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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#41; and B&#41; Axial &#40;A&#41; and coronal &#40;B&#41; chest CT images showing two masses in the anterior mediastinum&#58; a right mass &#40;white asterisk&#41; and a left mass &#40;black asterisk&#41;&#46; Note the presence of calcification foci in the left mass &#40;arrows&#41;&#46; C&#41; Axial CT image of the chest clearly showing the different attenuation characteristics of the mediastinal masses&#58; the right mass &#40;white asterisk&#41; has a mean attenuation of 83 Hounsfield units while the left mass &#40;black asterisk&#41; has a mean attenuation of 54 Hounsfield units&#44; suggesting an independent origin&#46; D&#41; and E&#41; Axial &#40;D&#41; and coronal &#40;E&#41; PET&#47;CT images showing the different metabolic activity of the two mediastinal masses &#40;greater FDG uptake by the left mass &#91;6&#46;1&#44; black asterisk&#93; than by the right mass &#91;3&#46;6&#44; white asterisk&#93;&#41;&#44; suggesting two independent tumors&#46; F&#41; Percutaneous biopsy sample of the left mediastinal mass showing neoplastic proliferation of epithelial cells surrounded by fibrous tissue and scant lymphocytes&#44; associated with type B3 thymoma &#40;hematoxylin and eosin&#41;&#46; G&#41; Percutaneous biopsy sample of the right mediastinal mass in which a mainly lymphocyte component is identified with some prominent epithelial cell nests&#44; associated with type B2 thymoma&#46; H&#41; Post-surgical macroscopic piece showing both contiguous masses &#40;white circle&#58; right mass&#59; black circle&#58; left mass&#41;&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT&#58; computed tomography&#59; FDG&#58; fluorodeoxyglucose&#59; PET&#47;CT&#58; positron emission tomography&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Thymomas are the most common primary anterior mediastinal tumors&#44; although a multifocal &#40;synchronous or metastatic&#41; presentation is exceptional&#58; less than 30 cases of synchronous thymomas have been reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> There is controversy surrounding the question of whether the presence of more than 1 mass in the anterior mediastinum represents independent multicentric &#40;synchronous&#41; tumors or satellite metastases from a single thymoma&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Several criteria have been put forward that may help differentiate multicentric thymomas from satellite metastases originating in a primary thymic tumor&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> but they do not factor in information obtained from morphological and metabolic imaging techniques&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a patient with 2 mediastinal masses&#44; seen on imaging techniques as 2 synchronous thymomas&#44; and confirmed as such by preoperative percutaneous biopsy of each mass&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our patient was a 75-year-old man who consulted for a respiratory infection&#44; and was found to have an abnormal mediastinal contour on chest X-ray&#46; Chest computed tomography &#40;CT&#41; confirmed the existence of 2 solid masses in the anterior mediastinum with different radiological characteristics&#44; suggesting 2 synchronous thymomas &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figs&#46; 1</a>A&#44; B and C&#41;&#46; The patient had no symptoms to suggest myasthenia gravis&#46; A positron emission tomography &#40;PET&#41;&#47;CT scan showed that each mediastinal mass had different metabolic activity &#40;the right mass showed a standardized uptake value &#91;SUV&#93; of 3&#46;6 while the left one had a SUV of 6&#46;1&#41;&#44; supporting the idea that these were 2 independent lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figs&#46; 1</a>D and E&#41;&#46; We decided to carry out radiologically-guided parasternal core needle biopsy of the 2 mediastinal masses&#44; confirming that they were both thymomas &#40;right mass&#44; type B2&#44; and left mass&#44; type B3&#44; according to World Health Organization &#91;WHO&#93; classification&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>F and G&#41;&#46; The patient underwent successful video-assisted thoracoscopy&#44; confirming that the 2 masses were synchronous thymomas classified as TNM stage I &#40;pT1N0&#41; and Masaoka stage IIB &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>H&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Multiple thymomas are rare&#44; and there are conflicting opinions in the scientific literature as to whether they correspond to metastases from a single primary thymic tumor or a multicentric&#47;multifocal origin&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> In general&#44; multiple thymomas are considered synchronous &#40;independent&#41; if they meet the following criteria&#58; 1&#41; lesions are stage I &#40;an intact capsule theoretically prevents the spread of the tumor outside its