Current Clinical Trials

Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)

Standard treatment options:

Operable:

1. En bloc surgical resection if possible. In patients with myasthenia gravis, operative mortality can be minimized with close attention to respiratory support when planning surgical treatment.
2. Following surgical resection, radiation therapy is generally recommended whether or not the surgical resection has been complete, especially for stage III and stage IVa patients. Retrospective clinical studies show improved local control and survival with the addition of postoperative radiation therapy.[1-3][Level of evidence: 3iiiDiv]

Inoperable (stages III and IV with vena caval obstruction, pleural involvement, pericardial implants, etc.):

• Radiation therapy: In patients who have residual macroscopic tumor following biopsy or attempted resection, radiation therapy has been reported to achieve local control in 60% to 90% of the cases. Because of an increased risk of radiation-induced injury, doses greater than 60 Gy should be avoided. Overall 5-year survival rates of approximately 50% are reported for patients with unresectable stage III tumors.[4-6][Level of evidence: 3iiiDiv] Of uncertainty is whether patients who undergo tumor debulking have a better prognosis than those who undergo biopsy only.[4,6]

Treatment options under clinical evaluation:

1. Chemotherapy: Only a few phase II clinical studies have evaluated the role of chemotherapy in adequate numbers of patients. Combination chemotherapy has been reported to produce both complete and partial remissions; however, some of the complete remissions have been pathologically confirmed at subsequent surgery. In a series of 30 patients with stage IV or locally progressive recurrent tumor following radiation therapy, the PAC regimen (cisplatin, doxorubicin, cyclophosphamide) achieved a 50% response rate, including three complete responses. The median duration of response was 12 months, and the 5-year survival rate was 32%.[7] [Level of evidence: 3iiiDiv] In another series, the ADOC regimen (doxorubicin, cisplatin, vincristine, cyclophosphamide) produced a 92% response rate (34 of 37 patients), including complete responses in 43% of the patients.[8] A study of combined chemotherapy with cisplatin and etoposide produced responses in 9 of 16 patients treated, with a median response duration of 3.4 years and a median survival of 4.3 years.[9] In yet another study, 9 of 28 patients with invasive thymoma or thymic carcinoma who received four cycles of etoposide, ifosfamide, and cisplatin at 3-week intervals had partial responses.[10] The median duration of response was 11.9 months (range, <1 to 26 months), and the median overall survival was 31.6 months. The 1-year and 2-year survival rates were 89% and 70%, respectively.[10][Level of evidence: 3iiiDiv] Other combination chemotherapy regimens remain under evaluation (E-1C99).

   Of uncertainty is whether combination chemotherapy regimens are more effective than single agents; no prospective comparisons have been conducted. Transient partial responses have been reported with single-agent doxorubicin, maytansine, cisplatin, ifosfamide, and corticosteroids. Corticosteroids and many chemotherapeutic agents are lympholytic; shrinkage of thymic tumors with substantial lymphoid cell infiltration may reflect shrinkage of the nonmalignant components of the tumors rather than the malignant epithelial components.

   A retrospective analysis of 17 patients treated with cisplatin alone or in combination with prednisone revealed an overall response rate of 64%.[11] Cisplatin alone (50 mg/m² every 21 days), however, was associated with a partial response rate of only 10% (2 of 20 patients) in a phase II study (EST-2582).[12] Treatment with single-agent ifosfamide was associated with five complete responses and one partial response in 13 patients with advanced thymoma in another prospective study.[13]




2. Neoadjuvant chemotherapy followed by resection: A few studies have reported on the use of chemotherapy followed by surgery with or without radiation therapy for patients with clinically advanced disease.[14,15] One series of 16 patients with stage III or stage IVa disease were treated with initial ADOC chemotherapy. All patients achieved a clinical response to chemotherapy. Eleven patients had residual histologic tumor and received postoperative radiation therapy. The median survival of the entire group was 66 months.[14] Another similar study of 12 patients reported 100% survival and 73% disease-free survival at 7 years.[16][Level of evidence: 3iiiDiv] Additional clinical studies are needed to confirm the value of preoperative chemotherapy before it can be recommended for routine use in this disease.



3. Combined chemotherapy and radiation therapy for unresectable tumors: An intergroup study of patients with unresectable disease who received the PAC regimen (cisplatin, doxorubicin, and cyclophosphamide) followed by thoracic radiation reported a 5-year survival rate of 52%.[17][Level of evidence: 3iiiDiv]

Check for U.S. clinical trials from NCI's PDQ Cancer Clinical Trials Registry that are now accepting patients with thymoma and thymic carcinoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.

