Invasive thymoma with extensive growth in the superior vena cava;report of a case

An anterior mediastinal tumor was incidentally found in a 58-year-old asymptomatic woman on a medical checkup. Computed tomography (CT) demonstrated a large tumor plugging the almost entire lumen of the superior vena cava (SVC), and 3 nodules in the bilateral lungs. The tumor seemed most likely an advanced thymoma or thymic carcinoma extending into the SVC and presenting with lung metastases. The patient underwent a combined resection of the invasive tumor and the SVC under cardiopulmonary bypass (CPB), and lung wedge resection for the nodules. The bilateral brachiocephalic veins were reconstructed with the separate grafts. The invasive tumor and the lung nodules were histologically confirmed as thymoma. Resection and reconstruction of the SVC was successfully performed under CPB for extirpation of an invasive thymoma with extensive intracaval growth. Combination chemotherapy for the relapsing lung metastases finally achieved complete response 41 months after surgery.     

A case of invasive thymoma with retroperitoneal recurrence]

A case of invasive thymoma with retroperitoneal recurrence is reported. A 55-year-old man with invasive thymoma (Masaokas classification, Stage IVa) underwent thymo-thymectomy, partial resection of left upper lobe, resection of phrenic nerve and partial resection of parietal pleura on March 14, 1989. Histological findings revealed thymoma with predominantly lymphocytic type. Two years after the operation, the tumor of retroperitoneal recurrence was discovered in abdominal CT. This retroperitoneal tumor was huge in size (16 x 12 cm) and extended into posterior mediastinum via aortic hiatus. The patient underwent resection of tumor through thoracotomy and laparotomy on April 23, 1991, after two cycles of chemotherapy. Histological findings revealed thymoma with predominantly lymphocytic type. This case was rare among patients with recurrence of thymoma as far as the site of recurrence is concerned.     

Metastatic lung tumor developing 15 years after resection of invasive thymoma

A 57-year-old man with myasthenia gravis had undergone extended thymothymomectomy for invasive thymoma and postoperative irradiation 15 years ago. At present, an abnormal shadow on his left lung field on chest X-ray and an elevated SCC-Ag level led us to suspect primary lung cancer (squamous cell lung cancer). He underwent left lower lobectomy and partial resection of the upper lobe. After the operation, this tumor was indentified pathologically as a thymoma. Comparing this tumor with the previous invasive thymoma, we concluded that the present lesion was a metastasis of the former thymoma. This case suggests that a metastatic lung tumor should be suspected when an abnormal shadow is detected on chest X-ray following extended thymothymomectomy for invasive thymoma.     

Metastatic lung tumor developing 15 years after resection of invasive thymoma]

A 57-year-old man with myasthenia gravis had undergone extended thymothymomectomy for invasive thymoma and postoperative irradiation 15 years ago. At present, an abnormal shadow on his left lung field on chest X-ray and an elevated SCC-Ag level led us to suspect primary lung cancer (squamous cell lung cancer). He underwent left lower lobectomy and partial resection of the upper lobe. After the operation, this tumor was identified pathologically as a thymoma. Comparing this tumor with the previous invasive thymoma, we concluded that the present lesion was a metastasis of the former thymoma. This case suggests that a metastatic lung tumor should be suspected when an abnormal shadow is detected on chest X-ray following extended thymothymomectomy for invasive thymoma.     

Extended operation for invasive thymoma with intracaval and intracardiac extension.

Two cases of invasive thymoma with intracaval and intracardiac extension into the right atrium are reported. Radical excisions and reconstructions of the superior vena cava (SVC) requiring extracorporeal circulation were performed. Invasive thymoma with this growth pattern is extremely rare, and patients with SVC obstruction should be evaluated for the resection of tumors and reconstruction of the SVC.     

