Radiologic–Pathologic Conferences of The University of Texas M. D.

Anderson
Cancer Center
Invasive Thymoma
Mylene T. Truong1, Bradley S. Sabloff, Gregory W. Gladish, Gary J. Whitman, Reginald F. Munden

A 43-year-old woman presented with a

2-day history of chest pain and short-
ness of breath. Chest radiography
showed left mediastinal widening and left pleural
Although most thymomas are encapsulated
with a histologically bland appearance, some may
be locally invasive or metastasize to distant or-
gans. Infiltration of the pleura, lung, great vessels,
include obliteration of fat planes in the mediasti-
num, pleural or pericardial thickening, encase-
ment of the mediastinal vessels, and irregular
interface with the adjacent lung. On MRI, thy-
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thickening (Fig. 1A). Chest CT showed a homoge-
neous lobulated left anterior mediastinal mass adja-
cent to the aortic arch (Fig. 1B). Nodular left pleural
thickening extended into the major fissure and in-
volved the diaphragm. CT-guided core needle bi-
opsy revealed a lymphoid-predominant thymoma
(Fig. 1C). The patient was treated with cyclophos-
phamide, doxorubicin and cisplatin, followed by
surgical resection. An extrapleural pneumonectomy
with diaphragmatic reconstruction was performed.
Results of surgical pathology showed invasive thy-
moma involving the lung, pleura, and diaphragm.
Thymoma is an indolent epithelial neoplasm
of the thymus that accounts for nearly half of all
primary tumors of the anterior mediastinum [1].
The peak incidence of thymoma is in the fifth
and sixth decades of life with no predilection for
sex [2]. Thymoma is rarely seen in children. Ap-
proximately half of the patients are asympto-
matic, with the diagnosis made incidentally
through chest radiographs obtained for other rea-
sons. Symptoms may occur because of mass ef-
fect of the tumor on the trachea, the recurrent
laryngeal nerve, the esophagus, or the superior
vena cava. Patients may present with chest pain,
cough, dyspnea, respiratory tract infections,
hoarseness, dysphagia, or signs of superior vena
cava syndrome. Forty percent of patients with
thymomas have paraneoplastic syndromes.
These syndromes include myasthenia gravis,
pure red cell aplasia, hypogammaglobulinemia,
endocrinopathy, and connective tissues disorders.
Approximately 30–40% of thymoma patients
have myasthenia gravis, and 10–15% of patients
with myasthenia gravis have thymomas [3].
pericardium, chest wall, or diaphragm occurs in
30–50% of cases. The most widely used staging
classification of thymoma was devised by
Masaoka et al. [4], based on the presence of cap-
sular invasion. Stage I thymomas are completely
encapsulated macroscopically with no micro-
scopic capsular invasion. Stage II thymomas
show invasion through the capsule into the medi-
astinal fat or pleura. Stage III thymomas show
macroscopic invasion into neighboring organs.
Stage IV thymomas are associated with pleural or
pericardial implants or distant metastases.
Histologically, thymomas can be classified ac-
cording to the predominant cell type. Mixed lym-
phoepithelial cell type is the most common,
followed by lymphoid predominant; epithelial
cell predominant is the rarest form of thymoma.
Marino and Muller-Hermelink [5] subdivided
thymomas on the basis of the epithelial cell on-
togeny. Subdivisions include cortical, medullary,
and mixed types.
On radiographs, thymomas are usually seen as
round or oval anterior mediastinal masses, which
can protrude to one side or extend to both hemitho-
races. Although most thymomas arise in the ante-
rior superior mediastinum, they can be found in
the neck, the posterior mediastinum, the pleura, or
the lung. Calcification may be detected in the cap-
sule or scattered throughout the tumor. Thymomas
usually measure between 5 and 10 cm in diameter
and commonly have smooth lobulated borders. On
CT, thymomas are soft-tissue lesions that often en-
hance uniformly with the IV administration of
contrast material. Necrosis and hemorrhage may
occur. CT findings suggestive of tumor invasion
momas have intermediate signal intensity on
T1-weighted images and show increased sig-
nal intensity on T2-weighted images, ap-
proaching that of fat. MRI can be used to
evaluate for evidence of vascular invasion and
diaphragmatic involvement.
For stage I thymomas, surgical resection is cura-
tive. Up to 12% of cases without gross or micro-
scopic evidence of invasion recur locally. En bloc
removal of the thymus and adjacent mediastinal fat
has also been used to treat myasthenia gravis with
or without an associated thymoma. Thymomas are
radiosensitive, and radiation therapy is used as an
adjunct to surgical resection for invasive disease.
Recent trials of combined-modality therapy sug-
gest that neoadjuvant and adjuvant chemotherapy
may further improve long-term survival in patients
with advanced-stage thymomas.
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2. Wilkins EW Jr, Grillo HC, Scannell JG, Moncure
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3. Lara PN Jr. Malignant thymoma: current status and fu-
ture directions. Cancer Treat Rev 2000;26:127–131
4. Masaoka A, Monden Y, Nakahara K, Tanioka T. Fol-
low-up study of thymomas with special reference to
their clinical stages. Cancer 1981;48:2485–2492
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A B C
Fig. 1.—43-year-old woman with stage IV invasive thymoma.
A, Posteroanterior chest radiograph shows contour abnormality of left anterior mediastinum (arrow) with circumferential nodular left pleural thickening.
B, Chest CT scan confirms lobulated left anterior mediastinal mass (curved arrow) associated with nodular pleural implant (straight arrow) along lateral aspect of left hemithorax.
C, Photomicrograph of histopathologic specimens shows lymphocytes and epithelial cell clusters with thick fibrous bands, consistent with thymoma. (H and E, low power)
Received February 6, 2003; accepted without revision February 12, 2003.
1
All authors: Division of Diagnostic Imaging, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 57, Houston, TX 77030. Address correspondence to M. T. Truong.
AJR 2003;181:1504 0361–803X/03/1816–1504 © American Roentgen Ray Society

1504 AJR:181, December 2003

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