The role of adjuvant chemotherapy in patients with thymoma and thymic carcinoma following surgery: a systematic literature review and meta-analysis

Introduction

Thymoma and thymic carcinoma are rare tumors and relatively uncommon in clinical settings, yet they remain the most common neoplasms originating from the thymus in the anterior mediastinum (1). Both thymoma and thymic carcinoma originate from thymic epithelial cells. In thymoma, the epithelial cells lack cytological atypia, and thymoma may present as locally invasive tumors, thus they can be considered potentially malignant. Thymic carcinomas have both a malignant cellular appearance and behaviour (1,2). They mostly occur in the anterior superior mediastinum, and most patients can achieve good curative effects after surgical resection. However, about one-third of patients with thymic tumors are diagnosed in the advanced stage when there is local invasion or distant metastasis, making it hard to radically remove the tumor with surgery. In these cases, chemotherapy, radiotherapy, chemoradiotherapy, and other methods are also used for treatment (2-4).

For patients with stage I thymic tumors, whether thymoma or thymic carcinoma, surgical treatment can achieve good therapeutic outcomes. For advanced thymoma, postoperative radiotherapy is recommended to improve overall survival (OS). For locally advanced thymoma that cannot be completely removed, induction chemotherapy is often used first to determine whether surgery and subsequent radiotherapy or chemotherapy are appropriate. For patients with stage II–IV thymic carcinoma, the latest guidelines suggest postoperative radiotherapy or chemotherapy. For patients with stage IVB thymoma, comprehensive chemotherapy is recommended (2-6).

On the one hand, the purpose of chemotherapy is to reduce the tumor load and create opportunities for subsequent surgery or radiotherapy; on the other hand, chemotherapy aims to slow down disease progression. Chemotherapy can be used in different stages of treatment. Commonly used treatment modalities include preoperative chemotherapy plus surgery, surgery plus postoperative chemotherapy (POCT), or radiochemotherapy. Palliative chemotherapy is often used for patients with thymic tumors with distant metastasis (4).

A recent study in the treatment of thymoma and thymic carcinoma concluded that although patients were responsive to POCT, postoperative radiotherapy resulted in an OS benefit (5). Despite previous studies (5-10) suggesting that multimodal therapy, including POCT, can improve the complete resection rate and OS rate in thymoma patients, it remains controversial. Surgical treatment is the mainstay of thymoma treatment, and the completeness of resection seems to be the most important prognostic factor (8). One study concluded that adjuvant chemotherapy is not routinely used but can be combined with radiotherapy in early thymoma after R0 resection (9).

In the treatment of thymic carcinoma, whether POCT reduces local recurrence and distant metastasis is still controversial (7). However, some studies have shown that postoperative adjuvant radiotherapy can significantly improve the OS of thymoma and thymic carcinoma patients (5,10). Therefore, there is still ongoing debate regarding the benefits of POCT for advanced thymoma and thymic carcinoma, and there is currently no recent meta-analysis available on this topic. Hence, it is essential for us to carry out this latest meta-analysis.

Our systematic review and meta-analysis are designed to assess various factors, including OS and disease-free survival (DFS), in patients with thymic tumors. The objective is to determine whether POCT can provide benefits for patients with advanced thymoma and thymic carcinoma. We present this article in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1157/rc).

Methods

Search method

We performed a comprehensive search using PubMed, Embase, Cochrane Library, and Medline Systematic Review databases to identify relevant English-language literature published prior to October 1, 2023. Medical keywords were utilized to search for all possible synonyms of thymoma and thymic carcinoma, as well as combinations of terms related to chemotherapy, including POCT and/or adjuvant chemotherapy, and treatment (Table S1). The search was restricted to English publications. Our search process is based on a systematic review and meta-analysis guide (11). The work has been performed in line with PRISMA and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines (12). The search process is illustrated in Figure 1.

