MALIGNANCIES OF THE THYMUS

Imaging Thymoma
Edith M. Marom, MD

survival.6,7 The objectives of this review are to discuss the

Abstract: Thymoma is a rare tumor, although it is the most common
imaging features of thymoma, the advantages, and limitations
primary neoplasm of the anterior mediastinum. In the majority of
of each imaging modality in establishing the diagnosis, stag-
thymoma patients, imaging is requested for investigation of symp-
ing, and prognosis of thymoma.
toms related to their tumor, although an increasing number of
Initial investigation of a thymoma starts with a chest
asymptomatic patients are discovered incidentally due to the in- radiograph, which is followed by chest CT for further char-
creased utilization of computed tomography for screening or for acterization and staging. Rarely, in selected cases, additional
imaging of other unrelated diseases. This review will focus on the imaging is used such as magnetic resonance imaging (MRI)
goals of imaging thymoma, the imaging features of thymoma, as or nuclear medicine studies.
well as the advantages and limitations of each imaging modality in
establishing the diagnosis, staging, and prognosis of thymoma.
Key Words: Thymomas, Computed tomography (CT), Chest radi- CHEST RADIOGRAPHY
ography, Magnetic resonance imaging, Nuclear medicine. Between 45 and 80% of thymomas are visible by chest
radiography.8 Thymomas usually appear as an ovoid or lob-
(J Thorac Oncol. 2010;5: S296–S303) ulated, smooth, well-marginated mass, projecting over the
mediastinum typically protruding unilaterally (Figure 1), al-
though rarely may be seen to protrude bilaterally over the
T hymomas are the most common primary neoplasm of the
anterior mediastinum but account for less than 1% of all
adult malignancies.1 The majority arise in the upper anterior
mediastinum.8,9 The mass can be seen from the thoracic inlet
to the cardiophrenic angle. At times, the chest radiograph
may appear entirely normal and at other times changes may
mediastinum in proximity to the pulmonary artery and/or be more subtle. The presence of a normal structure in the
ascending aorta, corresponding to the position of the normal anterior mediastinum, the anterior junction line, negates the
thymus. Rarely, however, they can be found in unusual presence of an anterior mediastinal mass in the retrosternal
locations such as the posterior mediastinum or lower neck.2,3 region. Unfortunately, the anterior junction line is seen in the
Thymomas are usually slow-growing tumors manifesting minority of normal individuals. This is a 1 to 3 mm line
with local extension, which tend to spread along the serosal created by four layers of pleura as the lungs approximate
surfaces, i.e., along the pleura and pericardium, whereas anteriomedially, anterior to the heart and great vessels (Fig-
extrathoracic metastases are uncommon.4,5 In the majority of ure 2). Thickening of this line is a sign of a space-occupying
patients with thymoma, imaging is requested for investigation lesion in the anterior mediastinum (Figure 3). The lateral film
of symptoms related to their tumors: either due to local is of help for confirmation as often a mass will be seen in the
compression or invasion of thoracic structures or due to retrosternal region, and when small, may be more easily
systemic paraneoplastic disease. There is, however, an in- detected on the lateral film without the superimposition of the
creasing number of asymptomatic patients incidentally dis- heart and mediastinum.
covered to have thymoma due to the increased utilization of Chest radiographic signs for tumor invasiveness are
computed tomography (CT) for screening and the investiga- limited but should be searched for. These include an irregular
tion of other symptoms of unrelated diseases. The goal of border with the adjacent lung, suggestive of invasion into the
imaging is to identify the tumor and stage it appropriately, lung; elevation of the hemidiaphragm, suggestive of phrenic
with emphasis on local invasion and distant spread because nerve involvement; and pleural nodularity.9
invasion has been known as the most significant factor for The advantage of the chest radiograph is in its low-
radiation dose, low price, and its availability. It lacks sensi-
tivity for smaller tumors and lacks specificity for differenti-
Department of Diagnostic Radiology, The University of Texas M. D. ating a thymoma from other anterior mediastinal masses,
Anderson Cancer Center, Houston, Texas.
Disclosure: The author declares no conflicts of interest. such as metastatic disease, lymphoma, or for example, germ
Address for correspondence: Dr. Edith M. Marom, Department of Diagnostic cell tumor. Thus, once an anterior mediastinal mass is iden-
Imaging, The University of Texas M. D. Anderson Cancer Center, 1400 tified by chest radiography, patients should be further char-
Pressler - Unit 1478, Houston, TX 77030. E-mail: emarom@mdander acterized and staged by cross-sectional imaging, usually CT.
son.org
Copyright © 2010 by the International Association for the Study of Lung Patients with a normal chest radiograph but strong clinical
Cancer suspicion for thymoma are also referred for CT due to its
ISSN: 1556-0864/10/0510-0296 great sensitivity.

