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BACKGROUND: Thymic carcinoma is a type of rare and highly malignant tumor. Limited information was available on prognostic factors of late-stage thymic carcinoma. The aim of this study was to identify factors that impact prognosis and to define the relationship between survival and surgical intervention in patients with Masaoka stage IV thymic carcinoma. METHODS: From 1973 to 2015, a total of 311 consecutive patients were enrolled in this study with pathologic confirmed Masaoka stage IV thymic carcinoma from the Surveillance, Epidemiology, and End Results database. Kaplan-Meier analyses, Cox-regression analyses and propensity score matching (PSM) were performed to evaluate prognosis. RESULTS: In the multivariate analysis, larger tumor size, distant metastasis and positive lymph node status were associated with poorer outcome. After PSM, no receipt of surgery was the prognostic factor indicating poorer survival [hazard ratio (HR) 1.985, 95% confidence interval (CI) 1.007–3.913, P=0.048 for overall survival (OS); HR 1.649, 95% CI: 1.009–2.697, P=0.046 for disease-specific survival (DSS)]. Subgroup analysis indicated that significantly improved survival with surgery was observed in patients who were

It is uncertain whether thymic neuroendocrine tumors (NET) associated with Cushing's syndrome (CS) produce corticotropin-releasing hormone (CRH) and adrenocorticotropin hormone (ACTH) and whether the thymus contains ACTH and/or CRH cells that could originate NET. The clinicopathologic features of 5 typical (TC) and 6 atypical carcinoids (ATC), 10 additional non-neoplastic thymi, 6 adrenal glands with bilateral nodular hyperplasia and 8 adrenal cortical adenomas were reviewed. Representative slides were immunostained for ACTH and CRH. Four (36.4%) of the 11 patients had CS. The incidence of Masaoka stage IV was higher (p 0.0001) in patients with ATC than TC. Only 2 (18.1%) of the 11 patients were alive at follow-up. Ten NET were CRH immunoreactive and 6 were ACTH immunoreactive. Thymic NET with CS exhibited stronger immunoreactivity for ACTH and CRH than those without CS. Non-neoplastic thymi exhibited scattered ACTH and CRH immunoreactive cells. Normal adrenal cortex and glands with bilateral nodular hyperplasia showed diffuse CRH immunoreactivity while adrenal adenomas showed no or only focal CRH immunoreactivity. Literature review showed no association between thymic NET and adrenal adenomas. The thymus contains CRH and ACTH immunoreactive cells that are probably the origin of thymic NET. Neoplasms associated with CS exhibit strong immunoreactivity for both hormones, suggesting that CRH probably plays a role in the pathogenesis of CS. As adrenals with bilateral nodular hyperplasia exhibit diffuse CRH immunoreactivity and adrenal cortical adenomas either lack this finding or show few immunoreactive cells, this marker may be useful to distinguish these lesions.

Background: The use of video-assisted thoracic surgery (VATS) in the treatment of thymoma is becoming more and more common. The aim of this study was to evaluate safety and effectiveness of thoracoscopic treatment of thymoma and, more importantly, to report long-term follow-up results of a large single-center cohort. Methods: A retrospective review of a prospective database was performed. In total, 150 patients who underwent VATS resection for thymoma at Peking University People’s Hospital from April 2001 to November 2014 were retrospectively reviewed. Results: Average operation time was 140.1±54.2 min, median blood loss was 50 mL (range, 10–700 mL), median post-operative drainage time was 3 days (range, 1–11 days), and median length of post-op stay was 5 days (range, 2–20 days); 134 patients (89.3%) were followed up successfully. Median follow-up was 59.5 months (range, 2–187 months). Five- and 10-year recurrence free survival (RFS) rates of entire group were 96.5% and 94.4%, respectively; 5- and 10-year RFS rates for Masaoka stages I + II were 98.1% and 98.1%, respectively; 5- and 6-year RFS rates for Masaoka stage III were 90% and 60%, respectively. One case of recurrence in ve Masaoka stage IV patients was observed, and 4-year RFS was 80%. Multivariable analysis indicated that recurrence tended to occur in Masaoka stages III + IV patients (P=0.037, HR =12.69, 95% CI: 1.17–138.22) and older patients had a lower risk of recurrence (P=0.029, HR =0.87, 95% CI: 0.77–0.99). Myasthenia gravis (MG) presented in 44 patients (29.3%), of which 36 patients (81.8%) were followed up. Nine patients achieved complete remission, and 19 patients had symptom improvement after surgery. Overall response rate of MG was 77.8% (28/36). Conclusions: VATS was a safe and effective procedure for treatment of thymomas with satisfactory prognosis. MG with thymoma treated by VATS had comparable neurological outcome to that associated with the trans-sternal approach.

We report the case of a 44-year-old woman with Masaoka stage IV, World Health Organization type B1 thymoma associated with pure red cell aplasia, thrombocytopenia, and myasthenia gravis, which occurred during preoperative chemotherapy with high-dose methylprednisolone. Noninvasive positive-pressure ventilation, intravenous immunoglobulin infusion, and methylprednisolone pulse therapy were performed for the myasthenic crisis. Disseminated thymoma was markedly reduced after these treatments, and macroscopic complete resection was performed after achieving control of pure red cell aplasia, myasthenia gravis, and thrombocytopenia using cyclosporine A. Chemotherapy, including high-dose methylprednisolone, may carry a risk of myasthenic crisis, although the regimen is effective against lymphocyte-rich thymoma.

