Interpretation of NCCN guidelines version 1. 2023 thymomas and thymic carcinomas_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LI Jiahe ¹ , XIANG Guangyu ¹ , ZHANG Jipeng ² , JIA Chenghui ² , CHANG Ting ³ , RUAN Zhe ³ , GONG Li ⁴ ,  LU Qiang ²

1. Basic Medical College, Air Force Military Medical University, Xi’an, 710032, P. R. China;
2. Department of Thoracic Surgery, Tangdu Hospital, Air Force Military Medical University, Xi’an, 710038, P. R. China;
3. Department of Neurology, Tangdu Hospital, Air Force Military Medical University, Xi’an, 710038, P. R. China;
4. Department of Pathology, Tangdu Hospital, Air Force Military Medical University, Xi’an, 710038, P. R. China;

Corresponding author：

LU Qiang, Email: luqiang@fmmu.edu.cn

Keywords：

Thymoma; thymic carcinoma; NCCN guidelines; guideline interpretation

DOI：

10.7507/1007-4848.202302009

Video：

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National Comprehensive Cancer Network (NCCN) has updated and released the latest content of NCCN guidelines version 1. 2023 thymomas and thymic carcinomas (known as "guidelines"). The guideline sets standards for the diagnosis and treatment of thymoma and thymic carcinoma based on high quality clinical evidence and the latest advances in research. There have been some updates and revisions in the latest two versions of the guidelines, mainly focusing on the principles of radiotherapy, the principles of systematic therapy, multidisciplinary participation and the improvement of some footnotes, compared with the first version of the guidelines in 2022. In this paper, the contents of the new guideline will be interpreted in order to provide reference for the work of thymoma and thymic carcinoma in our country at the present stage.

Citation： LI Jiahe, XIANG Guangyu, ZHANG Jipeng, JIA Chenghui, CHANG Ting, RUAN Zhe, GONG Li, LU Qiang. Interpretation of NCCN guidelines version 1. 2023 thymomas and thymic carcinomas. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(4): 506-513. doi: 10.7507/1007-4848.202302009 Copy

