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The Power of Independent Thinking
Love Gov Video Series: Presentation at Draper University
Recorded: Tuesday, November 3, 2015
David J. Theroux, Founder and President of the Independent Institute, presents the idea and concept behind Love Gov: From First Date to Mandate, the award-winning, satirical video series that portrays the federal government as an overbearing boyfriend Scott Gov Govinsky who foists his good intentions on a hapless, idealistic college student, Alexis Smith.
To watch the web series, follow this link
Experts: David J. TherouxType: Other EventIssues: Banking and Finance, Bureaucracy and Government, Business, Civil Liberties/ Human Rights, Collectivism, Corporate Welfare, Culture/ Society, Economic Policy, Education, Energy, Fiscal Policy/Debt, Free Market Economics, Freedom, Government Power, Government Secrecy, Government Waste/Pork, Health Care, Housing, Labor and Employment, Political Ideology and Philosophy, Privacy, Property Rights, Public Health/ Consumer Protection, Regulation and Deregulation, Taxes, Trade, Welfare
C.S. Lewis on Mere Liberty and the Evils of Statism
Recorded: Saturday, August 2, 2014
David J. Theroux, founder and president of The Independent Institute and the C.S. Lewis Society of California, discusses the writings of C.S. Lewis and Lewis's views on individual liberty, natural law and statism.
The presentation was the keynote talk at the first annual conference of Christians for Liberty, that was held at St. Edwards University in Austin, TX, August 2, 2014.
Experts: David J. TherouxType: Other EventIssues: Bureaucracy and Government, Civil Liberties/ Human Rights, Collectivism, Culture/ Society, Education, Family, Freedom, Government Power, Political Ideology and Philosophy, Politics, Privacy, Privatization, Property Rights, Regulation and Deregulation, Religion, Science, Taxes, Welfare
Full Video of The Independent Institutes 25th Anniversary Gala for Liberty
Recorded: Tuesday, November 15, 2011
Part 1 |
Part 2
Part 3
Part 4
Part 5
Full Video of The Independent Institutes 2011 25th Anniversary Gala for Liberty held November 15, 2011.
Part 1: Introductory Remarks and Tribute to Robert Higgs
Part 2: Tribute to Mario Vargas Llosa
Part 3: History of The Independent Institute and Fund for the Future
Part 4: Tribute to Lech Walesa
Part 5: Special Tributes, Sponsors, and Credits
Experts: Leszek Balcerowicz, Price V. Fishback, Robert Higgs, Ron Paul, Jorge Quiroga, David J. Theroux, Archbishop Desmond M. Tutu, Mario Vargas Llosa, Lech Wałęsa, Yuri Yarim-AgaevType: Independent Institute EventIssues: Bureaucracy and Government, Business, Civil Liberties/ Human Rights, Constitutional Law, Defense and Foreign Policy, Democracy, Economic History and Development (U.S.), Economic Policy, Government Power, History (International), History (U.S), Latin America, Nationalism, Political Ideology and Philosophy, Politics, Privatization, Property Rights, Terrorism and National Crises
Bush, Obama, and Presidential Power
Recorded: Wednesday, January 7, 2009
Ron Paul, Richard Shenkman, and Ivan Eland, author of Recarving Rushmore, discuss which presidents were the best and worst at promoting peace, prosperity, and liberty.
Experts: Ivan Eland, Ron Paul, Richard Shenkman, David J. TherouxType: TelevisionIssues: Defense and Foreign Policy, Government Power, History (U.S), Politics
A Gala for Liberty: The Independent Institutes Gala Reception and Dinner
Recorded: Tuesday, September 16, 2008
Part 1 |
Part 2
Part 3
Part 4
Experts: George B. N. Ayittey, Michael J. Boskin, William K. Bowes, Jr., Andy Garcia, David J. Theroux, Archbishop Desmond M. Tutu, Alvaro Vargas LlosaType: Independent Institute EventIssues: Business, Civil Liberties/ Human Rights, Collectivism, Culture/ Society, Democracy, Economic History and Development (International), Economic History and Development (U.S.), Economic Policy, Entertainment, Free Market Economics, Freedom, History (U.S), Nationalism, Political Ideology and Philosophy, Property Rights, Race Issues, Regulation and Deregulation, Religion, Taxes, Terrorism and National Crises, Trade, Welfare
David Theroux on KTVU2 on Government Taxes and Spending
Recorded: Friday, April 15, 2005
David Theroux discusses the breakdown of U.S. government tax spending and reducing the burden placed on taxpayers in a KTVU Channel 2 report.
Experts: David J. TherouxType: TelevisionIssues: Fiscal Policy/Debt, Taxes
Gore Vidal on Understanding Americas Terrorist Crisis
Recorded: Thursday, April 18, 2002
Filmed before a live audience on April 18, 2002, renowned author Gore Vidal rejects the blind patriotism expected by government officials and the mainstream media, and investigates U.S. foreign policy throughout recent history, showing how it has contributed to the terrorist crisis. With his famous wit and insight, Vidal also demonstrates the ways in which the War on Terrorism is being used to curtail civil liberties and shred the Bill of Rights.
Experts: Gore VidalType: Independent Institute EventIssues: Civil Liberties/ Human Rights, Culture/ Society, Defense and Foreign Policy, Political Ideology and Philosophy, Terrorism and National Crises


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Since release I've not seen much from the latest set played. Strange because I saw some promising files especially from Falkow.
Did the testers over react because of the OPed stuff in pre nurf 11? Do they need to rethink certain cards?
Have players seen how average the cards are and decided not to buy?
I only play Ben Mac, a couple of the mercs and the three headed dragon. Not to much effect I might add.

subset: commoncrawl


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|"Live or Die: Risk it All to Win it All!"
|(生か死か!?免許皆伝は命懸け!, Sei ka Shi ka!? Menkyo Kaiden wa Inochi Kake!)
|Episode data
|"A Feeling of Yearning, a Flower Full of Hope"
|Naruto #56
|"He Flies! He Jumps! He Lurks! Chief Toad Appears!"
|Chūnin Exam Arc
|Naruto Chapter #94, Naruto Chapter #95
|October 29, 2003
|October 28, 2006
Live or Die: Risk it All to Win it All! (生か死か!?免許皆伝は命懸け!, Sei ka Shi ka!? Menkyo Kaiden wa Inochi Kake!) is episode 56 of the original Naruto anime.
Jiraiya is seen spying on some girls. Naruto, still practising the Summoning Technique, summons a little frog, but gets angry and shouts at Jiraiya, who was still peeking. Then Naruto faints and Jiraiya comments on his determination.
The Third Hokage goes and sees Anko, telling her that Orochimaru and Anko have no connections any more. The Third Hokage also said that no one can stand Orochimaru, not even himself . Anko mentioned the Fourth Hokage but the Third said they must do it with their own strength.
Jiraiya wakes up Naruto using a pail of water. After a short conversation, Jiraiya tells Naruto to follow him. Jiraiya tells Naruto that they should bathe first. After bathing together, they return to Konohagakure to eat some ramen. Jiraiya tells him to eat a lot as if it's his last. After he finished eating, Naruto thanks Jiraiya for treating him, only to discover that Jiraiya had left, which forces him to pay for all his ramen.
When Naruto finally finds him, Jiraiya tells Naruto to hug his crush, and he attempts to hug Sakura, only to be punched by her. On the way, Jiraiya punches Naruto, as part of his training. After Naruto awakes, he pushes him down a cliff, to see if the Nine-Tails will react and protect Naruto.
Near the Hokage Stone Faces, are Iruka and the academy class, having a history class outside about the Hokage. The Third Hokage watches the class and Iruka invites him in. Iruka said that the Third Hokage was the strongest Hokage and a genius, and so he was called The Professor. The Third Hokage tells them to protect their loved ones, and when the students ask them who he loves, he said he loves Konohamaru and of course all the villagers.
Meanwhile, Naruto enters his subconscious and the Nine-Tails lends Naruto some of his chakra. Then Naruto finally summons Gamabunta.


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May 6, 2016
The driver of a car died after his Mitsubishi went airborne and struck a tree this afternoon.
The single vehicle crash happened around 2:50 p.m. on Old River Road, northwest of Greenville.
Trooper Everette Deans says 22-year-old David Young of Greenville died at the scene of the accident. He said Young's vehicle was west bound and lost control in a curve at the intersection of Lombard Avenue. The vehicle first struck a ditch, became airborne and then hit the tree.
The road was closed for nearly an hour because of the wreck. Trooper Deans says he does not believe speed or alcohol were a factor.
Click Here to access the online Public Inspection File
Viewers with disabilities can get assistance accessing this station's FCC Public Inspection File by contacting the station with the information listed below. Questions or concerns relating to the accessibility of the FCC's online public file system should be directed to the FCC at 888-225-5322, 888-835-5322 (TTY), or email@example.com.