Thymoma with synchronous pulmonary metastasis; report of a case

We report a resected case of thymoma with a solitary pulmonary metastasis. A 63-year-old woman had pointed out a solitary nodule in right lung field on chest X-ray. Computed tomography (CT) scan showed an anterior mediastinal tumor and a solitary lung nodule in the right lower lobe. Extended thymectomy and partial resection of right lung was performed. Pathological diagnosis showed an invasive thymoma (type B3) and a pulmonary metastasis. Post operative radiotherapy was administered and she is doing well 19 months following the resection. Thymoma with a solitary synclonous pulmonary metastasis is rare and is classified into Masaoka stage IVb. Generally, thymoma cases with distant metastasis are not indication for operation. But, if radical resection is possible, operation is recommended for good prognosis.     

恶性胸腺瘤侵犯大血管的手术治疗及术后生存调查

目的分析恶性胸腺瘤患者的手术方式及其预后,以期寻找到侵犯大血管的恶性胸腺瘤的最佳治疗方案。方法回顾性总结2003年1月至2008年12月期间有明确肿瘤侵犯大血管的患者19例,其中行Y型血管置换术2例,行双根人工血管置换6例,行单根上腔静脉和(/或)其属支置换术6例,行上腔静脉和(/或)其属支成形术5例。5例患者行主动脉和(/或)其属支外膜剥离。13例患者同时切除受侵犯肺组织,行解剖学肺段切除2例,行肺叶切除11例。12例患者因肿块完全侵犯膈神经,行单侧膈神经切除11例,行双侧膈神经切除1例。结果 19例患者平均生存期44.1(3～114)个月。1年生存率88.2%(15/17),3年生存率64.7%(11/17),5年生存率50%(4/8)(截至2012年10月)。结论恶性胸腺瘤侵犯上腔静脉和无名静脉并致梗阻不应成为纵隔肿瘤局部根治性切除的禁忌。掌握手术指征和禁忌,争取根治性切除是提高生存率的关键。术后的后续治疗,尤其是放疗,也是延长患者生存时间的因素之一。     

Prosthetic replacement and tangential resection of the superior vena cava in chest tumors

AIM: Infiltration of the superior vena cava (SVC) due to advanced non small cell lung cancer (NSCLC) or thymoma can be treated by prosthetic replacement or tangential resection. These two technical procedures and their results are described. METHODS: From 1988 to 2002, we performed 37 SVC resections: 21 replacements with polytetrafluoroethylene (PTFE) prostheses and 16 tangential exereses. Sixteen patients affected by locally advanced NSCLC (12 T4; 4 extracapsular N2) and 5 subjects with thymoma (Stage III Masaoka) underwent prosthetic replacement of the SVC. After neoadjuvant polychemotherapy, tangential resection was performed on 12 patients with extracapsular N2 NSCLC, and in 1 patient with T4 and in 3 patients with T3a disease. We performed prosthetic replacement in 18 cases using a straight prosthesis (?18-20 mm). A bridge (10-14 cm) between the innominate vein and the right atrium was created in 3 patients. The main indication for a prosthetic replacement was infiltration of more than 30% of the circumference of the SVC. There were 4 thromboembolic complications (19%), with one intraoperative death (4.8%). Tangential resection of the SVC for infiltration <20% was performed both manually and with staplers (double clamping) without any major complications. RESULTS: Mean survival was 23 months in those patients who had undergone PTFE replacement for T4 lung cancer and for thymoma. Mean survival was 15 months in those who had undergone tangential resections for NSCLC with extracapsular N2. We performed restaging of the tumor using chest angio-CT scan in 11 patients, one year after the operation. We found 80% patency in 7 SVC prostheses and 50% patency in 4 others: the two bridges between the left innominate vein and the right atrium appeared to be partially closed but were compensated by important collateral circles. CONCLUSION: SVC replacement, associated with pulmonary resection or removal of mediastinal masses, can be performed in selected cases. It should not be considered as palliative treatment because of the important perioperative risks. SVC tangential resection involves fewer surgical problems. However, since this procedure is used mostly for N2 NSCLC subjects, patients have a low mean survival in spite of adjuvant therapy.     