Figure 1 Flow diagram of the enrolled patients. *, thymoma and thymic carcinoma. Note: one of the eligible articles contains data on both thymoma and thymic carcinoma.

Selection criteria

Articles that met the following criteria were included: (I) patients were diagnosed with thymoma and/or thymic carcinoma; (II) the study compared the management of thymoma and/or thymic carcinoma with POCT and without POCT; (III) long-term follow-up with survival data that provided information on survival outcomes, including DFS and/or OS.

Only studies published in English were considered, although it is acknowledged that this approach may have limitations due to the exclusion of Chinese literature. However, restricting the search to English publications is a common practice in certain research fields, as it helps enhance research efficiency and quality. Duplicate publications were excluded, as were publications that did not contain original data, such as review articles, case reports, and letters.

Two researchers independently reviewed the titles and abstracts of the retrieved articles using the aforementioned selection criteria. During the screening process, articles that were clearly ineligible were rejected. In cases where the abstract was inconclusive, a further assessment of the full text was conducted. Any discrepancies were resolved through discussion with a third party.

Statistical analysis

All data, including hazard ratio (HR) and 95% confidence interval (CI), were extracted from each eligible study to analyze the effects on OS and DFS of each treatment method. HR and 95% CI values are best obtained directly from the literature, but where this was not possible, we used the Engauge Digitizer software to extract survival curves and followed the methodology outlined by Parmer et al. (13) to estimate the values according to other relevant data in the article.

After obtaining the HR and the 95% CI interval values, we used ReviewManager software to automatically convert them into logHR and standard error (SE). The I² statistic measures the degree of dispersion in the data by calculating the sum of squares of the differences between each data point and the mean of the dataset. A larger I² value indicates greater heterogeneity in the dataset, while a smaller I² value indicates less heterogeneity. The results were as follows: 0–40% is low heterogeneity; 40–70% is moderately heterogeneous; >70% is highly heterogeneous.

In the case of low heterogeneity, we choose the fixed-effects model, and in the case of high heterogeneity, we choose the random-effects model. The random-effects model decomposes the variation in the observed data into fixed effects between individuals and random effects within individuals (14). By including these effects, this model can better address the heterogeneity between individuals. For high heterogeneity, we conducted a meta-regression to determine the potential sources of bias. Bilateral P≤0.05 is considered statistically significant. We also used funnel plots and Egger’s regression test to assess publication bias, which increased the robustness of the analysis results. All the analyses were carried out with Revman version 5.30.

Results

Literature results

We searched the databases PubMed, Embase, Cochrane Library, and Medline and retrieved a total of 6,124 articles. Following review of the titles and abstracts, 221 articles were deemed as eligible and 5,903 articles were considered ineligible (Table S1). Following detailed review of the full text, 210 articles were excluded: 31 articles focused on the research of different chemotherapy regimes; 26 articles reported cases on the use of chemotherapy; 47 articles focused on various chemotherapy drugs; in 63 articles patients received a combination of radiotherapy, neoadjuvant therapy, and targeted therapy; 30 articles were based around thymic tumors; and 2 articles were deleted due to duplication. Finally, 11 studies (3 on thymoma and 8 on thymic carcinoma) were selected for analysis (6,10,15-22). The main characteristics of these studies are summarized in Tables 1,2.

Patients results

In the included studies, there were 1,243 patients with thymoma in Masaoka-Koga stage I, 574 in stage II, 733 in stage III, and 346 in stage IV. For thymic carcinoma, the corresponding numbers of patients in each stage were 101, 366, 1,041, and 279, respectively. Patients with thymic carcinoma were distributed across all stages. There were 106 thymoma patients who received POCT, compared to 964 who did not. For thymic carcinoma, the numbers were 470 and 1,250, respectively.