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Finding the Best (and Worst) Deals in College Tuition
Putting kids through college is something most parents expect will cost a bundle -- and it does. Just take a look at the Department of Education's College Affordability and Transparency website, which gives the lowdown on the costs, as well as trends in tuition rates. It's not a pretty picture.


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Arusha and Moshi-based street children have found a new sanctuary to ease life hardships through training how to play the rugby.
The initiative has been taken by the Rhino Rugby Football Club (RRFC) that took trouble to stage a fund raising gala to cater for the children's training costs.
The gala was held at the New Mount Meru Hotel in Arusha whereby over $150,000 was raised to cater for the newly devised plan with a double edge to upgrade life of the children and at the same time to promote the game.
Nearly 350 guests from various institutions and organisations attended the 'Rhino Ball' which was also graced by the visiting rugby team from Dar es Salaam—the Leopards.
The event was organised by Peter Morgan, who is the Doric Group executive director. He said the planned street children rugby project is another way of intensifying cooperation through sports and also meant to extend the corporate social responsibility.
The 'Street Children for Rugby' initiative is also being highly supported by Hughes Motors (Tanzania) Limited.
"We have already enrolled 30 street children for the course," said Robert Odundo, acting director for Hughes, adding that the project will invest US $ 240,000 for the initiative.
Earlier this year, the rugby national team coach, Michael Hooke, joined forces with the Arusha Rhinos Rugby Club and Hughes Motors in yet another sporting initiative to introduce the game to schools here.
'Try Rugby' was the motto behind the school campaign aimed at recruiting youngsters, precisely students and encouraging the youth to start playing what should be a new game to them.
"Rugby is less complicated than most people think," Hooke was quoted as saying. "All you need is grass, or essentially an open space and you are in a game."
He added that even where there are no rugby balls, coconuts could be used as alternative ball.
The rugby promotional campaign was also intended to be spread to the Tanzania Military Academy (TMA) in Monduli where the game is set to gain tempo among soldiers.
The national coach admitted that rugby, which was introduced in Tanzania in 2006, remains an alien game compared to the well-established events like the popular football or netball, but he was optimistic over increased awareness in Tanzania.
The rugby campaign coordinator, Kittyler Juma, said the first rugby promotional event for students started with remarkable success, enrolling more than 800 students from 16 schools in Arusha.
Lucas Laurent and Claude Joseph are among the young students who were recruited.
"It is a game that makes you use both muscles and brains," Laurent said.


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"Remember that perfect fit is a combination of the right size and the right style for your figure."
•Meet Tomima
Tomima Edmark is the leading undergarment expert. Here are
her suggestions for the best bra styles for you to choose in order
to get the best feel and fit possible.
"Almost every type of bra (strapless,
etc.) on the market today can be found in almost any size. Manufacturers
do this because the demand exists. However, just because a bra
style is available in your size doesn't mean it will work for
you. You need to know your figure and its limitations.
By way of example, take strapless bras. After a size 40D, a strapless
bra is simply not going to work as well as a strapless bra will
on a woman with a smaller cup and band size. You are better off
with a long
line bra.
Convertible bras - These are not really for anyone with heavy or large breasts. Manufacturers make
them in your size, but those skimpy straps might be uncomfortable.
A demi cup in large band sizes is simply not going to give the same support as a full cup bra.
Wide-set strap bras will not work on women with sloping shoulders.
Bandeau bras work best for the young and for smaller, well-supported breasts. Large busted women will look droopy.
Triangle bras simply have less breast coverage. Large breasted women will have breast spillage and almost no support."


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A gold medal experience
Canada is playing the U.S for Olympic gold, and the only way of knowing the score is when the co-pilot provides an update over the PA system and the loud hum of the 20-seat plane. The past 10 days have been spent in Corner Brook visiting family, skiing, eating and coming down with a bad case of Olympic fever. Im cracked about all who skated, skied and skeletoned, and NEED to be watching the battle for hockey gold. Instead, Im on a small aircraft with no bathrooms, let alone in-flight TV. Who knew when the trip was booked two months ago that the return flight would coincide with the most anticipated puck play since the 1972 Canada-Russia series. Its one-zip for Canada before the tires leave the tarmac. Somewhere between Grand Falls and Gander, I guess, the co-pilot announces its two-nil. Yes! I yell to myself. Before our descent into St. John's, were told that, unfortunately, the Yanks have scored. From the collective sigh, it appears Im not the only one consumed by the game. In the terminal, its on many of the TVs in the departure lounge. People are gathered around the screens watching, clutching fists at ever American rush and grimacing at every shot. They are even listening to it in the washrooms, as the game is piped over the PA. Outside the baggage pickup, a large crowd has gathered at the tourism kiosk, where the game is being shown on a large screen. Our ride home has e-mailed and said he might be late picking us up if the score is close. A one goal lead with three minutes to go explains why hes not there yet. So, we join the anxious throng and watch the clock tick down. Everyone is on edge as they wait to celebrate. Then, of course, Parise slips one by Luongo to tie it in the dying seconds. The crowd deflates like a balloon popped by the sharpest pin. As it disperses quickly, one person is overheard telling a City Wide cab driver to get him to the hotel as fast as possible. With overtime about to start, we settle in expecting itll be some time before our ride shows. But a few minutes after the face-off, he breezes through the automatic doors. He had left his house when buzzer sounded on regulation time. We load the car and head home, hoping to catch a bit of hockey history wanting to see another Canadian gold. En route, I fiddle with the FM dial to see, if by chance, we can pick up the game. Somewhere around 87-point something, play-by-play announcer Chris Cuthbert is heard trying to say something over a loud crowd. Either the U.S. or Canada has suffered a sudden death. Unable to wait another second, I check Facebook and see a friend had already posted CROSBY! Canada had won. My reaction was as much relief as it was jubilation. Although I didnt get to see the game live or on TV, it was good to experience such a Canadian moment with different people at different times and different ways...on a plane, in an airport bathroom, around a tourism kiosk, and in the front seat of a car. To me, that shows the breath of what Canadas win meant to Canadians. It also shows what the Vancouver Olympics had come to mean. The Feds might have been under fire for the Own the Podium program, but I think its results helped give this large country a huge dose of pride. And after the recession, the war in Afghanistan, Haiti and everything else thats been going on, we needed such a golden lift. Hopefully, we can sustain it for a while.


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Following his run on "The Ultimate Fighter 12," Michael Johnson heeded a recommendation to move to Albuquerque, N.M., where trainers Greg Jackson and Mike Winkeljohn frequently worked with his reality-show coach, UFC welterweight champ Georges St-Pierre.
But it didn't take long for Johnson to see that Jackson's MMA wasn't the right fit.
So when he traveled to Florida to help Gesias "JZ" Cavalcante prepare for a fight in Strikeforce, Johnson took up an offer to train with a band of veterans culled largely from American Top Team.
"It was probably the best decision of my life," Johnson today told MMAjunkie.com Radio (www.mmajunkie.com/radio). "I'm not saying Greg Jackson's is not a great camp. Because it is. But I don't think I would be at the level I am if I had stayed down in Albuquerque as opposed to being here."
Once a loosely organized group, the Florida camp, now called JACO Hybrid Training Center, is now linked with some of the biggest names in the sport. Rashad Evans, Eddie Alvarez, Alistair Overeem, Melvin Guillard and Anthony Johnson are but a few of the fighters that hone their skills at the camp's gym in Delray Beach, Fla.
"The huge difference with me is the one-on-one time I have with coaches," Johnson said of his new digs. "I think Greg was so busy that I missed out on a lot of opportunities to work and figure out what type of fighter I want to be and what type of fighter I need to be. I think that was the main issue for me.
"It's so well-organized down in Florida. There's never a dull moment in the gym. We set time apart so well and get work in before practices. I'm doing jiu-jitsu, I'm hitting mitts with Henry Hooft, and then I go into a team practice. Then I've got different appointments set up during the day with my coaches. I'm just progressing like that."
Of course, as the gym progresses, so increases the chance that it could be overrun by young and established hopefuls looking to have the success the current fighters enjoy.
Johnson said the process of letting in (or pushing out) fighters and trainers is a democratic process.
"That's a hard decision to make," he said. "That falls back on some of the coaches and [Glenn Robinson] and the fighters with who we allow in the gym. It's not an open-door policy. You've either got to be invited in with somebody to help them train or work out a deal with the gym. As long as we keep that and don't get too crazy with guys coming in off and on, I think our team will stay intact."
But of course, he can't be sure. The gym recently welcomed ex-champ Vitor Belfort into its midst while he was training for Jon Jones at UFC 152, and there are sure to be others that want a quick tuneup or a whole camp before they step into the cage.
For now, though, things are running smoothly, and that's allowing Johnson (11-6 MMA, 3-2 UFC) to flourish. After a 1-2 stretch post-TUF, he enjoys a two-fight win streak. On Friday he meets Danny Castillo (14-4 MMA, 4-1 UFC), who's won his past three.
They meet at UFC on FX 5, which takes place at Minneapolis' Target Center. Johnson vs. Castillo is part of the FUEL TV-televised preliminary card prior to main-card fights on FX. The bout was shifted to UFC on FX 5 when UFC 151 recently was canceled.
Castillo brings solid striking to the table but excels in wrestling. Johnson said he gives his opponent credit for sticking around in the UFC, but he isn't too complimentary.
"Nothing really impresses me with him," Johnson said. "He's just a grinder. He takes people down and holds them for decisions. That's what I've gotten from watching his fights. But it's kind of hard to impress me with anything. He's just another wrestler that I've got to face.
"I'm going to defend all his takedowns, and I'm going to wear on him, and I'm going to look to finish."
Should he win, Johnson plans to ask the UFC for a top-tier opponent, or at least a name who could take his career to the next level. With all the work he's put in, he feels he deserves it.
For more on UFC on FX 5, check out the UFC Rumors section of the site.
MMAjunkie.com Radio broadcasts Monday-Friday at noon ET (9 a.m. PT) live from Mandalay Bay Resort & Casino's Race & Sports Book. The show is hosted by "Gorgeous" George Garcia, MMAjunkie.com lead staff reporter John Morgan and producer Brian "Goze" Garcia. For more information or to download past episodes, go to www.mmajunkie.com/radio.