S296 Journal of Thoracic Oncology • Volume 5, Number 10, Supplement 4, October 2010
Journal of Thoracic Oncology • Volume 5, Number 10, Supplement 4, October 2010 Imaging Thymoma

FIGURE 1. Fifty-seven-year-old previously

healthy man imaged with a chest radiograph after
a motor vehicle accident. Posterior-anterior (A)
chest radiograph demonstrates a mass (curved
arrow) abutting and inseparable from the heart
confirmed to be in the anterior mediastinum
(black arrows) on the lateral chest radiograph (B).
Contrast-enhanced chest computed tomography
(CT) (C) revealed a 12 cm mass (T) compressing
the lateral wall of the right ventricle. Biopsy con-
firmed this to be a thymoma. H, heart.

FIGURE 2. Sixty-eight-year-old man imaged due

to symptoms of recurrent nausea and vomiting.
The frontal chest radiograph (A) shows a pencil
thin line (black arrowheads) from the level of the
right first costomanubrial junction proceeding ob-
liquely inferiorly to the left, which represents the
anterior junction line. Contrast-enhanced chest
computed tomography (CT) (B) shows this line
represents the point of contact of pleura as the
lungs come in contact anterior to the cardiovascu-
lar structures(white arrows).

COMPUTED TOMOGRAPHY the abutting vessels is crucial for preoperative staging

CT is more definite in the diagnosis of thymoma, with and therapeutic planning. Multiplannar reformatting of the
its increased sensitivity in identifying mediastinal masses, axial CT images is easily performed with the current use
when compared with chest radiography. Thymomas have a of multidetector CT scanners and may aid in surgical
typical CT appearance that when seen is highly suggestive of planning.
the diagnosis. In addition to the appearance of the primary Typically, thymomas are closely related to the superior
tumor, their pattern of spread differs from other tumors that pericardium that is anterior to the aorta, pulmonary artery, or
may be found in the anterior mediastinum. Thymoma rarely superior vena cava, although they have been described anywhere
presents with metastatic lymphadenopathy or with metastatic from the lower neck to the cardiophrenic border (Figure 3). The
pulmonary nodules where as other tumors, which com- tumor is usually well defined, round or lobulated, homogenous,
monly present with an anterior mediastinal mass, such as and enhances after contrast injection.8 Nevertheless, at times, it
lung cancer, do. Although intravenous contrast is not can be heterogeneous, or even cystic, because of areas of
needed for identification of the thymic mass, its role is hemorrhage and necrosis. The tumor can be partially or com-
important with locally invasive tumors when evaluation of pletely outlined by fat and may contain punctuate, course, or

Copyright © 2010 by the International Association for the Study of Lung Cancer S297
Marom Journal of Thoracic Oncology • Volume 5, Number 10, Supplement 4, October 2010

FIGURE 3. Sixty-one-year-old woman imaged for

staging of a newly discovered early breast cancer.
Posterior-anterior chest radiograph (A) shows
thickening of the anterior junction line (black ar-
rowheads) confirmed on the lateral chest radio-
graph (B) to represent an anterior mediastinal
mass (curved white arrow) anterior to but sepa-
rate from the ascending aorta (black arrowhead).
Contrast-enhanced chest computed tomography
(CT) (C) confirmed the presence of a well-demar-
cated lobulated anterior mediastinal mass
(straight white arrow) confirmed at surgery to
represent an invasive thymoma (stage II).

