and Methods 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. Results 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. Conclusions 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.

14665 Background: Compared to other epithelial malignancies, genetic abnormalities are relatively rare in thymomas, they increase with increasing malignant behavior. C-Kit is highly expressed in thymic carcinomas (80%) but infrequent in thymomas. Scanty information is available on the role of C-Kit mutations in thymic carcinomas. Methods: Patients with surgically unresectable WHO B3 or C thymomas were enrolled in this study. Patients had to have performance status 0–2, good organ function and measurable disease. Imatinib was administered at 600 mg PO daily. The dose was increased to 800 mg (400 mg BID) if progression was observed in absence of clinical deterioration or no major response was achieved after two month treatment. Results: 7 patients were recruited at one institution, form June 2005 to August 2006. Two patients had WHO B3 and 5 had C, 2 had Masaoka stage IVA and 5 stage IVB, 4 had PS 2 and 3 PS 1, 6 were male, median age was 67 (range 36–76) and none had associated paraneoplastic syndromes. Th...