Treatment of Thymic Carcinoma When Complete Resection Is Achievable Upfront (Masaoka-Koga Stage I–III / TNM Stage I–IIIA)

This protocol addresses thymic carcinoma in patients presenting at Masaoka-Koga stage I, II, or III (corresponding to TNM stage I, II, or IIIA), where upfront complete surgical resection is judged to be achievable.

Clinical scenario

Thymic carcinoma at Masaoka-Koga stage I–III (TNM stage I–IIIA) with complete resection deemed achievable upfront. This applies to stage I/II tumours and to a subset of stage III tumours classified as stage IIIA/T3 in the IASLC/ITMIG TNM system.

Treatment approach (partial overview)

Surgery is the first step of treatment. The standard operative approach involves wide exposure of the mediastinum, followed by complete removal of the tumour along with the residual thymus and surrounding perithymic tissue. When the tumour is widely invasive at stage III, the operative plan extends to en bloc removal of affected neighbouring structures. Full operative details, lymphadenectomy guidance, sequencing, and evidence grades are in the structured protocol →

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1093/annonc/mdv277

Treatment algorithm for resectable thymic tumour (Masaoka-Koga stage I–III, TNM stage I–IIIA).

If complete resection is deemed to be achievable upfront, as it is the case in Masaoka-Koga stage I/II and some stage III tumours (classified as stage I, II, IIIA/T3 in the IASLC/ITMIG TNM proposed system), surgery represents the first step of the treatment [IV, A], possibly followed by postoperative radiotherapy and, less frequently, chemotherapy (Table 5).

Upfront surgery [IV, A]. The standard approach is median sternotomy [IV, A], which allows the wide opening of the mediastinum and both pleural cavities, followed by evaluation of macroscopic capsular invasion, infiltration of perithymic and mediastinal fat, peritumoural and pleural adherences and involvement of surrounding structures.

Generally, complete thymectomy including the tumour, the residual thymus gland and perithymic fat is preferred because local recurrences have been observed after partial thymectomy when part of the thymus gland is left behind [IV, B].

If the tumour is widely invasive (stage III/IV), en bloc removal of all affected structures, including lung parenchyma (usually through limited resection), pericardium, great vessels, nerves and pleural implants, should be carried out [IV, A].

Systematic lymphadenectomy (N1 + N2) is strongly recommended in case of thymic carcinoma due to the high rate of lymphatic spread (20% versus 3% in thymomas) [V, B].

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