Ruptured thymoma causing mediastinal hemorrhage resected via partial sternotomy

A case of a ruptured thymoma causing mediastinal hemorrhage and hemothorax that was electively resected by a partial sternotomy approach is presented. This case and others previously reported illustrate that a sudden onset of dyspnea and chest pain accompanied by acute mediastinal widening on chest roentgenogram in a previously healthy patient should suggest the diagnosis of a ruptured thymoma. An upper part sternotomy approach may be as safe and effective as a less invasive surgical procedure in resection of noninvasive thymomas, even if dense tumor adhesion exists.     

Surgical strategy for invasive pulmonary and mediastinal tumors requiring superior vena cava reconstruction

During the past 16 years, 22 patients were operated on concomitantly with superior vena cava (SVC) reconstruction in our university hospital. Among them, 19 patients had anterior mediastinal tumor and 3 advanced lung cancer. They were 13 males and 9 females, ranging in age from 16 to 70 (mean, 51.4) years. Severe SVC syndrome was found in 10 cases of them. The anterior mediastinal tumors consisted of invasive thymoma in 10 cases, thymic Hodgkin's disease in 2, seminoma in 2, and thymic cancer, thymic carcinoid, thyroid cancer, metastasis of chondrosarcoma and yolk sac tumor in each one. Regarding SVC reconstruction, anatomical bypass was performed in 18 cases, in addition to a radical resection of the tumor. The left innominate vein was reconstructed in 5, the right innominate vein including SVC in 4 and bilateral veins in 9. Extra-anatomical bypass was performed in 4 cases with unresectable tumors because of severe SVC syndrome. Subclavian-femoral vein bypass was performed in one and internal jugular-femoral vein bypass in 3. In anatomical bypass, 7 cases have been alive now though 11 died, and graft patency rate was 82% in the right and 38% in the left. All 4 cases with extraanatomical bypass showed improvement of SVC syndrome, but died one to seven months postoperatively. In conclusions, radical operation with reconstruction of SVC was effective to long-term survival and improvement of SVC syndrome. Extraanatomical bypass improved postoperative quality of life remarkably.     

Invasive thymoma with endobronchial polypoid growth

A rare case of invasive thymoma with endobronchial polypoid growth is presented. A 68-year-old woman presented with coughing and sputum. The chest X-ray and computed tomography (CT) findings demonstrated a large mass with a calcified lesion in the left hilar region. A bronchoscopic examination showed a polypoid tumor in the left B³b bronchus. The tumor was surgically resected and revealed a unique polypoid endobronchial extension. This tumor was pathologically diagnosed to be invasive thymoma.     

Spontaneous regression of an invasive thymoma

Although there are many reports of spontaneous regression of noninvasive thymoma, there are no reports of spontaneous regression of an invasive thymoma. Moreover, the mechanism of the spontaneous regression is still unknown. The present case concerns a 47-year-old man who presented with chest pain. Computed tomography (CT) showed a large anterior mediastinal mass with left pleural effusion that occluded the innominate vein. The tissue obtained by video-assisted thoracic surgery suggested a diagnosis of invasive thymic carcinoma. One month later CT showed prominent regression of the tumor, and the tumor was completely resected. On pathology, the diagnosis was thymoma type B3.     

A case of a large invasive thymoma successfully treated by using a combination of artery infusion of CDDP and operation

A 21-year-old male was admitted with SVC syndrome. Chest X-ray film showed an abnormal density on the upper mediastinum, that was recognized thymoma on the needle aspiration specimen. The large tumor, which extensively infiltrated the surrounding tissues (SVC, the right brachiocephalic vein, bilateral lungs and the pericardium) led us to choose preoperative chemotherapy. CDDP (cisdiammin-edichloroplatinum) was infused through the right IMA (internal mammary artery). After obtaining the major response the tumor mass was resected with adjacent structure accompised vessels reconstructions. Histological examination revealed totally necrosed tissue. Three years after initiation of therapy, the patient is doing well. The therapy with CDDP injection into selective IMA for invasive thymoma before operation was considered to be very useful utilized.     

