Cancer Medicine :: Thymus Cancer

Thymus Cancer

Making treatment decisions

After a thymic tumor is found and tests have been done to get a sense of its likely stage, your cancer care team will discuss your treatment options with you. Factors important in choosing a treatment include the type and stage of the cancer, whether or not it is resectable (able to be completely removed with surgery), and whether you have any other serious medical problems. Because thymic cancer is rare, it is often hard to accurately predict the effectiveness of treatment strategies, and in many cases the best way to treat this cancer is still not clear

Selecting a treatment plan is an important decision, and you should take the time to think about all of your choices. If time permits, it is often a good idea to seek a second opinion. A second opinion can provide more information and help you feel more confident about the treatment plan chosen.

The main treatments for thymus cancer are:

Surgery

Radiation

Chemotherapy

Surgery for thymus cancer

Whenever possible, surgery is used to treat thymus cancers. If you have thymus cancer, one of the first things your doctor will do is to try to determine whether or not the cancer is completely resectable (removable) with surgery.

The most common surgery for thymus tumors is complete removal of the thymus (including any tumor). This is called a thymectomy. In most cases the surgery is done through a median sternotomy, an incision down the middle of the chest that splits the sternum (breast bone), permitting thorough removal of the thymus and tumor.

If the tumor has grown into nearby structures, the surgeon may also need to remove parts of those structures in order to remove all areas of tumor spread. This could mean removing parts of the pleura (tissue coating the lung), pericardium (the sac containing the heart), nerves, the superior vena cava (a large vein leading to the heart), and/or lung.

Some doctors may advise surgery even if the tumor is not completely resectable, as is the case with many stage III thymomas and with most stage IV thymomas. In these cases, the doctor might remove as much tumor as possible (called debulking), and then recommend further treatment with radiation therapy and/or chemotherapy. But not all doctors agree that surgery helps people live longer in these situations. In some cases, chemotherapy or radiation therapy may be given before surgery to try to shrink the tumor so that it can be more easily removed completely.

Possible side effects of surgery

Possible complications depend on the extent of the surgery and your health beforehand. Serious complications can include excessive bleeding, wound infections, and pneumonia.

You will need to stay in the hospital for several days after the surgery. Because the surgeon usually will have to open your chest for the operation, the incision will hurt for some time after surgery. Your activity will be limited for at least a month or two.

Some people may need to have part or all of a lung removed. If your lungs are in good condition (other than the presence of the cancer) you can usually return to normal activities after a lobe or even an entire lung has been removed. If you already have lung problems such as emphysema or chronic bronchitis (which are common among heavy smokers), you may become short of breath with activities after surgery.

Radiation therapy for thymus cancer

Radiation therapy is the use of high-energy radiation in the form of x-rays or radioactive particles to kill cancer cells.

There are several situations in which radiation therapy might be used. After surgery, radiation therapy is sometimes given to try to kill any small deposits of cancer that may not have been removed during surgery. This, called adjuvant therapy, is done for nearly all stage III and IV thymomas and for all thymic carcinomas, even when no visible tumor was left behind.

Some doctors may use radiation therapy to try to shrink larger tumors before surgery, especially if the tumor isn't completely resectable. But not all doctors agree this is useful. Some patients who can’t have surgery are treated with radiation therapy alone, although this is not as effective as surgery. Sometimes chemotherapy is given with radiation to help it work better.

In people with advanced disease, radiation therapy can be used to help ease (palliate) symptoms from the cancer such as shortness of breath, pain, bleeding, or trouble swallowing.

The type of radiation therapy used most often to treat thymic cancer is external beam radiation therapy (EBRT). This type of radiation therapy uses x-rays from a machine outside the patient's body to kill cancer cells. The treatment is much like getting an x-ray, but the radiation is more intense. The procedure itself is painless. Before your treatments start, the medical team will take careful measurements to determine the correct angles for aiming the radiation beams and the proper dose of radiation. They may also do special CT scans to help plan your treatments. Each treatment lasts only a few minutes, although the setup time — getting you into place for treatment — usually takes longer. Most often, radiation treatments are given 5 days a week for several weeks.

A type of EBRT called three-dimensional conformal radiation therapy (3D-CRT) is often used to treat thymic cancers. This technique allows doctors to more accurately target the tumor while reducing the radiation exposure to nearby healthy tissues such as the lungs and the heart. This may offer a better chance of increasing the success rate and reducing side effects.

