Surveys

Dear Colleague,

We would like to invite you to share your experience in your daily practice to identify areas of agreement and potential controversy in the current global clinical and pathology practice of the diagnosis and treatment of thymic epithelial tumors.

We appreciate you are taking the time to fill in the survey!

NOTE: It is important that you tick your subspecialty as that will open the survey that is tailored to your subspecialty.

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Part 1 - GENERAL

1. Name of person who completes survey (voluntary)

2. Country of person who completes survey

3. Years of practice since completion of training

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4. Your main subspecialty (questions in the rest of the survey depend on your answer to this question)

4. Main subspecialty

4g. What is your main subspecialty?

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5. How many new cases of thymic epithelial tumors (TETs) do you see per year?

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6. Size of institution

a. <300 beds
b. 300-600 beds
c. >600 beds

7. Name of institution

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8. Prior to treatment of a newly diagnosed TET, in which of these scenarios do you have a multidisciplinary discussion

Mark all answers that apply

8. Prior to treatment of a newly diagnosed TET, in which of these scenarios do you have a multidisciplinary discussion

a. Clinical stage I
b. Clinical stage II
c. Clinical stage III
d. Clinical stage IV
e. We rarely or never have a multidisciplinary discussion prior to treatment of TET

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9. Which of the following medical specialties are present at your multidisciplinary conference prior to treatment of TET?

Mark all answers that apply

9. Which of the following medical specialties are present at your multidisciplinary conference prior to treatment of TET?

9g. What other medical specialists are present at your multidisciplinary conference?

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10. Which staging system do you use

a. AJCC/UICC TNM staging
b. Masaoka-Koga staging
c. Both
d. Neither of the above

10a. Which other staging system do you use?

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11. How did you find out about this survey?

Mark all answers that apply

11. How did you find out about this survey?

11i. If Other - How did you find out about this survey?

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THANK YOU FOR YOUR TIME AND CONTRIBUTION!

Part 2 - DETAILED

MEDICAL ONCOLOGY

Based on AJCC/UICC TNM Staging

Med_Onk_01. Do you communicate with your radiologist before starting treatment on locally invasive mediastinal lesion?

Med_Onk_01e. If "other", please elaborate

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Med_Onk_02. How do you most commonly manage THYMOMAS at TNM stage cM1a/IVA patients in case of single metastasis?

Med_Onk_02. How do you most commonly manage thymomas at TNM stage M1a/IVA patients in case of single metastasis?

Med_Onk_02g. If "other", please elaborate

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Med_Onk_03. How do you most commonly manage THYMOMAS at TNM stage cM1a/IVA patients in case of oligometastatic (2-4 metastases) disease?

Med_Onk_03. How do you most commonly manage thymomas at TNM stage M1a/IVa patients in case of oligometastatic (2-4 metastases) disease?

Med_Onk_03g. If "other", please elaborate

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Med_Onk_04. How do you most commonly manage THYMOMAS at TNM stage cM1a/IVA patients in case of multiple (≥ 5) unilateral metastases?

Med_Onk_04. How do you most commonly manage THYMOMAS at TNM stage M1a/IVA patients in case of multiple (≥ 5) unilateral metastases?

Med_Onk_04g. If "other", please elaborate

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Med_Onk_05. How do you most commonly manage THYMOMAS at TNM stage cM1a/IVA patients in case of multiple bilateral metastases?

Med_Onk_05. How do you most commonly manage THYMOMAS at TNM stage M1a/IVA patients in case of multiple bilateral metastases?

Med_Onk_05g. If "other", please elaborate

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Med_Onk_06. How do you most commonly manage THYMIC CARCINOMAS at TNM stage cM1a/IVA patients in case of single metastasis?

Med_Onk_06. How do you most commonly manage THYMIC CARCINOMAS at TNM stage M1a/IVA patients in case of single metastasis?

Med_Onk_06g. If "other", please elaborate

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Med_Onk_07. How do you most commonly manage THYMIC CARCINOMAS at TNM stage cM1a/IVA patients in case of oligometastatic (2-4 metastases) disease?

Med_Onk_07. How do you most commonly manage THYMIC CARCINOMAS at TNM stage M1a/IVA patients in case of oligometastatic (2-4 metastases) disease?

Med_Onk_07g If "other", please elaborate

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Med_Onk_08. How do you most commonly manage THYMIC CARCINOMAS at TNM stage cM1a/IVA patients in case of multiple (≥ 5) unilateral metastases?