1.	Marx A, Chan JKC, Chalabreysse L, et al. The 2021 WHO classification of tumors of the thymus and mediastinum: What is new in thymic epithelial, germ cell, and mesenchymal tumors? J Thorac Oncol, 2022, 17(2): 200-213.
2.	Liu H, Gu Z, Qiu B, et al. A recurrence predictive model for thymic tumors and its implication for postoperative management: A Chinese alliance for research in thymomas database study. J Thorac Oncol, 2020, 15(3): 448-456.
3.	Fu H, Gu ZT, Fang WT, et al. Long-term survival after surgical treatment of thymic carcinoma: A retrospective analysis from the chinese alliance for research of thymoma database. Ann Surg Oncol, 2016, 23(2): 619-625.
4.	Litvak AM, Woo K, Hayes S, et al. Clinical characteristics and outcomes for patients with thymic carcinoma: evaluation of Masaoka staging. J Thorac Oncol, 2014, 9(12): 1810-1815.
5.	Kondo K, Monden Y. Therapy for thymic epithelial tumors: A clinical study of 1, 320 patients from Japan. Ann Thorac Surg, 2003, 76(3): 878-884.
6.	Eng TY, Fuller CD, Jagirdar J, et al. Thymic carcinoma: State of the art review. Int J Radiat Oncol Biol Phys, 2004, 59(3): 654-664.
7.	NCCN guidelines version 1. 2023 thymomas and thymic carcinomas. URL: https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1469. Accessed on 2022-12-31.
8.	Dong J, Li W, Zeng Q, et al. CT-guided percutaneous step-by-step radiofrequency ablation for the treatment of carcinoma in the caudate lobe. Medicine (Baltimore), 2015, 94(39): e1594.
9.	Leuzzi G, Rocco G, Ruffini E, et al. Multimodality therapy for locally advanced thymomas: A propensity score-matched cohort study from the European Society of Thoracic Surgeons Database. J Thorac Cardiovasc Surg, 2016, 151(1): 47-57.
10.	Dong J, Yuan S, Chang B, et al. An exploratory study of CT-guided percutaneous radiofrequency ablation for stage I thymoma. Cancer Imaging, 2019, 19(1): 80.
11.	Vogel J, Berman AT, Lin L, et al. Prospective study of proton beam radiation therapy for adjuvant and definitive treatment of thymoma and thymic carcinoma: Early response and toxicity assessment. Radiother Oncol, 2016, 118(3): 504-509.
12.	Lideståhl A, Johansson G, Siegbahn A, et al. Estimated risk of radiation-induced cancer after thymoma treatments with proton- or X-ray beams. Cancers (Basel), 2021, 13(20): 5153.
13.	Zhu HJ, Hoppe BS, Flampouri S, et al. Rationale and early outcomes for the management of thymoma with proton therapy. Transl Lung Cancer Res, 2018, 7(2): 106-113.
14.	Loehrer PJ, Wang W, Johnson DH, et al. Octreotide alone or with prednisone in patients with advanced thymoma and thymic carcinoma: An Eastern Cooperative Oncology Group Phase Ⅱ Trial. J Clin Oncol, 2004, 22(2): 293-299.
15.	Palmieri G, Montella L, Martignetti A, et al. Somatostatin analogs and prednisone in advanced refractory thymic tumors. Cancer, 2002, 94(5): 1414-1420.
16.	Kitadai R, Okuma Y. Future perspective of chemotherapy and pharmacotherapy in thymic carcinoma. Cancers (Basel), 2021, 13(20): 5239.
17.	Moran CA, Weissferdt A, Kalhor N, et al. ThymomasⅠ: A clinicopathologic correlation of 250 cases with emphasis on the World Health Organization schema. Am J Clin Pathol, 2012, 137(3): 444-450.
18.	WHO Classification of Tumours Editorial Board. Thoracictumours. In: WHO Classification of Tumours. 5th ed 5. Lyon, France: International Agency for Research on Cancer, 2021.
19.	Taylor C, Munro AJ, Glynne-Jones R, et al. Multidisciplinary team working in cancer: What is the evidence? BMJ, 2010, 340: c951.
20.	Pillay B, Wootten AC, Crowe H, et al. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Cancer Treat Rev, 2016, 42: 56-72.
21.	Roden AC, Ahmad U, Cardillo G, et al. Thymic carcinomas-A concise multidisciplinary update on recent developments from the Thymic Carcinoma Working Group of the International Thymic Malignancy Interest Group. J Thorac Oncol, 2022, 17(5): 637-650.