margins&#41;&#59; 2&#41; there are less than 3 thymomas&#59; 3&#41; the size of the thymomas is relatively similar&#59; and 4&#41; the histology of each tumor is different&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Very few studies recommend radiological or metabolic criteria to differentiate primary &#40;independent&#41; thymic tumors from metastatic &#40;dependent&#41; lesions&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> although CT&#44; MRI or PET&#47;CT may all provide information that can help predict the degree of malignancy of thymic epithelial tumors in some cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> In our patient&#44; it is interesting to note the clearly different morphological characteristics on CT of the two mediastinal masses &#40;attenuation variations and presence of calcification foci in one of the masses&#41; and their different metabolic affinity for fluorodeoxyglucose &#40;FDG&#41; &#40;the right mass showed an SUV of 3&#46;6&#44; and the left mass 6&#46;1&#41;&#46; In view of these different radiological and metabolic characteristics&#44; we decided to perform a preoperative percutaneous biopsy of the two masses to characterize them histologically and rule out the possibility of 2 different types of malignancy &#40;e&#46;g&#46;&#44; thymoma and germ cell tumor or lymphoma&#41;&#46; We have not found any previously published cases of preoperative confirmation by percutaneous core needle biopsy of 2 synchronous thymomas &#40;in a previous paper&#44; 1 of the patient&#8217;s 2 tumors was biopsied<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#41;&#46; In our case&#44; the mass with the lowest attenuation on CT that contained calcification foci and had the highest metabolism in PET&#47;CT was classified as type B3 thymoma&#44; whereas the mass with the highest density on CT and the lowest metabolic activity on PET&#47;CT was classified as type B2 thymoma&#46; There was therefore a correlation between the WHO histological subtype and PET&#47;CT metabolic activity &#40;type B3 thymomas have a worse prognosis than type B2&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We believe that in a patient with multiple thymomas&#44; metabolic and radiological characterization of the lesions can help differentiate between multiple synchronous thymomas and satellite metastases of a single thymic tumor and optimize therapeutic management&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Gorospe-Saras&#250;a L&#44; Ajuria-Illarramendi O&#44; Vicente-Zapata I&#44; Mu&#241;oz-Molina GM&#44; Fra-Fern&#225;ndez S&#44; Caba&#241;ero-S&#225;nchez A&#44; et al&#46; Diagn&#243;stico de dos timomas sincr&#243;nicos mediante t&#233;cnicas de imagen &#40;TC y PET&#47;TC&#41; y confirmaci&#243;n mediante biopsia percut&#225;nea&#46; Arch Bronconeumol&#46; 2021&#59;57&#58;560&#8211;562&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#41; and B&#41; Axial &#40;A&#41; and coronal &#40;B&#41; chest CT images showing two masses in the anterior mediastinum&#58; a right mass &#40;white asterisk&#41; and a left mass &#40;black asterisk&#41;&#46; Note the presence of calcification foci in the left mass &#40;arrows&#41;&#46; C&#41; Axial CT image of the chest clearly showing the different attenuation characteristics of the mediastinal masses&#58; the right mass &#40;white asterisk&#41; has a mean attenuation of 83 Hounsfield units while the left mass &#40;black asterisk&#41; has a mean attenuation of 54 Hounsfield units&#44; suggesting an independent origin&#46; D&#41; and E&#41; Axial &#40;D&#41; and coronal &#40;E&#41; PET&#47;CT images showing the different metabolic activity of the two mediastinal masses &#40;greater FDG uptake by the left mass &#91;6&#46;1&#44; black asterisk&#93; than by the right mass &#91;3&#46;6&#44; white asterisk&#93;&#41;&#44; suggesting two independent tumors&#46; F&#41; Percutaneous biopsy sample of the left mediastinal mass showing neoplastic proliferation of epithelial cells surrounded by fibrous tissue and scant lymphocytes&#44; associated with type B3 thymoma &#40;hematoxylin and eosin&#41;&#46; G&#41; Percutaneous biopsy sample of the right mediastinal mass in which a mainly lymphocyte component is identified with some prominent epithelial cell nests&#44; associated with type B2 thymoma&#46; H&#41; Post-surgical macroscopic piece showing both contiguous masses &#40;white circle&#58; right mass&#59; black circle&#58; left mass&#41;&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT&#58; computed tomography&#59; FDG&#58; fluorodeoxyglucose&#59; PET&#47;CT&#58; positron emission tomography&#46;</p>"
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Scientific letter
Diagnosis of two synchronous thymomas with imaging techniques (CT and PET/CT) and confirmation with percutaneous biopsy
Diagnóstico de dos timomas sincrónicos mediante técnicas de imagen (TC y PET/TC) y confirmación mediante biopsia percutánea
Luis Gorospe-Sarasúaa,
Corresponding author
luisgorospe@yahoo.com

Corresponding author.
