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Radiation Oncology

American Radium Society Appropriate Use Criteria for Radiation Therapy in the Multidisciplinary Management of Thymic Carcinoma

To identify the key insights or developments described in this article

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JAMA Oncology

Published Online: May 15, 2023

Special Communication

Article Information and Disclosures

Stephen G. Chun, MD¹;

Andreas Rimner, MD²;

Arya Amini, MD³;

Joe Y. Chang, MD, PhD¹;

Jessica Donington, MD⁴;

Martin J. Edelman, MD⁵;

Yimin Geng, PhD¹;

Matthew A. Gubens, MD⁶;

Kristin A. Higgins, MD⁷;

Puneeth Iyengar, MD, PhD⁸;

Benjamin Movsas, MD⁹;

Matthew S. Ning, MD¹;

Henry S. Park, MD, MPH¹⁰;

George Rodrigues, MD, PhD¹¹;

Andrea Wolf, MD¹²;

Charles B. Simone II, MD¹³

Author Affiliations

¹The University of Texas MD Anderson Cancer Center, Houston
²Memorial Sloan Kettering Cancer Center, New York, New York
³City of Hope National Medical Center, Duarte, California
⁴University of Chicago, Chicago, Illinois
⁵Fox Chase Comprehensive Cancer Center, Philadelphia, Pennsylvania
⁶Helen Diller Family Comprehensive Cancer Center, University of California San Francisco
⁷Winship Cancer Institute, Emory University, Atlanta, Georgia
⁸The University of Texas at Southwestern Medical Center, Dallas
⁹Henry Ford Cancer Institute, Detroit, Michigan
¹⁰Yale School of Medicine, New Haven, Connecticut
¹¹Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada
¹²Mount Sinai Health System, New York, New York
¹³New York Proton Center, New York, New York

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Abstract

Importance Thymic carcinoma is rare, and its oncologic management is controversial due to a paucity of prospective data. For this reason, multidisciplinary consensus guidelines are crucial to guide oncologic management.

Objective To develop expert multidisciplinary consensus guidelines on the management of common presentations of thymic carcinoma.

Evidence Review Case variants spanning the spectrum of stage I to IV thymic carcinoma were developed by the 15-member multidisciplinary American Radium Society (ARS) Thoracic Appropriate Use Criteria (AUC) expert panel to address management controversies. A comprehensive review of the English-language medical literature from 1980 to 2021 was performed to inform consensus guidelines. Variants and procedures were evaluated by the panel using modified Delphi methodology. Agreement/consensus was defined as less than or equal to 3 rating points from median. Consensus recommendations were then approved by the ARS Executive Committee and subject to public comment per established ARS procedures.

Findings The ARS Thoracic AUC panel identified 89 relevant references and obtained consensus for all procedures evaluated for thymic carcinoma. Minimally invasive thymectomy was rated as usually inappropriate (regardless of stage) due to the infiltrative nature of thymic carcinomas. There was consensus that conventionally fractionated radiation (1.8-2 Gy daily) to a dose of 45 to 60 Gy adjuvantly and 60 to 66 Gy in the definitive setting is appropriate and that elective nodal irradiation is inappropriate. For radiation technique, the panel recommended use of intensity-modulated radiation therapy or proton therapy (rather than 3-dimensional conformal radiotherapy) to reduce radiation exposure to the heart and lungs.

Conclusions and Relevance The ARS Thoracic AUC panel has developed multidisciplinary consensus guidelines for various presentations of thymic carcinoma, perhaps the most well referenced on the topic.

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Article Information

Accepted for Publication: March 9, 2023.

Published Online: May 15, 2023. doi:10.1001/jamaoncol.2023.1175

Corresponding Author: Stephen G. Chun, MD, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030 (sgchun@mdanderson.org).

Author Contributions: Drs Chun and Geng had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Chun, Amini, Chang, Edelman, Higgins, Iyengar, Movsas, Rodrigues, Wolf, Simone.

Acquisition, analysis, or interpretation of data: Chun, Rimner, Chang, Donington, Edelman, Geng, Gubens, Iyengar, Ning, Park, Wolf.

Drafting of the manuscript: Chun, Rimner, Edelman, Geng, Higgins, Rodrigues, Simone.

Critical revision of the manuscript for important intellectual content: Chun, Rimner, Amini, Chang, Donington, Edelman, Gubens, Higgins, Iyengar, Movsas, Ning, Park, Rodrigues, Wolf.

Administrative, technical, or material support: Higgins, Simone.

Supervision: Rimner, Donington, Movsas, Simone.

Conflict of Interest Disclosures: Dr Chun reported receiving grants from National Institutes of Health (NIH) (R50 CA275822) and personal fees from AstraZeneca, PLC, Norton Healthcare, Inc, ViewRay, Inc, Curio Science, Inc, Japanese Society for Radiation Oncology, and Henry Ford Health Systems outside the submitted work. Dr Rimner reported receiving grants from NIH/National Cancer Institute (NCI) (P30 CA008748 Cancer Center Institutional Grant), NIH/NCI (R01CA258821-01A1), Varian Medical Systems, AstraZeneca, Merck, Boehringer Ingelheim, and Pfizer and personal fees from AstraZeneca, Merck, and MoreHealth outside the submitted work; and serving as International Thymic Malignancies Interest Group Vice President and International Mesothelioma Interest Group Board Member. Dr Amini reported receiving research support from Varian Medical Systems, RefleXion Medical, and Genentech outside the submitted work. Dr Chang reported receiving grants from Bristol Myers Squibb (BMS) BMS-MDACC Research Alliance and personal fees from IBA (clinical advisory committee) and Legion Healthcare Partners (clinical advisory committee) outside the submitted work. Dr Donington reported receiving personal fees from AstraZeneca, BMS, Merck, and Roche/Genentech outside the submitted work. Dr Edelman reported serving as a data and safety monitoring board member for AstraZeneca, Takeda, GlaxoSmithKline, and Seattle Genetics; receiving personal fees (advisory board) from Novocure and InterVenn; and receiving personal fees (consulting) from Omega Therapeutics, WindMIL, Regeneron/Sanofi, Flame, and Proventus outside the submitted work; and stock options for Biomarker Strategies and Creatv MicroTech. Dr Gubens reported receiving personal fees from AstraZeneca, Sanofi, iTeos, BMS, Surface, Genzyme, Genentech/Roche, Cardinal Health, Guardant, Gilead, AnHeart, and Summit and grants from Amgen, Celgene, Johnson & Johnson, Merck, Novartis, OncoMed, and Trizell outside the submitted work. Dr Higgins reported serving on an advisory board/as a consultant for AstraZeneca and Janssen Pharmaceuticals, receiving grants from RefleXion Medical and Jazz Pharmaceuticals, and serving as a consultant for Genentech during the conduct of the study. Dr Iyengar reported receiving grants from Incyte and personal fees from AstraZeneca outside the submitted work. Dr Movsas reported receiving grants (research support to department) from Varian Medical Systems, ViewRay, and Philips outside the submitted work; in addition, Dr Movsas had a patent for lung phantom pending. Dr Park reported receiving grants from RefleXion Medical and Merck and personal fees from AstraZeneca, BMS, RefleXion, Curio Science, G1 Therapeutics, and Galera Therapeutics outside the submitted work. Dr Simone reported receiving honorarium from Varian Medical Systems outside the submitted work. No other disclosures were reported.

Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Additional Contributions: The panel thanks Andrea Taylor of the American Radium Society for administrative and technical support in the development of these Appropriate Use Criteria consensus guidelines. This contribution was uncompensated.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.