22.	Brown GTF, Bekker HL, Young AL. Quality and efficacy of multidisciplinary team (MDT) quality assessment tools and discussion checklists: A systematic review. BMC Cancer, 2022, 22(1): 286.
23.	王仓红, 朱靓, 陈博洋, 等. 肿瘤多学科团队诊疗模式评价指标体系的构建. 循证护理, 2022, 8(23): 3209-3213.
24.	Strange CD, Ahuja J, Shroff GS, et al. Imaging evaluation of thymoma and thymic carcinoma. Front Oncol, 2022, 11: 810419.
25.	Oramas DM, Moran CA. Thymoma: Challenges and pitfalls in biopsy interpretation. Adv Anat Pathol, 2021, 28(5): 291-297.
26.	Rappaport JMP, Huang J, Ahmad U. Thymic malignancy-Updates in staging and management. Surg Oncol Clin N Am, 2020, 29(4): 581-601.
27.	Chiappetta M, Lococo F, Pogliani L, et al. Masaoka-Koga and TNM staging system in thymic epithelial tumors: Prognostic comparison and the role of the number of involved structures. Cancers (Basel), 2021, 13(21): 5254.
28.	Wright CD. Management of thymomas. Crit Rev Oncol Hematol, 2008, 65(2): 109-120.
29.	Detterbeck FC, Nicholson AG, Kondo K, et al. The Masaoka-Koga stage classification for thymic malignancies: Clarification and definition of terms. J Thorac Oncol, 2011, 6(7 Suppl 3): S1710-S1716.
30.	Burt BM, Yao X, Shrager J, et al. Determinants of complete resection of thymoma by minimally invasive and open thymectomy: Analysis of an international registry. J Thorac Oncol, 2017, 12(1): 129-136.
31.	Friedant AJ, Handorf EA, Su S, et al. Minimally invasive versus open thymectomy for thymic malignancies: Systematic review and meta-analysis. J Thorac Oncol, 2016, 11(1): 30-38.
32.	Davenport E, Malthaner RA. The role of surgery in the management of thymoma: A systematic review. Ann Thorac Surg, 2008, 86(2): 673-684.
33.	Zhang C, Wang Q, Hu L, et al. The prognostic value of postoperative radiotherapy for thymoma and thymic carcinoma: A propensity-matched study based on SEER database. Cancers (Basel), 2022, 14(19): 4938.
34.	Hamaji M, Shah RM, Ali SO, et al. A meta-analysis of postoperative radiotherapy for thymic carcinoma. Ann Thorac Surg, 2017, 103(5): 1668-1675.
35.	Jackson MW, Palma DA, Camidge DR, et al. The impact of postoperative radiotherapy for thymoma and thymic carcinoma. J Thorac Oncol, 2017, 12(4): 734-744.
36.	Falkson CB, Vella ET, Ellis PM, et al. Surgical, radiation, and systemic treatments of patients with thymic epithelial tumors: A systematic review. J Thorac Oncol, 2022, S1556-0864(22): 01877-9.
37.	Lim YJ, Kim E, Kim HJ, et al. Survival impact of adjuvant radiation therapy in masaoka stage Ⅱ to Ⅳ Thymomas: A systematic review and meta-analysis. Int J Radiat Oncol Biol Phys, 2016, 94(5): 1129-1136.
38.	Bott MJ, Wang H, Travis W, et al. Management and outcomes of relapse after treatment for thymoma and thymic carcinoma. Ann Thorac Surg, 2011, 92(6): 1984-1991.
39.	Ma WL, Lin CC, Hsu FM, et al. Clinical outcomes for patients with thymoma and thymic carcinoma after undergoing different front-line chemotherapy regimens. Cancer Med, 2022, 11(18): 3445-3456.
40.	Conforti F, Pala L, De Pas T, et al. Investigational drugs for the treatment of thymic cancer: A focus on phase 1 and 2 clinical trials. Expert Opin Investig Drugs, 2022, 31(9): 895-904.
41.	Grassin F, Paleiron N, André M, et al. Combined etoposide, ifosfamide, and cisplatin in the treatment of patients with advanced thymoma and thymic carcinoma. A French experience. J Thorac Oncol, 2010, 5(6): 893-897.
42.	Meurgey A, Girard N, Merveilleux du Vignaux C, et al. Assessment of the ITMIG statement on the WHO histological classification and of the eighth TNM staging of thymic epithelial tumors of a series of 188 thymic epithelial tumors. J Thorac Oncol, 2017, 12(10): 1571-1581.

