Thymoma is a malignant epithelial-nature neoplasm of the thymus characterized with slow growth, tendency to local spreading. Thymoma is an extremely rare malignant tumor. Here a clinical case with difficult differential diagnosis of thymus cancer is reported. Скачать в формате PDF
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УДК 616 -006.699
76.29.49: ОНКОЛОГИЯ

Styazhkina S.N.
Izhevsk State Medical Academy of the Ministry of Health of the RF,
Izhevsk, Russia
Idiatullin R.M., Suhanov S.A., Lozhkin E.A.
Republican Clinical Oncology Dispensary named after S.G. Primushko
of the Ministry of Healthcare of Udmurt Republic ,
Izhevsk, Russia (herein RCOD)

Abstract. Thymoma is a malignant epithelial -nature neoplasm of the thymus characterized with slow growth,
tendency to local spreading. Thymoma is an extremely rare malignant tumor. Here a clinical case with difficult
differential diagnosis of thymus cancer is reported.
Keywords: thymus cancer, clinical case, nonresectable tumor, thymoma, thyroid cancer

Introduction. Thymoma is a malignant epithelial -
nature neoplasm of the thymus characterized by slow
growth, tendency to local spreading. Thymoma is an
extre mely rare malignant tumor. Thymus cancer
incidence rate is 0.13 per 100 000 population [1]. The
maximum incidence rate according to age is between
35 and 70 years old. It is assumed that this tumor is
developed due to impaired immune processes, in
particul ar, autoimmune systemic diseases, besides,
according to some available information the Epstein -
Barr virus and irradiation of the mediastinum can also
contribute [5, 6, 7]. Distant metastases are typically
localized in the lungs, pleura, pericardium, diaphr agm.
Extrathoracic metastases are rare [2, 3, 4] .

ASJ № ( 35) / 20 20 11

Case description. Patient G., born 1973, has been
under the regular medical check -up in RCOC, Izhevsk
since December 2018 with the diagnosis :
Primary disease: рТ 1bN2M1b (LYM, ADR) IVb
thymus cancer. After biopsy of the tumor on January
10, 2019. After 5 chemotherapy treatment cycles in
August 2019. Progression in October 2019 – metastatic
lesion of the lung. The palliative chemotherapy is in
progress. Comorbids: hypertensive disease of the 2 nd
stage, risk 4 ; mitral valve prolapse 1 st degree;
congestive heart failure I; functional class 2; chronic
bronchitis, non -acute; respiratory failure III.
Case history: in 2017 the patient started
experiencing some neck pain, then hoarseness. He did
not seek medical atte ntion. In September 2018 he got
worse and came to City Clinical Hospital No.2 of the
Ministry of Health of the UR (herein Hospital No.2)
where he was examined by an ear nose throat doctor
and a neurologist, anti -inflammatory therapy was
carried out for exa cerbation of dorsopathy, but it had no
effect. In December 2018 he was re -examined in
Hospital No.2 and sent to an oncologist. On December
21, 2018 he was first examined in RCOC where the
thyroid cancer was suspected, examination was
conducted. CT of the t horacic region dated December
21, 2018 showed: conglomerated solid mass in superior
mediastinum, with irregular contours, up to
53 х62х68mm large, the process invaded the lumen of
the trachea, adjacent sections of the esophagus and the
right lobe of the thyroid gland; single lymph nodes up
to 19x25mm large at the level of tracheal bifurcation
were detected in the mediastinum; a solid ovoid mass
with irregular contours up to 23 х30mm large in the
right adrenal gland. Neck ultrasound of December 21,
2018 showed: ultrasound signs of tumor -caused
damage to the right lobe of the thyroid gland – middle
third and lower third replaced by inhomogeneous
hypoechoic mass the most part of which ha d
retrosternal localization (primary thyroid tumor, or
tumor sprouting from the outside), lymphadenopathy of
the neck on the right - hypoechoic nodes of up to 0.7cm
in diameter, a hypoechoic node of up to 2.1cm in
diameter in the supraclavicular region on the right. The
case was reviewed at the interdisciplinary conference
on December 21, 2018: additional examination,
surgical treatment in RCOD was recommended. Fiber
optic laryngoscopy dated December 26, 2018:
periorganic deformation of upper third of the t rachea
and upper third of the esophagus, with subcompensated
stenosis. Fine -needle aspiration biopsy of the mass in
the right lobe of the thyroid gland with ultrasound
navigation was completed on December 26, 2018.
Cytological conclusion No. 60 of December 26, 2018:
malignant neoplasm.
On January 09, 2019 the patient was admitted to
RCOD with a complaint of permanent shortness of
breath on minimum exertion, continuous intense pain
in the occipital region, cervical spine, generalized
weakness, hoarseness.
The examination detected: the larynx was
displaced to the left by the tumor. In the right
supraclavicular region, a dense fixed painful
conglomerate of lymph nodes of up to 2cm in diameter
was palpated. Dense mobile painless lymph nodes of up
to 0.5 cm in d iameter were palpated on both lateral
surfaces of the neck. The glottis was narrowed,
paralysis of the right vocal fold.
On January 10, 2019 tracheostomy and biopsy of
superior mediastinum tumor was done. Intraoperative
pattern looked as follows: the right lateral and posterior
tracheal walls, the lower pole of the right thyroid lobe,
the prethyroid muscles above the sternum, the fatty
tissue were infiltrated by a gray tumor, the process was
recognized as nonresectable. Histologic examination
No.121546 of J anuary 17, 2019: the malignant small -
large cell tumor was detected among the fibrofatty and
muscle tissue with ingrowth into the struma -type tissue
of the thyroid gland, the small -cell G III carcinoma
looked more probable.

