A 49-year-old male with a clinical history of cough, low expectoration and increased dyspnea, which, if on maximum exertion, was performed at moderate efforts with 3 weeks of evolution.
Personal history: ex-smoker for 5 years (1.5 bp/day), high blood pressure, ocular hypertension, operated on due to tibia fracture and arthritis complicated 13 years ago with osteomyelitis, umbilical herniophy.
Physical manifestations: no fever, no chest pain, eupneic at rest, no constitutional syndrome, decreased ventilation in the left hemithorax.
Weight=73.4 Kg, height=1.69 m.
Analytical: mild leukocytosis (11.3x10^9/l) and mild neutrophilia (74.7%), biochemistry and coagulation: normal.
Arterial gas: pH=7.41, pO2=74.0 mmHg, pCO2=36.3 mmHg.
CXR: mass with regular contours of 10.8 x 8.4 cm in the left anterior mediastinum extending to the ipsilateral hilium compressing it, moderate left pleural effusion.
Fibrobronchoscopy: no endobronchial tumor, diffuse mucosal hyperemia.
Respiratory function tests: FEV1=2010 l.(59%), FVC=2290 l.(54.8%), Tiffenau index=8.
FNAC: epithelial cells with a slight degree of atypia and abundant lymphocytes, presence of histiocytes, multinucleated giant cells and eosinophils, some areas of necrosis (cytology suggestive of thymoma).
The patient underwent colonoscopy: parietal and diaphragmatic nodules, pulmonary nodules in LII (and intra-operative pathological anatomy of lymphoid tissue and pleural material in anterior mediastinum effusion), evacuation of 2000 ml of tumor tissue.
Definitive pathological results were:
- Pleural fluid cytology: reactive mesothelial hyperplasia
- parietal and diaphragmatic biopsy: hyalinized fibrous tissue, fibrous and muscular tissue
- Mediastinal mass biopsy: cytokeratin positive epithelial cells and CAM 5.2, CD-3 positive lymphoid cells compatible with cortical thymoma.
1.
Because it was an invasive thymoma (stage-III) associated with adenocarcinoma, neoadjuvant chemotherapy, surgery and subsequent radiotherapy were planned.
Qt consisted of: adriamycin 50 mg/m2 and CDDP 100 mg/m2 in three cycles with an interval of 21 days.
In the second and third cycles, the CDDP dose was reduced to 75 mg/m2 due to vomiting and drowsiness.
In the control CT after chemotherapy, a 25% reduction in size was observed, maintaining the extension of the peripheral portion approximately 25%, keeping the pulmonary artery extending toward the hilium x 6.3 cm and contacting the left pulmonary artery with the compression.
The surgery was performed en bloc removal of the thymoma together with a left pneumonectomy and mediastinal lymphadenectomy encompassing the lymph nodes of areas 5, 6, 7, 8 and 9.
The left phrenic and vagus nerves were due to tumor invasion.
In the immediate postoperative period the patient presented anemia without requiring transfusion and was discharged on the fifth day of the intervention.
The pathology results were: all lymph nodes free of tumor, the previous diagnosis of thymoma is confirmed and a tumor proliferation index of 20%.
