Primary Thymic Epithelial Neoplasms Showing Combined Features of Thymoma and Thymic Carcinoma

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Abstract
Thymic epithelial neoplasms are unusual tumors that may span the gamut from clinically benign, well-differentiated lesions (encapsulated thymoma) to overtly malignant, poorly differentiated neoplasms (thymic carcinoma). It has been commonly believed that lesions displaying obvious cytologic features of malignancy (i.e., thymic carcinoma) represent a unique and separate group that is histogenetically distinct from thymoma. We have studied 22 cases of thymic epithelial neoplasms characterized by the admixture of areas displaying conventional features of thymoma with areas showing features of thymic carcinoma. The tumors occurred in six women and 16 men whose ages ranged from 23 to 83 years (median, 53). The lesions presented in eight patients with symptoms of chest discomfort resulting from the involvement of surrounding structures; in 14 patients, they were asymptomatic and discovered incidentally on routine chest radiographs. Histologically, most tumors showed a combination of conventional thymomatous elements with well-differentiated squamous-cell carcinoma (10 cases), followed by thymoma and poorly-differentiated squamous carcinoma (seven cases) and spindle-cell thymoma with poorly-differentiated squamous carcinoma (five cases). Areas of transition between the two different components could be identified in most cases. In five cases, areas showing the features of clear-cell carcinoma could be seen either arising from squamous carcinomatous elements or within the thymomatous component, and in one case transitions between lymphoepithelioma-like carcinoma and anaplastic carcinoma could be observed. Two patients had a history of myasthenia gravis with biopsy-proven thymomas in whom the tumors had been monitored without treatment for 10 and 14 years before the sudden enlargement of the mass. The resected specimens in both patients showed the emergence of a carcinoma arising from a thymoma. The present cases appear to support the existence of a continuum in the spectrum of differentiation between thymoma and thymic carcinoma, suggesting a close histogenetic relationship between these two conditions. Such findings are important not only for our understanding of these tumors but may also play a significant role in the assessment of the biologic behavior and management of these lesions.