Sometimes, an advanced form of 3D-CRT, called intensity-modulated radiation therapy (IMRT) is used. It uses a computer-driven machine that moves around the patient as it delivers radiation. Along with shaping the radiation beams and aiming them at the tumor from several angles, the intensity (strength) of the beams can be adjusted to minimize the dose reaching the most sensitive normal tissues. Most major hospitals and cancer centers are now able to provide IMRT.

Possible side effects of radiation therapy

Common side effects of radiation therapy include fatigue, mild skin changes (like a sunburn), nausea, and vomiting. Radiation can damage bone marrow leading to low blood counts. This can lead to anemia (low red blood cell counts) which can cause people to feel weak and tired. It can also lead to low white blood cell counts, which increases the risk of serious infections. Radiation to the chest can also irritate the esophagus (the tube between the mouth and stomach), which could cause problems such as painful swallowing. Abdominal radiation therapy can also lead to diarrhea and poor appetite. These problems are generally temporary and improve after radiation treatment is done.

Chest radiation therapy can also damage lungs. This can lead to trouble breathing and shortness of breath. Although this usually gets better after radiation treatments stop, sometimes the damage is long-term (or even permanent).

If radiation therapy is used together with chemotherapy, the side effects are often worse.

If you are having any side effects from radiation therapy, tell your doctor or nurse. In most cases there are ways to help control these symptoms.

Chemotherapy for thymus cancer

Chemotherapy (chemo) uses anti-cancer drugs that are given intravenously (into a vein) or by mouth. These drugs enter the bloodstream and reach throughout the body, making this treatment especially useful for cancer that may have spread to organs beyond the thymus.

Chemo may be used in several situations.

It may be given after surgery to try to kill any cancer cells that may have been left behind. This is called as adjuvant treatment.

It may be given before surgery to try to shrink tumors that are not otherwise resectable. This is known as neoadjuvant therapy.

In people who have advanced cancer or are not healthy enough for surgery, chemo may be the main treatment.

Chemo is sometimes combined with radiation to help it work better. This is known as chemoradiation or chemoradiotherapy.

Doctors give chemo in cycles, with each period of treatment followed by a rest period to allow the body time to recover. Chemo cycles generally last about 3 to 4 weeks, and initial treatment typically involves 4 to 6 cycles. Chemo is often not recommended for patients in poor health, but advanced age by itself is not a barrier to getting chemo.

Several chemo drugs may be used in the treatment of thymomas and thymic carcinomas, including:

Doxorubicin (Adriamycin^®)

Epirubicin (Ellence^®)

Cisplatin

Carboplatin

Cyclophosphamide (Cytoxan^®)

Ifosfamide (Ifex^®)

Vincristine (Oncovin^®)

Etoposide (VP-16)

Paclitaxel (Taxol^®)

Pemetrexed (Alimta^®)

5-fluorouracil (5-FU)

Gemcitabine (Gemzar^®)

The corticosteroid drug prednisone is often given with chemo.

These drugs are usually given in combination to try to increase their effectiveness. For example, the combination of cisplatin, doxorubicin, and cyclophosphamide (called PAC) with or without prednisone is often used to treat thymoma. The combination of carboplatin and paclitaxel may be used to treat thymic carcinoma

Possible side effects of chemotherapy

Chemo drugs work by attacking cells that are dividing quickly, which is why they work against cancer cells. But other cells in the body, such as those in the bone marrow, the lining of the mouth and intestines, and the hair follicles, also divide quickly. These cells are also likely to be affected by chemo, which can lead to side effects.

The side effects of chemo depend on the type and dose of drugs you are given and how long they are used. These side effects can include:

Hair loss

Mouth sores

Loss of appetite

Nausea and vomiting

Chemo can also affect the blood forming cells of the bone marrow, leading to:

Increased chance of infections (due to low white blood cell counts)

Easy bruising or bleeding (due to low blood platelet counts)

Fatigue (due to low red blood cell counts)

These side effects usually go away after treatment is finished and there are often ways to lessen them. For example, drugs can be given to help prevent or reduce nausea and vomiting. If you do have side effects, be sure to ask your doctor or nurse about medicines to help reduce or manage them effectively.

Some drugs can have other side effects. For example, cisplatin and paclitaxel can damage nerves (called neuropathy). This can sometimes lead to pain, burning or tingling sensations, sensitivity to cold or heat, or weakness in the hands and feet. Cisplatin can also affect the nerves of the ear, leading to hearing loss. In most cases these problems improve or even go away once treatment is stopped, but they may last a long time in some people. You should report this, as well as any other side effects or changes you notice while getting chemotherapy, to your medical team so that you can get prompt treatment for them. In some cases, the doses of the chemotherapy drugs may need to be reduced or treatment may need to be delayed or stopped to prevent the effects from getting worse.