curvilinear calcifications8,9 (Figure 4). At presentation,

thymomas are usually 5 to 10 cm large although have been
described from a few millimeters to 34 cm.8
One of the important though challenging roles of CT is
to determine local tumor invasiveness. This is crucial as
tumor invasiveness has been shown to strongly correlate with
prognosis10,11 and dictates the therapeutic approach. The most
common staging system used today, which guides the CT
interpretation, is the Masaoka staging system.12 Briefly, stage
I is when the tumor is macroscopically and microscopically
completely encapsulated. Stage IIa is when there is macro-
scopic invasion into surrounding fatty tissue or mediastinal
pleura, whereas stage IIb is when there is microscopic inva-
sion into the capsule. Stage III is when there is macroscopic
invasion into a neighboring organ such as pericardium, great
vessels, or lung. Stage IVa is when there is pleural or
pericardial dissemination and stage IVb when there is lym-
phogenous or hematogenous metastatic disease. Stage IV is
readily identified by CT (Figure 4), and at times, local
invasion into neighboring organs can readily be seen such as
direct invasion into the superior vena cava, brachiocephalic
FIGURE 4. Contrast-enhanced chest computed tomogra- veins, heart, or encasement of coronary arteries (Figure 5). It
phy (CT) of a 57-year-old woman obtained after an anterior has been clinically known that CT cannot differentiate local
mediastinal mass was discovered on a routine chest radio- disease accurately, and indeed, involvement of the pericar-
graph. The CT shows an anterior mediastinal mass with cen-
dium (stage III) versus abutment of it and identification of
tral calcifications and some heterogeneity with some low-
attenuation regions (curved arrow), whereas other shows capsular or pericapsular involvement (stage II) cannot be
enhancement (medial to the calcifications). Note the pleural visualized directly. Unfortunately, there have been very few
drop metastasis (straight arrow). At surgery, patient was studies looking at CT predictors of invasiveness, and those
found to have invasive thymoma with pleural drop metastases. that have been performed are small.

S298 Copyright © 2010 by the International Association for the Study of Lung Cancer
Journal of Thoracic Oncology • Volume 5, Number 10, Supplement 4, October 2010 Imaging Thymoma

Perhaps, the most important role of the initial CT is not

necessarily to distinguish stage I (purely encapsulated tumor)
from higher stages but to distinguish between those tumors
that should be treated with neoadjuvant therapy and those that
should proceed directly to surgery. Currently, it is recom-
mended that patients with stages III and IV should receive
neoadjuvant therapy.18 –23 In an internal review of 57 surgi-
cally treated patients in M. D. Anderson Cancer Center, we
found that CT was able to distinguish early disease (stages I
and II) from more advanced disease (stages III and IV), data
that should be published shortly. Similar to the published
surgical series, we found that size was useful but only for the
extreme tumors. Tumors smaller than 5 cm were unlikely to
be invasive. Tumors larger than 11 cm were much more
likely to be advanced disease (stages III or IV). Nevertheless,
there was substantial overlap for those presenting with tumors
from 5 to 11 cm, and within this range, size could not reliably
FIGURE 5. Sixty-eight-year-old man evaluated due to weight distinguish between early and advanced disease.
loss of 12 pounds during a period of a year, persistent hoarse- There are few studies focusing on the CT appearance of
ness, and chronic cough. Contrast-enhanced chest computed thymomas, when compared with the World Health Organi-
tomography (CT) showed an infiltrative anterior mediastinal zation (WHO) classification. Unfortunately, in these studies,
mass biopsy proven to represent thymoma, contiguous with
thymic cancers were included in the evaluation.24 –27 When
the pericardium insinuating itself along the pericardial recesses
(black stars) surrounding the left main coronary artery (black excluding the thymic cancers, CT could not distinguish be-
arrow). Note the compression of the superior vena cava (ar- tween the different histologic subtypes of the WHO classifi-
rowhead). a, ascending aorta. cation for thymoma.24 –27 This may be due to the inherent
problems within the WHO classification of thymoma, rather
than due to the imaging itself.11 Such problems include (a) the
There has been one study published so far, comparing poor interobserver and intraobserver reproducibility of the
the CT appearance of 50 thymoma tumors to their Masaoka pathology classifications; (b) the morphologic heterogeneity
staging.13 In this study, the authors attempted to separate and variations in morphology from field to field in thymoma;
stage I disease from any capsular invasion. They found that and (c) the inability of the WHO classification system to
larger tumors were more likely to be invasive, although no predict clinical outcome.7,28,29
cutoff value was established. In their study, invasive tumors CT is currently the cross-section modality of choice for
were more likely to be heterogeneous with low-attenuation evaluating patients with a suspected anterior mediastinal
areas within the tumor, which was seen in 60% of invasive mass, and this is despite the relatively large radiation dose,
tumors (16/27), when compared with 22% (5/23) of stage I when compared with chest radiographs. CT is readily avail-
tumors. Similarly, calcifications were more common in inva- able and is quite accurate in distinguishing a mediastinal mass
sive tumors, seen in 54% versus only 6% of stage I tumors. caused by thymoma compared with other mediastinal tumors,
Lobulated contours were more common in invasive tumors which usually differ in the appearance of the primary and the
(59%), when compared with stage I tumors (35%). Partial or pattern of metastatic spread, both of which are readily de-
complete obliteration of fat planes around the tumor was not tected by chest CT.
helpful in distinguishing invasive (stages II–IV) from nonin-
vasive (stage I) thymomas. Most of the CT features showed
overlap, and a reliable distinction between stage I or higher MAGNETIC RESONANCE IMAGING
remains difficult. The routine role of MRI in the identification and stag-
There have been surgical series, trying to establish a ing of thymoma is limited but is valuable in select circum-
relationship between the size of thymoma and survival. Be- stances. MRI features of thymoma are not specific. Thymoma
cause size is readily available by CT, they should be men- has signal characteristics similar to or higher than muscle on
tioned. Smaller series looking at up to 70 patients with T1-weighted images, and on T2-weighted images, the signal
thymoma found no correlation between tumor size and sur- is higher than muscle and may approach that of fat, making it
vival.14,15 On the other hand, larger surgical series looking at difficult to differentiate the thymoma from the surrounding
118 to 179 patients found that larger tumors were associated fat.8,30 Fat-suppression techniques may be useful in this
with worse outcome.6,16,17 There was no total agreement scenario (Figure 6). Heterogeneity of the tumor on MRI,
between these studies on the cutoff value that would best similar to what was seen in CT studies, is indeed associated
distinguish between the less favorable tumors as one sug- with more of an invasive status, but there is a great overlap,
gested 8 cm, another 10 cm, and the other 11 cm as the ideal and noninvasive tumors may also show this heterogeneity,
cutoff value. These cutoff values may be problematic, know- making this feature unreliable to distinguish invasive status
ing that at CT most thymomas at presentation are 5 to 10 cm, using this feature alone.26,31 In fact, such MRI features are
and thus fall within the uncertainty zone as to their prognosis. more useful for distinguishing thymic cancer rather than