1. Marx A, Chan JKC, Chalabreysse L, et al. The 2021 WHO classification of tumors of the thymus and mediastinum: What is new in thymic epithelial, germ cell, and mesenchymal tumors? J Thorac Oncol, 2022, 17(2): 200-213.
2. Liu H, Gu Z, Qiu B, et al. A recurrence predictive model for thymic tumors and its implication for postoperative management: A Chinese alliance for research in thymomas database study. J Thorac Oncol, 2020, 15(3): 448-456.
3. Fu H, Gu ZT, Fang WT, et al. Long-term survival after surgical treatment of thymic carcinoma: A retrospective analysis from the chinese alliance for research of thymoma database. Ann Surg Oncol, 2016, 23(2): 619-625.
4. Litvak AM, Woo K, Hayes S, et al. Clinical characteristics and outcomes for patients with thymic carcinoma: evaluation of Masaoka staging. J Thorac Oncol, 2014, 9(12): 1810-1815.
5. Kondo K, Monden Y. Therapy for thymic epithelial tumors: A clinical study of 1, 320 patients from Japan. Ann Thorac Surg, 2003, 76(3): 878-884.
6. Eng TY, Fuller CD, Jagirdar J, et al. Thymic carcinoma: State of the art review. Int J Radiat Oncol Biol Phys, 2004, 59(3): 654-664.
7. NCCN guidelines version 1. 2023 thymomas and thymic carcinomas. URL: https://www.nccn.org/guidelines/guidelines-detail?category=1&id=1469. Accessed on 2022-12-31.
8. Dong J, Li W, Zeng Q, et al. CT-guided percutaneous step-by-step radiofrequency ablation for the treatment of carcinoma in the caudate lobe. Medicine (Baltimore), 2015, 94(39): e1594.
9. Leuzzi G, Rocco G, Ruffini E, et al. Multimodality therapy for locally advanced thymomas: A propensity score-matched cohort study from the European Society of Thoracic Surgeons Database. J Thorac Cardiovasc Surg, 2016, 151(1): 47-57.
10. Dong J, Yuan S, Chang B, et al. An exploratory study of CT-guided percutaneous radiofrequency ablation for stage I thymoma. Cancer Imaging, 2019, 19(1): 80.
11. Vogel J, Berman AT, Lin L, et al. Prospective study of proton beam radiation therapy for adjuvant and definitive treatment of thymoma and thymic carcinoma: Early response and toxicity assessment. Radiother Oncol, 2016, 118(3): 504-509.
12. Lideståhl A, Johansson G, Siegbahn A, et al. Estimated risk of radiation-induced cancer after thymoma treatments with proton- or X-ray beams. Cancers (Basel), 2021, 13(20): 5153.
13. Zhu HJ, Hoppe BS, Flampouri S, et al. Rationale and early outcomes for the management of thymoma with proton therapy. Transl Lung Cancer Res, 2018, 7(2): 106-113.
14. Loehrer PJ, Wang W, Johnson DH, et al. Octreotide alone or with prednisone in patients with advanced thymoma and thymic carcinoma: An Eastern Cooperative Oncology Group Phase Ⅱ Trial. J Clin Oncol, 2004, 22(2): 293-299.
15. Palmieri G, Montella L, Martignetti A, et al. Somatostatin analogs and prednisone in advanced refractory thymic tumors. Cancer, 2002, 94(5): 1414-1420.
16. Kitadai R, Okuma Y. Future perspective of chemotherapy and pharmacotherapy in thymic carcinoma. Cancers (Basel), 2021, 13(20): 5239.
17. Moran CA, Weissferdt A, Kalhor N, et al. ThymomasⅠ: A clinicopathologic correlation of 250 cases with emphasis on the World Health Organization schema. Am J Clin Pathol, 2012, 137(3): 444-450.
18. WHO Classification of Tumours Editorial Board. Thoracictumours. In: WHO Classification of Tumours. 5th ed 5. Lyon, France: International Agency for Research on Cancer, 2021.
19. Taylor C, Munro AJ, Glynne-Jones R, et al. Multidisciplinary team working in cancer: What is the evidence? BMJ, 2010, 340: c951.
20. Pillay B, Wootten AC, Crowe H, et al. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A systematic review of the literature. Cancer Treat Rev, 2016, 42: 56-72.
21. Roden AC, Ahmad U, Cardillo G, et al. Thymic carcinomas-A concise multidisciplinary update on recent developments from the Thymic Carcinoma Working Group of the International Thymic Malignancy Interest Group. J Thorac Oncol, 2022, 17(5): 637-650.
