THYMOMA CASE REPORT

M. JUHA NAUFAL NST

150100054
DEPARTEMENT OF RADIOLOGY
MEDICAL FACULTY
UNIVERSITY OF SUMATERA UTARA
 CASE REPORT

• An 8-year-old boy presented to the pediatric clinic with a 3-month history of

intermittent cough and occasional pain in the right upper chest. There was no
history of dysphagia or dyspnea. General physical and systemic examination,
including lymph nodes and genitalia were normal.
• The chest radiograph revealed a right perihilar shadow with mediastinal widening.
Computed tomography (CT) chest revealed a large, (maximum diameter 7.2 cm)
lobulated, homogenous soft tissue mass in the anterior mediastinum arising from
the right side of the thymus gland. The mass was overlying the superior vena cava
and brachiocephalic vein; however, the fat planes were maintained. The posterior
surface of the mass was partly abutting the pericardium. There was no
lymphadenopathy or pleural effusion, and both the lungs were normal.
 RADIOLOGY IMAGING
• X-Ray (PA)

Opaque mass around hylus

Thymic wave sign
 CT SCAN

• large (maximum diameter 7.2 cm), lobulated,

homogenous soft tissue mass in the anterior
mediastinum arising from the right side of the
thymus gland.
• The mass was overlying the superior vena cava and
brachiocephalic vein; however, the fat planes were
maintained. The posterior surface of the mass was
partly abutting the pericardium.
 TREATMENT

• With a provisional diagnosis of thymoma, the boy underwent a midline

sternotomy. There was a solitary, well-encapsulated, multi septated mass
measuring around 7.5 cm × 3.5 cm × 3 cm arising from the thymus and
overlying the superior vena cava and brachiochephalic vein. The lower part was
abutting the pericardium; however, the lesion could be easily separated from
the pericardium and the great vessels. Complete resection was performed. The
patient had an uneventful recovery and was discharged on the seventh
postoperative day.
THYMOMA
 DEFINITION

• Thymoma is a major mediastinal neoplasm originating from epithelial cells of

the medulla or thymus gland cortex, usually with the presence of non-
neoplastic lymphocytes.
• Thymoma is a tumor that occurs in adults about 40% found with symptoms of
local compression while the other 30-45% is found with myasthenia gravis.
• Thymoma has a correlation with other paraneoplastic syndromes such as
hypogammaglobulinemia aquisita, pure red cell aplasia, Graves' disease,
pernicious anemia, polymyositis dermatomyositis and Cushing's syndrome
 ETIOLOGY

• The etiology of thymoma has not been explained. However, it has been linked
to various systemic syndromes. As many as 30-40% of thymoma patients
experience symptoms suggestive of MG (myasthenia gravis)
• An additional 5% of patients who have thymoma have other systemic
syndromes, including red blood cell aplasia, dermatomyositis, systemic lupus
erythematous, Cushing's syndrome, and antidiuretic hormone secretion
syndrome
 PATHOGENESIS

• Autoimmune thymoma involves changes in the circulation of the T-cell subset.

Major T-cell abnormalities are related to the acquisition of the phenotype
CD45RA + on naive CD4 + T cells during the intratumorous thymopoiesis
terminal, followed by export of activated CD4 + T cells into the circulation.
• In addition to T-cell defects, B-cell lymphopenia has been observed in
immunodeficiency-related thymomas, with hypogammaglobulinemia and
opportunistic infections.
 STAGING

Masaoka Thymoma Staging

 SIGN & SYMPTOMS

• Cough
• Chest pain
• Signs of respiratory tract distress
• Dysphagia
• Myasthenia gravis in 30-65% cases
 RADIOLOGY FINDINGS

• Diagnostics of patients with thymoma begins with anamnesis and abnormal shadows
found in the thorax on X-ray. Computed tomography (CT) helps in the clinical stage
of thymoma, especially for capsulated lesions. Special attention is paid to evaluating
the relationship of the tumor with adjacent mediastinal structures, and predicting
the feasibility of a biopsy or radical surgical procedure. MG CT patients show
sensitive, specific results and an efficient modality for detecting thymoma, but less for
detecting thymic hyperplasia
 TREATMENT

• Corticosteroids
Case reports have documented oral glucocorticoid administration resulting in regression of
invasive thymoma. In the case, the patient showed a complete regression for thymoma and
related symptoms and remained without radiological recurrence after 12 months.
• Multidiscipline approach
A multidisciplinary approach to thymomas therapy has been recommended. In one trial
conducted by the MD Anderson Cancer Center, the treatment regimen consisted of
induction chemotherapy (ie, 3 cyclophosphamide courses, doxorubicin, cisplatin, and
prednisone), resection surgery, postoperative radiation therapy, and consolidation
chemotherapy (ie, 3 courses of chemotherapy) cyclophosphamide, doxorubicin, cisplatin,
and prednisone).
 TREATMENT

• Chemotherapy
Several reports in the literature show that thymomas are chemosensitive tumors.
Fornasiero and colleagues reported successful cases and several long-term
casualties following the administration of the cisplatin / vincristine / doxorubicin /
cyclophosphamide regimen in 32 patients, 47% complete and 90% response rate.
 SURGERY

Initial management in most cases of thymomas is surgical. Surgical excision

provides histological characteristics of the tumor and provides staging
information that helps in determining the need for adjuvant therapy.
Patients with stage IVA are treated with pleuropneumonectomy. Median survival
was 86 months, and Kaplan-Meier survival was 75% at 5 years and 50% at 10
years
 SURGERY

• Pre-Operation
Preoperative adjuvant radiation therapy has been used to increase the likelihood of complete resection if a CT
scan shows a very large or invasive tumor. Patients with a preoperative diagnosis of MG and thymoma should
optimize their health condition before surgery by using cholinesterase inhibitors and plasmapheresis if
indicated.
• Operation
If the tumor is small and easily accessible, a complete thymectomy is performed by removing the fat close to
the mediastinum. If the tumor is invasive, besides performing a total thymectomy, it is also performed on the
pericardium, pleura, lungs, phrenic nerve, venous innominate, or superior vena cava
 SURGERY

• Post Operation
The use of postoperative radiation therapy in stage II thymomas is more
questionable. Thymoma is a tumor that may take at least 10 years to recur;
Therefore, short-term follow-up will not represent a relapse.
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