Med_Onk_08. How do you most commonly manage THYMIC CARCINOMAS at TNM stage M1a/IVA patients in case of multiple (≥ 5) unilateral metastases?

Med_Onk_08g. If "other", please elaborate

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Med_Onk_09. How do you most commonly manage THYMIC CARCINOMAS at TNM stage cM1a/IVA patients in case of multiple bilateral metastases?

Med_Onk_09. How do you most commonly manage THYMIC CARCINOMAS at TNM stage M1a/IVA patients in case of multiple bilateral metastases?

Med_Onk_09g. If "other", please elaborate

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Med_Onk_10. What is your preoperative minimal clinical/neurological and laboratory test set in terms of:

a) myasthenia gravis and other autoimmune diseases

b) tumor markers, particularly germ cell tumors

Mark all answers that apply

Med_Onk_10. What is your preoperative minimal clinical/neurological and laboratory test set

a. Perform antibody testing for myasthenia gravis on all patients
b. Perform antibody testing for myasthenia gravis on symptomatic patients only
c. Perform antibody testing for various autoimmune diseases on all patients
d. Perform antibody testing for autoimmune disease on symptomatic patients only
e. Perform serologic test for germ cell tumors on all patients with prevascular mediastinal mass
f. Perform serologic test for germ cell tumors on selected patients
g. No serologic markers for germ cell tumors are performed
h. No antibody testing for myasthenia gravis or autoimmune diseases performed
i. Other

Med_Onk_10c. Which specific tests do you perform for various autoimmune diseases?

Med_Onk_10f. On which patients do you perform serologic GCT test?

Med_Onk_10e/f. What serologic GCT tests do you routinely perform? Mark all answers that apply

AFP
HCG
LDH
Other

Med_Onk_10e/f-1. What other serologic tests do you perform in GCT patients?

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Med_Onk_11. What is your preferred chemotherapy regimen in the neoadjuvant/adjuvant setting for patients with THYMOMA?

a. PAC (cisplatin, doxorubicin, and cyclophosphamide)
b. ADOC (cisplatin, doxorubicin, vincristine, cyclophosphamide)
c. Carboplatin/paclitaxel
d. Cisplatin/etoposide
e. Etoposide/ifosfamide/cisplatin
f. Other

Med_Onk_11f. If "other", please elaborate

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Med_Onk_12. What is your preferred chemotherapy regimen in the neoadjuvant/adjuvant setting for patients with THYMIC CARCINOMA?

a. PAC (cisplatin, doxorubicin, and cyclophosphamide)
b. ADOC (cisplatin, doxorubicin, vincristine, cyclophosphamide)
c. Carboplatin/paclitaxel
d. Cisplatin/etoposide
e. Etoposide/ifosfamide/cisplatin
f. Other

Med_Onk_12f. If "other", please elaborate

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Med_Onk_13. What is your preferred chemotherapy regimen for patients with patients with advanced, inoperable THYMOMA?

a. PAC (cisplatin, doxorubicin, and cyclophosphamide)
b. ADOC (cisplatin, doxorubicin, vincristine, cyclophosphamide)
c. Carboplatin/paclitaxel
d. Cisplatin/etoposide
e. Etoposide/ifosfamide/cisplatin
f. Other

Med_Onk_13f. If "other", please elaborate

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Med_Onk_14. What is your preferred chemotherapy regimen for patients with patients with advanced, inoperable THYMIC CARCINOMA?

a. PAC (cisplatin, doxorubicin, and cyclophosphamide)
b. ADOC (cisplatin, doxorubicin, vincristine, cyclophosphamide)
c. Carboplatin/paclitaxel
d. Cisplatin/etoposide
e. Etoposide/ifosfamide/cisplatin
f. Other

Med_Onk_14f. If "other", please elaborate

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Med_Onk_15. What is your preferred systemic therapy in the second line setting for patients with advanced, inoperable THYMOMA?

Med_Onk_15j. If "other", please elaborate

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Med_Onk_16. What is your preferred systemic therapy in the second line setting for patients with advanced, inoperable THYMIC CARCINOMA?

