Journal of Medical Society

CASE REPORT
Year
: 2013  |  Volume : 27  |  Issue : 2  |  Page : 151--153

A rare case of advanced thymic carcinoma: A case report


Ng Javan1, Ningombam Jitendra1, Rosemary Vumkhoching1, L Chaoba Singh2,  
1 Department of Surgery, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal, Manipur, India
2 Department of Anesthesia, RIMS, Imphal, Manipur, India

Correspondence Address:
Ng Javan
Department of Surgery, Jawaharlal Nehru Institute of Medical Sciences, Porompat, Imphal, Manipur - 795 005
India

Abstract

We present here a case of advanced thymic carcinoma in a 45-year-old lady who came to us with complaints of chest pain, cough, and dyspnea on exertion. Contrast enhanced computed tomography (CECT) of the chest of the patient showed an anterior mediastinal mass with prominent superior vena cava. The patient underwent debulking of the thymic mass; complete resection could not be done because the tumor was found infiltrating the superior vena cava, pericardium, and left innominate vein. The final histopathological diagnosis was a thymic carcinoma. Postoperatively, the patient received 60 Gy of radiotherapy and three cycles of adjuvant chemotherapy consisting of cisplatin, doxorubicin, and etoposide. We conclude that surgery in combination with adjuvant chemotherapy and radiotherapy are beneficial even in patients in an advanced stage of thymic carcinoma.



How to cite this article:
Javan N, Jitendra N, Vumkhoching R, Singh L C. A rare case of advanced thymic carcinoma: A case report.J Med Soc 2013;27:151-153


How to cite this URL:
Javan N, Jitendra N, Vumkhoching R, Singh L C. A rare case of advanced thymic carcinoma: A case report. J Med Soc [serial online] 2013 [cited 2023 Jan 29 ];27:151-153
Available from: https://www.jmedsoc.org/text.asp?2013/27/2/151/121602


Full Text

 Introduction



Thymic carcinomas are rare epithelial tumors of the thymus. Thymic carcinomas and invasive thymomas jointly constitute only 0.2 to 1.5% of the malignancies in adults. [1] Thymic epithelial tumors have an indolent clinical course and are often associated with vague and subtle symptoms. Approximately 30% of the patients are asymptomatic and local symptoms when present, include pain in the chest or back, cough, hoarseness, and dyspnea. A small proportion of patients may present with superior vena cava syndrome and weight loss. [2] Usually they are at an advanced stage when diagnosed and have both a high recurrence and poor survival rate. [1] Due to the rarity of the case, there is no standard modality of treatment available especially in advanced cases. [3],[4] Surgery forms the mainstay of therapy in thymic malignancies. However, they are also sensitive to chemotherapy and radiation therapy. [5]

 Clinical Feature/Case Report



A 45-year-old female manual laborer was admitted with complaints of chest pain, cough, and dyspnea on exertion. On examination, she was found to have a mild engorgement of neck vein and dilated anterior chest veins. Examination of the respiratory and cardiovascular systems was found to be normal. On investigation, her blood parameters including complete hemogram, liver and kidney function tests, blood sugar, and electrocardiograph (ECG) were all within the normal limit. Chest X-ray showed mediastinal widening and contrast enhanced computed tomography (CECT) of the thorax revealed anterior mediastinal mass [Figure 1] with a prominent superior vena cava (SVC). Fine needle aspiration cytology was done which was inconclusive. With a provisional diagnosis of thymic mass, the patient underwent sternotomy and debulking of the tumor [Figure 2]. Complete resection of the thymic mass could not be done as it was infiltrating the SVC, pericardium, and left innominate vein. The final histopathological diagnosis of the surgical specimen was reported as thymic carcinoma [Figure 3], type C; stage IV (WHO classification). Postoperatively, the patient received 60 Gy of radiotherapy and three cycles of adjuvant chemotherapy consisting of cisplatin, doxorubicin, and etoposide. The patient is doing well without apparent recurrence of tumor and metastasis after 36 months of surgery.{Figure 1}{Figure 2}{Figure 3}

 Discussion



Anterior mediastinal mass includes neoplasms like thymomas, lymphomas, thymic carcinomas, thymic carcinoids, thymolipomas, germ cell tumors, parathyroid adenomas, or non-neoplastic conditions like intrathoracic goiter, thymic cysts, lymphangiomas, and aortic aneurysms. [6] Most of the benign mediastinal masses are seen in asymptomatic patients; however, symptomatic patients often have malignant mediastinal lesions. Thymic carcinomas are rare neoplasms and account for less than 10% of thymic tumors. [2] Thymic carcinoma mostly appears to arise de novo, but in rare instances, they can also arise in thymomas. [7]