, Odile Ajuria-Illarramendib, Irene Vicente-Zapataa, Gemma María Muñoz-Molinac, Sara Fra-Fernándezc, Alberto Cabañero-Sánchezc, Mónica García-Cosío-Piquerasd, Diego Bueno-Sacristánd, Paola Arrietae, Rosa Mariela Mirambeaux-Villalonae
a Servicio de Radiodiagnóstico, Hospital Universitario Ramón y Cajal, Madrid, Spain
b Servicio de Medicina Nuclear, Hospital Universitario Ramón y Cajal, Madrid, Spain
c Servicio de Cirugía Torácica, Hospital Universitario Ramón y Cajal, Madrid, Spain
d Servicio de Anatomía Patológica, Hospital Universitario Ramón y Cajal, Madrid, Spain
e Servicio de Neumología, Hospital Universitario Ramón y Cajal, Madrid, Spain
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#41; and B&#41; Axial &#40;A&#41; and coronal &#40;B&#41; chest CT images showing two masses in the anterior mediastinum&#58; a right mass &#40;white asterisk&#41; and a left mass &#40;black asterisk&#41;&#46; Note the presence of calcification foci in the left mass &#40;arrows&#41;&#46; C&#41; Axial CT image of the chest clearly showing the different attenuation characteristics of the mediastinal masses&#58; the right mass &#40;white asterisk&#41; has a mean attenuation of 83 Hounsfield units while the left mass &#40;black asterisk&#41; has a mean attenuation of 54 Hounsfield units&#44; suggesting an independent origin&#46; D&#41; and E&#41; Axial &#40;D&#41; and coronal &#40;E&#41; PET&#47;CT images showing the different metabolic activity of the two mediastinal masses &#40;greater FDG uptake by the left mass &#91;6&#46;1&#44; black asterisk&#93; than by the right mass &#91;3&#46;6&#44; white asterisk&#93;&#41;&#44; suggesting two independent tumors&#46; F&#41; Percutaneous biopsy sample of the left mediastinal mass showing neoplastic proliferation of epithelial cells surrounded by fibrous tissue and scant lymphocytes&#44; associated with type B3 thymoma &#40;hematoxylin and eosin&#41;&#46; G&#41; Percutaneous biopsy sample of the right mediastinal mass in which a mainly lymphocyte component is identified with some prominent epithelial cell nests&#44; associated with type B2 thymoma&#46; H&#41; Post-surgical macroscopic piece showing both contiguous masses &#40;white circle&#58; right mass&#59; black circle&#58; left mass&#41;&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT&#58; computed tomography&#59; FDG&#58; fluorodeoxyglucose&#59; PET&#47;CT&#58; positron emission tomography&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Thymomas are the most common primary anterior mediastinal tumors&#44; although a multifocal &#40;synchronous or metastatic&#41; presentation is exceptional&#58; less than 30 cases of synchronous thymomas have been reported in the literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> There is controversy surrounding the question of whether the presence of more than 1 mass in the anterior mediastinum represents independent multicentric &#40;synchronous&#41; tumors or satellite metastases from a single thymoma&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Several criteria have been put forward that may help differentiate multicentric thymomas from satellite metastases originating in a primary thymic tumor&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> but they do not factor in information obtained from morphological and metabolic imaging techniques&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a patient with 2 mediastinal masses&#44; seen on imaging techniques as 2 synchronous thymomas&#44; and confirmed as such by preoperative percutaneous biopsy of each mass&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our patient was a 75-year-old man who consulted for a respiratory infection&#44; and was found to have an abnormal mediastinal contour on chest X-ray&#46; Chest computed tomography &#40;CT&#41; confirmed the existence of 2 solid masses in the anterior mediastinum with different radiological characteristics&#44; suggesting 2 synchronous thymomas &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figs&#46; 1</a>A&#44; B and C&#41;&#46; The patient had no symptoms to suggest myasthenia gravis&#46; A positron emission tomography &#40;PET&#41;&#47;CT scan showed that each mediastinal mass had different metabolic activity &#40;the right mass showed a standardized uptake value &#91;SUV&#93; of 3&#46;6 while the left one had a SUV of 6&#46;1&#41;&#44; supporting the idea that these were 2 independent lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figs&#46; 1</a>D and E&#41;&#46; We decided to carry out radiologically-guided parasternal core needle biopsy of the 2 mediastinal masses&#44; confirming that they were both thymomas &#40;right mass&#44; type B2&#44; and left mass&#44; type B3&#44; according to World Health Organization &#91;WHO&#93; classification&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>F and G&#41;&#46; The patient underwent successful video-assisted thoracoscopy&#44; confirming that the 2 masses were synchronous thymomas classified as TNM stage I &#40;pT1N0&#41; and Masaoka stage IIB &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>H&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Multiple thymomas are rare&#44; and there are conflicting opinions in the scientific literature as to whether they correspond to metastases