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Ann Thorac Surg 1996;61:521-524
© 1996 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Surgical Treatment for Invasive Thymoma, Especially When the Superior Vena Cava Is Invaded

Department of Thoracic Surgery, Chest Disease Research Institute, Kyoto University, Kyoto, Japan

Accepted for publication September 22, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. We analyzed the operative outcome of extensive surgery for invasive thymoma, especially in those with thymomas invading the superior vena cava, the left innominate vein, or both.

Methods. We treated 41 patients with invasive thymoma, including 34 stage III, 5 stage IVa, and 2 stage IVb thymomas. Thirty-eight patients received radiotherapy preoperatively or postoperatively. In 12 patients with invasion of the superior vena cava or innominate vein, we performed angioplasty, reconstruction, or both.

Results. The overall 5-year survival rate was 77% and the 10-year survival rate was 59%. In the stage III group, there was a significant difference between those with complete and those with incomplete resection. Ten of 12 patients who had angioplasty with or without reconstruction of the superior vena cava or innominate vein survived without recurrence of the tumors.

Conclusion. Angioplasty and vascular reconstruction are recommended because successful treatment for invasive thymomas depends on complete resection of the tumors.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Unlike most malignant tumors, thymomas rarely have distant metastases, but they are apt to invade and to disseminate through neighboring organs. Because of anatomic relation, thymomas often invade the pericardium, lungs, and large vessels, especially the superior vena cava (SVC), and may cause SVC syndrome.

We performed extensive operations for invasive thymoma. This report analyzes the operative outcome in patients with stage III or stage IV thymoma, especially in those with thymomas invading the SVC.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
We treated a total of 329 patients with mediastinal tumor from 1967 to the end of 1992 in our department. Among these, there were 104 thymomas (32%), 45 of them stage III or stage IV according to the classification of Masaoka and colleagues [1]:

• Stage I: Macroscopically encapsulated and microscopically no capsular invasion
  
• Stage II: Macroscopic invasion into surrounding fatty tissue or mediastinal pleura, or microscopic invasion into capsule
  
• Stage III: Macroscopic invasion into neighboring organs
  
• Stage IVa: Pleural or pericardial dissemination
  
• Stage IVb: Lymphogenous or hematogenous metastasis
  

Operation was performed in 41 patients: 23 males and 18 females, aged 16 to 76 years (mean age, 50 years). Fourteen of the patients (34%) had myasthenia gravis. There were 34 stage III, 5 stage IVa, and 2 stage IVb tumors. Two patients received chemotherapy, 1 pre- and 1 postoperatively. Complete resection was performed in 22, incomplete resection in 16, and exploratory thoracotomy in 3. All the patients with stage IV thymoma had incomplete resection. When infiltration into other organs was suspected, preoperative radiotherapy (⁶⁰Co) was performed. Thirty-eight patients (93%) received radiotherapy. Preoperative radiotherapy was performed in 11 patients (27%).

Routinely, we perform total removal of the tumor and thymus gland through a median sternotomy, including invaded neighboring organs. If necessary, we reconstruct the SVC using artificial graft. The organs or structures subjected to combined resection were pericardium in 21 cases, lung in 17, SVC or innominate vein in 12, and chest wall in 2. With regard to the 12 patients who received combined resection of the SVC and innominate vein, Figure 1 shows the operative methods for SVC or left innominate vein reconstruction. Expanded polytetrafluoroethylene was used as the graft and patch for all vessel angioplasties or reconstructions. To avoid cerebral edema by SVC cross-clamping for reconstruction, we performed bypass from the left innominate vein to the auricle of the right atrium in all patients having SVC reconstruction, and 1 patient also received barbiturate to suppress cerebral metabolism.

View larger version (20K): [in this window] [in a new window]   Fig 1. . Schema of angioplasty and venous reconstruction in 12 patients.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The 5-year survival rates of patients with stages I and II were 100% and 87.5%, respectively, and corresponding 10-year survival rates were 100% and 73%, respectively. Figure 2 shows the survival rates with stages III, IVa, and IVb thymomas. The overall 5-year survival rate was 77% and the 10-year survival rate was 59%. The 5-year survival rate was 82% and the 10-year rate was 66% for stage III thymoma; respective rates were 67% and 33% for stage IVa thymoma. All of the stage IVb thymoma patients died within 30 months. There was a significant difference in survival between patients with stage III and stage IVb thymomas (p < 0.01). Figure 3 shows the survival rates after complete and incomplete resection in patients with stage III thymoma. Whereas the 5-year and 10-year survival rates were 94% for the complete-resection group, the 5-year survival rate was only 35% for the incomplete-resection group, a significant difference (p < 0.01). The survival rates of stage III patients with or without preoperative radiotherapy are shown in Figure 4. There was no significant difference between the groups.

View larger version (17K): [in this window] [in a new window]   Fig 2. . Survival rate for operated invasive thymomas by stage.

View larger version (13K): [in this window] [in a new window]   Fig 3. . Survival rate for stage III invasive thymomas according to degree of operation.

View larger version (13K): [in this window] [in a new window]   Fig 4. . Survival rate for stage III invasive thymomas with or without preoperative radiotherapy (RT). (NS = not significant.)

