Preoperative Treatment of Patients With High Risk Thymoma

• Radiographic response to preoperative chemoradiotherapy by comparing pre and post treatment CT scans. [ Time Frame: 16 weeks ] [ Designated as safety issue: No ]
• Rate of complete resection following preoperative chemoradiotherapy as determined by pathologic examination of the specimen(s). [ Time Frame: 1-5 weeks ] [ Designated as safety issue: No ]
• Toxicities throughout the study. [ Time Frame: 15 years ] [ Designated as safety issue: Yes ]
• The role of PET in predicting resectability, Masaoka stage and histologic type, as well as the response to preoperative chemoradiotherapy by comparing pre and post treatment PET scans [ Time Frame: 10 years ] [ Designated as safety issue: Yes ]
• Immunohistochemical assessment of relevant markers before and after chemoradiation (EGFR, p53,and Ki-67). [ Time Frame: 10-12 years ] [ Designated as safety issue: No ]
• Blood-based correlative studies: genetic polymorphisms (EGFR, DNA repair, inflammatory gene pathways) and serologic analysis (EGFR, VEGF, bFGF, pro-MMP2 levels) [ Time Frame: 8-10 years ] [ Designated as safety issue: No ]
• Recurrence rates and failure patterns following the treatment regimen. [ Time Frame: 5-7 years ] [ Designated as safety issue: Yes ]

• Radiographic response to preoperative chemoradiotherapy by comparing pre and post treatment CT scans.
• Rate of complete resection following preoperative chemoradiotherapy as determined by pathologic examination of the specimen(s).
• Toxicities throughout the study.
• The role of PET in predicting resectability, Masaoka stage and histologic type, as well as the response to preoperative chemoradiotherapy by comparing pre and post treatment PET scans
• Immunohistochemical assessment of relevant markers before and after chemoradiation (EGFR, p53, MHC Class I, CD80, CD86, CD95).
• Blood-based correlative studies: genetic polymorphisms (EGFR, DNA repair, inflammatory gene pathways) and serologic analysis (EGFR, VEGF, bFGF, pro-MMP2 levels)
• Recurrence rates and failure patterns following the treatment regimen.

This is a phase II study for patients with thymoma or thymic carcinoma thought to be at significant risk for recurrence following surgical removal. This study involves the use of combined chemotherapy and radiation therapy prior to surgery, in hopes of increasing the chances of complete resection. The chemoradiotherapy protocol is one which has been used extensively for other diseases, and the side effects are therefore well-documented. Patients with thymomas thought to be at significant risk for recurrence (by x-ray and pathology criteria) will be allowed to participate, and will undergo combined chemotherapy with radiation to the chest followed by surgical removal of the tumor and postoperative chemotherapy. The main outcome measured will be the rate of pathological complete response (e.g. no active tumor in the resected specimen) to the preoperative treatment. Patients will receive postoperative treatment based on surgical and pathologic criteria.

Past experience has suggested that the ability to completely remove the thymoma using surgery is important in preventing recurrence. Strategies which would help the surgeon's ability to completely remove the tumor therefore need to be investigated.

This study represents a multi-institutional, phase II pilot trial of preoperative chemoradiotherapy followed by surgical resection and postoperative chemotherapy for patients with invasive thymoma or thymic carcinoma at significant risk for recurrence. We hypothesize that this strategy will be well-tolerated and produce response and resectability rates exceeding those previously published involving surgical resection alone, or preoperative chemotherapy followed by surgery. Patients with locally advanced thymoma, based on radiographic and biopsy criteria, will undergo pretreatment computed tomography (CT) scan and positron emission tomography (PET) followed by concurrent (simultaneous) chemotherapy (cisplatin and etoposide) and radiation. After this therapy, patients will be reassessed using computed tomography (CT) and PET, and undergo surgical resection of their tumors. Following resection, patients will be either observed, or treated with postoperative chemotherapy, or chemotherapy and radiation. Correlative genomic, serologic and pathologic studies will also be performed.

• Drug: cisplatin and etoposide
  Cisplatin: 50mg/m2 - administered on days 1,8,29&36 Etoposide: 50 mg/m2 - administered on days 1-5 & 29-33
• Procedure: Surgical Resection
  Resection will take place 4-8 weeks after completion of radiotherapy.
• Radiation: Concurrent Radiotherapy
  Preoperative External Beam Radiotherapy

• Registration
  Cisplatin, Etoposide & concurrent radiotherapy
  Interventions:

  • Drug: cisplatin and etoposide
  • Radiation: Concurrent Radiotherapy
• Surgical Resection
  No distant Progression post Registration Arm
  Intervention: Procedure: Surgical Resection
• Post Resection
  Assessment post surgical procedure to determine if at higher risk of recurrence or if complete resection could not be achieved.
  Intervention: Drug: cisplatin and etoposide

Inclusion Criteria:

• Biopsy-proven thymoma or thymic carcinoma.
• Invasive thymoma determined by specific radiographic criteria determined by CT scan.
• Acceptable kidney, liver, bone marrow, and respiratory functions.
• Karnofsy performance status greater than 80%.
• Patients must have a CT of the chest with IV contrast within 60 days of enrollment.
• Tumors larger than 8cm in greatest diameter on CT scan.
• For tumors 5-8cm in greatest diameter on CT scan, one or more of the following radiographic criteria must also be present on IV contrast CT Scan:
• Multifocal calcification
• Heterogeneous appearance
• Irregular of scalloped borders
• Obvious great vessel invasion or encirclement

Exclusion Criteria:

• Considered unable to medically tolerate surgical resection at the time of initial presentation.
• Radiographic evidence of stage IVA thymoma.
• Pretreatment biopsy showing WHO type A thymoma unless obvious great vessel invasion/encirclement is present on CT scan.
• Previous radiation therapy to the chest which would preclude the administration of radiation.
• Patents receiving other investigational drugs.