- Case report
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- Open Peer Review
Giant thymoma successfully resected via median sternotomy and anterolateral thoracotomy: a case report
© The Author(s). 2018
- Received: 2 February 2018
- Accepted: 4 April 2018
- Published: 10 April 2018
Some patients with thymoma present with a very large mass in the thoracic cavity. Although the most effective treatment for thymoma is surgical resection, it is difficult to perform because of the size of the tumor and the infiltration of tumor into the surrounding organs and vessels. We report a patient with a giant thymoma that was completely resected via a median sternotomy and left anterolateral thoracotomy.
A 63-year-old woman presented with a mass in the left thoracic cavity that was incidentally found on a chest X-ray. Chest computed tomography revealed a giant mass (16 × 10 cm) touching the chest wall and diaphragm and pressed against the heart and left upper pulmonary lobe. Complete resection was performed via a median sternotomy and left anterolateral thoracotomy. The tumor was histologically diagnosed as a WHO type B2 thymoma, Masaoka stage II.
Giant thymomas tend to grow expansively without invasion into surrounding organs and vessels. Surgical resection that employs an adequate approach must be considered, regardless of the size of the tumor.
- Giant thymoma
- Median sternotomy
- Anterolateral thoracotomy
- CT computed tomography
- WHO World Health Organization
- FDG-PET F18-fluorodeoxyglucose positron emission tomography
- AchR acetylcholine receptor
- MG myasthenia gravis
Thymic epithelial neoplasms are commonly located in the anterior mediastinum. The tumors typically show slow-growing behavior. Patients present with various clinical signs and symptoms that are associated with expansion of the tumor; the most effective treatment modality is surgery . Giant thymomas are very rare and difficult to resect because of the size of the tumor and involvement of surrounding organs. Here, we report a case of giant thymoma that was completely resected via a median sternotomy and anterolateral thoracotomy.
Characteristics of patients with giant thymoma
Tumor size (cm)
13 × 10 × 10
median + right anterolateral
12 × 14 × 12
20 × 14 × 8
17 × 12 × 7
18 × 14 × 11
14 × 13 × 8
20 × 11 × 2
21 × 7 × 7
13 × 10
19 × 16 × 15
left hemic lamshell
16 × 10 × 7
median + left anterolateral
Surgical resection is generally accepted to be the most effective treatment for thymoma, and complete resection is an important prognostic indicator of long-term outcome . Large size is a poor prognostic factor in thymoma, and complete resection largely contributes to a successful treatment outcome for patients with giant thymoma. Although thymomas can present as huge masses, tumor stage may not always be correlated with tumor size . Interestingly, most giant thymomas have been found to be low grade histologically, without invasion into the surrounding organs and vessels, and have been completely resected (Table 1). The noninvasiveness of giant thymomas might account for their presentation as very large tumors.
A median sternotomy is the standard procedure for resecting a thymoma of normal size, but the procedure is controversial for giant thymoma (Table 1). A clamshell incision was used for an emergency operation for a patient with shock due to bleeding of a thymoma . This approach enables access to both hila and the pleural cavity. One patient underwent resection via a hemiclamshell approach, which allows access to the upper thoracic cavity . Both the clamshell and hemiclamshell incisions are more invasive than other approaches. A posterolateral approach was used for 2 patients [9, 11]. This approach is suitable for a tumor that extends to the inferior cavity, but a second surgery is needed to confirm complete thymectomy. A median sternotomy is suitable for patients with possible invasion of the innominate vein [7, 8], but access to the hila or posterior thorax can be difficult for cases of giant thymomas. Three patients with giant thymoma underwent resection via the anterolateral approach, which allows extension of the incision to include a posterolateral or hemiclamshell approach [6, 12, 14]. Only one patient with giant thymoma underwent resection via a median sternotomy and anterolateral thoracotomy , which was the approach we used for our patient. This approach allows wide access to the tumor and involved organs, regardless of their location in the thoracic cavity.
Some thymoma patients develop MG after thymectomy (“post-thymectomy MG”) regardless of whether or not they have a history or signs or symptoms of MG. Post-thymectomy MG develops in 1.0% to 28% of thymoma patients who have undergone thymectomy [18–23]. Previous reports showed that elevated preoperative serum AchR antibody levels and World Health Organization type B thymoma were risk factors for post-thymectomy MG [24, 25]. Our case corresponds to patients at high risk post-thymectomy MG, and requires careful follow-up for early detection of MG.
We reported a rare case of giant thymoma that was successfully resected via median sternotomy and left anterolateral thoracotomy. Giant thymomas tend to be low-grade tumors that do not infiltrate adjacent organs and vessels. For successful treatment of giant thymoma, curative surgical resection must be considered, regardless of tumor size.
This study was supported in part by JSPS KAKENHI Grant Number JP 15 K10272.
Availability of data and materials
The data supporting the conclusions of this article are included within the article.
All authors participated in the design of the case report and coordination, and helped to draft the manuscript. YA and AI wrote the manuscript. HO, SK, TM, HO, and YA collected and analyzed clinical data of the patient. SS, MW, and KS carried out the pathological diagnosis and provided images of the gross pathology and histopathology. All authors read and approved the final manuscript.
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Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of the Journal of Cardiothoracic Surgery.
The authors declare that they have no competing interests.
