Multimodality Treatment of Neuroendocrine Tumors of the Thymus

Long-term effect of everolimus in recurrent thymic neuroendocrine neoplasia

PURPOSE

Neuroendocrine neoplasia (NEN) of the thymus is a very rare entity with a poor prognosis. None of the treatments was proofed by studies. Usually, therapy protocols for bronchopulmonary carcinoids are used. So far no data exist on the effect of mammalian target of rapamycin (mTOR) inhibitors. We describe our long-term experience with everolimus and give a thorough review of the therapeutic strategies used so far.

PATIENTS AND METHODS

Four patients (mean age 46 years, range 37-55) with progressing thymic NEN (t-NEN) (two well-differentiated atypical carcinoids and two atypical carcinoids with large cell characteristics) were treated with everolimus 10 mg/day after the failure of at least one previous medical therapy. Everolimus was applied after a mean interval of 32.4 months (range 5-56) after the first diagnosis. The follow-up included clinical examination, imaging and chromogranin A testing in 3 or 6 monthly intervals.

RESULTS

We observed stable disease for a mean of 20.8 months. Both patients with large cell characteristics t-NEN (Ki-67 of 20%) had rapid progress after 7 and 10 months and had more previous therapies (three and six) than the patients with well-differentiated t-NEN (Ki-67 5% and 10%, progress after 24 and 42 months, one and two previous therapies). No severe side effects occurred. In three of four patients, everolimus led to stable disease for the longest compared to the other nonsurgical therapies used.

CONCLUSION

Comparing the sparse data available everolimus is a promising treatment for t-NEN at least in second-line therapy. A low Ki-67 index was associated with a better outcome.

Metastatic thymic carcinoid responds to chemoradiation and octreotide: A case report

RATIONALE

Thymic carcinoids are a rare type of malignant neuroendocrine tumors which have a poor prognosis due to their distant metastasis, invasive behaviour, and postoperative recurrence. Surgical resection is still the fundamental mode for treating thymic carcinoids. Here, we report the rapid shrinkage of an atypical thymic carcinoid with multiple metastases following chemoradiation plus octreotide as a first-line therapy PATIENT CONCERNS:: A 39-year-old Chinese man presented with chest tightness, dyspnea with a history of lumbago and untreated malignant thymoma.

DIAGNOSIS

Thoracic computed tomography (CT) scan revealed an anterior mediastinal mass with pulmonary and multiple bone metastases as well as bilateral pleural and pericardial effusions. Percutaneous needle biopsy was performed on the mediastinal mass and the pathological diagnosis was neuroendocrine carcinoma of moderately differentiation (atypical carcinoid) INTERVENTIONS:: The tumor was considered unresectable because of extensive invasion into the lung and various bones. The patient was started on paclitaxel and oxaliplatin per 21 days for 4 cycles, and on 20 mg of depot formulation of octreotide once per 21 days. After 2 cycles of chemotherapy, the patient received concurrently mediastinal radiotherapy (39.6 Gy × 22 fractions).

OUTCOMES

A follow-up CT of the chest at the completion of his fourth chemotherapy regimen demonstrated, approximately 22% of tumor shrinkage. There were no signs of disease progression but the patient refused further chemoradiation treatment. The patient received monthly treatment of octreotide and zoledronate and his progression-free survival reached 18 months. Due to uncontrollable disease progression, the patient expired.

LESSONS

Early diagnosis and radical surgery of thymic carcinoid are very important. However, radiotherapy (combined/noncombined chemotherapy) must be considered if radical resection is not performed. We believe that further study of chemoradiation and octreotide with the palliative intent of preparing tumors for shrinkage is warranted as a strategy to improve curative management of neuroendocrine tumors.

Successful Pregnancies after the Treatment of a Thymic Carcinoid

The present report describes the case of a woman diagnosed with an adrenocorticotropic hormone- (ACTH-) secreting thymic carcinoid associated with Cushing's syndrome. Treatment consisted of tumour resection and 131-I-meta-iodobenzylguanidine (MIBG) therapy. In spite of her iatrogenic menopausal state she twice became pregnant and delivered two healthy babies but developed recurrences during both pregnancies. The last recurrence presented as a primary breast cancer. Despite poor prognosis our patient survived for eleven years. To our knowledge this is the first report of successful pregnancy and delivery in a patient with a thymic carcinoid.

Thymic neuroendocrine tumour (carcinoid): clinicopathological features of four patients with different presentation

Thymic carcinoids are aggressive and present at an advanced stage. This article describes the utility of (68)Gallium-1,4,7,10-traazacyclododecane-NI, NII, NIII, NIIII-tetra acetic acid-(D)-Phel1-Tyr3-octreotide positron emission tomography ((68)Ga DOTATOC PET-CT-scan) and clinicopathological features of four thymic carcinoid tumours. Two typical, one atypical, and one large cell neuroendocrine carcinoma (LCNEC) were analysed. There were three males and one female with a mean age of 33 years. Three patients had a stage III and one had a stage II tumour. Preoperative (68)Ga DOTATOC PET-CT-scan of three patients did not show uptake of radiotracer in the tumour. Three patients were disease free at 19-27 months follow-up. The patient with LCNEC developed recurrence in the lumbar vertebrae. There is no locoregional recurrence of tumour in any of our patients. Complete surgical resection of the tumour with invaded adjacent structures, postoperative radiotherapy to the tumour bed helps in obtaining disease free survival.