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For the dark rush, a really good open is...
Skel Warrior -> Soul Blade -> Shade -> Nue -> Rats/EXRiza/Succ
Usually the skel or shade will die off buff your entire field with the Liz, and you can use soul blade to force an early sin. It is devastating verse any file with a "lynchpin 3 or 4" like guardian, serpent, orcs, or EX Lap.
Soul blade swordswoman totally annihilates a lot of files. Surprised we don't see her more.


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The Power of Independent Thinking
Randy Simmons | The True Costs of Green Energy
Recorded: Monday, April 27, 2015
Senior Fellow Randy Simmons joins WSVA radio's Mike Schikman to talk about the true costs of green energy including government funding and incentives for renewable energy.
Experts: Randy T SimmonsType: RadioIssues: Bureaucracy and Government, Energy, Environment, Free Market Economics, Property Rights, Public Choice Theory, Regulation and Deregulation
Robert Nelson on Environmentalism as Religion
Recorded: Monday, May 21, 2012
Senior Fellow Robert Nelson, author of The New Holy Wars talks about the the religious implications between church, state, and environmentalism with Anthony Gill on Research on Religion.
Experts: Robert H. NelsonType: RadioIssues: Culture/ Society, Environment, Religion
Randal Rucker Discuses the Resilience of Private Beekeeping on the John Batchelor Show
Recorded: Thursday, June 30, 2011
Research Fellow Randal Rucker (co-author of Plowshares and Pork Barrels: The Political Economy of Agriculture) appeared on the John Batchelor Show to discuss the resilience of honeybees through private beekeeping in the face of colony collapse disorder.
Experts: Randal R. RuckerType: RadioIssues: Business, Environment, Labor and Employment, Science
Robert Higgs on the U.S. Governments Ethanol Scam
Recorded: Saturday, May 14, 2011
Here is Independent Institute Senior Fellow Robert Higgs speaking on Ethanol Subsidies Have Many Bad Consequences, from the Mises Circle seminar, Agricultural Subsidies: Down on the D.C. Farm, held May 14th in Indianapolis.
Experts: Robert HiggsType: Other EventIssues: Agriculture, Energy, Environment, Government Waste/Pork
Bureaucracy vs. The Environment: What Should Be Done?
Recorded: Wednesday, June 28, 2006
Part 1 |
Part 2
Part 3
Environmental quality has been a major public concern since the first Earth Day in 1970, yet the maze of environmental regulations enacted since has fostered huge government bureaucracies better known for waste and failure than for innovation and success.
Experts: Carl P. Close, Michael Shaw, Randy T SimmonsType: Independent Institute EventIssues: Environment
The Frankenfood Myth?
Recorded: Tuesday, December 13, 2005
For millennia, farmers all over the world have bred crops for their resistance to disease, productivity, and nutritional value. Today, few topics have the power to inspire as much international furor and misinformation as the development and distribution of genetically altered foods.
Experts: Bruce N. Ames, Henry I. MillerType: Independent Institute EventIssues: Agriculture, Business, Environment, Public Health/ Consumer Protection, Science


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We were emailed earlier today from an Apple Valley source that our singlet was worn by the Minnesota State defending, and now current champion – Mark Hall from Apple Valley. First off, congratulations Mark that is an incredibly tremendous achievement. To win something of that magnitude once is fantastic, but to do it four times and only be a sophomore?…Clearly eating his morning "Wheaties" has never been an issue. Very impressive. I would like to thank Mark, and his Apple Valley coaches for letting him wear our prototype dye-sub singlet. We are glad we were able to be involved on a stage like that, and then for the wrestler who is featured in that singlet to be such a great kid, and go off to win! Talk about Teehive #sweetness. We were also sent an image of the 4x champ after his match, and I've attached that photo. Plus, the Star Tribune wrote an article about the victory, our product, and compared our design to The University of Oregon's style! The article link is below:
We are in the process of expanding our company's identity, and formally releasing our sub-brand MOVEU. This brand will feature dye-sub products for athletes and their respected sports. The sports we are going to immediately feature are basketball, lacrosse, softball, track, and wrestling. We are very excited for this site launch and product release! We have some very fashionable stuff brewing so stay tuned.
Power to the Athlete.


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I've been working on a semi-decent file recently when I scored a full copy of Velvet in the recent ex lotto. It's been working well, and it's got a positive w/l ratio, but I'm wondering if I could tweak it a little to make it better.
1 Henrietta
2 Violet x2
3 Traitor to God / Leicester
4 Beast Emperor / Rivera
5 The Kraken
2x Shade
3x Hellsmoke
3x Crest Halberd Soldier
3x Chaoslady / Annarose
3x Holy Mother of Blood / Velvet
3x 6th Heaven Devil / Shvarra
2x Angry mob
3x Soul Pact
1x Neglected Soul
1x Overdose
1x Corruption
Basic Shade>Hellsmoke start to start building the field, either going second shade or Annarose. I try to let the second shade die to activate violet when I'll have at least a copy or two of hellsmoke or halberd (for obvious reasons), and I like having Halberd on the field before Velvet. And with the atk buffs from velvet, annarose & Angry Mob, Shvarra can destroy the enemy field with ease, both with his action, and his close.
Neglected soul is pretty awesome in this file, considering all the tempory atk buffs I can get easily to reactivate close skills.
Some of the things that don't always work out that well at first glance would be the cem retrieval SS, as it's hard to get them to activate when I want, and difficult still to get back specifically what I want, such as losing both Hellsmoke and Halberd soldier in the same turn so I really can't make use of the returned copies. Of course when they do activate at the right time, the effects are brilliant.
Anyway, if people have got thoughts or suggestions, I'd love to hear them. It's a fun file and I'd like to get it to work even more consistently.