Meta-analysis for OS

All 11 studies (3 on thymoma and 8 on thymic carcinoma) provided data on the OS rate. The comparison between POCT and non-POCT in thymoma and thymic carcinoma, the heterogeneity between trials was lower than the base value of I² (I²=30%). Consequently, we employed a fixed-effects model for the analysis. Our analysis showed that POCT did not influence the OS rate (HR =0.87, 95% CI: 0.68–1.10; P=0.23; Figure 2A). Comprehensive analysis showed that POCT did not improve the survival rate of patients (P>0.05).

Figure 2 Forest plot for overall survival. (A) Forest plot for overall survival of thymoma and thymic carcinoma; (B) forest plot for overall survival of thymoma; (C) forest plot for overall survival of thymic carcinoma. HR <1 means a better prognosis in the POCT group. I²<40% suggests a fixed-effects model, otherwise choose a random-effects model. The same study appears multiple times because we extracted and analyzed different data (tumor classification, staging) from the same article. CI, confidence interval; HR, hazard ratio; IV, inverse variance; POCT, postoperative chemotherapy; SE, standard error.

The comparison between POCT and non-POCT in thymoma demonstrates that because the heterogeneity between the trials is lower than the I² base value (I²=27%), the fixed-effects model was adopted. It seems that POCT improved the OS rate of patients with thymoma (HR =1.23, 95% CI: 0.63–2.40; P=0.55; Figure 2B). In patients with thymic carcinoma, as the heterogeneity among trials is low (I²=0%), the fixed-effects model was used. Our analysis showed that POCT can improve the prognosis of patients and significantly improve the OS rate (HR =0.67, 95% CI: 0.50–0.89; Figure 2C; P=0.006).

Meta-analysis for DFS

Of the 11 studies (3 on thymoma and 8 on thymic carcinoma), 1 article on thymoma provided data on DFS, and 4 articles on thymic carcinoma provided data on DFS. The comparison between POCT and non-POCT in thymoma and thymic carcinoma, the heterogeneity among trials is low (I²=21%). The fixed-effects model was used, and our analysis revealed that POCT did not influence the DFS rate (HR =0.92, 95% CI: 0.54–1.58; P=0.76; Figure 3A). Comprehensive analysis showed that POCT did not improve the DFS of patients (P>0.05).

Figure 3 Forest plot for disease-free survival of thymoma and thymic carcinoma. (A) Forest plot for disease-free survival of thymoma and thymic carcinoma; (B) forest plot for disease-free survival of thymoma; (C) forest plot for disease-free survival of thymic carcinoma. HR <1 indicates a better prognosis in the POCT group. I²<40% suggests a fixed-effects model, otherwise choose a random-effects model. The same study appears multiple times because we extracted and analyzed different data (tumor classification, staging) from the same article. CI, confidence interval; HR, hazard ratio; IV, inverse variance; POCT, postoperative chemotherapy; SE, standard error.

The comparison between POCT and non-POCT in thymoma, due to the high heterogeneity between trials (I²=62%; we used a random-effects model to enhance the robustness of the results), it seems that POCT did not improve the DFS of patients with (HR =0.50, 95% CI: 0.06–3.97; P=0.52; Figure 3B). In patients with thymic carcinoma, the heterogeneity among trials is low (I²=0%), and therefore, the fixed-effects model was used, which showed that POCT did not improve the DFS of patients (HR =1.03, 95% CI: 0.57–1.88; P=0.91; Figure 3C).

Sensitivity analysis and publication bias

Sensitivity analysis and publication bias assessment play a crucial role in ensuring the reliability and robustness of research findings. They help identify and correct for any potential biases, such as selective reporting and publication bias, that may affect the validity of the results. By conducting sensitivity analysis, researchers can assess the impact of different assumptions or methods on the results, thus ensuring the consistency and objectivity of the findings.

In the context of this study on thymoma and thymic carcinoma, it is worth noting that the number of meta-analysis studies available is relatively small. This limitation may affect the generalizability and applicability of the findings. Additionally, the asymmetry observed in the funnel plot makes it challenging to determine if there is true publication bias. To address these issues, we utilized RevMan 5.3 software and followed the Cochrane Intervention Measures Systematic Review Manual to systematically evaluate the quality of eligible studies. By employing I² statistics and random effects models, we aimed to minimize the impact of heterogeneity on the results.

