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Should We Resect Asymptomatic, Enlarged Thymus Glands? Smit Singla1, Leslie A Litzky2, Larry R Kaiser3, *Joseph B Shrager41Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA;2Department of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA;3The University of Texas, Houston, TX;4Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford School of Medicine and VA Palo Alto Healthcare System, Stanford, CA BACKGROUND: Patients frequently present to thoracic surgeons with an “enlarged thymus” incidentally identified on cross-sectional imaging. We sought to determine if thymectomy is appropriate in patients with these diffusely enlarged glands (DETs). METHODS: Retrospective review of experience with thymectomy in patients without Myasthenia Gravis (MG) at one institution over 15 years. Patients were contacted for up-to-date follow-up. RESULTS: 117 thymectomies were performed for diagnoses other than MG. Of 109 patients (93%) with complete data, 36 presented with a gland judged by the surgeon to be diffusely enlarged, while 73 had a discrete mass. Nearly all patients with DETs underwent transcervical thymectomy; most with discrete masses underwent sternotomy. Of the 36 patients with a DET, 18/36 (50%) occurred in patients with no symptoms referable to the thymus; 18/36 (50%) were symptomatic. No patients (0/18; 0%) with an asymptomatic DET had an ultimate pathological diagnosis that would have been an indication for resection (8 normal ± benign cyst; 10 “hyperplasia” ± cyst). Of the symptomatic DETs, 4/18 (22.2%) were found to represent lymphoma, but none represented thymoma or other tumor requiring resection (p=0.06; symptomatic versus asymptomatic). Of the 73 patients with a discrete mass, a slightly greater percentage (45/73; 61.6%) were symptomatic, and both the symptomatic and asymptomatic patients had a high rate of pathological diagnoses that represented a clear indication for resection (24/45 [53.3%] and 12/28 [42.8%] respectively, thymoma or other solid tumor). Of the 25/109 patients initially given a pathological diagnosis of thymic hyperplasia, on re-review of the pathology only 3/25 (12%) had true cellular hyperplasia. Interestingly, 2 (67%) of these 3 patients developed an autoimmune disorder on long-term follow-up. None of the other 22 patients with lesser degrees of “hyperplasia” developed subsequent autoimmune disease. CONCLUSIONS: Asymptomatic patients with a diffusely enlarged thymus gland can be followed expectantly because they have a 0% incidence of significant thymic pathology. Symptomatic patients with DET may have lymphoma, so biopsy is most appropriate. Nearly half of patients with discrete thymic masses have tumors that should be resected, but more accurate non-invasive diagnostic techniques are required to better differentiate within this group among processes that should/should not be resected. The finding that autoimmune disorders develop in most patients with true thymic cellular hyperplasia suggests that a pathophysiological relationship may exist between these entities.
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