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Topic Contents
- General Information About Thymoma and Thymic Carcinoma Treatment
- Cellular Classification of Thymoma and Thymic Carcinomas
- Stage Information for Thymoma and Thymic Carcinomas
- Treatment Option Overview for Thymoma and Thymic Carcinoma Treatment
- Thymoma
- Thymic Carcinoma
- Recurrent Thymoma and Thymic Carcinoma
- Changes to This Summary (09 / 17 / 2012)
- About This PDQ Summary
- Get More Information From NCI
Thymoma and Thymic Carcinoma Treatment (PDQ®): Treatment - Health Professional Information [NCI]
This information is produced and provided by the National Cancer Institute (NCI). The information in this topic may have changed since it was written. For the most current information, contact the National Cancer Institute via the Internet web site at http://cancer.gov or call 1-800-4-CANCER.
Thymoma and Thymic Carcinoma Treatment
General Information About Thymoma and Thymic Carcinoma Treatment
Disease Overview
Thymomas and thymic carcinomas are epithelial tumors of the thymus. The term, thymoma, is customarily used to describe neoplasms that show no overt atypia of the epithelial component. A thymic epithelial tumor that exhibits clear-cut cytologic atypia and histologic features no longer specific to the thymus is known as a thymic carcinoma (also known as type C thymoma).[1]
Incidence and mortality
Invasive thymomas and thymic carcinomas are relatively rare tumors, which together represent about 0.2% to 1.5% of all malignancies.[2] The overall incidence of thymoma is 0.15 cases per 100,000, based on data from the National Cancer Institute Surveillance, Epidemiology and End Results (SEER) Program.[3] Thymic carcinomas are rare and have been reported to account for only 0.06% of all thymic neoplasms.[4] In general, thymomas are indolent tumors with a tendency toward local recurrence rather than metastasis. Thymic carcinomas, however, are typically invasive, with a higher risk of relapse and death.[5,6]
Age at onset
Most patients with thymoma or thymic carcinoma are aged 40 through 60 years.[7]
Unique disease features
The etiology of these types of tumors is not known. In about 50% of the patients, thymomas/thymic carcinomas are detected by chance with plain-film chest radiography.[7]
Ninety percent of thymomas and thymic carcinomas occur in the anterior mediastinum.[8] They are the most common malignancies of the anterior mediastinum.[9]
World Health Organization pathologic classification of tumors of the thymus and stage correlate with prognosis.[1] Although some thymoma histologic types are more likely to be invasive and clinically aggressive, treatment outcome and the likelihood of recurrence appear to correlate more closely with the invasive/metastasizing properties of the tumor cells.[1,10] Therefore, some thymomas that appear to be relatively benign by histologic criteria may behave very aggressively. Independent evaluations of both the tumor invasiveness (using staging criteria) and tumor histology should be combined to predict the clinical behavior of a thymoma.
Thymoma and thymic carcinoma should be differentiated from a number of nonepithelial thymic neoplasms, including the following:[1,11]
- Neuroendocrine tumors.
- Germ cell tumors.
- Lymphomas.
- Stromal tumors.
- Tumor-like lesions (such as true thymic hyperplasia).
- Thymic cysts.
- Metastatic tumors.
- Lung cancer.
Thymoma-associated autoimmune disease involves an alteration in circulating T-cell subsets.[12,13] The primary T-cell abnormality appears to be related to the acquisition of the CD45RA+ phenotype on naive CD4+ T cells during terminal intratumorous thymopoiesis, followed by export of these activated CD4+ T cells into the circulation.[14] In addition to T-cell defects, B-cell lymphopenia has been observed in thymoma-related immunodeficiency, with hypogammaglobulinemia (Good syndrome) and opportunistic infection.[15,16] Patients with thymoma-associated myasthenia gravis can produce autoantibodies to a variety of neuromuscular antigens, particularly the acetylcholine receptor and titin, a striated muscle antigen.[17,18]
Approximately 50% of thymomas are diagnosed when they are localized within a capsule and do not infiltrate.
At the time of diagnosis, the majority of patients with thymoma or thymic carcinoma are asymptomatic.[7] Typical clinical symptoms and signs that are indicative of anterior mediastinal mass effects include the following:
- Coughing.
- Chest pain.
- Signs of upper airway congestion.
Paraneoplastic autoimmune syndromes are associated with thymoma and are rarely associated with thymic carcinomas.[19,20,21]
- Myasthenia gravis is the most common autoimmune disease associated with thymoma. Approximately 30% to 65% of patients with thymoma have been diagnosed with myasthenia gravis in reported series.[22,23]
- Autoimmune pure red cell aplasia and hypogammaglobulinemia are the next most common paraneoplastic syndromes after myasthenia gravis, and affect approximately 5% and 5% to 10%, respectively, of patients with thymoma.[8]
Other autoimmune disorders associated with thymoma include the following:[7,15,24]
- Acute pericarditis.
- Addison disease.
- Agranulocytosis.
- Alopecia areata.
- Cushing syndrome.
- Hemolytic anemia.
- Limbic encephalopathy.
- Myocarditis.
- Nephrotic syndrome.
- Parahypopituitarism.
- Pernicious anemia.
- Aplastic anemia.
- Polymyositis.
- Rheumatoid arthritis.
- Sarcoidosis.
- Scleroderma.
- Sensorimotor radiculopathy.
- Sjögren syndrome.
- Stiff-person syndrome.
- Systemic lupus erythematosus.
- Thyroiditis.
- Ulcerative colitis.
Prognosis and Survival
Although the oncologic prognosis of thymoma is reported to be more favorable in patients with myasthenia gravis than in patients without myasthenia gravis,[8,25] data are conflicting as to whether the presence of myasthenia gravis is an independent predictor of better outcome. Patients with myasthenia gravis are diagnosed with earlier stage disease and more often undergo complete surgical resection.[25] Treatment with thymectomy may not significantly improve the course of thymoma-associated myasthenia gravis.[26,27]
Thymoma has been associated with an increased risk for second malignancies. In a review of the SEER database of thymoma cases in the United States between 1973 and 1998, 849 cases were identified (overall incidence 0.15 per 100,000 person-years).[3] In this study, there was an excess risk of non-Hodgkin lymphoma and soft tissue sarcomas.
Risk of second malignancy appears to be unrelated to any of the following:[3,27,28]
- Thymectomy.
- Radiation therapy.
- A clinical history of myasthenia gravis.
Standard primary treatment for patients with these types of tumors is surgical resection with en bloc resection for invasive tumors, if possible.[5,7,8,29] Depending on tumor stage, there are multimodality treatment options, which include the use of radiation therapy and chemotherapy with or without surgery.[7,30]
Thymic carcinomas have a greater propensity to capsular invasion and metastases than thymomas. Patients more often present with advanced disease, with a 5-year survival of 30% to 50%.[31] Owing to the paucity of cases, optimal management of thymic carcinoma has yet to be defined. As with thymoma, primary treatment is surgical resection; however, multimodality treatment with surgery, radiation, and chemotherapy are often used because of the more advanced stage and greater risk of relapse.
Because of the increased risk for second malignancies and the fact that thymoma can recur after a long interval, it has been recommended that surveillance should be lifelong.[27] The measurement of interferon-alpha and interleukin-2 antibodies is helpful to identify patients with a thymoma recurrence.[32]
Related Summary
Another PDQ summary containing information related to thymoma includes the following:
- Unusual Cancers of Childhood (thymoma in children).
Cellular Classification of Thymoma and Thymic Carcinomas
The following cellular classification of thymoma and thymic carcinoma is largely based on the classification scheme presented in a World Health Organization (WHO) monograph published in 1999.[1] Malignant thymoma is invasive disease (as defined either macroscopically or microscopically) that continues to retain typically "bland" cytologic characteristics. Thymomas are a mixture of epithelial cells and lymphocytes, often T-cells, and the malignant component is represented by the epithelial cells. Malignant cytologic characteristics are considered thymic carcinomas.
Both histologic classification of thymomas and stage may have independent prognostic significance.[2,3] A few series have reported the prognostic value of the WHO classifications. In large, retrospective analyses of 100 and of 178 thymoma cases, disease-free survivals at 10 years were 95% to 100% for type A, 90% to 100% for type AB, 83% to 85% for type B1, 71% to 83% for type B2, 36% to 40% for type B3, and 28% for type C.[4,5] In both series, stage and complete resection were significant independent prognostic factors. An analysis of 273 patients treated over a 44-year period found 20-year survival rates of 100%, 87%, 91%, 59%, and 36% for patients with type A, AB, B1, B2, and B3 tumors, respectively.[2]
Recurrent karyotype abnormalities have been documented in thymomas.[6] Type A thymomas have chromosome 6q deletions including the HLA locus and p21. Type B2 and B3 thymomas have additional chromosome 5q (adenomatous polyposis coli locus), 13q (retinoblastoma locus), and 17p (p53) deletions.[7] Amplifications in regions of chromosome 16 (cadherin-encoding gene) and chromosome 18 (bcl-2) have also been seen.[8] Gene expression profiling study has shown a correlation of expression of a number of genes including adhesion molecule cten, ets-1 oncogene and glycosylphosphatidyl inositol-anchored protein with thymoma stage.[9,10,11]
Thymoma is a thymic epithelial tumor in which the epithelial component exhibits no overt atypia and retains histologic features specific to the normal thymus.[1] Immature non-neoplastic lymphocytes are present in variable numbers depending on the histologic type of thymoma. The histologic types of thymoma are as follows:
- Type A thymoma