We conducted funnel plot analysis and Egger’s regression test on the included studies of thymoma and thymic carcinoma, using OS as the evaluation indicator. The results showed that the P values of Egger’s test were both greater than 0.05 (thymoma: P=0.12; thymic carcinoma: P=0.18), indicating no significant publication bias statistically. Furthermore, the scatter plots revealed that most points fell within the range of the inverted funnel and exhibited a relatively symmetrical distribution, further supporting the low likelihood of publication bias in this study. These findings suggest that the results of the included studies are relatively reliable, with no significant bias detected. Specific data and graphical results are shown in Tables 3,4, as well as Figure 4.

Figure 4 Meta-analytic funnel plot of POCT for thymoma (A) and thymic carcinoma (B). POCT, postoperative chemotherapy; SE, standard error.

Discussion

As far as we know, this is one of the biggest studies to evaluate the value of POCT in thymoma and thymic carcinoma. A total of 11 studies pertaining to thymoma and thymic carcinoma were included in our analysis, encompassing a cohort of 2,209 patients, of which 576 received POCT and 1,633 underwent other postoperative treatments. Our findings revealed that POCT conferred a favorable OS benefit for patients with thymic carcinoma (HR =0.67, 95% CI: 0.50–0.89; P=0.006). Our analysis had several strengths. Firstly, we used the Engauge Digitizer software to extract survival curves and obtained adjusted HR values using the method described by Parmar et al. (13), instead of crude HR values. This ensured a more accurate analysis. Secondly, we assessed the sensitivity and heterogeneity of the included literature. Lastly, we included data from studies published after 2000, which allowed us to reflect the latest advancements in surgical and POCT.

Thymic tumors are relatively rare in clinical practice. In our reviewed studies, further refinement is needed for the subgroup analysis of adjuvant chemotherapy in this study. This is because most studies have focused on investigating the risk factors for thymic tumors and the impact of postoperative radiotherapy on OS and/or DFS. There have been few articles that comprehensively analyze the detailed Masaoka-Koga stage and its corresponding risk factors and other postoperative treatment methods. During our literature screening process, it became evident that there is a clear need for further improvement in the available data concerning thymic tumors. The ongoing Chinese Integrated Cancer Registry project, in which we are actively involved, has the potential to make extraordinary breakthroughs in the future.

Is chemotherapy required after surgery for thymoma (or thymic carcinoma)? Guidelines recommend that the treatment for thymoma (or thymic carcinoma) patients with Masaoka-Koga stage II or above, which can be surgically resected, should be evaluated and discussed by a multidisciplinary team (3). The latest 2023 edition of “Expert Consensus on Clinical Diagnosis and Treatment of Thymic Epithelial Tumors in China” suggests that adjuvant chemotherapy is not recommended for patients with Masaoka-Koga I–III thymic epithelioma (or thymic carcinoma) after R0 resection. The decision as to whether to combine chemotherapy with routine radiotherapy after resection of the thymic epithelial tumor with R1 or R2, or not, should be based on the tumor stage, invasiveness, and the patient’s physical condition (23). Guidelines and consensus for thymic tumors tend to favor a comprehensive evaluation of individual patient conditions. However, in our study, adjuvant chemotherapy for thymoma appeared to be non-essential. This may be attributed to the fact that thymoma are predominantly localized invasive tumors, with most leaning towards benign characteristics. On the other hand, adjuvant chemotherapy for thymic carcinoma showed statistically significant differences in OS, consistent with the results of most literature studies (24-26). Guidelines also consider recommendations for postoperative treatment in relation to the resection status. In a recent study by Rimner et al., it was found that the use of postoperative radiation therapy (PORT) was associated with improved OS in advanced-stage R0 resected thymic carcinoma patients (27). This should also be taken into consideration. However, unfortunately, due to a lack of relevant detailed data and limited retrospective studies in this regard (with no response from authors when contacted for additional information), further subgroup analysis cannot be conducted. This may require future multicenter, prospective clinical trials to further validate. Nonetheless, our study provides preliminary guidance for evidence-based exploration of POCT for thymic tumors.