Copyright © 2010 by the International Association for the Study of Lung Cancer S299
Marom Journal of Thoracic Oncology • Volume 5, Number 10, Supplement 4, October 2010

Under certain circumstances, MRI may prove valuable.

Patients, who cannot receive iodinated contrast material used
at CT, can have their vessels evaluated for possible invasion
by MRI. This can be performed with or without the use of
MRI contrast material (Figure 7). Because of MRIs superior
contrast resolution, when compared with CT, in select cases,
MRI can prove useful in identifying the nodular wall thick-
ening seen in cystic thymomas, absent from congenital
cysts.9,33 Rarely, thymic hyperplasia may be difficult to dis-
tinguish from diffuse thymoma. In cases where history is
most suspicious for thymoma and not for hyperplasia, chem-
ical shift MRI helps differentiate thymic hyperplasia from
thymic malignancy in patients 16 years of age or older.34,35
This technique relies on the difference in resonance fre-
quency between protons in water and those of protons in
trigyceride molecules. This technique is much more sensitive
in detecting microscopic fat within tissue as compared with
the detection of microscopic fat by fat-suppressed MR tech-
FIGURE 6. Sixty-two-year-old previously healthy man com-
niques or with CT detection of fat. Finally, in patients in
plained of new cough and was found to have an anterior
mediastinal mass by chest radiography. Fat-suppressed T2- whom detailed imaging of the lung is not of interest, and
weighted magnetic resonance imaging (MRI) axial image of radiation is to be avoided, MRI could prove a good substitute
the chest at the level of the left pulmonary artery (*) shows to imaging instead of CT.
a heterogeneous high-intensity mass (M) involving the ante- The advantage of MRI in investigating the anterior
rior mediastinum displacing the mediastinum posteriorly. At mediastinum is the lack of radiation, the fact that vessel
surgery, tumor was found to be invasive into perithymic fat, involvement can be investigated without the use of intrave-
stage IIa. a, aorta. nous contrast and its superior contrast resolution. The disad-
vantage is that the examination is relatively lengthy and
provides poor investigation of the lung parenchyma. Thus, if
invasive status of thymoma.26 Dynamic MRI looking at time the etiology of the anterior mediastinal mass is not known,
to peak contrast enhancement, although used in other tumors, complete investigation of it by MRI, including the lungs is
cannot distinguish between thymoma and other major ante- not optimal.
rior mediastinal masses such as thymic carcinoma, lym-
phoma, or germ cell tumor32 and, thus, is not used clinically.
Although MRI has the capabilities of multiplanar imaging, NUCLEAR MEDICINE
this is easily obtained with multidetector chest CT with its Although nuclear medicine techniques have been used
improved spatial resolution. in the past for the evaluation of various thymic lesions, the