Med_Onk_16j. If "other", please elaborate

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Med_Onk_17. How would you describe your experience using immune checkpoint inhibitors in patients with THYMOMA?

a. I have never used it.
b. I have used it as part of my routine practice.
c. I have used it within a clinical trial.
d. I have used it in both routine practice and clinical trials.
e. Other

Med_Onk_17e. If "other", please elaborate

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Med_Onk_18. If you have not used immune checkpoint inhibitors for patients with THYMOMA, what would be the reasons?

a. Not reimbursed in my country.
b. Due to concern about side effects.
c. Both
d. Other

Med_Onk_18d. If "other", please elaborate

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Med_Onk_19. How would you describe your experience using immune checkpoint inhibitors in patients with THYMIC CARCINOMA?

a. I have never used it.
b. I have used it as part of my routine practice.
c. I have used it within a clinical trial.
d. I have used it in both routine practice and clinical trials.
e. Other

Med_Onk_19e. If "other", please elaborate

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Med_Onk_20. If you have not used immune checkpoint inhibitors for patients with THYMIC CARCINOMA, what would be the reasons?

a. Not reimbursed in my country.
b. Due to concern about side effects.
c. Both
d. Other

Med_Onk_20d. If "other", please elaborate

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Med_Onk_21. Do you consider using NGS testing for patients with thymic epithelial tumors?

a. No - I don’t think it provides any utility at this time.
b. No - I think it will be valuable, but is not reimbursed in my country.
c. Yes, I can offer it to all patients (thymoma and thymic carcinoma).
d. Yes, I can offer for all thymoma patients only
e. Yes, I can offer for all thymic carcinoma patients only
f. Other

Med_Onk_21f. If "other", please elaborate

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Med_Onk_22. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis

Mark all answers that apply

Med_Onk_22. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis

a. I usually DO NOT use it when SCREENING patients for thymoma
b. I usually DO use it when SCREENING patients for thymoma
c. I usually DO NOT use it when STAGING patients with thymoma
d. I usually DO use it for STAGING patients with thymoma
e. I use it only in special circumstance
f. Not applicable

Med_Onk_22e. If "e", please elaborate

Med_Onk_22f. If "not applicable":

a. I do not order chest imaging studies for patients with myasthenia gravis
b. I usually order a chest MRI and not a chest CT to screen for thymic lesions in patients with myasthenia gravis
c. I usually order a chest MRI and not a chest CT to stage patients with thymoma
d. I employ chest CT and MRI equally when screening for thymic lesions in patients with myasthenia gravis
e. I employ chest CT and MRI equally when staging patients with thymoma

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THANK YOU FOR YOUR TIME AND CONTRIBUTION!

NEUROLOGY

Based on AJCC/UICC TNM Staging

Neu_01. How often do you observe associated neuromuscular junction diseases in patients with thymoma/thymic carcinoma?

Selected Value: 0

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Neu_02. In your clinical experience, have you observed cases of other paraneoplastic neurological diseases associated with thymoma?

Please specify type and number

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Neu_03. How frequently do you use thymoma classification systems (TNM staging, Masaoka Koga staging, etc.) in clinical practice in patients with associated neurological autoimmune diseases?

a. Never
b. Rarely
c. Often
d. Always

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Neu_04. How often do you interact with other specialists (thoracic surgeons, radiologists, pathologists, oncologists, radiotherapists, etc.) in planning treatment of patients with thymoma and associated neurological autoimmune diseases?

Neu_04. How often do you interact with other specialists (thoracic surgeons, radiologists, pathologists, oncologists, radiotherapists, etc.) in planning treatment of patients with thymoma and associated neurological autoimmune diseases?

Neu_04e. If "other", please specify

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Neu_05. What is your suggested preoperative minimal test set in patients with thymoma?

Mark all answers that apply

Neu_05. What is your suggested preoperative minimal test set in patients with thymoma?

a. Perform antibody testing for myasthenia gravis on all patients
b. Perform antibody testing for myasthenia gravis on symptomatic patients only
c. Perform antibody testing for various autoimmune diseases on all patients
d. Perform antibody testing for autoimmune disease on symptomatic patients only
e. No antibody testing for myasthenia gravis or autoimmune diseases are performed
f. Perform neurophysiological testing (RNS-EMG and/or SF-EMG) on all patients
g. Perform neurophysiological testing (RNS-EMG and/or SF-EMG) on symptomatic patients only
h. Other

Neu_05c. If marked c - which specific tests do you perform?

Neu_05d. If marked d - which specific tests do you perform?

Neu_05h. If marked "Other" - please specify

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Neu_06. What is your approach to patients who are asymptomatic for neuromuscular plaque disorders but have positive autoantibodies and/or pathologic neurophysiological studies before thymoma resection?