Background: This study investigated the usefulness of fluorine-18 fluorodeoxyglucose-positron emission tomography (FDG-PET) during the treatment of thymic epithelial tumors in combination with Ki-67 evaluation based on surgical cases in our department. Methods: Between November 2003 and May 2011, 39 patients with thymic epithelial tumor underwent preoperative FDG-PET. The maximum standardized uptake value (SUVmax) of each category within Masaoka stage, World Health Organization classification, tumor diameter, myasthenia gravis, and Ki-67 label index were compared. To examine risk factors for relapse, SUVmax, age, sex, and surgical radicality were investigated in addition to those items. Results: The mean SUVmax was 4.5 (range, 1.2 to 14.6) and was significantly higher for Masaoka stage IV than for I and II (all p < 0.008) and for World Health Organization classified thymic cancer compared with all other types (all p < 0.0001). Mean SUVmax revealed significantly higher values for large tumors than for small tumors (p = 0.02). Mean SUVmax was significantly higher for high Ki-67-positive samples (p = 0.0004), indicating a strong correlation between SUVmax and the Ki-67 label index (ρ = 0.77, p = 0.0001). SUVmax accurately reflected therapeutic efficacy in patients with induction therapy. Univariate analysis revealed Masaoka stages III and IV and pathologically incomplete resection as risk factors for relapse. On multivariate analysis, independent risk factors for relapse comprised only Masaoka stages III and IV. Conclusions: FDG-PET SUVmax does reflect proliferation and invasiveness of thymic epithelial tumors and can provide an index for diagnosis and treatment, although it is not a risk factor for relapse. FDG-PET is also useful for evaluating induction therapy efficacy and detecting relapse. © 2013 The Society of Thoracic Surgeons.

Background: Thymic tumors are the most frequent anterior mediastinal tumors. However, no randomized clinical trials provide definitive treatment guidance for the management of Masaoka stage IV patients. The aim of this study is to determine the values of multimodal therapy in Masaoka stage IV thymic tumors. Methods: We retrospectively studied 26 patients with Masaoka stage IV thymic tumors that were diagnosed between 2006 and 2014. Twenty-two patients were treated with surgical resection, postoperative irradiation, and adjuvant cisplatin-based chemotherapy. The remaining four patients with inoperable diseases were given radiotherapy and/or chemotherapy. Thymic carcinomas were found in 17 patients. Stage IVa disease occurred in 9 patients (pleural dissemination: 6, pericardial dissemination: 3); while the remaining 17 were stage IVb disease. Radiation dose was escalated to 60–66 Gy if the gross disease had been noted. Total radiation doses ranged from 50 to 66 Gy. Results: For all patients, the survival rates were 69.2% for 5-year overall survival, 38.5% for progression-free survival, and 57.7% for locoregional recurrence-free survival. The median survival was 49.98 months (range, 5.93–138.57 months) and the median progression-free survival was 28.83 months (range, 2.33–121.33 months). For 17 patients with thymic carcinomas, the survival rates were 58.8% for 5-year overall survival, 41.2% for progression-free survival, and 58.8% for locoregional recurrence-free survival. Their median survival was 45.07 months (range, 3.53–121.33 months) and the median progression-free survival was 16.73 months (range, 2.33–121.33 months). The predictor of progression-free and locoregional recurrence-free survival was the surgical intervention (surgery vs. biopsy only, P Conclusions: Multimodal therapy improved the survival outcome of patients with stage IV thymic tumors. Surgical resection (including debulking surgery) was the key contributor of progression-free survival and locoregional control.

7107 Background: Thymoma and thymic carcinoma (TC) are rare tumors, but represent the most common neoplasms of the anterior mediastinum. The vast majority of TET present in early stages with little data existing on factors influencing survival in patients with advanced or stage IV disease. Methods: A retrospective analysis was performed on patients with confirmed TET (histology and with tissue blocks) seen at IUSCC diagnosed between 1976 and 2011. Patient demographics including Masaoka stage, histology, and sites of metastasis were linked with progression free survival (PFS) and overall survival (OS). Results: Our analysis included 102 patients with stage IV TET: 50 presented de novo and 52 developed stage IV disease following primary treatment. When stratified by tumor histology (thymoma or TC), patients with TC had considerably poorer PFS (p=1.87x10-7) and OS (p=7.72x10-8). The median PFS for TC was 13 months (range 4 to 39) and the MST was 36 months (range 4 to 115). PFS at 5-years was 21% and 0% but the five-year OS was 84% and 29% for thymoma and TC, respectively. Ten year OS was 55% for patients with thymoma and 0% for those with TC. Pleural (>3 vs. -5). Conclusions: Patients with TC have significantly poorer PFS and OS when compared to thymoma confirming that TC is a distinct clinical entity from thymoma. Patients with thymoma may have prolonged survival, despite having residual disease. Although current staging places patients with pleural metastasis (Masaoka stage IVA) and those with lung nodules (stage IVB) as separate categories, our data would suggest that those with lung nodules have similar survival with those who have pleural metastasis.