Type A thymoma (also known as spindle cell thymoma and medullary thymoma) accounts for approximately 4% to 7% of all thymomas.[2,3] Approximately 17% of this type may be associated with myasthenia gravis.[2] Morphologically, the tumor is composed of neoplastic thymic epithelial cells that have a spindle/oval shape, lack nuclear atypia, and are accompanied by few, if any, nonneoplastic lymphocytes.[1] The appearance of this tumor can be confused with that of a mesenchymal neoplasm, but the immunohistochemical and ultrastructural features are clearly those of an epithelial neoplasm. Most type A thymomas are encapsulated. (Refer to the Stage Information for Thymoma and Thymic Carcinomas of this summary for more information). Some, however, may invade the capsule and, on rare occasion, may extend into the lung. Chromosome abnormalities, when present, may correlate with an aggressive clinical course.[12] The prognosis for this tumor type is excellent and have long-term survival rates (15 years or more) that are reported to be close to 100% in retrospective studies.[2,3]
- Type AB thymoma
Type AB thymoma (also known as mixed thymoma) accounts for approximately 28% to 34% of all thymomas.[2,3] Approximately 16% of this type may be associated with myasthenia gravis.[2] Morphologically, type AB thymoma is a thymic tumor in which foci having the features of type A thymoma are admixed with foci rich in nonneoplastic lymphocytes.[1] The segregation of the different foci can be sharp or indistinct, and a wide range exists in the relative amount of the two components. The prognosis for this tumor type is good and have long-term survival rates (≥15 years ) that are recently reported to be approximately 90%.[2,3]
- Type B1 thymoma
Type B1 thymoma (also known as lymphocyte-rich thymoma, lymphocytic thymoma, predominantly cortical thymoma, and organoid thymoma) accounts for approximately 9% to 20% of all thymomas and depends on the study cited.[2,3] Approximately 57% of cases may be associated with myasthenia gravis.[2] Morphologically, this tumor resembles the normal functional thymus because it contains large numbers of cells that have an appearance almost indistinguishable from normal thymic cortex with areas resembling thymic medulla.[1] The similarities between this tumor type and the normal active thymus are such that distinction between the two may be impossible on microscopic examination. The prognosis for this tumor type is good and has a long-term survival rate (20 years or more) of approximately 90%.[2,3]
- Type B2 thymoma
Type B2 thymoma (also known as cortical thymoma and polygonal cell thymoma) accounts for approximately 20% to 36% of all thymomas and depends on the study cited.[2,3] Approximately 71% of cases may be associated with myasthenia gravis.[2] Morphologically, the neoplastic epithelial component of this tumor type appears as scattered plump cells with vesicular nuclei and distinct nucleoli among a heavy population of nonneoplastic lymphocytes.[1] Perivascular spaces are common and on occasion very prominent. A perivascular arrangement of tumor cells that results in a palisading effect may be seen. This type of thymoma resembles type B1 thymoma in its predominance of lymphocytes, but foci of medullary differentiation are less conspicuous or absent. Long-term survival is decidedly worse than for thymoma types A, AB, and B1. The 20-year survival rate (as defined by freedom-from-tumor death) for this thymoma type is approximately 60%.[2]
- Type B3 thymoma
Type B3 thymoma (also known as epithelial thymoma, atypical thymoma, squamoid thymoma, and well-differentiated thymic carcinoma) accounts for approximately 10% to 14% of all thymomas. Approximately 46% of this type of tumor may be associated with myasthenia gravis.[2] Morphologically, this tumor type is predominantly composed of epithelial cells that have a round or polygonal shape and that exhibit no atypia or mild atypia.[1] The epithelial cells are admixed with a minor component of nonneoplastic lymphocytes, which results in a sheet-like growth of neoplastic epithelial cells. The 20-year survival rate (as defined by freedom-from-tumor death) for this thymoma type is approximately 40%.[2]
Thymic Carcinoma
Thymic carcinoma (also known as type C thymoma) is a thymic epithelial tumor that exhibits a definite cytologic atypia and a set of histologic features no longer specific to the thymus but rather similar to those histologic features observed in carcinomas of other organs.[1] In contrast to type A and B thymomas, thymic carcinomas lack immature lymphocytes. Any lymphocytes that are present are mature and usually admixed with plasma cells. Hypothetically, thymic carcinoma may arise from malignant transformation of a pre-existing thymoma.[13] This hypothetical evolution could account for the existence of thymic epithelial lesions that exhibit combined features of thymoma and thymic carcinoma within the same tumor.[14]
Thymic carcinomas are usually advanced when diagnosed and have a higher recurrence rate and worse survival compared with thymoma.[15,16] In a retrospective study of 40 patients with thymic carcinoma, the 5-year and 10-year actuarial overall survival rates were 38% and 28%, respectively.[15] In contrast to the thymomas, the association of thymic carcinoma and autoimmune disease is rare.[17]
Histologic subtypes of thymic carcinoma include the following:
- Squamous cell (epidermoid) thymic carcinoma
This type of thymic carcinoma exhibits clear-cut cytologic atypia. In routinely stained sections, the keratinizing form exhibits equally clear-cut evidence of squamous differentiation in the form of intercellular bridges and/or squamous pearls, while the nonkeratinizing form lacks obvious signs of keratinization. Another subtype, basaloid carcinoma, is composed of compact lobules of tumor cells that exhibit peripheral palisading and an overall basophilic staining pattern caused by the high nucleocytoplasmic ratio and the absence of keratinization.
- Lymphoepithelioma-like thymic carcinoma
This type of thymic carcinoma has morphologic features indistinguishable from those of lymphoepithelial carcinoma of the respiratory tract. The differential diagnosis with germ cell tumors, particularly seminomas, can be difficult but important for treatment.
- Sarcomatoid thymic carcinoma (carcinosarcoma)
This is a type of thymic carcinoma in which part or all of the tumor resembles one of the types of soft tissue sarcoma.
- Clear cell thymic carcinoma
This is a type of thymic carcinoma composed predominantly or exclusively of cells with optically clear cytoplasm.
- Mucoepidermoid thymic carcinoma
This type of thymic carcinoma has an appearance similar to that of mucoepidermoid carcinoma of the major and minor salivary glands.
- Papillary thymic adenocarcinoma
This type of thymic carcinoma grows in a papillary fashion. This histology may be accompanied by psammoma body formation, which may result in a marked similarity with papillary carcinoma of the thyroid gland.
- Undifferentiated thymic carcinoma
This is a rare type of thymic carcinoma that grows in a solid undifferentiated fashion but without exhibiting sarcomatoid (spindle cell or pleomorphic) features.
Combined Thymoma
Combinations of the above histologic types can occur within the same tumor. For these cases, the term, combined thymoma, can be used, followed by a listing of the components and the relative amount of each component.[1]
Stage Information for Thymoma and Thymic Carcinomas
Computed tomography (CT) with intravenous contrast may be useful in the diagnosis and clinical staging of thymoma, especially for noninvasive tumors. CT is usually accurate in predicting the following:
- Tumor size.
- Location.
- Invasion into vessels, the pericardium, and the lungs.
However, CT cannot predict invasion or resectability with accuracy.[1,2] Appearance of the tumor on CT may be related to the World Health Organization (WHO) histologic type.[3] A retrospective study involving 53 patients who underwent thymectomy for thymic epithelial tumors indicated that smooth contours with a round shape were most suggestive of type A thymomas, and irregular contours were most suggestive of thymic carcinomas. Calcification was suggestive of type B thymomas. In this study, however, CT was found to be of limited value differentiating type AB, B1, B2, and B3 thymomas.[4]
Most patients with thymic carcinomas present initially with any of the following:
- Cough.
- Chest pain.
- Phrenic nerve palsy.
- Superior vena cava syndrome.
Patients may have evidence of invasion of contiguous mediastinal structures at presentation. Thymic carcinoma can metastasize to any of the following:
- Regional lymph nodes.
- Bone.
- Liver.
- Lungs.
An evaluation for sites of metastases may be warranted for these patients.
Positron emission tomography of 18-flouro-deoxyglucose (FDG-PET) as well as thallium single-photon emission computed tomography have been reported in small series for diagnosis and evaluation of therapeutic outcomes in thymic carcinoma.[5,6,7,8] Two small series reported that FDG uptake was related to the invasiveness of thymic carcinoma.[7,8] This raises the possibility of FDG-PET utilization for diagnosis, treatment planning, and monitoring for recurrence. Sensitivity, specificity impact on clinical therapeutic decisions, remains to be defined.
Histologic classification of thymoma is not sufficient to distinguish biologically benign thymomas from malignant thymomas. The degree of invasion or tumor stage is generally thought to be a more important indicator of overall survival.[1,9,10]
Evaluating the invasiveness of a thymoma involves the use of staging criteria that indicate the presence and degree of contiguous invasion, the presence of implants, and lymph node or distant metastases regardless of histologic type. Although no standardized staging system exists, the one proposed by Masaoka in 1981 is commonly employed.[11] It was revised in 1994 and is shown below.[11]
Thymoma Staging System of Masaoka 1994a
|Macroscopically, completely encapsulated; microscopically, no capsular invasion.
|Macroscopic invasion into surrounding fatty tissue or mediastinal pleura; microscopic invasion into capsule.
|Macroscopic invasion into neighboring organs (pericardium, lung, and great vessels).
|Pleural or pericardial dissemination.
|Lymphogenous or hematogenous metastases.
Application of this staging system to a series of 85 surgically treated patients confirmed its value in determining prognosis, with 5-year survival rates of 96% for stage I disease, 86% for stage II disease, 69% for stage III disease, and 50% for stage IV disease.[11,13] In a large, retrospective study involving 273 patients with thymoma, 20-year survival rates (as defined by freedom from tumor death) according to the Masaoka staging system were reported to be 89% for stage I disease, 91% for stage II disease, 49% for stage III disease, and 0% for stage IV disease.[9]
In a retrospective analysis of 130 resected, thymoma patients, the WHO pathological classification was tightly correlated with stage and by multivariate analysis, tumor size, completeness of resection, histologic subtype, and stage were significant prognostic factors for survival. Of note, only four patients received neoadjuvant cisplatin-based chemotherapy and complete resection was possible in 95% of cases. The 5-year survival rate of the 11 stage IV patients was 47%.[12]