Mark all answers that apply

Neu_06. What is your approach to patients who are asymptomatic for neuromuscular plaque disorders but have positive autoantibodies and/or pathologic neurophysiological studies before thymoma resection?

a. Referral of the patient to a neuromuscular center for in-depth research of myasthenic symptoms
b. Post-operative autoantibody titre assay on all patients
c. Post-operative autoantibody titre assay only in patients who become symptomatic
d. Follow-up of autoantibody titre assay over time on all patients.
e. Pre-operative immunomodulatory treatment (IVIg or PLEX) on all patients in order to prevent post-operative myasthenic crisis
f. Clinical and possibly neurophysiological follow-up
g. Other

Neu_06d. If marked d, at what time point?

Neu_06f. If marked f, how frequently?

Neu_06g. If marked "Other" - please specify

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Neu_08. In your clinical experience what factors are most associated with the development of post-operative myasthenic crisis in patients undergoing surgical resection of thymoma?

Mark all answers that apply

Neu_08. In your clinical experience what factors are most associated with the development of post-operative myasthenic crisis in patients undergoing surgical resection of thymoma?

Neu_08j. Please specify surgery-related factors

Neu_08k. Please specify thymoma subtype

Neu_08i. Please specify other factors

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Neu_09. What percentage of your myasthenic patients who underwent surgical resection of the thymoma required anytime post-operative immunomodulatory or immunosuppressive therapy?

Provide your best estimate of the percentage range

Neu_09. What percentage of your myasthenic patients who underwent surgical resection of the thymoma required anytime post-operative immunomodulatory or immunosuppressive therapy?

Selected Value: 0

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Neu_10. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis

Mark all answers that apply

Neu_11. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis

a. I usually DO NOT use it when SCREENING patients for thymoma
b. I usually DO use it when SCREENING patients for thymoma
c. I usually DO NOT use it when staging patients with thymoma
d. I usually DO use it for staging patients with thymoma
e. I use it only in special circumstance
f. Not applicable

Neu_11e. If e, please elaborate

Neu_11f. If "not applicable":

a. I do not order chest imaging studies for patients with myasthenia gravis
b. I usually order a chest MRI and not a chest CT to screen for thymic lesions in patients with myasthenia gravis
c. I usually order a chest MRI and not a chest CT to stage patients with thymoma
d. I employ chest CT and MRI equally when screening for thymic lesions in patients with myasthenia gravis
e. I employ chest CT and MRI equally when staging patients with thymoma

____________________________________________________________________________

THANK YOU FOR YOUR TIME AND CONTRIBUTION!

PATHOLOGY

Based on AJCC/UICC TNM Staging

Pat_01. If you have a multidisciplinary conference with the pathologist, which cases are reviewed?

a. All mediastinal tumors (benign and malignant)
b. Malignant mediastinal tumors only
c. We do not have a multidisciplinary conference with the pathologist for mediastinal tumors
d. Other

Pat_01d. Describe the situation in which you have a multidisciplinary conference with the pathologist

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Pat_02. In your institution, how often does the resection specimen come oriented and with additionally resected anatomical structures and surgical margins clearly marked to pathology?

Pat_02. How often does the resection specimen come oriented?

Pat_02e. Describe the situation in which the specimen comes oriented

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Pat_03. How do surgeons and pathologists communicate in regards to resection specimens?

Mark all answers that apply

Pat_03. How do surgeons and pathologists communicate in regards to resection specimens?

Pat_3f. Describe the way of communication with surgeon

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Pat_04. How often do you review the radiological report when taking samples from the resected tumor?

Mark all answers that apply

Pat_04. How often do you review the radiological report when taking samples from the resected tumor?

a. Always
b. When I have trouble with orienting the tumor and identifying anatomical structures
c. When I cannot find the lesion
d. When I cannot find the lymph nodes
e. I do not review
f. I do not have an access to the radiological report

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Pat_05. How often do you review the radiological report when analyzing mediastinal tumor biopsy?

Mark all answers that apply

Pat_05. How often do you review the radiological report when analyzing mediastinal tumor biopsy?

a. Always
b. In all/majority of carcinoma cases
c. In all/majority of neuroendocrine tumor/carcinoma cases
d. In all/majority of thymoma cases
e. In all/majority of lymphadenopathies
f. In all/majority of young patients
g. I do not review
h. I do not have an access to the radiological report

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Pat_06. In what material do you usually subtype thymomas?

Mark all answers that apply

Pat_06. In what material do you usually subtype thymomas?

a. In resected tumors
b. In surgical biopsy obtained during mediastinoscopy/mediastinotomy
c. In transthoracic core biopsy
d. In fine needle aspiration (smears and/or cell block)

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Pat_07. How do you define lung invasion?

a Invasion through the outer elastic lamina of the visceral pleura?
b. Invasion through the entire visceral pleura into the lung parenchyma?