Pleuropneumonectomy with combined resection of diaphragma, superior vena cava, and pericardium, for invasive thymoma with pleural dissemination

A 63-year-old female was admitted to our hospital with chief complaint of exertional dyspnea. Right massive pleural effusion was found. After chest drainage was performed, chest CT scan and MRI showed several masses in the anterior mediastinum and on the diaphragma. Mesothelioma was suspected for needle biopsy. Pleuropneumonectomy with combined resection of diaphragma, superior vena cava and pericardium was performed. Histologically, the Tumor was mixed thymoma. She is well and alive for three years after operation. Pleuropneumonectomy may be a choice of effective treatments for invasive thymoma with pleural dissemination.     

Is postoperative radiotherapy for thymoma effective?

OBJECTIVE: The authors determined the effect of postoperative mediastinal irradiation in preventing local and pleural recurrence of thymoma. SUMMARY BACKGROUND DATA: The role of mediastinal irradiation after incomplete resection or biopsy of an invasive thymoma is well established. However, routine use of adjuvant mediastinal irradiation for patients with thymoma after complete resection remains controversial. METHODS: During the 19-year period from 1973 to 1992, operations were performed on 89 patients with thymoma. Of these 89 patients, 80 patients who underwent gross complete tumor resection including adjacent tissues that appeared to be invaded by tumor were selected for this study. The effects of postoperative mediastinal irradiation on the recurrence rate of thymoma were analyzed according to histologic type, clinical stage, and whether adhesions to or invasion of the pleura or pericardium were present. RESULTS: Recurrence of thymoma was observed in 13 of 80 (16.3%) patients. No recurrence was observed in 23 patients with noninvasive thymoma. In patients with invasive thymoma whose tumor was macroscopically adherent to the pleura but not microscopically invasive (p1), recurrence was observed in 4 of 11 patients (36.4%) when mediastinal irradiation was not performed, but in none of 10 patients who received mediastinal irradiation. However, in patients with microscopic pleural invasion (p2), a high recurrence rate was observed with mediastinal irradiation (40%, 6/15 patients) or without mediastinal irradiation (30%, 3/10 patients). Postoperative mediastinal irradiation for patients with microscopical invasion to pericardium (c2) did not decrease the recurrence rate. Analysis of the mode of recurrence showed that mediastinal irradiation may have been effective in preventing local recurrence, but it did not control the pleural dissemination that was observed in 12 of 13 recurrent cases. CONCLUSIONS: Mediastinal irradiation is not necessary for patients with noninvasive thymoma. In patients with invasive thymoma, postoperative mediastinal irradiation is effective in preventing recurrence in patients with p1 thymoma, but not in patients with p2 or c2 tumors. Further adjuvant therapy should be performed to supplement mediastinal irradiation in patients with p2 or c2 thymoma, even after complete resection.     

Thoracoscopic Resection of Middle Mediastinal Noninvasive Thymoma: Report of a Case

We performed thoracoscopic resection of a middle mediastinal noninvasive thymoma in a 69-year-old woman. Chest computed tomography on admission showed a tumor, 75 x 48 x 32 mm in size, and pathological examination revealed a spindle-cell, noninvasive thymoma, of type A according to the World Health Organization classification, and stage I according to the Masaoka staging system. Thymomas are prone to ectopic occurrence, and should be considered in the differential diagnosis of middle mediastinum tumors.     