General information about clinical trials is also available from the NCI Web site.

References

1. Ariaratnam LS, Kalnicki S, Mincer F, et al.: The management of malignant thymoma with radiation therapy. Int J Radiat Oncol Biol Phys 5 (1): 77-80, 1979.  [PUBMED Abstract]
   
   
2. Penn CR, Hope-Stone HF: The role of radiotherapy in the management of malignant thymoma. Br J Surg 59 (7): 533-9, 1972.  [PUBMED Abstract]
   
   
3. Curran WJ Jr, Kornstein MJ, Brooks JJ, et al.: Invasive thymoma: the role of mediastinal irradiation following complete or incomplete surgical resection. J Clin Oncol 6 (11): 1722-7, 1988.  [PUBMED Abstract]
   
   
4. Ciernik IF, Meier U, Lütolf UM: Prognostic factors and outcome of incompletely resected invasive thymoma following radiation therapy. J Clin Oncol 12 (7): 1484-90, 1994.  [PUBMED Abstract]
   
   
5. Jackson MA, Ball DL: Post-operative radiotherapy in invasive thymoma. Radiother Oncol 21 (2): 77-82, 1991.  [PUBMED Abstract]
   
   
6. Mornex F, Resbeut M, Richaud P, et al.: Radiotherapy and chemotherapy for invasive thymomas: a multicentric retrospective review of 90 cases. The FNCLCC trialists. Fédération Nationale des Centres de Lutte Contre le Cancer. Int J Radiat Oncol Biol Phys 32 (3): 651-9, 1995.  [PUBMED Abstract]
   
   
7. Loehrer PJ Sr, Kim K, Aisner SC, et al.: Cisplatin plus doxorubicin plus cyclophosphamide in metastatic or recurrent thymoma: final results of an intergroup trial. The Eastern Cooperative Oncology Group, Southwest Oncology Group, and Southeastern Cancer Study Group. J Clin Oncol 12 (6): 1164-8, 1994.  [PUBMED Abstract]
   
   
8. Fornasiero A, Daniele O, Ghiotto C, et al.: Chemotherapy for invasive thymoma. A 13-year experience. Cancer 68 (1): 30-3, 1991.  [PUBMED Abstract]
   
   
9. Giaccone G, Ardizzoni A, Kirkpatrick A, et al.: Cisplatin and etoposide combination chemotherapy for locally advanced or metastatic thymoma. A phase II study of the European Organization for Research and Treatment of Cancer Lung Cancer Cooperative Group. J Clin Oncol 14 (3): 814-20, 1996.  [PUBMED Abstract]
   
   
10. Loehrer PJ Sr, Jiroutek M, Aisner S, et al.: Combined etoposide, ifosfamide, and cisplatin in the treatment of patients with advanced thymoma and thymic carcinoma: an intergroup trial. Cancer 91 (11): 2010-5, 2001.  [PUBMED Abstract]
    
    
11. Park HS, Shin DM, Lee JS, et al.: Thymoma. A retrospective study of 87 cases. Cancer 73 (10): 2491-8, 1994.  [PUBMED Abstract]
    
    
12. Bonomi PD, Finkelstein D, Aisner S, et al.: EST 2582 phase II trial of cisplatin in metastatic or recurrent thymoma. Am J Clin Oncol 16 (4): 342-5, 1993.  [PUBMED Abstract]
    
    
13. Highley MS, Underhill CR, Parnis FX, et al.: Treatment of invasive thymoma with single-agent ifosfamide. J Clin Oncol 17 (9): 2737-44, 1999.  [PUBMED Abstract]
    
    
14. Rea F, Sartori F, Loy M, et al.: Chemotherapy and operation for invasive thymoma. J Thorac Cardiovasc Surg 106 (3): 543-9, 1993.  [PUBMED Abstract]
    
    
15. Macchiarini P, Chella A, Ducci F, et al.: Neoadjuvant chemotherapy, surgery, and postoperative radiation therapy for invasive thymoma. Cancer 68 (4): 706-13, 1991.  [PUBMED Abstract]
    
    
16. Shin DM, Walsh GL, Komaki R, et al.: A multidisciplinary approach to therapy for unresectable malignant thymoma. Ann Intern Med 129 (2): 100-4, 1998.  [PUBMED Abstract]
    
    
17. Loehrer PJ Sr, Chen M, Kim K, et al.: Cisplatin, doxorubicin, and cyclophosphamide plus thoracic radiation therapy for limited-stage unresectable thymoma: an intergroup trial. J Clin Oncol 15 (9): 3093-9, 1997.  [PUBMED Abstract]
    
    

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