from a single primary thymic tumor or a multicentric&#47;multifocal origin&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;3</span></a> In general&#44; multiple thymomas are considered synchronous &#40;independent&#41; if they meet the following criteria&#58; 1&#41; lesions are stage I &#40;an intact capsule theoretically prevents the spread of the tumor outside its margins&#41;&#59; 2&#41; there are less than 3 thymomas&#59; 3&#41; the size of the thymomas is relatively similar&#59; and 4&#41; the histology of each tumor is different&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Very few studies recommend radiological or metabolic criteria to differentiate primary &#40;independent&#41; thymic tumors from metastatic &#40;dependent&#41; lesions&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> although CT&#44; MRI or PET&#47;CT may all provide information that can help predict the degree of malignancy of thymic epithelial tumors in some cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;10</span></a> In our patient&#44; it is interesting to note the clearly different morphological characteristics on CT of the two mediastinal masses &#40;attenuation variations and presence of calcification foci in one of the masses&#41; and their different metabolic affinity for fluorodeoxyglucose &#40;FDG&#41; &#40;the right mass showed an SUV of 3&#46;6&#44; and the left mass 6&#46;1&#41;&#46; In view of these different radiological and metabolic characteristics&#44; we decided to perform a preoperative percutaneous biopsy of the two masses to characterize them histologically and rule out the possibility of 2 different types of malignancy &#40;e&#46;g&#46;&#44; thymoma and germ cell tumor or lymphoma&#41;&#46; We have not found any previously published cases of preoperative confirmation by percutaneous core needle biopsy of 2 synchronous thymomas &#40;in a previous paper&#44; 1 of the patient&#8217;s 2 tumors was biopsied<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#41;&#46; In our case&#44; the mass with the lowest attenuation on CT that contained calcification foci and had the highest metabolism in PET&#47;CT was classified as type B3 thymoma&#44; whereas the mass with the highest density on CT and the lowest metabolic activity on PET&#47;CT was classified as type B2 thymoma&#46; There was therefore a correlation between the WHO histological subtype and PET&#47;CT metabolic activity &#40;type B3 thymomas have a worse prognosis than type B2&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">We believe that in a patient with multiple thymomas&#44; metabolic and radiological characterization of the lesions can help differentiate between multiple synchronous thymomas and satellite metastases of a single thymic tumor and optimize therapeutic management&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interests</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Gorospe-Saras&#250;a L&#44; Ajuria-Illarramendi O&#44; Vicente-Zapata I&#44; Mu&#241;oz-Molina GM&#44; Fra-Fern&#225;ndez S&#44; Caba&#241;ero-S&#225;nchez A&#44; et al&#46; Diagn&#243;stico de dos timomas sincr&#243;nicos mediante t&#233;cnicas de imagen &#40;TC y PET&#47;TC&#41; y confirmaci&#243;n mediante biopsia percut&#225;nea&#46; Arch Bronconeumol&#46; 2021&#59;57&#58;560&#8211;562&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A&#41; and B&#41; Axial &#40;A&#41; and coronal &#40;B&#41; chest CT images showing two masses in the anterior mediastinum&#58; a right mass &#40;white asterisk&#41; and a left mass &#40;black asterisk&#41;&#46; Note the presence of calcification foci in the left mass &#40;arrows&#41;&#46; C&#41; Axial CT image of the chest clearly showing the different attenuation characteristics of the mediastinal masses&#58; the right mass &#40;white asterisk&#41; has a mean attenuation of 83 Hounsfield units while the left mass &#40;black asterisk&#41; has a mean attenuation of 54 Hounsfield units&#44; suggesting an independent origin&#46; D&#41; and E&#41; Axial &#40;D&#41; and coronal &#40;E&#41; PET&#47;CT images showing the different metabolic activity of the two mediastinal masses &#40;greater FDG uptake by the left mass &#91;6&#46;1&#44; black asterisk&#93; than by the right mass &#91;3&#46;6&#44; white asterisk&#93;&#41;&#44; suggesting two independent tumors&#46; F&#41; Percutaneous biopsy sample of the left mediastinal mass showing neoplastic proliferation of epithelial cells surrounded by fibrous tissue and scant lymphocytes&#44; associated with type B3 thymoma &#40;hematoxylin and eosin&#41;&#46; G&#41; Percutaneous biopsy sample of the right mediastinal mass in which a mainly lymphocyte component is identified with some prominent epithelial cell nests&#44; associated with type B2 thymoma&#46; H&#41; Post-surgical macroscopic piece showing both contiguous masses &#40;white circle&#58; right mass&#59; black circle&#58; left mass&#41;&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CT&#58; computed tomography&#59; FDG&#58; fluorodeoxyglucose&#59; PET&#47;CT&#58; positron emission tomography&#46;</p>"
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Article information
ISSN: 15792129
Original language: English
DOI:10.1016/j.arbr.2021.05.020
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