While our study included patients with thymoma and thymic carcinoma at all stages, it is worth noting that the literature included in our analysis had a higher proportion of late-stage thymoma patients (stage III–IV) and stage II–IV thymic carcinoma patients. Multiple studies have shown that surgical resection may be the optimal choice for early-stage thymoma (thymic carcinoma) patients (7,28-30). Another study involving 607 patients with thymic epithelial tumors revealed that in completely resected pT3N0M0 thymic carcinoma patients with invasion of the superior vena cava or brachiocephalic veins, adjuvant chemotherapy significantly improved both DFS and OS (25). This finding aligns with our study results, indicating the potential benefits of POCT in thymic carcinoma patients. In a retrospective study conducted at a single medical center, 108 patients with thymoma or thymic carcinoma who underwent different first-line chemotherapy regimens showed similar long-term DFS and OS rates in patients with stage III/IVA and stage IVB disease (31). However, there is a limited amount of research available on the efficacy of different chemotherapy agents, and further prospective studies are needed for a more comprehensive investigation. Data from a study involving 12 patients with advanced thymic carcinoma treated at Nippon Medical School Hospital (Tokyo, Japan) demonstrated that the combination of cisplatin with nanoparticle-bound paclitaxel is a safe and effective chemotherapy regimen for advanced thymic carcinoma, showing promising potential for the treatment of late-stage thymic carcinoma (26). However, a study by Falkson et al. suggested that adjuvant chemotherapy in thymoma patients does not significantly impact prognosis, indicating that patients with poorer prognosis may be selected for adjuvant chemotherapy. This finding aligns with the recommendations in the guidelines, which emphasize the preference for personalized and targeted treatments based on individual patient conditions (5). The opinions on POCT for thymic tumors vary among studies, and controversy regarding the postoperative treatment of thymic tumors remains.

Furthermore, a study evaluating the efficacy and safety of platinum-based chemotherapy in patients with B3 thymoma and thymic carcinoma indicated that surgery is the primary treatment modality for B3 thymoma (32). This suggests that pathological classification may be an important factor influencing prognosis. In light of these circumstances, we aimed to gain a more comprehensive understanding of the prognostic factors associated with POCT, such as Masaoka-Koga staging, pathology, and different chemotherapy regimens. Unfortunately, the data included in the literature had significant limitations and flaws, preventing subgroup analysis of these relevant factors (Table 5). As a result, our analysis requires further data to explore whether POCT truly benefits patients with thymic tumors.

Similarly, in some studies, adjuvant chemotherapy has been shown to reduce distant metastasis and prolong OS in thymic carcinoma, while postoperative radiotherapy has demonstrated survival benefits in both thymoma and thymic carcinoma, particularly in patients at high risk of mortality (5,33). Thus, it appears that postoperative radiotherapy may be more beneficial for OS in patients. Overall, due to the rarity of thymic tumors, the limited number of patients included in our study, and the incompleteness of research data, prospective studies are needed to further evaluate the efficacy of POCT in the treatment of thymic tumors. Therefore, conducting prospective studies is essential to gain deeper insights into the effectiveness of POCT in treating thymic tumors. Nevertheless, our research provides innovative and evidence-based advancements in the understanding of POCT for thymic tumors.