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- Gray GF, Thymoma GWTIII. A clinicopathologic study of 54 cases. Am J Surg Pathol. 1979;3:235–49.View ArticlePubMedGoogle Scholar
- Cheng MF, Tsai CS, Chiang PC, Lee HS. Cardiac tamponade as manifestation of advanced thymic carcinoma. Heart Lung. 2005;34:136–41.View ArticlePubMedGoogle Scholar
- Takanami I, Takeuchi K, Naruke M. Noninvasive large thymoma with a natural history of twenty-one years. J Thorac Cardiovasc Surg. 1999;118:1134–5.View ArticlePubMedGoogle Scholar
- Lerman J. Anterior mediastinal masses in children. Semin in Anesth, Periop med. Pain. 2007;26:133–40.Google Scholar
- Santoprete S, Ragusa M, Urbani M, Puma F. Shock induced by spontaneous rupture of a giant thymoma. Ann Thorac Surg. 2007;83:1526–8.View ArticlePubMedGoogle Scholar
- Yamazaki K, Yoshino I, Oba T, Yohena T, Kameyama T, Tagawa T, et al. Ectopic pleural thymoma presenting as a giant mass in the thoracic cavity. Ann Thorac Surg. 2007;83:315–7.View ArticlePubMedGoogle Scholar
- Fazlıoğullari O, Atalan N, Gürer O, Akgün S, Arsan S. Cardiac tamponade from a giant thymoma: case report. J Thorac Cardiovasc Surg. 2012; https://doi.org/10.1186/1749-8090-7-14.
- Takenaka T, Ishida T, Handa Y, Tsutsui S, Matsuda H. Ectopic thymoma presenting as a giant intrathoracic mass: a case report. J Cardiothorac Surg. 2012;7:68.View ArticlePubMedPubMed CentralGoogle Scholar
- Filosso PL, Delsedimeb L, Cristoforia RC, Sandria A. Ectopic pleural thymoma mimicking a giant solitary fibrous tumour of the pleura. Interact Cardiovasc Thorac Surg. 2012;15:930–2.View ArticlePubMedPubMed CentralGoogle Scholar
- Spartalis ED, Karatzas T, Konofaos P, Karagkiouzis G, Kouraklis G, Tomos P. Unique presentation of a giant mediastinal tumor as kyphosis: a case report. J Med Case Rep. 2012;6:99.View ArticlePubMedPubMed CentralGoogle Scholar
- Aydin Y, Sipal S, Celik M, Araz O, Ulas AB, Alper F, et al. A rare thymoma type presenting as a giant intrathoracic tumor: lipofibroadenoma. Eurasian J Med. 2012;44:176–8.View ArticlePubMedPubMed CentralGoogle Scholar
- Saito T, Makino T, Hata Y, Koezuka S, Otsuka H, Isobe K, et al. Giant thymoma successfully resected via anterolateral thoracotomy: a case report. J Cardiothorac Surg. 2015;10:110.View ArticlePubMedPubMed CentralGoogle Scholar
- Zhao W, Fang W. Giant thymoma successfully resected via hemiclamshell thoracotomy: a case report. J Thorac Dis. 2016;8:E677–80.View ArticlePubMedPubMed CentralGoogle Scholar
- Alexiev BA, Yeldandi AV. Ectopic pleural thymoma in a 49-year-old woman: a case report. Pathol Res Pract. 2016;212:1076–80.View ArticlePubMedGoogle Scholar
- Girard N, Mornex F, Van Houtte P, Cordier JF, van Schil P. Thymoma: a focus on current therapeutic management. J Thorac Oncol. 2009;4:119–26.View ArticlePubMedGoogle Scholar
- Davenport E, Malthaner RA. The role of surgery in the management of thymoma: a systematic review. Ann Thorac Surg. 2008;86:673–84.View ArticlePubMedGoogle Scholar
- Wright CD, Wain JC, Wong DR, Donahue DM, Gaissert HA, Grillo HC, et al. Predictors of recurrence in thymic tumors: importance of invasion, World Health Organization histology, and size. J Thorac Cardiovasc Surg. 2005;130:1413–21.View ArticlePubMedGoogle Scholar
- Nakajima J, Murakawa T, Fukami T, Sano A, Takamoto S, Ohtsu H. Postthymectomy myasthenia gravis: relationship with thymoma and antiacetylcholine receptor antibody. Ann Thorac Surg. 2008;86:941–5.View ArticlePubMedGoogle Scholar
- Sun XG, Wang YL, Liu YH, Zhang N, Yin XL, Zhang WJ. Myasthenia gravis appearing after thymectomy. J Clin Neurosci. 2011;18:57–60.View ArticlePubMedGoogle Scholar
- Fershtand JB, Shaw RR. Malignant tumor of the thymus gland, myasthenia gravis developing after removal. Ann Intern Med. 1951;34:1025–35.View ArticlePubMedGoogle Scholar
- Kondo K, Monden Y. Myasthenia gravis appearing after thymectomy for thymoma. Eur J Cardiothorac Surg. 2005;28:22–5.View ArticlePubMedGoogle Scholar
- Namba T, Brunner NG, Grob D. Myasthenia gravis in patients with thymoma, with particular reference to onset after thymectomy. Medicine (Baltimore). 1978;57:411–33.View ArticleGoogle Scholar
- Obata S, Yamaguchi Y, Sakio H, Momiki S, Arita M. Myasthenia gravis developed after extirpation of thymoma. Rinsho Kyobu Geka. 1983;3:729–33.PubMedGoogle Scholar
- Yamada Y, Yoshida S, Iwata T, Suzuki H, Tagawa T, Mizobuchi T, et al. Risk factors for developing postthymectomy myasthenia gravis in thymoma patients. Ann Thorac Surg. 2015;99:1013–9.View ArticlePubMedGoogle Scholar
- Ruffini E, Filosso PL, Mossetti C, Bruna MC, Novero D, Lista P, et al. Thymoma: interrelationships among World Health Organization histology, Masaoka staging and myasthenia gravis and their independent prognostic significance. A single-Centre experience. Eur J Cardiothorac Surg. 2011;40:146–53.View ArticlePubMedGoogle Scholar