Some investigators maintain that the Masaoka staging system does not accurately predict outcome for thymic carcinoma.[14,15] In one retrospective study evaluating 43 cases of thymic carcinoma, prognosis was found to be dependent solely on tumor invasion of the innominate artery.[15]
Treatment Option Overview for Thymoma and Thymic Carcinoma Treatment
Most thymomas are diagnosed and staged at the time of surgical intervention. Surgical resection is the preferred treatment of patients who can tolerate surgery and have a mediastinal mass that is suspected of being a thymoma. A complete, surgical resection is recommended for patients with either stage I or stage II disease. A complete resection of all tumors can be achieved in nearly all stage I and stage II patients and in 27% to 44% of stage III patients. Postoperative radiation therapy (PORT) is generally employed for stage II and stage III patients. Patients with stage IVa disease can only rarely be resected completely and are usually offered debulking surgery and PORT with or without chemotherapy.
Thymic Carcinoma
The optimal treatment of thymic carcinoma remains undefined because of its rarity. Most patients with thymic carcinomas present initially with any of the following:
- Cough.
- Chest pain.
- Phrenic nerve palsy.
- Superior vena cava syndrome.
Most patients with thymic carcinoma have evidence of invasion of contiguous mediastinal structures at presentation.
Thymic carcinoma can metastasize to the following areas:
- Regional lymph nodes.
- Bone.
- Liver.
- Lungs.
Treatment options include the following:[1]
- Surgery.
- Radiation.
- Multimodality approach, such as:
- Surgical resection.
- Radiation therapy.
- Cisplatin-based chemotherapy.
For patients with clinically resectable disease, surgical resection is often the initial therapeutic intervention. For clinically borderline or frankly unresectable lesions, neoadjuvant (preoperative) chemotherapy or thoracic radiation therapy, or both, is given.[2] Patients presenting with locally advanced disease should be carefully evaluated and undergo multimodality therapy. Patients with poor performance status and high associated operative risks are generally not considered for these types of aggressive treatments. Patients with metastatic disease may respond to combination chemotherapy.
Stage I and Stage II Thymoma
Excellent long-term survival can be obtained following complete surgical excision for a pathologic stage I thymoma. There appears to be no benefit to adjuvant radiation therapy following complete resection of encapsulated noninvasive tumors.[1,2] For patients with stage II thymomas with pathologically demonstrated capsular invasion, adjuvant radiation therapy following complete surgical excision has been considered a standard of care despite the lack of prospective clinical trials.[3,4]
Most studies use 40 Gy to 70 Gy with standard fractionation scheme (1.8–2.0 Gy/fraction). Some, but not all, retrospective clinical studies show improved local control and survival with the addition of postoperative radiation therapy (PORT).[5,6,7,8][Level of evidence: 3iiiDiv] More recent retrospective studies have found no outcome difference in patients treated with or without PORT following complete resection of the thymic tumor.[8,9,10,11,12]
In the largest series reported to date, data was obtained from 1,320 Japanese patients.[8] The Masaoka clinical stage was found to correlate well with prognosis of thymoma and thymic carcinoma. Patients with stage I thymoma were treated with surgery only, and patients with stage II thymoma underwent surgery and additional radiation therapy. Prophylactic mediastinal radiation therapy did not appear to prevent local recurrences effectively in patients with totally resected stage II thymoma.
The role and risks of adjuvant radiation therapy for patients with completely resected stage II thymomas need further study. To avoid the potential morbidity and costs associated with thoracic radiation, PORT may be reserved for stage II patients where adjacent organs are within a few millimeters or involve of the surgical margin as determined by both pathological and intraoperative findings.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I thymoma and stage II thymoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Operable or Potentially Operable Stage III and Stage IVA Thymoma
Stage III thymoma may be difficult to identify prior to surgery as invasion of adjacent subtle invasion to the adjacent organs may only be identified at the time of mediastinal exploration. Such patients often receive aggressive surgical resection including wide surgical margins with consideration of adjuvant radiation therapy. Invasion of local organs can be apparent on pretreatment computed tomographic imaging. Such patients may be offered combined modality treatment with chemotherapy followed by surgery and/or radiation therapy.[13,14,15,16,17,18,19,20] The optimal strategy for induction therapy, which minimizes operative morbidity and mortality and optimizes resectability rates and ultimately survival, currently remains unknown.
Two large series have reported outcomes. In the first study, data was obtained from 1,320 Japanese patients.[8] The Masaoka clinical stage was found to correlate well with prognosis of thymoma and thymic carcinoma. Patients with stage III thymoma underwent surgery and additional radiation therapy. Patients with stage IV thymoma were treated with radiation therapy or chemotherapy. For patients with stage III or stage IV thymoma, the 5-year survival rates were 93% for patients treated with total resection, 64% for patients treated with subtotal resection, and 36% for patients whose disease was inoperable. Prophylactic mediastinal radiation therapy did not appear to prevent local recurrences effectively in patients with totally resected stage III thymoma. Adjuvant therapy including radiation or chemotherapy did not appear to improve the prognosis in patients with totally resected stage III or stage IV thymoma.[8]
In the second study, 1,334 patients diagnosed and treated between 1973 and 2005 were identified in a SEER database. At a relatively short median follow-up of 65 months, radiation therapy did not appear to increase the risk of cardiac mortality or secondary malignancy. Routine use of PORT did not appear to improve long-term survival.[20]
Most invasive thymomas have been found to be relatively sensitive to cisplatin-based combination chemotherapy regimens. The combinations that follow have reported objective response rates from 79% to 100% with subsequent resectability rates ranging between 36% and 69%:[13,14,15,16,17,18,19,21]
- The combination of cisplatin, doxorubicin, and cyclophosphamide (PAC) with or without prednisone.
- The combination of cisplatin, doxorubicin, vincristine, and cyclophosphamide (ADOC).
- The combination of cisplatin, etoposide, and epirubicin.
Long-term survival rates following induction chemotherapy and surgery with or without radiation therapy and consolidation chemotherapy have ranged from 50% at 4 years, 77% at 7 years and, respectively, 86% and 76% for stage III and IV patients at 10 years in different published series.[14,16,17,22]
However, similar results have been reported with preoperative radiation therapy without chemotherapy, particularly if great vessels are involved (5-year overall survival rate of 77% and 10-year OS rate of 59%).[23,24]
An intergroup trial conducted in the United States reported a predicted 5-year OS rate of 52% in 26 patients receiving the PAC chemotherapy regimen followed by radiation therapy without surgery.[18]
The role of surgical debulking for patients with either stage III or stage IVA disease is controversial. Phase II data suggests that prolonged survival can be accomplished with chemotherapy and radiation therapy alone in many patients presenting with locally advanced or even metastatic thymoma.[18] Therefore, the value of surgery may be questioned if complete, or at the very least, near complete extirpation cannot be accomplished.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage III thymoma and stage IV thymoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Standard treatment options for patients with operable disease include the following:
|En bloc surgical resection.
|PORT may be considered, especially for patients with close or involved surgical margins and for stage III and stage IVA patients.
|Induction chemotherapy followed by surgery with or without radiation.
Standard treatment options for patients with inoperable disease (stage III and stage IV with vena caval obstruction, pleural involvement, pericardial implants, etc.) include the following:
|Induction chemotherapy followed by surgery or radiation.
|Induction chemotherapy followed by surgery and radiation.
|Radiation therapy.
Treatment options under clinical evaluation:
Areas of active clinical evaluation for patients with thymoma include the following:
- New drug regimens.
- Variation of drug doses in current regimens.
- New radiation therapy schedules and techniques.
Thymic Carcinoma
Thymic carcinomas have a greater propensity to capsular invasion and metastases than thymomas. Patients more often present with advanced disease and have a 5-year survival rate of 30% to 50%.[1] Owing to the paucity of cases, optimal management of thymic carcinoma has yet to be defined. As with thymoma, in most published series, carefully selected patients with clearly resectable, well-defined disease, have received complete surgical extirpation. For clinically borderline or frankly unresectable lesions, induction chemotherapy, thoracic radiation therapy, or both, have been used.
In most published studies, surgery has been followed by adjuvant radiation therapy. A prescriptive dose range has yet to be identified; most studies use 40 Gy to 70 Gy with standard fractionation scheme (1.8 Gy–2.0 Gy/fraction).
In the largest series reported to date, data was obtained from 1,320 Japanese patients.[2] The Masaoka clinical stage was found to correlate well with prognosis of thymoma and thymic carcinoma. Patients with thymic carinoma were treated with radiation therapy or chemotherapy. For patients with thymic carcinoma, the 5-year survival rates were 67% for patients treated with total resection, 30% for patients treated with subtotal resection, and 24% for patients whose disease was inoperable. Adjuvant therapy including radiation or chemotherapy did not appear to improve the prognosis in patients with thymic carcinoma.[2]