Fig ure 1. Histological examination.

Immune histochemical test No.122199 of January
28, 2019: cytokeratin АЕ 1/АЕ 3 (+); cytokeratin 7 (+);
р63 (+); chromogranin ( -); synaptophysin (+) locally,
up to 2% of the tumor cells; thyrocalcitonin ( -); TTF -1
(-); РАХ 8 ( -/+) with background. Conclusion:
papillary, follicular and medullary thyroid carcinomas
were excluded; the histologic pattern and the
immunophenotype of thyroid tissue evidenced the
presence of G III hybrid carcinoma without signs of
organ specificity (the main component was glandular
squamous cell carcinoma, the minor component was

12 ASJ № ( 35) / 20 20
neuroendocrine carcinoma making up 2% of the

Figure 2. Immunohistochemical examination ( р63).

On January 29, 2019 the case was reviewed at the
interdisciplinary conference to determine further
tactics; it was recommended that the patient be sent f or
consultation in the Federal State Budgetary Institution
"N.N. Blokhin National Medical Research Center of
Oncology" of the Ministry of Health of the Russian
Federation (hereinafter NMRCO).
Histologic preparations were revised in NMRCO.
Histological conc lusion No. 8080/2019 of February 28,
2019 for blocks No. 121546: morpho -
immunohistochemical pattern of the tumor did not
contradict the pattern of intrathyroidal thymic cancer.
Computed tomography of thoracic organs conducted on
March 11, 2019 showed the f ollowing: conglomerate of
merging tumor lymph nodes up to 6x4.6 cm large and
up to 7 cm long was detected in the anterior
mediastinum; the tumor surrounded and compressed
the trachea along the right semicircle, merged with the
supraclavicular, subclavicula r, parasternal and
paratracheal lymph nodes; common carotid artery
passed in the thickness of the tumor; bifurcation lymph
nodes in the mediastinum were up to 3.2x1.5 cm,
parasternal lymph nodes 2.4x1.2 cm; a nodular
formation up to 3.9x2.3 cm large was de tected in the
right adrenal gland spreading to its limbs. Taking into
account the CT data the diagnosis was made: thymus
cancer Т1bN2M1b IVb. One line of chemotherapy was
scheduled. Starting from March 22, 2019 5 cycles of
chemotherapy were performed with TCarbo regimen.
After 4 cycles the CT data showed positive dynamics
within stabilization ( -27.6%). The 6th cycle was not
performed due to hematological toxicity – grade 3
thrombocytopenia, grade 1 leukopenia, grade 2
neutropenia, grade 2 anemia. Computed t omography of
thoracic organs conducted on August 02, 2019 showed
the following: conglomerate of merging tumor lymph
nodes up to 4.6 х3.4 cm large and up to 6.5 cm long was
detected in the anterior mediastinum; the bifurcation
node decreased to 2.1x1.1 cm, the parasternal ones on
the left remained up to 2.1 cm; formation in the right
adrenal gland decreased to 2.2x1.2 cm. On August 07,
2019 the patient was recommended to get medical
supervision at the assigned community clinic.
On October 16, 2019 at control examination in
RCOD the computed tomography of neck, thoracic
organs, abdominal organs showed the following:
conglomerated solid ma ss with irregular contours
59 х72х87 mm large was detected in the superior
mediastinum; mediastinal lymph nodes were up to
12 х24 mm; solid mass up to 25 х48 mm large was
detected in the right adrenal gland, it was impossible to
exclude invasion of the hepati c capsule; solid mass with
a diameter of 11 mm appeared in S8 of the left lung.
On November 06, 2019 telemedicine consultation
was held with NMRCO – the patient was recommended
to take systemic therapy with GemCis regimen to tumor
progression, capecitabin e therapy could be offered
The plan of chemotherapy with GemCis regimen
was worked out at the interdisciplinary conference on
November 07, 2019.
At the beginning of palliative chemotherapy the
patient complained of shortness of breath at res t,
generalized weakness, intense pain in the right side of
the neck relieved by narcotic analgesics, discomfort in
the chest; objectively the general state of the patient
was ECOG 2, solid fixed conglomeration of lymph
nodes with a diameter of up to 6 cm w as palpated in the
right supraclavicular region, bilateral paralysis of the
vocal folds, the glottis was narrowed to 3 mm. The 1 st
chemotherapy cycle was performed; hospital treatment
for the 2 nd cycle was postponed due to
thrombocytopenia, neutropenia. On December 23,
2019 the 2 nd cycle of palliative chemotherapy was
performed with GemCis regimen and the patient
underwent it with grade 0 toxicity.
Control computed tomography of the neck,
thoracic organs, abdominal organs conducted on
December 30, 2019 show ed the following:
conglomerated solid mass with irregular contours
50 х50х88 mm large was detected in the superior
mediastinum; mediastinal lymph nodes were up to
13 х18 mm; solid mass up to 15 х30 mm was detected in
the right adrenal gland; solid mass with a diameter up
to 11 mm in S8 of the left lung showed no dynamics.
The 3 rd cycle of chemotherapy with GemCis
regimen was performed on January 29, 2020. The