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Pat_08. How do you define great vessels invasion?

a. Invasion into adventitia
b. Outer elastic lamina
c. Invasion into media
d. Invasion into intima
e. Invasion through the entire wall into the lumen of the vessel

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Pat_09. How do you define neural invasion?

a. Invasion of the tumor into the nerve
b. Perineural invasion
c. Both

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Pat_10. How do you report TET after neoadjuvant therapy?

a. Percentage of viable tumor cells as seen on slides
b. Percentage of viable tumor cells taking into account gross necrosis
c. I do not report the percentage of viable tumor
d. Other

Pat_10d. Please explain your way of reporting tumors after neoadjuvant therapy

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Pat_11. Lymph node sampling on resection specimens

Mark all answers that apply

Pat_11. Lymph node sampling on resection specimens

a. I sample lymph nodes routinely from thymectomy specimens
b. I sample lymph nodes from thymectomy specimens ONLY in carcinomas
c. I evaluate separately submitted lymph nodes
d. Each INDIVIDUAL LYMPH NODE is registered separately
e. Each LYMPH NODE STATION is processed separately
f. Other

Pat_11f. What is your way of lymph node sampling?

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Pat_12. How do you evaluate margins?

a. I ink the entire surface of a thymectomy specimen and consider it a margin
b. I consult the surgeon and only ink the margins that were pointed out
c. I try to orient the specimen myself and ink what I think is the margin
d. I do not ink the specimen

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Pat_13. In which situations do you usually use immunohistochemical tests?

Mark all answers that apply

Pat_13. In which situations do you usually use immunohistochemical tests?

a. In all/majority of biopsies
b. In all/majority of thymoma resections
c. In all/majority of thymic carcinoma resections
d. In all/majority of thymic neuroendocrine neoplasm resections
e. Other

Pat_13e. Describe the situations when you use IHC tests

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Pat_14. Do you use digital pathology in thymic pathology?

Mark all answers that apply

Pat_14. Do you use digital pathology in thymic pathology?

a. Yes, I use digital pathology for diagnosis
b. Yes, I use digital pathology to measure size of invasion into adipose tissue
c. Yes, I use digital pathology for consultation purposes/second review
d. No, I do not have the opportunity to use digital pathology

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Pat_15. Do you use artificial intelligence for the evaluation of thymic tumors?

Pat_15. Do you use artificial intelligence for the evaluation of thymic tumors

No
Yes

Pat_15a. Please comment on when and how you use AI for TET evaluation

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Pat_16. Do you report micrometastases in lymph nodes?

No
Yes

Pat_16a. How do you report lymph node micrometastases?

a. As negative lymph node
b. As positive lymph node
c. Other

Pat_16c. Describe your way of reporting lymph node micrometastases

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Pat_17. Do you report isolated tumor cells in lymph nodes?

No
Yes

Pat_17b. How do you report isolated tumor cells in lymph nodes?

a. As negative lymph node
b. As positive lymph node
c. Other

Pat_17c. Describe your way of isolated tumor cells reporting in lymph nodes

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THANK YOU FOR YOUR TIME AND CONTRIBUTION!

THORACIC SURGERY

Based on AJCC/UICC TNM Staging

Sur_01. How often do you communicate with your radiologist before starting treatment on locally invasive mediastinal lesion

Sur_01e. Describe the conditions in which you communicate with your radiologist:

____________________________________________________________________________

Sur_02. What do you primarily want to know from the radiologist?

a. Diagnostic consideration (thymic tumor, germ cell tumor, or lymphoma)
b. Which neighboring structure is just in close touch or is already invaded by the tumor?
c. Whether there is any lymph node involvement by the tumor?
d. Whether additional imaging is helpful for therapeutic decision making?

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Sur_03. How do you most commonly manage TNM stage cM1a/IVA patients in case of single metastasis?

Sur_03. How do you most commonly manage TNM stage M1a/IVA patients in case of single metastasis?

Sur_03g. Describe your way of management TNM stage M1a/IVA patients with single metastasis

____________________________________________________________________________

Sur_04. How do you most commonly manage TNM stage cM1a/IVA patients in case of oligometastatic (2-4 metastases) disease?

Sur_04. How do you most commonly manage TNM stage M1a/IVA patients in case of oligometastatic (2-4 metastases) disease?

Sur_04g. Describe your way of management TNM stage M1a/IVA patients with oligometastatic (2-4 metastases) disease

____________________________________________________________________________

Sur_05. How do you most commonly manage TNM stage cM1a/IVA patients in case of multiple (≥ 5) unilateral metastases?