All patients with a mediastinal mass should undergo thorough investigation to determine the type of mass and extent of disease. These tests should include CECT of the chest, positron emission tomography (PET) scan, radiolabeled octreotide scan (optional), and complete blood counts including platelets. Pulmonary function tests and magnetic resonance imaging (MRI) of the chest can also be done if clinically indicated. [6] The classification and staging of thymic epithelial neoplasms has long been a matter of debate. The two classifications commonly followed and widely accepted are the Masaoka staging system and the classification by the World Health Organization (WHO). Thymic carcinoma is designated as type C by the WHO. [2],[8]

Surgery forms the mainstay of treatment, as complete resection represents the most significantly favorable prognostic factor on an overall rate of survival. However, thymic malignancies are also sensitive to chemotherapy and radiation therapy. Systemic chemotherapy is primarily used for the treatment of metastatic or recurrent disease. In an advanced stage, chemotherapy is also used as neoadjuvant therapy with the aim to achieve a complete surgical resection. [4],[8]

Due to the rarity of the case, there is no standard modality of treatment available, especially in advanced cases. [3],[4] The management of patients with thymic epithelial tumors has mainly been based upon retrospective series, uncontrolled nonrandomized trials, or expert opinion. The stage-based proposal of therapeutic strategies for thymic carcinoma for Masaoka stage I-II is complete resection (with or without radiotherapy), and for incomplete resection, radiotherapy has to be given. For stage III-IVa, surgery with en bloc resection of the tumor and involved structures, with postoperative radiotherapy has to be given. For an unresectable tumor, initially neoadjuvant chemotherapy is given and if the tumor becomes resectable, surgery with en bloc resection of the tumor and involved structures, with postoperative radiotherapy has to be given. If the tumor is still unresectable after neoadjuvant chemotherapy, definite radiotherapy has to be given. For stage IVb, treatment is chemotherapy. [2],[8]

The prognosis of advanced thymic carcinoma is poor, but a combined modality therapy including surgery, chemotherapy, and radiation can be effective for some advanced cases of thymic carcinoma. [4] The most important prognostic factor for overall survival is the extent of resection. Hosaka et al.[9] in their review have shown that the surgical outcome of patients with thymic carcinoma depends on the Masaoka stage and histologic grade. Patients with an early Masaoka stage and low or intermediate histologic grade have a favorable prognosis.

 Conclusion



Thymic carcinoma is a rare tumor of the thymus and there is no standard modality of treatment available especially in advanced cases; hence, the prognosis of advanced cases is usually poor. Even though our case was of an advanced thymic carcinoma, it has shown a good response to surgical debulking and postoperative chemotherapy and radiotherapy.

References

1Stachowicz-Stencel T, Bien E, Balcerska A, Godzinski J, Synakiewicz A, Madziara W, et al. Thymic carcinoma in children: A report from the Polish Pediatric Rare Tumors Study. Pediatr Blood Cancer 2010;54:916-20.
2Venuta F, Anile M, Diso D, Vitolo D, Rendina EA, De Giacomo T, et al. Thymoma and thymic carcinoma. Eur J Cardiothorac Surg 2010;37:13-25.
3Hashimoto H, Oshika Y, Obara K, Sato K, Matsukuma S, Tanaka Y. Advanced thymic carcinoma effectively treated by surgical resection and postoperative radiation therapy: Report of a case. Kyobu Geka 2010;63:415-8.
4Kuriyama S, Ohashi R, Matsuda K, Sugano K, Muraki K, Minakata K, et al. Twelve cases of advanced thymic carcinoma: A clinical review. Nihon Kokyuki Gakkai Zasshi 2010;48:604-8.
5Rajan A, Giaccone G. Chemotherapy for thymic tumors: Induction, consolidation, palliation. Thorac Surg Clin 2011;21:107-14.
6Ettinger DS, Akerley W, Bepler G, Blum MG, Chang A, Cheney RT, et al. Thymic malignancies. J Natl Compr Canc Netw 2010;8:1302-15.
7Kuo TT, Chan JK. Thymic carcinoma arising in thymoma is associated with alterations in immunohistochemical profile. Am J Surg Pathol 1998;22:1474-81.
8Girard N. Thymic epithelial tumours: From basic principles to individualised treatment strategies. Eur Respir Rev 2013;22:75-87.
9Hosaka 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;89:912-7.