FIGURE 7. Fifty-three-year-old woman was found

to have mediastinal widening by chest radiography
after complaining of new facial swelling. A noncon-
trast enhanced magnetic resonance imaging (MRI)
was obtained for further characterization of the
mass and for evaluation of the superior vena cava.
Axial double inversion recovery sequence (A), a
black blood technique, at the level of the left pul-
monary artery (*), reveals an anterior mediastinal
mass (M) displacing the mediastinum posteriorly
(A ⫽ aorta), extending into the superior vena cava
(arrowhead). Axial Fiesta sequence (B) at the same
level of A shows the tumor within the superior vena
cava (arrowhead) using white blood technique.
Coronal imaging of the tumor within the superior
vena cava extending toward the right atrium (RA) is
demonstrated in both double inversion recovery,
black blood technique (C) and Fiesta sequence
(white blood technique) (D). Ao, ascending aorta;
LV, left ventricle.

S300 Copyright © 2010 by the International Association for the Study of Lung Cancer
Journal of Thoracic Oncology • Volume 5, Number 10, Supplement 4, October 2010 Imaging Thymoma

FIGURE 8. Sixty-seven-year-old woman with

stage IVa thymoma. Contrast-enhanced chest
computed tomography (CT) (A) shows an anterior
mediastinal mass (straight white arrow) with a
central calcification and pleural metastases
(curved arrows). Indium 111 octreotide coronal
whole body scan (B) demonstrates faint uptake in
the primary anterior mediastinal mass only
(straight black arrow). Normal uptake is seen in
the kidneys (K), liver (L), and spleen (curved black
arrow). Axial [18F]fluorodeoxyglucose positron
emission tomography (FDG-PET) scan (C) at the
level of CT image (B) demonstrates 18F-fluorode-
oxyglucose uptake in both the primary anterior
mediastinal tumor (black straight arrow) and the
pleural metastases (curved black arrow).

diagnostic criteria overlap considerably.36 –38 Evaluation of value (SUV), overlaps between the low-grade and high-grade
the thymus with thallium 201 (201Tl) is equal or superior to thymomas.40 – 43 Neither the FDG SUV nor another tracer
that with CT. Using the early (15 minutes) and delayed used with PET, carbon 11-labeled acetate can differentiate
phases (180 minutes) after injection is helpful in differenti- between early thymoma, Masaoka stage I/II tumors, and stage
ating between the normal thymus, hyperplastic thymus, and III/IV tumors. Thus, it cannot aid in trying to establish who
thymoma, in patients with myasthenia gravis.36 However, the may benefit from neoadjuvant therapy. In addition, the FDG
examination suffers from low resolution, low throughput, and activity of some thymomas can be similar to the mediastinal
overlap in criteria. blood activity and increased FDG uptake, similar to that seen
Indium 111 octreotide shows increased uptake with in thymomas that can be seen in patients with thymic hyper-
thymoma but does not differentiate hyperplasia from normal plasia. The latter is more common in the pediatric population,
thymus. Once again, its low spatial resolution limits its use found in 73% of untreated patients up to the age of 13 years
(Figure 8), but it has one advantage over morphologic imag- and in 8% of patients in their fourth decade.44 Patterns of
ing. It is sometimes used to determine thymic tumor uptake to FDG activity and not just the SUV itself, in conjunction with
identify patients who may respond to treatment with oct- the CT appearance of the mediastinal abnormality, are helpful
reotide, an octapeptide somatostatin analog that has a high in establishing the nature of disease. As with other malignan-
cies, FDG-PET was shown in a small thymoma study to be
affinity for a selective somatostatin subtype (SST2) receptor.
particularly useful in the detection of distant malignant
In normal human thymus, the thymic epithelial cells seem to
spread41 (Figure 8). Whether this will prove to be cost
be the major site of the SST production. Neuroendocrine
beneficial has not yet been shown.
tumors show high affinity for octreotide and can be treated
with it. Octreotide alone or in combination with prednisone is
sometimes used as salvage therapy for patients with relapse FOLLOW-UP
of advanced thymoma.39 There are no published recommendations as to the
During the last decade, positron emission tomography frequency and timing of follow-up after treatment of thy-
(PET), in particular with [18F]fluorodeoxyglucose (FDG) has moma nor is there consensus as to the imaging modality to be
proven useful for staging and imaging many tumors. Studies used in this follow-up. Because late recurrence in thymoma is
assessing the evaluation of thymoma with FDG-PET are not uncommon, seen even more than 5 or 10 years after
small, but the data are not promising. Although FDG uptake resection, follow-up may be lengthy. Because complete re-
was found to be much higher in thymic cancer than thymoma, section of recurrence obtains similar outcome compared with
the amount of uptake, or as it is termed standardized uptake those patients without recurrence, this follow-up may be