Sur_05. How do you most commonly manage TNM stage M1a/IVa patients in case of multiple (≥ 5) unilateral metastases?

Sur_05g. Describe your way of management TNM stage M1a/IVA patients with multiple (≥ 5) unilateral metastases

____________________________________________________________________________

Sur_06. How do you most commonly manage TNM stage cM1a/IVA patients in case of multiple bilateral metastases?

Sur_06. How do you most commonly manage TNM stage M1a/IVA patients in case of multiple bilateral metastases?

Sur_06g. Describe your way of management TNM stage M1a/IVA patients with multiple bilateral metastases

____________________________________________________________________________

Sur_07. What is your preoperative minimal clinical/neurological and laboratory test set in terms of:

a) myasthenia gravis and other autoimmune diseases

b) tumor markers, particularly germ cell tumors

Mark all answers that apply

Sur_07. What is your preoperative minimal clinical/neurological and laboratory test set

a. Perform antibody testing for myasthenia gravis on all patients
b. Perform antibody testing for myasthenia gravis on symptomatic patients only
c. Perform antibody testing for various autoimmune diseases on all patients
d. Perform antibody testing for autoimmune disease on symptomatic patients only
e. Perform serologic test for germ cell tumors on all male patients with prevascular mediastinal mass
f. Perform serologic test for germ cell tumors on selected patients
g. No serologic markers for germ cell tumors are performed
h. No antibody testing for myasthenia gravis or autoimmune diseases performed
i. Other

Sur_07c. Which specific tests do you perform for various autoimmune diseases?

Sur_07f. On which patients do you perform serologic GCT test?

Sur_07e. What serologic GCT tests do you routinely perform? (Mark all answers that apply)

AFP
HCG
LDH
Other

Sur_07e-1. What other serologic tests do you perform in GCT patients?

____________________________________________________________________________

Sur_08. Which is your most common surgical approach for ≤3 cm TET (centrally located)?

Sur_08h. Please specify your most common surgical approach for ≤3 cm TET (centrally located)

____________________________________________________________________________

Sur_09. Which is your most common surgical approach for >3 cm TET (centrally located)?

Sur_09h. Please specify your most common surgical approach for >3 cm TET (centrally located)

____________________________________________________________________________

Sur_10. Which is your most common surgical approach in case of first pleural recurrence in the side of previous surgery?

a. Minimally invasive (RATS/VATS)
b. Thoracotomy
c. Depends on the number and location of the recurrences
d. Other

Sur_10d. Please specify your most common surgical approach in case of first pleural recurrence in the side of previous surgery

____________________________________________________________________________

Sur_11. How do you most commonly surgically treat patients with TETs AND myasthenia gravis?

a. Thymomectomy only
b. Thymectomy
c. Extended thymectomy
d. Other

Sur_11d. Please specify your most common surgical treatment method in patients with TETs AND myasthenia gravis

____________________________________________________________________________

Sur_12. Do you routinely perform extended lymphadenectomy (N1 and N2) in TET or only if the size is > 3 cm?

Sur_12. Do you routinely perform extended lymphadenectomy (N1 & N2) in TET or only if the size is > 3 cm?

a. In all cases
b. Only if TET > 3cm
c. Never

____________________________________________________________________________

Sur_13. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis

Mark all answers that apply

Sur_13. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis

a. I usually DO NOT use it when SREENING patients for thymoma
b. I usually DO use it when SCREENING patients for thymoma
c. I usually DO NOT use it when staging patients with thymoma
d. I usually DO use it for staging patients with thymoma
e. I use it only in special circumstance
f. Not applicable

Sur_13e. Please specify in which circumstances you use CT with iodinated intravenous contrast in patients WITH myasthenia gravis

Sur_13f. If "Not applicable", please explain (Mark all answers that apply)

a. I do not order chest imaging studies for patients with myasthenia gravis
b. I usually order a chest MRI and not a chest CT to screen for thymic lesions in patients with myasthenia gravis
c. I usually order a chest MRI and not a chest CT to stage patients with thymoma
d. I employ chest CT and MRI equally when screening for thymic lesions in patients with myasthenia gravis
e. I employ chest CT and MRI equally when staging patients with thymoma

____________________________________________________________________________

Sur_14. How do you send resection specimens to pathology?