Limitations

Given the rarity of thymic epithelial neoplasms, it is not surprising that there is a lack of high-quality evidence. Several limitations may have affected the results of this study. Firstly, in this meta-analysis, we were unable to obtain detailed individual patient data, which would not have allowed for a comprehensive analysis of factors other than OS and DFS. Secondly, it is uncertain whether these patients were managed by multiple surgeons following different guideline-recommended chemotherapies, which adds to the heterogeneity of the data. Thirdly, the inclusion and exclusion criteria varied among the retrospective studies included. Fourthly, as this study did not include certain non-English literature (including Chinese literature), it may have led to insufficient coverage of some regional studies or data, which constitutes a limitation of the study. Finally, for some studies, survival data could not be extracted, and contacting the authors was not possible. The limited sample size, inconsistent effects, and methodological limitations also contributed to the overall limitations of this study.

Future research should consider expanding the sample size, extending the time span, incorporating other clinical factors, and adopting more comprehensive study methods to obtain more accurate and reliable conclusions. It is imperative to conduct multi-center prospective clinical trials to confirm the findings presented in this study and provide more robust evidence.

Conclusions

Our study indicates that while POCT did not show a significant improvement in OS among patients with advanced thymoma, it holds promise for significantly enhancing long-term survival in patients with thymic carcinoma. Multicenter, prospective clinical trials are needed to validate our findings. Nonetheless, our research makes a significant contribution to the evidence-based investigation of postoperative treatment for thymic tumors.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1157/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1157/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1157/coif). The authors have no conflicts of interest to declare