Octreotide

A drug called octreotide (Sandostatin^® and Sandostatin LAR^®) may also help some people with advanced thymoma. This is not a typical chemo drug. It is a man-made version of a hormone called somatostatin. The drug is effective in some cases because somatostatin attaches to the thymoma cells and causes them to stop growing or die. Side effects of this drug can include pain or burning at the injection site, stomach cramps, nausea, vomiting, headaches, dizziness, and fatigue. It is also linked to increased risk of gallstones.

Treatment of thymus cancers by extent and type of tumor

Whether or not a thymus cancer is considered resectable (removable by surgery) is one of the most important factors in determining treatment options. The type of tumor is also important. Thymic carcinomas are more likely to grow and spread quickly than thymomas and often require more aggressive treatment.

Resectable cancers

For patients with resectable cancers (almost all stage I and II thymus cancers, most stage III cancers, and small number of stage IV cancers), surgery offers the best chance for long-term survival if it can be tolerated. This typically includes removal of the entire thymus and, depending on the extent of the disease, maybe parts of nearby organs or blood vessels as well.

Early stage thymomas (such as stage I and II) do not usually require further treatment after surgery as long as the tumor was removed completely. For early thymomas, radiation therapy may be considered if there is concern that any tumor was left behind.

Patients with more advanced stage thymomas (such as stages III and IV) may be treated with radiation after surgery, even if all of the tumor was removed. If the tumor couldn’t be removed completely, radiation therapy is usually given after surgery. Depending on how much cancer was left behind, chemotherapy (chemo) may be added as well.

Patients with thymic carcinomas, which are more likely to come back after treatment, are typically given radiation after surgery, even if the doctor feels the cancer was completely removed. Chemo is usually given as well, especially if some of the cancer is left behind after surgery.

Unresectable cancers

This group includes cancers that are too close to vital structures or that have spread too far to be removed completely (which includes many stage III and most stage IV cancers), as well as cancers in people who are too ill for surgery.

In some cases, doctors may advise giving chemo, radiation therapy, or both first to try to make the tumor resectable. If it shrinks enough, surgery is done. This is then followed by further treatment with chemo or radiation therapy.

Surgery may be the first treatment for some unresectable cancers, to try to remove as much of the tumor as possible. This is known as debulking. Radiation therapy and/or chemo are then given. The hope is that the surgery may help the other treatments work better and may help people live longer, even if it doesn't cure the cancer. Studies of this approach have had mixed results.

For patients who can’t have surgery, either because the cancer has spread too far or because they are too sick from other serious medical conditions, chemo and radiation therapy are the main treatment options.

Because unresectable cancers can be hard to treat, taking part in a clinical trial of a newer form of treatment may be a reasonable option.

Recurrent thymus cancer

When cancer comes back after treatment it is called recurrent. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the liver or bone).

Treatment for thymus cancer that has recurred (come back) after initial treatment depends on the location of the recurrence and on what the original treatment was. If the recurrence is not too widespread, surgery may be an option and would offer the best chance for long-term survival. But in most cases, the treatment options may be limited to radiation therapy and/or chemo. These treatments can often be effective in controlling the cancer for a time, although they are very unlikely to result in a cure.

Because recurrent cancers can often be hard to treat, clinical trials of new types of treatment may be a good option.

What happens after treatment for thymus cancer?

For most people with thymus cancer, treatment may remove or destroy the cancer. Completing treatment can be both stressful and exciting. You may be relieved to finish treatment, but find it hard not to worry about cancer coming back. (When cancer comes back after treatment, it is called recurrence.) This is a very common concern in people who have had cancer.

It may take a while before your fears lessen. But it may help to know that many cancer survivors have learned to live with this uncertainty and are leading full lives.

For other people, the cancer may never go away completely. These people may get regular treatments with chemotherapy, radiation therapy, or other therapies to try to help keep the cancer in check. Learning to live with cancer that does not go away can be difficult and very stressful. It has its own type of uncertainty.

Follow-up care

When treatment ends, your doctors will still want to watch you closely. It is very important to go to all of your follow-up appointments. During these visits, your doctors will ask questions about any problems you may have and may do exams and lab tests or x-rays and scans to look for signs of cancer or treatment side effects. Almost any cancer treatment can have side effects. Some may last for a few weeks to months, but others can last the rest of your life. This is the time for you to talk to your cancer care team about any changes or problems you notice and any questions or concerns you have.

There is no widely agreed upon follow-up schedule for people with thymus cancer. Your doctor will most likely want to see you fairly frequently (every couple of months or so) at first. The time between visits may be extended if there are no problems. Most patients get a chest CT every year, at least for a while.