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
The results of surgical therapy for invasive thymoma have been reported by various institutions [2–6]. Even some patients with only incomplete resection and postoperative radiotherapy have been reported to have long survival times [7, 8]; however, most investigators have insisted that complete resection of the tumor is needed for longer survival [3, 5, 6]. Our results, too, showed that complete resection of the tumor leads to a significantly better outcome. Thymomas frequently invade the neighboring organs—lung, heart, and large vessels—and occasionally cause SVC syndrome. In 3 thymoma patients with SVC syndrome, we performed preoperative irradiation to reduce the tumor size. After radiotherapy, complete resection was feasible in 1 stage III patient. Positive extensive operation may lead to longer survival, even in patients with large-vessel involvement [5].

Shamji and co-workers [2] stated that preoperative irradiation may prevent intraoperative thoracic dissemination, but its rate of effectiveness is not yet known. Because radiotherapy is effective for thymoma and thymomas frequently show local recurrence, we performed preoperative irradiation when infiltration of other organs was suspected. However, there was no significant difference in the outcome in stage III patients with and without preoperative radiotherapy.

There have been several recent reports on the efficacy of preoperative chemotherapy [10, 11], so a study of thymomas with dissemination remains a forthcoming target. The usefulness of thermo-chemotherapy has also been reported [12].

With regard to angioplasty or reconstruction of the SVC or innominate vein, 10 of these 12 patients survived up to 92 months with the longest observation period. Moreover, 4 of 5 patients treated with reconstruction of the SVC or innominate vein survived without recurrence of the tumors. Therefore, it appears feasible to perform extensive operations even when large vessels are involved with thymoma.

Because thymomas frequently show local recurrence, reoperation for recurrent tumors has been reported [2, 4]. We performed reoperation for recurrent thymoma in 3 patients: once in 2 patients and twice in 1. The patient who underwent reoperation twice is still alive without recurrence 17 years after the first operation. Of the 2 patients who underwent one reoperation, one committed suicide 18 years after the first operation, and the other is still alive without recurrence 5 years after the operation.

Based on our results with surgical therapy for 41 invasive thymomas, we make the following conclusions. Because the prognosis of invasive thymoma is influenced by whether resection is complete or incomplete, it is preferable to perform extensive surgery even when large vessels are involved. Although in our patients, preoperative radiotherapy did not contribute to the outcome, the reduction of tumor size made complete resection possi-ble in some of them. Finally, active surgical therapy for recurrent thymoma results in longer survival.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Wada, Department of Thoracic Surgery, Chest Disease Research Institute, Kyoto University, 53 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, Japan 606.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Masaoka A, Monden Y, Nakahara K, Tanioka T. Follow-up study of thymomas with special reference to their clinical stages. Cancer 1981;48:2485–92.[Medline]
2. Shamji F, Pearson FG, Todd TRJ, Ginsberg RJ, Ilves R, Cooper JD. Results of surgical treatment for thymoma. J Thorac Cardiovasc Surg 1984;87:43–7.[Abstract]
3. Cohen DJ, Ronnigen LD, Graeber GM, et al. Management of patients with malignant thymoma. J Thorac Cardiovasc Surg 1984;87:301–7.[Abstract]
4. Wilkins EW Jr, Grillo HC, Scannell JG, Moncure AC, Mathisen DJ. Role of staging in prognosis and management of thymoma. Ann Thorac Surg 1991;51:888–92.[Abstract]
5. Shimizu N, Moriyama S, Aoe M, Nakata M, Ando A, Teramoto S. The surgical treatment of invasive thymoma. Resection with vascular reconstruction. J Thorac Cardiovasc Surg 1992;103:414–20.[Abstract]
6. Ciernik IF, Meier U, Lutolf UM. Prognostic factors and outcome of incompletely resected invasive thymoma following radiation therapy. J Clin Oncol 1994;12:1484–90.[Abstract]
7. Urgesi A, Monetti U, Rossi G, Ricardi U, Casadio C. Role of radiation therapy in locally advanced thymoma. Radiother Oncol 1990;19:273–80.[Medline]
8. Kersh CR, Eisert D, Hazra TA. Malignant thymoma: role of radiation therapy in management. Radiology 1985;156:207–9.[Abstract/Free Full Text]
9. Ichinose Y, Ohta M, Yano T, Yokoyama H, Asoh H, Hata K. Treatment of invasive thymoma with pleural dissemination. J Surg Oncol 1993;54:180–3.[Medline]
10. Macchiarini P, Chella A, Ducci F, et al. Neoadjuvant chemotherapy, surgery, and postoperative radiation therapy for invasive thymoma. Cancer 1991;68:706–13.[Medline]
11. Rea F, Sartori F, Loy M, et al. Chemotherapy and operation for invasive thymoma. J Thorac Cardiovasc Surg 1993;106:543–9.[Abstract]
12. Higashiyama M, Doi O, Kodama K, Yokouchi H. Intrathoracic chemothermotherapy following panpleuropneumonectomy for pleural dissemination of invasive thymoma. Chest 1994;105:1884–5.[Abstract/Free Full Text]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hiromi Wada Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yagi, K. Articles by Wada, H. Search for Related Content PubMed PubMed Citation Articles by Yagi, K. Articles by Wada, H.