A multi-institutional retrospective outcome analysis of 186 patients with thymic carcinoma has been reported.[2] This study failed to detect a long-term survival benefit in patients treated with subtotal resection nor any statistically significant survival augmentation from the addition of adjuvant radiation to surgical resection. The authors stipulated that no definitive conclusions could be made regarding the role of adjuvant radiation therapy in thymic carcinoma as a result of sample size limitations.
The 5-year survival rates for patients with totally resected thymic carcinoma were 81.5% for patients treated with chemotherapy; 46.6% for patients treated with radiation chemotherapy; 73.6% for patients treated with radiation therapy alone; and, 72.2% for patients who received no adjuvant treatment.[2]
The results from this study call into question conventional thinking regarding the efficacy of an aggressive multimodality approach including debulking, radiation therapy, and cisplatin-based chemotherapy.[3,4,5] While other studies support the addition of adjuvant radiation and chemotherapy, optimum treatment regimens are undetermined.
Chemotherapy is also utilized in the management of patients with inoperable thymic carcinoma. Most regimens used are similar to those used to treat thymoma and include cisplatin.[6,7,8,9,10]
Objective responses and improved outcomes compared to historical data have been reported from small uncontrolled studies. Combinations of doxorubicin, cyclophosphamide, and vincristine and cisplatin have also shown favorable responses in studies.[6,7,8] Etoposide, ifosfamide, and cisplatin (VIP) was utilized in a prospective North American Intergroup trial.[9] There was a 25% (2 of 8 patients) partial response rate. The 1-year and 2-year survival rates were 75% and 50%, respectively.
Standard treatment options for patients with operable disease include the following:
|En bloc surgical resection.
|Postoperative radiation therapy may be considered whether or not the surgical resection has been complete, and especially for stage III and stage IVA patients.
Standard treatment options for patients with inoperable disease (stage III and stage IV with vena caval obstruction, pleural involvement, pericardial implants, etc.) include the following:
|Radiation therapy.
|Chemotherapy with or without surgery and/or radiation therapy.
|Chemoradiation therapy.
Treatment options under clinical evaluation:
Areas of active clinical evaluation for patients with thymic carcinoma include the following:
- New drug regimens.
- Variation of drug doses in current regimens.
- New radiation therapy schedules.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with thymic carcinoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Recurrent Thymoma and Thymic Carcinoma
Patients with recurrent thymomas who undergo re-resection of recurrent disease may have prolonged survival when complete resection is attained.[1] However, only a minority of patients may be candidates for resection.
In a review of 395 patients who underwent resections for thymic epithelial tumors, 67 had tumor recurrence and 22 underwent a re-resection procedure.[2] The 10-year survival rate was 70%. In a second series, 30 of 266 patients initially treated by total resection of the tumor had a recurrence, and in all 30 patients surgical resection had been attempted.[3] Complete resection of the recurrent tumor was obtained in ten cases. Overall 5-year and 10-year survival rates for the 30 patients with recurrent thymomas were 48% and 24%, respectively.
Of note, patients in these series may have received chemotherapy and/or radiation therapy in addition to surgery.
A number of studies have demonstrated that certain chemotherapy drugs can induce tumor responses as single agents or in combination. In general, higher response rates have been reported with combinations; however, no randomized trials have been conducted to date.
A phase II trial of cisplatin (50 mg/m2) reported an objective response rate of 10% among 21 patients.[4] Six of 13 patients treated with single-agent ifosfamide had objective responses.[5] Octreotide with or without prednisone may induce responses in patients with octreotide scan-positive thymoma. Six of 16 patients achieved objective responses to octreotide (1.5 mg/day subcutaneously) associated with prednisone (0.6 mg/kg/day orally for 3 months, 0.2 mg/kg/day orally during follow-up).[6]
In a second study, 2 complete (5.3%) and 10 partial responses (25%) were observed among 42 patients.[7]
In general, combination chemotherapy produces complete and partial remissions; some of the complete remissions have been pathologically confirmed at subsequent surgery.
In a series of 30 patients with stage IV or locally progressive recurrent tumor following radiation therapy, the PAC regimen (cisplatin, doxorubicin, cyclophosphamide) achieved a 50% response rate, including three complete responses. The median duration of response was 12 months, and the 5-year survival rate was 32%.[8][Level of evidence: 3iiiDiv]
In another study, the ADOC regimen (doxorubicin, cisplatin, vincristine, cyclophosphamide) produced a 92% response rate (34 of 37 patients), including complete responses in 43% of patients.[9]
One study of combined chemotherapy with cisplatin and etoposide produced responses in 9 of 16 patients treated, with a median response duration of 3.4 years and a median survival of 4.3 years.[10]
Nine of 28 patients with invasive thymoma or thymic carcinoma who received four cycles of etoposide, ifosfamide, and cisplatin (VIP) at 3-week intervals had partial responses.[10] The median duration of response was 11.9 months (range, <1–26 months), and the median overall survival (OS) rate was 31.6 months. The 1-year and 2-year survival rates were 89% and 70%, respectively.[10][Level of evidence: 3iiiDiv] Nine of 34 patients treated with VIP had partial responses (32%; 95% confidence interval, 16%–52%). The median follow-up was 43 months (range, 12.8–52.3 months), the median duration of response was 11.9 months (range, <1–26 months), and the median OS rate was 31.6 months. Based on Kaplan-Meier estimates, the 1-year and 2-year survival rates were 89% and 70%, respectively. These results appear to be inferior to other combinations.
Standard treatment options:
|Repeat surgical resection, particularly for local recurrences and, in some cases, pleural and pericardial implants. Postoperative radiation therapy has been used for patients with incomplete resections and has been employed in selected patients following complete resection of recurrent thymoma.[1]
|Radiation therapy (when possible, based on previous treatment).
|Corticosteroids in unresectable tumors that have not responded to radiation therapy.
Treatment options under clinical evaluation:
Areas of active clinical evaluation for patients with recurrent thymoma or thymic carcinoma include:
- New drug regimens.
- Variation of drug doses in current regimens.
- New radiation therapy schedules.
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent thymoma and thymic carcinoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Changes to This Summary (09 / 17 / 2012)
The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.
General Information About Thymoma and Thymic Carcinoma Treatment
Updated Cameron et al. as reference 8.
Added Berman et al. as reference 12.
Added text to state that in a second study, patients were identified in a SEER database and at median follow-up of 64 months, radiation therapy did not appear to increase the risk of cardiac mortality or secondary malignancy, nor did routine use of postoperative radiation therapy appear to improve long-term survival (cited Fernandes et al. as reference 20).
Thymic Carcinoma
Added Igawa et al. as reference 10.
This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.
About This PDQ Summary
Purpose of This Summary
This PDQ cancer information summary for health professionals provides comprehensive, peer-reviewed, evidence-based information about the treatment of thymoma and thymic carcinoma. It is intended as a resource to inform and assist clinicians who care for cancer patients. It does not provide formal guidelines or recommendations for making health care decisions.
Reviewers and Updates
This summary is reviewed regularly and updated as necessary by the PDQ Adult Treatment Editorial Board, which is editorially independent of the National Cancer Institute (NCI). The summary reflects an independent review of the literature and does not represent a policy statement of NCI or the National Institutes of Health (NIH).
Board members review recently published articles each month to determine whether an article should:
- be discussed at a meeting,
- be cited with text, or
- replace or update an existing article that is already cited.
Changes to the summaries are made through a consensus process in which Board members evaluate the strength of the evidence in the published articles and determine how the article should be included in the summary.
The lead reviewers for Thymoma and Thymic Carcinoma Treatment are:
- Janet Dancey, MD, FRCPC (Ontario Institute for Cancer Research & NCIC Clinical Trials Group)
- Giuseppe Giaccone, MD, PhD (National Cancer Institute)
Any comments or questions about the summary content should be submitted to Cancer.gov through the Web site's Contact Form. Do not contact the individual Board Members with questions or comments about the summaries. Board members will not respond to individual inquiries.
Levels of Evidence
Some of the reference citations in this summary are accompanied by a level-of-evidence designation. These designations are intended to help readers assess the strength of the evidence supporting the use of specific interventions or approaches. The PDQ Adult Treatment Editorial Board uses a formal evidence ranking system in developing its level-of-evidence designations.
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The preferred citation for this PDQ summary is:
National Cancer Institute: PDQ® Thymoma and Thymic Carcinoma Treatment. Bethesda, MD: National Cancer Institute. Date last modified <MM/DD/YYYY>. Available at: http://cancer.gov/cancertopics/pdq/treatment/thymoma/HealthProfessional. Accessed <MM/DD/YYYY>.
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Last Revised: 2012-09-17
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text:
The Cat in the Hat Comes Back to the Library!
In celebration of Read Across America Day and in honor of Dr. Seuss's birthday, the Cat in the Hat is visiting the Peachtree Corners branch! Join us for a story, then shake the hand of the beloved character from the book series, "The Cat in the Hat." Don't forget to bring your camera! (All Ages)


