Case of the Stinky Ball

(aka Thymoma)

Bunmi Ogundimu
Radiation Oncology, PGY-3
51M
MVA Dec. 2011,
Jan. 2012 sudden onset c/p*
CXR  anterior mediastinal mass
CT Chest  6 x 4.5 x 6 cm mass ‘contacting
pericardium’

PHx: EtOH abuse, anxiety, Bipolar d/o, HTN

SHx: Construction worker, divorced, 17p-y
FHX: Nil*
CT Chest  6 x 4.5 x 6 cm mass ‘contacting
pericardium’
Pathology  consistent with thymoma
Culinary importance? Sweetbreads
Epidemiology:
0.15/100 00 per year in US
40-60 yo, median 52
M = F,
Symptoms:
40 -50% asymptomatic  incidental findings on
CXR
cough, chest pain*, dysphagia, SVCO
Paraneoplastic syndromes
45% Thymoma have
15% of MG have Thymoma

3% Thymoma have
50% of PRCA have Thymoma

3% Thymoma
10% of AOHGA have thymoma
P/E:
Pemberton signs, dullness to percussion (sternum),
Myasthenic symptoms…

Investigations:
CBC, basic chemistry, liver & renal function tests

CT Chest, ± MR, ± PET, no Octreotide scan

Biopsy
Risk Factors: Prognostic Factors:
ALL Masoaka Staging*
Thymus irradiation Resection completeness*
EBV infection WHO classification
MEN 1 or 2** Tumour size >10cm
Paraneoplastic syndromes
Surgery = mainstay RESECTABLE disease

Adjuvant RT:
positive, close margin (<1mm), capsule invasion,
Grade B
Microscopic Dose: 54-60 Gy
Gross/Residual Dose: 60-66 Gy
IMRT/3DCRT/Wedge pair/APPA

Adjuvant CT alone*
No indication
UNRESECTABLE disease
Medically Unfit :
CT = cisplatin, doxorubicin, cyclophosphamide
prednisone (CAPP)

Surgically Unift : , then surgery

Palliative chemotherapy
Palliative Radiation
Late recurrences
12% recur 12-20 yrs post-operatively

F/U:
q4-6mths: year 0-2; with annual CT chest
qannually afterwards; with annual CT chest
*Thymectomy May 24.2012
Pathology:
Thymoma, B2 (cortical thymoma) with focal B3
(well-differentiated carcinoma)
Pericapsular fat extension
Margin 0.5mm
Masaoka Stage IIA
Tumour board:
Role of adjuvant RT 6mths post-op?
f/u CT CAP, review of PET imaging  negative
No consensus regarding timing of adj RT
No disease recurrence/residual disease

F/U with Dr. Falkson Oct. 31st

Discuss risk of RT
second malignancy,
cardiac disease (pericarditis, restrictive cardiomyopathy,
MI, CHF)
RIL
Myelopathy rarely
RARE
Paraneoplastic Syndromes
Good Thoracic Surgeon
Pathology Review (margins, histology)
Referral to tertiary centre? Clinical trial?
Long-term F/U required
The ‘Stinky Ball’ is an annual gala fundraiser for
the Foundation of Thymic Cancer Research
(FTCR)
The name comes from a 3 year old
Alan Blaustein diagnosed with Stage IVa Thymic
cancer in 2005
His son named his surgical scars/cancer ‘stinky ball’
www.thymic.org
www.thestinkyball.org
www.itmig.org
The Management of Thymoma: A Systematic
Review and Practice Guideline (Falkson et. Al, 2009)
Handbook of Evidence Based Radiation Oncology,
2nd,Edition
Uptodate.com
Decision Making in Radiation Oncology: Vol 1
Clinical Radiation Oncology, 3rd Edition
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