Copyright © 2010 by the International Association for the Study of Lung Cancer S301
Marom Journal of Thoracic Oncology • Volume 5, Number 10, Supplement 4, October 2010

justified.45– 47 Currently, CT is most commonly used for this 17. Wright CD, Wain JC, Wong DR, et al. Predictors of recurrence in
follow-up. With the increased public concern of radiation in thymic tumors: importance of invasion, World Health Organization
histology, and size. J Thorac Cardiovasc Surg 2005;130:1413–1421.
young patients, it is unknown whether MRI will take a greater 18. Myojin M, Choi NC, Wright CD, et al. Stage III thymoma: pattern of
role in this follow-up, despite its lower spatial resolution and failure after surgery and postoperative radiotherapy and its implication
lengthy examination, when compared with CT. It also re- for future study. Int J Radiat Oncol Biol Phys 2000;46:927–933.
mains to be seen whether FDG-PET will be used in this 19. Girard N, Mornex F, Van Houtte P, et al. Thymoma: a focus on current
follow-up or it will be reserved for selected cases such as therapeutic management. J Thorac Oncol 2009;4:119 –126.
20. Falkson CB, Bezjak A, Darling G, et al. The management of thymoma: a
differentiating between nodular radiation changes and recur- systematic review and practice guideline. J Thorac Oncol 2009;4:911–919.
rence within the radiation field. If FDG uptake values will be 21. Rea F, Sartori F, Loy M, et al. Chemotherapy and operation for invasive
used to monitor disease progression/response, the FDG PET thymoma. J Thorac Cardiovasc Surg 1993;106:543–549.
scan must be performed in a meticulous matter, in the same 22. Venuta F, Rendina EA, Longo F, et al. Long-term outcome after
institution adhering to a strict imaging protocol, as SUV multimodality treatment for stage III thymic tumors. Ann Thorac Surg
2003;76:1866 –1872; discussion 1872.
measurements can be affected by many technical factors. 23. Venuta F, Rendina EA, Pescarmona EO, et al. Multimodality treatment
of thymoma: a prospective study. Ann Thorac Surg 1997;64:1585–1591;
discussion 1591–1592.
CONCLUSION 24. Yakushiji S, Tateishi U, Nagai S, et al. Computed tomographic findings
Imaging plays a crucial role in the diagnosis, staging, and prognosis in thymic epithelial tumor patients. J Comput Assist
and follow-up of patients with thymoma. The advantages and Tomogr 2008;32:799 – 805.
25. Jeong YJ, Lee KS, Kim J, et al. Does CT of thymic epithelial tumors
disadvantages of each imaging modality were discussed. enable us to differentiate histologic subtypes and predict prognosis? AJR
Currently, CT is the cross-sectional modality of choice for Am J Roentgenol 2004;183:283–289.
imaging thymoma. Whether MRI and/or PET-CT will play an 26. Sadohara J, Fujimoto K, Muller NL, et al. Thymic epithelial tumors:
increasing role in this disease remains to be seen. Hopefully, comparison of CT and MR imaging findings of low-risk thymomas, high-
collaborative international studies48 will improve our under- risk thymomas, and thymic carcinomas. Eur J Radiol 2006;60:70 –79.
27. Tomiyama N, Johkoh T, Mihara N, et al. Using the World Health
standing of this disease and enable us to predict local staging Organization Classification of thymic epithelial neoplasms to describe
by imaging to individualize patient care before surgery. CT findings. AJR Am J Roentgenol 2002;179:881– 886.
28. Chalabreysse L, Roy P, Cordier JF, et al. Correlation of the WHO schema
for the classification of thymic epithelial neoplasms with prognosis: a
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