text:
0 results match your search criteria on SwimOutlet.com. Sorry!
Sunscreen is the most important thing that you can ever wear outside. Depending on the SPF that you're after depends on how much coverage you're going to want when you go outdoors. When it comes to limiting yourself to putting on sunscreen just for when you're swimming, you shouldn't because it's best to keep it on any time that you go outside. Sunscreen is used to protect UV rays from entering your skin and preventing the chance of sunburn on your skin. Making sure that you reapply your sunscreen is just as important as first applying it. Depending on how long you've been out in the sun and what the number is on your sunscreen bottle corresponds to how and when you should reapply. If you have a higher number, then that means you have to reapply less.
What's also great is there are a fair number of sunscreens that are waterproof and last longer while you're in the water. While there is a conception of not needing sunscreen while you're in the water, UV rays can still penetrate through the water that you're swimming in, so putting on sunscreen is just as important as your suit. See how long you're going to be outside for and plan how high you need your SPF to be. SwimOutlet has a wide variety of sunscreen ranging from 15 SPF to even higher. If you need something more concentrated then there is even zinc available for the lifeguards and surfers. As long as you're wearing sunscreen you should be well-equipped to tackle any outdoor activity.


text:
search the archive
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bibliography and history of the book
cultural studies and historical approaches
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UPDATE: Emerging Spaces, Transforming Scapes (1/20/06; 3/24/06-3/26/06)
full name / name of organization:
contact email:
UPDATE: Emerging Spaces, Transforming Scapes - New Adjunct Workshop and Web Site
Deadline: January 20th, 2006
If you could, please post this update concerning "Emerging Spaces, Transforming Scapes," the Intersections Graduate Student Creative Conference 2006, in Toronto:
In association with the Toronto Universities Policy Discussion Group (TUPDiG) a new Adjunct Workshop and Web Site have been developed. For more information concerning the workshop and the conference please see the details that follow below, or please check the web site at the following URL:
The conference is hosted by graduate students of the York/Ryerson Joint Programme in Communication and Culture. We encourage all graduate students interested in Communication and Culture to submit to the new adjunct workshop and this creative conference, especially if students have some preliminary research completed after their last term of course work!
More announcements will follow shortly concerning keynote speakers, and other events at the conference. Our apologies for any cross posting.
We look forward to seeing you at the conference from March 24-26, 2006!!
Have a great new year!
Peter Ryan
The Toronto Universities Policy Discussion Group (TUPDiG)
For more on TUPDiG please see:
For more on the Adjunct Workshop Call For Papers (CFP) please see:
In conjunction with the Ryerson/York University Joint Graduate Programme in Communication & Culture, the Toronto Universities Policy Discussion Group invites graduate students to share their research in a special one-day workshop focusing on communications, culture, politics and policy. The workshop will be held as an adjunct session to the Communication & Culture Programme's fifth annual graduate student conference (24-26 March), to be held at Ryerson University, Toronto.
The workshop's aim is to support academic experimentation and discussion, towards developing a community of inter-disciplinary scholars concerned with political and policy-related issues.
Topics of interest include, but are not limited to:
Submissions from researchers trained outside the field of communications and culture, as well as from outside politics and policy studies are encouraged.
DEADLINE FOR SUBMISSIONS: Friday, 20 January 2006
The workshop will be oriented around sessions of two or three 10-15 minute paper presentations followed by questions.
All interested participants are asked to submit an abstract outlining the basic themes and argument their presentation will make. Abstract should be no more than 250 words (one typewritten page, double spaced) and submitted via email as an attachment in .TXT, .RTF, or Microsoft Word format. Name and contact information should not appear on this page.
Please include a separate page with the following information:
1. Title of presentation as it appears on the abstract
Presented by the Toronto Universities Policy Discussion Group: http://groups.yahoo.com/group/tupdig/
Communication and Culture Graduate Students Association: http://www.yorku.ca/cocugsa
The Call For Papers for "Intersections 2006," the Joint Graduate Programme in Communication & Culture
CFP DEADLINE: Friday, January 20th, 2006
Hosted by the students of the Joint Graduate Programme in
We invite all interested graduate students to join us for our 5th annual Intersections weekend Creative Conference. This year we areespecially interested in discussing the significance of both new and established scapes, and their relationships with and connections to imagined and physical spaces. Edges, nodes, networks, overflows, streams: the way we imagine our world is changing. We are at a point where it is important to reflect upon and consider older connectivities established through non-electronic media, while at the same time considering the potentials of new media through emerging communication technologies. Bodies, commodities, ideas, and technologies follow an exploding number of conduits between the local and the global, around, through, and behind nations and institutions.
The 2006 Intersections Conference will be the 5th annual event organized by the York/Ryerson joint
Open to all graduate students, this interdisciplinary conference welcomes submissions that take up these themes either through an academic paper presentation, an artistic expression, or an activist agenda. Details on subtopics and submission procedures follow below. We encourage all interested activists and scholars to participate and to come celebrate the Fifth Anniversary of the Intersections Conference!!
Invited submissions include papers, artwork and activist presentations that relate to the following broad themes:
1) Media and Culture
2) Technology in Practice
3) Politics and Policy
As an expanded event, this year EMERGING SPACES will include the following formats for disseminating and discussing ideas.
1) Paper presentations
2) Creative work with artist's talk
3) Poster session (with possible roundtable discussion)
Although these formats are tailored to accommodate academic papers, artwork and activist contributions respectively, all participants are encouraged to apply for whatever format is most interesting or appropriate for your submission.
All interested participants are asked to submit a textual abstract or artist's statement explaining the proposed presentation in light of the conference themes, and indicate which of the above three formats the presentation would take.
Abstract or statement should be no more than 250 words (approx. 1 typewritten page, double spaced) and submitted via email as an attachment in .TXT, .RTF, or Microsoft Word format.
Name and contact information should not appear on this page. Please include a separate page with the
1. Title of presentation as it appears on the abstract or statement
Artists are also asked to submit a small sample of their work for adjudication, by either email or post.
If sending creative works by email, please submit up to 10 jpegs sized to display onscreen or a multimedia clip with cumulative attachment size of 5mb or less. You may also direct us to an URL. Please number the pieces and put viewing instructions, comments and titles in your email if applicable.
If submitting creative works by post, please mail the proposal well before the deadline with a self-addressed, stamped envelope for return to the following address:
Intersections, c/o Graduate Communication and Culture
You may send a CD, DVD, cued video or other multimedia, the duration of which does not exceed 10 minutes. Alternatively, you may send up to 10 slides or printouts of work, illustrations or diagrams. Please include a slide or media list with title, size, media, and date, and viewing instructions for your work if applicable. Please do
Deadline: FRIDAY, JANUARY 20th, 2006.
Please e-mail inquiries and submissions to: intersec_at_ryerson.ca
CFP available online: http://www.yorku.ca/cocugsa/conference.html
Presented by the Communication and Culture Graduate Students
For more information about the Joint Programme in Communication and
cfp categories: