Thymoma

RAWA MUHSIN
 Definition

Thymic epithelial neoplasm exhibiting some

organotypic features, accompanied by variable
numbers of reactive lymphoid cells
Organotypic features
 lobulation
 medullary differentiation
 perivascular spaces
 presence of immature T lymphocytes
 Clinical

Age and gender

 5th to 6th decades
 Equal sex incidence
Symptoms
 Chest pain, dyspnea, paraneoplastic (myasthenia, red cell
aplasia, hypogammaglobulinemia, thyroiditis, SLE)
 Asymptomatic in 30%
Low-grade and indolent
 Distant metastases are rare
Surgical excision
 Radiation therapy for invasive or incompletely excised tumors
 Macroscopic

Well-circumscribed, encapsulated
Homogeneous tan-white, rubbery, lobulated
Solid, but may be cystic and multilocular
Additionally
 Calcifications in capsule or within tumor
 Multifocal
 Ectopic in posterior mediastinum, lung, neck, or pleura
 Necrosis and hemorrhage
Invasive tumors compromise adjacent structures
 Grossing

Ink outer surface

 If other structures attached also ink the true margins
1 section per 1 cm of greatest tumor dimension
 Minimum of five representative blocks regardless
 Additional sections if variegated to detect mixed types
 Solid areas in cystic tumors
Include inked surface in sections
 Classification

Suster & Moran WHO

Type A (spindle cell)

Type AB (spindle cell with abundant
Well-differentiated thymic epithelial lymphocytes)
neoplasm (thymoma)
Type B1 (lymphocyte predominant)

Type B2 (lymphoepithelial)
Moderately differentiated thymic
Type B3 (epithelial rich)
epithelial neoplasm (atypical thymoma)
Poorly differentiated thymic epithelial
Thymic carcinoma
neoplasm (thymic carcinoma)
Classification
 Cell types

Oval/spindle cells (types A, AB)

Round/epithelioid cells (types B1-3)
 Type A

Oval or spindle cells, scattered nuclear chromatin,

absent nucleoli, no mitotic activity
Few lymphocytes
Majority are low grade and encapsulated
 Type AB

Oval or spindle cells similar to those in type A

Abundant small T lymphocytes
 Type B1

Round/epithelioid cells with single small

eosinophilic nucleoli and abundant cytoplasm
Numerous small T lymphocytes predominate
Dilated perivascular spaces and areas of medullary
differentiation
 Type B2

Equal admixture of round epithelial cells and small

lymphocytes
Admixtures with B1 or B3 areas in ~30% of cases
 Report by providing percentage of various types present
 Type B3

Sheets of large epithelioid cells with nuclear

enlargement, dense chromatin, prominent nucleoli
Scant lymphocytes
Additionally
 Rare mitoses
 Raisin-like nuclei
 Abundant, eosinophilic cytoplasm with sharp borders
 Palisading around perivascular spaces
 Unusual types

Hemangiopericytic
Micronodular
Metaplastic
Adenoid
Sclerosing
Rosette-forming
 Immunohistochemistry

Antibody Pattern Positive Cases

p63 Nucleus 100% 122
CK5/6 Cytoplasm 99% 94
CD99 Membrane 94% 101

FOXN1 (99% in 76), CD205 (97% in 76), SDHB (100% in 62).

 Immunohistochemistry

Antibody Thymoma Thymic carcinoma

CD5 3% (422) 62% (230)

Mesothelin 2% (130) 64% (90)

CD117 0% (90) 67% (82)

 Prognostic factors

Tumor stage (most important)

Tumor size
Invasion of capsule
 A < AB < B1 < B2 < B3
Completeness of excision
 Modified Masaoka staging

Stages I (44%): 5-year survival of 90%

Stage II (23%): 5-year survival of 88%
Stage III (27%): 5-year survival of 67%
Stage IV (6%): 5-year survival of 50%
 Differential diagnosis

Lymphoblastic lymphoma
 No keratin-positive cells, rapid growth, younger age
Thymic carcinoma
 Overt cytologic features of malignancy with loss of organotypical
features of thymic differentiation
Neuroendocrine carcinoma
 Nested pattern, stippled chromatin, neuroendocrine markers
Acquired multilocular thymic cyst
 Cuboidal or squamous lining, severe inflammation, cholesterol cleft
granulomas
Solitary fibrous tumor
 IHC profile, ropy collagen, lack of immature T cells
Bonus