Mark all answers that apply

Sur_14. How do you send resection specimens to pathology?

a. Put resection specimen in formalin and send it to pathology, unoriented
b. Orient specimen with stitches
c. Orient specimen on laminated board
d. Orient specimen on towel
e. I walk the specimen to the pathologist and discuss the orientation
f. Digital photo of the specimen with labelled orientation
g. Ink
h. Other

Sur_14b. If you orient specimen with stitches - how do you index the stitches

Sur_14d. Do you stitch the specimen to the towel and label the towel with the orientation or how else you may do it?

Sur_14h. Please specify your way of specimen orientation

____________________________________________________________________________

Sur_15. Do you use the frozen section laboratory for assessment of TET resection specimens?

a. Never
b. Always for assessment of margins
c. Always for assessment of margins and establishing a preliminary diagnosis
d. Sometimes

Sur_15d. Please explain when you order frozen section assessment of TET

____________________________________________________________________________

THANK YOU FOR YOUR TIME AND CONTRIBUTION!

RADIATION ONCOLOGY

Based on AJCC/UICC TNM Staging

Rad_Onk_01. How often do you communicate with your radiologist before starting treatment on locally invasive mediastinal lesion?

Rad_Onk_01e. If other - please, explain

____________________________________________________________________________

Rad_Onk_02. What do you primarily want to know from the radiologist?

a. Diagnostic consideration (thymic tumor, germ cell tumor, or lymphoma)
b. Which neighboring structure is just in close touch or is already invaded by the tumor?
c. Whether there is any lymph node involvement by the tumor?
d. Whether additional imaging is helpful for therapeutic decision making?

____________________________________________________________________________

Rad_Onk_03. How do you most commonly manage the primary tumor of TNM stage M1a/IVA patients in case of SINGLE metastasis?

Rad_Onk_03h. What is the other method of management in case of single metastasis in the pleura?

____________________________________________________________________________

Rad_Onk_04. How do you most commonly manage primary tumor of TNM stage M1a/IVA patients in case of oligometastatic (2-4 metastases) disease?

Rad_Onk_04. How do you most commonly manage the primary tumor of TNM stage M1a/IVA patients in case of oligometastatic disease?

Rad_Onk_04h. What is the other method of management in case of oligometastatic pleural disease?

____________________________________________________________________________

Rad_Onk_05. How do you most commonly manage the primary tumor of TNM stage M1a/IVA patients in case of multiple unilateral metastases?

Rad_Onk_05h. What is the other method of management in case of multiple unilateral pleural metastases?

____________________________________________________________________________

Rad_Onk_06. How do you most commonly manage the primary tumor of TNM stage M1a/IVA patients in case of multiple bilateral metastases?

Rad_Onk_06h. What is the other method of management in case of multiple bilateral pleural metastases?

____________________________________________________________________________

Rad_Onk_07. Would you recommend postoperative radiation therapy (RT) for R0 TNM stage II type A and AB thymoma?

Rad_Onk_07. Would you recommend postoperative RT for R0 TNM stage II type A and AB thymoma?

a. Most likely yes
b. Generally no

Rad_Onk_07a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

____________________________________________________________________________

Rad_Onk_08. Would you recommend postoperative RT for R0 TNM stage II type B1-B3 thymoma?

a. Most likely yes
b. Generally no

Rad_Onk_08a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

____________________________________________________________________________

Rad_Onk_09. Would you recommend postoperative RT for R0 TNM stage III THYMOMA?

Rad_Onk_09. Would you recommend postoperative radiation therapy (RT) for R0 TNM stage III THYMOMA?

a. Most likely yes
b. Generally no

Rad_Onk_09a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

____________________________________________________________________________

Rad_Onk_10. Would you recommend postoperative RT for R1 TNM stage II THYMOMA?

a. Most likely yes
b. Generally no

Rad_Onk_10a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

____________________________________________________________________________

Rad_Onk_11. Would you recommend postoperative RT for R1 TNM stage III THYMOMA?

Rad_Onk_11. Would you recommend postoperative RT for R1 TNM stage III THYMOMA

a. Most likely yes
b. Generally no

Rad_Onk_11a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

____________________________________________________________________________

Rad_Onk_12. Would you recommend postoperative RT for R0 TNM stage IVA (pleural metastases) THYMOMA?

a. Most likely yes
b. Generally no

Rad_Onk_12a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

Rad_Onk_12b. If yes, what would you target?

a. Thymic bed only
b. Thymic bed and region of resected pleural metastases
c. Thymic bed and entire pleura (IMPRINT)
d. Pleura only

____________________________________________________________________________

Rad_Onk_13. Would you recommend postoperative RT for R0 TNM stage I THYMIC CARCINOMA?