It is important to keep health insurance. Tests and doctor visits cost a lot, and even though no one wants to think of their cancer coming back, this could happen.

Another concern is the possibility of developing a second type of cancer later on. Several studies have found that a person who has had thymoma is more prone than the average person to develop other cancers, particularly lymphoma. The reasons for this are not clear.

If treatment for thymus cancer stops working

If cancer keeps growing or comes back after one kind of treatment, it is possible that another treatment plan might still cure the cancer, or at least shrink it enough to help you live longer and feel better. But when a person has tried many different treatments and the cancer has not gotten any better, the cancer tends to become resistant to all treatment. If this happens, it's important to weigh the possible limited benefits of a new treatment against the possible downsides. Everyone has their own way of looking at this.

This is likely to be the hardest part of your battle with cancer− when you have been through many medical treatments and nothing's working anymore. Your doctor may offer you new options, but at some point you may need to consider that treatment is not likely to improve your health or change your outcome or survival.

If you want to continue to get treatment for as long as you can, you need to think about the odds of treatment having any benefit and how this compares to the possible risks and side effects. In many cases, your doctor can estimate how likely it is the cancer will respond to treatment you are considering. For instance, the doctor may say that more chemo or radiation might have about a 1% chance of working. Some people are still tempted to try this. But it is important to think about and understand your reasons for choosing this plan.

No matter what you decide to do, you need to feel as good as you can. Make sure you are asking for and getting treatment for any symptoms you might have, such as nausea or pain. This type of treatment is called palliative care.

Palliative care helps relieve symptoms, but is not expected to cure the disease. It can be given along with cancer treatment, or can even be cancer treatment. The difference is its purpose - the main purpose of palliative care is to improve the quality of your life, or help you feel as good as you can for as long as you can. Sometimes this means using drugs to help with symptoms like pain or nausea. Sometimes, though, the treatments used to control your symptoms are the same as those used to treat cancer. For instance, radiation might be used to help relieve bone pain caused by cancer that has spread to the bones. Or chemo might be used to help shrink a tumor and keep it from blocking the bowels. But this is not the same as treatment to try to cure the cancer.

At some point, you might benefit from hospice care. This is special care that treats the person rather than the disease; it focuses on quality rather than length of life. Most of the time, it is given at home. Your cancer may be causing problems that need to be managed, and hospice focuses on your comfort. You should know that while getting hospice care often means the end of treatments such as chemo and radiation, it doesn't mean you can't have treatment for the problems caused by your cancer or other health conditions. In hospice the focus of your care is on living life as fully as possible and feeling as well as you can at this difficult time. You can learn more about hospice in our document called Hospice Care.

Staying hopeful is important, too. Your hope for a cure may not be as bright, but there is still hope for good times with family and friends − times that are filled with happiness and meaning. Pausing at this time in your cancer treatment gives you a chance to refocus on the most important things in your life. Now is the time to do some things you've always wanted to do and to stop doing the things you no longer want to do. Though the cancer may be beyond your control, there are still choices you can make.

What`s new in research and treatment for thymus cancer?

There is always research going on in the area of thymic tumors. Scientists are looking for causes of thymic tumors, and doctors are working to improve treatments.

Because thymic tumors are relatively rare, more information from clinical trials is needed to decide which treatments are best for each type and stage. For example, the role of chemotherapy in treating thymomas is still being explored. In addition, new treatments are being developed and tested.

Researchers are looking for more accurate ways of predicting the aggressiveness of each tumor so that treatment can be more appropriately selected for each patient.

Some studies are looking to see if giving treatment with chemotherapy (chemo) and/or radiation before surgery can help patients with thymus cancer.

Removing or destroying all of the cancer cells is not the only consideration in treating patients with thymomas. Some paraneoplastic syndromes may persist even after the tumor has been treated. Researchers are studying the causes of these syndromes and the best ways to treat them.

While chemotherapy can often help shrink thymus cancers, it is not always effective and can have serious side effects. Chemo drugs work by attacking rapidly growing cells, which is the main cause of their side effects. As researchers have learned more about what makes cancer cells different from normal cells, they have begun to develop drugs that target these differences. Studies are now testing targeted therapies against cancers of the thymus. These targeted therapies include anti-angiogenesis drugs (which affect tumors by limiting their blood supply) and anti-growth factor drugs (which interfere with substances some cancer cells make to stimulate their own growth). Some of these drugs are already being used to treat other cancers, and are being studied for use against thymus cancers. These include cetuximab, erlotinib, and bevacizumab. Others being studied, such as milciclib and saracatinib are not yet approved to treat any type of cancer.

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