This article provides information about what Timoma is, how it develops, its symptoms, and its stages. Based on this information, you can find detailed information about Timoma diagnosis, treatment, surgical methods, risks, and how many days you may need to stay in the hospital after surgery.
What is Timoma?
Timoma is a tumor that originates from the thymus gland located behind the breastbone. The thymus gland is responsible for the production of T-lymphocytes in the immune system until puberty. After puberty, the thymus gland loses its function and shrinks. Tumors that develop in the thymus gland are called timomas.
You can click here for the educational video on Timoma.
IMPORTANT
Timoma is a very serious tumor.
If it is not appropriately treated, it can cause significant consequences, even though it is considered a simple and benign tumor.
Timoma Symptoms
Timomas may not cause any symptoms. If they continue to grow, they may cause pain in the front of the chest, or pressure on the trachea leading to bronchitis-like coughing. If they grow larger, they may press on nearby blood vessels, causing noticeable swelling in the face, enlargement of neck veins, and excessive redness of the face (superior vena cava syndrome) along with shortness of breath. However, these situations are very rare. Generally, there are no symptoms in patients with timoma.
Approximately 15% of timoma patients have a neurological disorder called Myasthenia Gravis. In Myasthenia Gravis, patients experience difficulty in vision (due to drooping eyelids), swallowing, and sometimes breathing. However, the most common complaint in patients with Myasthenia Gravis is fatigue in all muscle groups that develops as the day progresses.
Sometimes, patients with timomas may develop conditions like anemia, skin rashes, Kaposi’s sarcoma, and many other diseases unrelated to the timoma itself. These para-neoplastic syndromes are corrected with the treatment of timoma.
Timoma Stages
Timomas have four stages.
Stage I Timoma
In this early stage of timoma, the tumor is confined within a capsule. No symptoms are observed in patients. The boundaries of the tumor are regularly visible in the computed tomography (CT) scan. Surgery is often possible using a closed method. The recurrence rate is extremely rare. No additional treatment is required after surgery.
Stage II Timoma
In this stage, the tumor invades the capsule and extends outward. Distinguishing between stages I and II may not always be possible using CT images. This distinction is made based on the pathology examination of the removed tumor. Even in this stage, no additional treatment is required after surgery.
The following images show the CT scan and the timoma removed by surgery from a 51-year-old patient with stage II timoma.
Stage III Timoma
At this stage, the timoma extends beyond its capsule and infiltrates surrounding structures such as the lungs, trachea, blood vessels, and pericardium. Surgery can only be performed by experienced thoracic surgeons to minimize the risk of recurrence. Often, radiotherapy is applied before and sometimes after surgery.
Stage IV Timoma
At this stage, the timoma has spread to other organs (e.g., lungs, liver, adrenal glands).
Stage 4A Timoma
In stage 4A, the tumor has spread to the lung or pleura (lung lining). This is known as pleural implants or metastasis, not metastasis in the traditional sense.
The following CT scan shows metastasis/implantation on the right pleura in a patient with timoma.
Stage 4B Timoma
In stage 4B, the tumor has metastasized to other organs.
Timoma Diagnosis
Plain chest X-rays are not very useful in diagnosing timomas. A normal chest X-ray does not rule out the presence of a timoma. CT scans provide much more detailed information. In some cases, MRI imaging may also be required. If there is a suspicion, PET-CT scans may be necessary, though this is not always a requirement.
For patients who are candidates for surgery (stage I and II), a biopsy is usually not needed for well-defined tumors. However, a biopsy is essential for diagnosing stage III and IV timomas.
Timoma Treatment
If Myasthenia Gravis is present in a patient, it should first be treated appropriately with medication. This treatment is managed by the neurology department. Once Myasthenia Gravis is under control, treatment for timoma can proceed.
Timoma treatment depends on the stage of the timoma.
Stage I and II Timoma Treatment
In these stages, timoma should be surgically removed.
No additional treatment, such as chemotherapy or radiotherapy, is necessary after surgery.
Patients should be followed up every 6 months for 5 years. After that, annual check-ups are recommended.
Stage III Timoma Treatment
If the surgeon believes that the stage III timoma can be completely removed with surgery, the tumor will be removed surgically. Afterward, about 6 weeks of radiotherapy will be applied.
If the surgeon believes that the tumor cannot be completely removed surgically, chemotherapy (drug therapy) and radiotherapy (radiation therapy) will be applied first to reduce the spread of the tumor. Afterward, the tumor will be removed surgically.
Chemotherapy may continue after surgery if necessary. Whether chemotherapy is required will be decided by the hospital’s tumor board.
The patient will be followed up with exams every 3 months for 2 years, and then every 6 months for the next 3 years. After that, annual follow-ups will be performed.
The above image shows a CT scan of a female patient with stage III timoma. The patient received chemotherapy and radiotherapy first, and after the spread to the blood vessels was eliminated, the tumor was surgically removed.
Stage IV Timoma Treatment
Stage 4A: If possible, the tumor and its spread should be surgically removed, followed by chemotherapy and radiotherapy.
Stage 4B: In this stage, where the tumor has spread to other organs, surgery is no longer an option. Only chemotherapy and radiotherapy will be applied if necessary.
Timoma Surgical Methods
Both open and closed methods are used for timoma surgery.
Our preferred method is the closed (single-port VATS) surgery.
Open Surgery
Open surgery involves the removal of the timoma (tumor) located under the breastbone.
There are two approaches for open surgery:
- Sternotomy (cutting through the breastbone)
- Thoracotomy (cutting between the ribs)
The tumor should be completely removed, and surrounding fatty tissue should also be excised during the surgery.
The average hospital stay is 4 or 5 nights.
Open surgery is preferred for timomas in stages III and IV.
In experienced centers, the complication rate of the surgery is 5-10%.
Closed Surgery – Single Port Thoracoscopy (VATS)
As seen in the image, in the single-port VATS method, a 3 cm incision is made, and a camera is inserted through the side of the chest. The timoma and surrounding fatty tissue are removed in a special bag (endobag).
- This is a surgery requiring special experience.
- It is the least invasive method for the patient.
- The hospital stay is 2 nights.
- It can be used for timomas in stages I and II.
- The recovery time is much faster compared to open surgery. The complication rate is 5%.
Thymic Hyperplasia
After puberty, the thymus gland disappears. In some individuals, this disappearance does not occur, and it creates an image in front of the heart and behind the breastbone in a CT scan. This condition, called thymic hyperplasia, does not require treatment. If this image raises suspicion of timoma, it should be removed through closed surgery (VATS), and a pathology examination should be performed.
Thymic Cysts
These are cysts that develop from the thymus gland. They are located behind the breastbone, in front of the heart. Unlike timomas, thymic cysts are fluid-filled formations, not solid tumors. If they grow and cause pressure on the surrounding heart, lungs, and breastbone, they should be removed through closed surgery. They are benign lesions, and the likelihood of recurrence after surgery is low.