22. Brown GTF, Bekker HL, Young AL. Quality and efficacy of multidisciplinary team (MDT) quality assessment tools and discussion checklists: A systematic review. BMC Cancer, 2022, 22(1): 286.
23. 王仓红, 朱靓, 陈博洋, 等. 肿瘤多学科团队诊疗模式评价指标体系的构建. 循证护理, 2022, 8(23): 3209-3213.
24. Strange CD, Ahuja J, Shroff GS, et al. Imaging evaluation of thymoma and thymic carcinoma. Front Oncol, 2022, 11: 810419.
25. Oramas DM, Moran CA. Thymoma: Challenges and pitfalls in biopsy interpretation. Adv Anat Pathol, 2021, 28(5): 291-297.
26. Rappaport JMP, Huang J, Ahmad U. Thymic malignancy-Updates in staging and management. Surg Oncol Clin N Am, 2020, 29(4): 581-601.
27. Chiappetta M, Lococo F, Pogliani L, et al. Masaoka-Koga and TNM staging system in thymic epithelial tumors: Prognostic comparison and the role of the number of involved structures. Cancers (Basel), 2021, 13(21): 5254.
28. Wright CD. Management of thymomas. Crit Rev Oncol Hematol, 2008, 65(2): 109-120.
29. Detterbeck FC, Nicholson AG, Kondo K, et al. The Masaoka-Koga stage classification for thymic malignancies: Clarification and definition of terms. J Thorac Oncol, 2011, 6(7 Suppl 3): S1710-S1716.
30. Burt BM, Yao X, Shrager J, et al. Determinants of complete resection of thymoma by minimally invasive and open thymectomy: Analysis of an international registry. J Thorac Oncol, 2017, 12(1): 129-136.
31. Friedant AJ, Handorf EA, Su S, et al. Minimally invasive versus open thymectomy for thymic malignancies: Systematic review and meta-analysis. J Thorac Oncol, 2016, 11(1): 30-38.
32. Davenport E, Malthaner RA. The role of surgery in the management of thymoma: A systematic review. Ann Thorac Surg, 2008, 86(2): 673-684.
33. Zhang C, Wang Q, Hu L, et al. The prognostic value of postoperative radiotherapy for thymoma and thymic carcinoma: A propensity-matched study based on SEER database. Cancers (Basel), 2022, 14(19): 4938.
34. Hamaji M, Shah RM, Ali SO, et al. A meta-analysis of postoperative radiotherapy for thymic carcinoma. Ann Thorac Surg, 2017, 103(5): 1668-1675.
35. Jackson MW, Palma DA, Camidge DR, et al. The impact of postoperative radiotherapy for thymoma and thymic carcinoma. J Thorac Oncol, 2017, 12(4): 734-744.
36. Falkson CB, Vella ET, Ellis PM, et al. Surgical, radiation, and systemic treatments of patients with thymic epithelial tumors: A systematic review. J Thorac Oncol, 2022, S1556-0864(22): 01877-9.
37. Lim YJ, Kim E, Kim HJ, et al. Survival impact of adjuvant radiation therapy in masaoka stage Ⅱ to Ⅳ Thymomas: A systematic review and meta-analysis. Int J Radiat Oncol Biol Phys, 2016, 94(5): 1129-1136.
38. Bott MJ, Wang H, Travis W, et al. Management and outcomes of relapse after treatment for thymoma and thymic carcinoma. Ann Thorac Surg, 2011, 92(6): 1984-1991.
39. Ma WL, Lin CC, Hsu FM, et al. Clinical outcomes for patients with thymoma and thymic carcinoma after undergoing different front-line chemotherapy regimens. Cancer Med, 2022, 11(18): 3445-3456.
40. Conforti F, Pala L, De Pas T, et al. Investigational drugs for the treatment of thymic cancer: A focus on phase 1 and 2 clinical trials. Expert Opin Investig Drugs, 2022, 31(9): 895-904.
41. Grassin F, Paleiron N, André M, et al. Combined etoposide, ifosfamide, and cisplatin in the treatment of patients with advanced thymoma and thymic carcinoma. A French experience. J Thorac Oncol, 2010, 5(6): 893-897.
42. Meurgey A, Girard N, Merveilleux du Vignaux C, et al. Assessment of the ITMIG statement on the WHO histological classification and of the eighth TNM staging of thymic epithelial tumors of a series of 188 thymic epithelial tumors. J Thorac Oncol, 2017, 12(10): 1571-1581.

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