Rapid enlargement of a mediastinal mass: thymoma hemorrhage into a thymic cyst

A 52-year-old man was admitted to Matsudo City Hospital because of an anterior mediastinal mass. One month prior, when he suddenly suffered chest pain, computed tomography (CT) showed a 4 x 3 cm mass in the chest. On admission, the symptom disappeared. However, chest CT revealed rapid enlargement of the mass to 10 x 6 cm. Based on the CT findings, we suspected a tumor. Therefore, we performed a thymothymectomy. The mass, measuring 12 x 8 x 6 cm, contained a solid tumor and a fl uid-filled cyst. Pathology showed a thymoma and a multilocular thymic cyst. We speculated that hemorrhage from the thymoma spread into the multilocular thymic cyst and enlarged the mass.     

胸部肿瘤侵及大血管时的手术处理

目的 总结64例胸部肿瘤浸润大血管手术时的处理经验，分析上腔静脉（SVC）手术技术及指征以及肺动脉袖状切除的适应证。方法 回顾性分析1991年1月至1999年6月64例胸内大血管受到肿瘤浸润患者的手术经验。受侵血管包括肺动脉根部和（或）肺动脉干、上静脉和（或）下肺静脉根部、SVC和（或）无名静脉。结果 24例接受了不同类型的SVC手术，包括左及右无名静脉分别与右心房人工血管搭桥术1例、左无名静脉与右心房人工血管搭桥4例、右无名静脉与右心房搭桥3例、奇青脉切除并SVC部分切除11例、单纯SVC部分切除5例。SVC置换或搭桥除1例应用涤纶血管者外，其余均是Gore-Tex人工血管，5例部分切除者使用了缝合器，41例肺动脉部分或袖状切除（肺动脉袖状并支气管袖状成形4例）、左心房部分切除13例，应用肺血管阻断或临时架桥术，所有手术均成功进行，无手术死亡，无严重并发症。SVC切除后生存时间最长者已达15年，为1例恶性畸胎瘤患者，肺癌切除SVC、无名静脉搭桥患者术后生存最长者已达5年。结论 大血管包括SVC及肺血管阻断与成形技术以及SVC置换术，是根治性切除浸润大血管的胸部肿瘤的关键性技术，正确及时地应用可以提高根治性切除率和安全性，减少探查率。     

Results of surgical treatment for thymoma based on 66 patients

Sixty-six patients with thymoma have undergone surgical treatment since 1965 and have been assessed from the viewpoint of clinical manifestations and prognosis. Thirty-one patients with encapsulated thymoma were treated with total surgical resection alone, and they had no postoperative tumor recurrence. With the exception of one patient who died of respiratory insufficiency on the fourth day after the operation, 34 patients with invasive thymoma were evaluated on the basis of their postoperative prognosis. Fifteen patients with invasive thymoma died from 1 1/2 months to 10 years, 1 month postoperatively; 9 died of local or metastatic tumor and 6 died of other diseases. Associated autoimmune diseases, as well as the invasive tendency of the tumors, apparently affected the prognosis. Ten-year survival rates of the patients who underwent surgical treatment were as follows: 61.6% for the total group, 74.3% for those with encapsulated thymoma, and 49.4% for those with invasive thymoma. In the surgical treatment for invasive thymomas, one should aim to resect the tumor totally, even though adjacent tissues are resected simultaneously. Even for the patient with total resection of invasive tumor, postoperative radiation should be required. Finally, if residual tumor must be left during the operation, postoperative radiation as well as anticancer chemotherapy should be aggressively scheduled, because postoperative distant metastasis may appear in these patients with residual thymoma.     

A case of adenocarcinoma of thymus

We report an adenocarcinoma of the thymus in a 39-year-old male. The patient presented with chest pain, and the chest X-ray film and chest CT showed an abnormal mass in the mediastinum. A preoperative clinical diagnosis of invasive thymoma was suspected. The tumor was resected along with the pleura and pericardium. The pathological findings were compatible with those of adenocarcinoma of the thymus. Despite a thorough examination, no primary tumor could be found. An adenocarcinoma of the thymus is rare and to the authors knowledge there are few previous reports in the literature.