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. de Jong WK, Blaauwgeers JL, Schaapveld M, et al. Thymic epithelial tumours: a population-based study of the incidence, diagnostic procedures and therapy. Eur J Cancer 2008;44:123-30. [Crossref] [PubMed]
2. Petersen PM, Kalhauge A, Brandt B, et al. Management of thymomas and thymic carcinomas. Ugeskr Laeger 2020;182:V08190462.
3. Multidisciplinary Committee of Oncology. Chinese Physicians Association. hinese guideline for clinical diagnosis and treatment of thymic epithelial tumors (2021 Edition). Zhonghua Zhong Liu Za Zhi 2021;43:395-404. [Crossref] [PubMed]
4. Turna A, Sarbay İ. Multimodality approach in treatment of thymic tumors. J Thorac Dis 2020;12:7626-34. [Crossref] [PubMed]
5. 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 2023;18:299-312. [Crossref] [PubMed]
6. Kim S, Bull DA, Hsu CH, et al. The Role of Adjuvant Therapy in Advanced Thymic Carcinoma: A National Cancer Database Analysis. Ann Thorac Surg 2020;109:1095-103. [Crossref] [PubMed]
7. Sakai M, Onuki T, Inagaki M, et al. Early-stage thymic carcinoma: is adjuvant therapy required? J Thorac Dis 2013;5:161-4. [Crossref] [PubMed]
8. Lo Nigro C, Geraci G, Sciuto A, et al. Surgical treatment of thymoma: personal experience. G Chir 2012;33:318-23.
9. Hamaji M. The role of adjuvant chemotherapy following resection of early stage thymoma. Ann Cardiothorac Surg 2016;5:45-50. [Crossref] [PubMed]
10. Ruffini E, Detterbeck F, Van Raemdonck D, et al. Thymic carcinoma: a cohort study of patients from the European society of thoracic surgeons database. J Thorac Oncol 2014;9:541-8. [Crossref] [PubMed]
11. Siddaway AP, Wood AM, Hedges LV. How to Do a Systematic Review: A Best Practice Guide for Conducting and Reporting Narrative Reviews, Meta-Analyses, and Meta-Syntheses. Annu Rev Psychol 2019;70:747-70. [Crossref] [PubMed]
12. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. Int J Surg 2021;88:105906. [Crossref] [PubMed]
13. Parmar MK, Torri V, Stewart L. Extracting summary statistics to perform meta-analyses of the published literature for survival endpoints. Stat Med 1998;17:2815-34. [Crossref] [PubMed]
14. Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med 2002;21:1539-58. [Crossref] [PubMed]
15. Ma K, Gu Z, Han Y, et al. The application of postoperative chemotherapy in thymic tumors and its prognostic effect. J Thorac Dis 2016;8:696-704. [Crossref] [PubMed]
16. Okuda K, Yano M, Yoshino I, et al. Thymoma patients with pleural dissemination: nationwide retrospective study of 136 cases in Japan. Ann Thorac Surg 2014;97:1743-8. [Crossref] [PubMed]
17. Kondo K, Monden Y. Therapy for thymic epithelial tumors: a clinical study of 1,320 patients from Japan. Ann Thorac Surg 2003;76:878-84; discussion 884-5. [Crossref] [PubMed]
18. Song Z, Zhang Y. Adjuvant therapy in stage II thymic carcinoma. J Cancer Res Clin Oncol 2014;140:349-52. [Crossref] [PubMed]
19. Mao Y, Wu S. Treatment and survival analyses of completely resected thymic carcinoma patients. Onco Targets Ther 2015;8:2503-7. [Crossref] [PubMed]
20. Song Z, Zhang Y. Outcomes after surgical resection of thymic carcinoma: A study from a single tertiary referral centre. Eur J Surg Oncol 2014;40:1523-7. [Crossref] [PubMed]
21. 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;23:619-25. [Crossref] [PubMed]
22. Zhao Y, Gu H, Fan L, et al. Comparison of clinical features and survival between thymic carcinoma and thymic carcinoid patients. Eur J Cardiothorac Surg 2017;52:33-8. [Crossref] [PubMed]
23. Xu C, Zhang Y, Wang W, et al. Chinese expert consensus on the diagnosis and treatment of thymic epithelial tumors. Thorac Cancer 2023;14:1102-17. [Crossref] [PubMed]
24. Alkaaki A, Abo Al-Saud A, Di Lena É, et al. Factors predicting recurrence in thymic epithelial neoplasms. Eur J Cardiothorac Surg 2022;62:ezac274. [Crossref] [PubMed]
25. Tang EK, Chang JM, Chang CC, et al. Prognostic Factor of Completely Resected and Pathologic T3 N0 M0 Thymic Epithelial Tumor. Ann Thorac Surg 2021;111:1164-73. [Crossref] [PubMed]
26. Takahashi A, Noro R, Takano N, et al. Carboplatin plus nanoparticle albumin-bound paclitaxel for the treatment of thymic carcinoma. Mol Clin Oncol 2022;16:87. [Crossref] [PubMed]
27. Rimner A, Ahmad U, Lobaugh SM, et al. Postoperative Radiation Therapy for Thymic Carcinoma: An Analysis of the International Thymic Malignancy Interest Group/European Society of Thoracic Surgeons Database. J Thorac Oncol 2024;19:626-35. [Crossref] [PubMed]
28. Han L, Zhang B, Wu S. Successful concurrent chemoradiotherapy with cisplatin plus etoposide after incomplete resection for advanced thymic carcinoma. Oxf Med Case Reports 2019;2019:omz070. [Crossref] [PubMed]
29. Okereke IC, Kesler KA, Freeman RK, et al. Thymic carcinoma: outcomes after surgical resection. Ann Thorac Surg 2012;93:1668-72; discussion 1672-3. [Crossref] [PubMed]
30. Komaki R, Gomez DR. Radiotherapy for thymic carcinoma: adjuvant, inductive, and definitive. Front Oncol 2014;3:330. [Crossref] [PubMed]
31. 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;11:3445-56. [Crossref] [PubMed]
32. Hao Y, Si J, Jin J, et al. Comparison of Efficacy and Safety of Platinum-Based Chemotherapy as First-Line Therapy between B3 Thymoma and Thymic Carcinoma. Curr Oncol 2022;29:9452-60. [Crossref] [PubMed]
33. Yang G, Lee CY, Kim EY, et al. Clinical Outcomes of Thymic Carcinoma: The Role of Radiotherapy Combined with Multimodal Treatments. Cancers (Basel) 2023;15:2262. [Crossref] [PubMed]