ASJ № ( 35) / 20 20 13

patient underwent it with grade 2 hematologic toxicity
and grade 1 emetogenic toxicity.
At the momen t the patient is in a relatively
satisfactory condition, complains of periodic non -
intense dull pain in the right half of the occipital region,
neck, right side of the chest, intensifying in side
position, shortness of breath on exertion, palpitation,
gene ralized weakness. Examination detects solid fixed
conglomerate of lymph nodes of 3x3 cm large in the
right supraclavicular region, skin in the right
supraclavicular region is hyperemic, tracheostomy is
Conclusion. Unfortunately, the most unfa vorable
prognosis is observed in patients with nonresectable
forms of thymus cancer. In patients who have not
undergone surgical treatment the 5 -year survival is

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4. Machaladze Z.O., Davydov M.I., Polotsky
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5. Pikin О.V., Trakhtenberg А.Kh., Kolbanov
K.I., et al . Circular resection of the superior vena cava
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6. Polotsky B.E., Machaladze Z.O., Davydov
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Mullabaeva G.U 1., Kurbanov R.D 2., Jumaniyazov D.K 2
The Republican Specialized Center of Cardiology, Tashkent, Uzbekistan

Abstract . There 131 patients with Q -wave myocardial infarction were observed (mean age 51.9±9.13 year).
For all patients were prescribed beta -blockers, ACE inhibitors, statins, aspirin and if needful antiarrhythmics and
aldosterone blockators. The observational ti me was 24 months. During this period recurrent myocardial infarction
(RMI) observed in 39 (29.7%) patients. Analysis of the data showed that of the estimated factors most important for
prognosis of the RMI counts in acute early postinfarction angina pector is, arterial hypertension, diabetes Mellitus,
as well as the instrumental methods that reflect the functional state of the myocardium: LVMi, and ejection
fraction. No less important was the thrombolysis in the first hours of admission, heart rate at rest, estimated at 10 -
14 days of the disease. In addition, we can not exclude the relationship of RMI and overweight.
Key Words : recurrent myocardial infarction, prognostic model, integrated indicator.

According to the WHO in 2005 the in cidence of
acute myocardial infarction (MI) increased by 32.7%
compared with 1997 and amounted to 10.7 million
people in a population older than 50 [Cleland J.G.,
Coletta A.P et al. 2005]. The frequency of recurrent
myocardial infarction (RMI) is 25 -29%. R MI seriously
worsens the prognosis and further course of the disease,
causing a cascade of complications (heart failure (HF),
arrhythmias, a decrease in the quality of life), and also
significantly affect mortality rates [1]. Determining the
prognosis for MI is a difficult task, since it requires
taking into account a large number of interrelated
factors that have different prognostic significance [2,3].
Currently existing traditional approaches to risk
assessment are not always perfect, which makes it
diff icult to choose the appropriate treatment tactics for
this category of patients.
The purpose of the study was to carry out an
integrated assessment of risk factors for PIM, allowing
to predict its development within the next 2 years
already by 10 -14 days o f the disease.
Materials and methods: We examined 131 male
patients with primary Q wave MI, aged 30 to 69 years
(51.9 ± 9.13 years). The diagnosis was established on
the basis of the WHO criteria in the presence of two of
three signs: a characteristic atta ck of anginal pain or its
equivalent lasting at least 30 minutes, the appearance of
pathological Q or QS in two or more ECG leads, and
creatinine phosphokinase activity exceeding the upper
limit norms more than 2 times. All patients were
familiarized with the protocol and agreed to participate
in the study. The study did not include patients with the
following MI complications and concomitant
pathology: atrial fibrillation; AV blockade of the II -III
degree; arterial hypotension (blood pressure <100/60
mm Hg ); at the age over 65; with chronic diseases
complicated by renal and liver failure; decompensated
diabetes mellitus; malignant arterial hypertension;
oncological diseases; consequences of acute
cerebrovascular accident; echo -negative patients.
At the stationary stage of AMI, treatment was
carried out in accordance with the recommendations for
the management of MI patients with ST segment