a. Most likely yes
b. Generally no

Rad_Onk_13a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

____________________________________________________________________________

Rad_Onk_14. Would you recommend postoperative RT for R0 TNM stage II THYMIC CARCINOMA?

a. Most likely yes
b. Generally no

Rad_Onk_14a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

____________________________________________________________________________

Rad_Onk_15. Would you recommend postoperative RT for R0 TNM stage III THYMIC CARCINOMA?

a. Most likely yes
b. Generally no

Rad_Onk_15a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

____________________________________________________________________________

Rad_Onk_16. Would you recommend postoperative RT for R1 TNM stage I THYMIC CARCINOMA?

a. Most likely yes
b. Generally no

Rad_Onk_16a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

____________________________________________________________________________

Rad_Onk_17. Would you recommend postoperative RT for R1 TNM stage II THYMIC CARCINOMA?

a. Most likely yes
b. Generally no

Rad_Onk_17a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

____________________________________________________________________________

Rad_Onk_18. Would you recommend postoperative RT for R1 TNM stage III THYMIC CARCINOMA?

a. Most likely yes
b. Generally no

Rad_Onk_18a. If yes - what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

____________________________________________________________________________

Rad_Onk_19. Would you recommend postoperative RT for R0 TNM stage IVA (pleural metastases) THYMIC CARCINOMA?

Rad_Onk_19. Would you recommend postoperative RT for R0 TNM stage IVA (pleural metastases) thymic carcinoma?

a. Most likely yes
b. Generally no

Rad_Onk_19a. If yes, what radiation dose do you deliver?

a. 45 Gy
b. 50-54 Gy
c. 55-60 Gy
d. >60 Gy

Rad_Onk_19b. If yes, what would you target?

a. Thymic bed only
b. Thymic bed and region of resected pleural metastases
c. Thymic bed and entire pleura (IMPRINT)
d. Pleura only

____________________________________________________________________________

Rad_Onk_20. Would you recommend postoperative RT for THYMIC NEUROENDOCRINE NEOPLASM?

a. Most likely yes
b. Generally no

Rad_Onk_20a. If yes, at which TNM stage and which extend of resection (R0, R1, R2)? Mark all answers that apply

____________________________________________________________________________

Rad_Onk_21. Which radiation technic do you use?

Mark all answers that apply

Rad_Onk_21. Which radiation technic do you use?

a. 3DCRT
b. IMRT
c. Proton therapy

____________________________________________________________________________

Rad_Onk_22. When do you recommend starting RT relative to surgery (assuming the patient has a quick recovery from surgery)?

Rad_Onk_22. When do you recommend starting RT relative to surgery?

____________________________________________________________________________

Rad_Onk_23. If patients received neoadjuvant chemotherapy, do you use the pre-chemotherapy volume or post-chemotherapy volume for radiation planning?

Rad_Onk_23. If patients received neoadjuvant CTX, do you use the pre-CTX volume or post-CTX volume for radiation planning?

a. Pre-chemotherapy tumor volume
b. Post-chemotherapy tumor volume
c. It depends on the tumor volume
d. It depends on the patient
e. It depends on the surgical resection status

____________________________________________________________________________

Rad_Onk_24. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis

Mark all answers that apply

Rad_Onk_24. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis:

a. I usually DO NOT use it when SCREENING patients for thymoma
b. I usually DO use it when SCREENING patients for thymoma
c. I usually DO NOT use it when staging patients with thymoma
d. I usually DO use it for staging patients with thymoma
e. I use it only in special circumstance
f. Not applicable

Rad_Onk_24e. Please specify in which circumstances you use CT with iodinated intravenous contrast in patients WITH myasthenia gravis

Rad_Onk_24f. If you answered "Not applicable", please explain

a. I do not order chest imaging studies for patients with myasthenia gravis
b. I usually order a chest MRI and not a chest CT to screen for thymic lesions in patients with myasthenia gravis
c. I usually order a chest MRI and not a chest CT to stage patients with thymoma
d. I employ chest CT and MRI equally when screening for thymic lesions in patients with myasthenia gravis
e. I employ chest CT and MRI equally when staging patients with thymoma

____________________________________________________________________________

THANK YOU FOR YOUR TIME AND CONTRIBUTION!

DIAGNOSTIC RADIOLOGY

Based on AJCC/UICC TNM Staging

Rad_01. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis

Mark all answers that apply

Rad_01. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis:

a. I usually do not approve/protocol it when screening patients for thymoma
b. I usually do approve/protocol it when screening patients for thymoma
c. I usually do not approve/protocol it when staging patients with thymoma
d. I usually do approve/protocol it for staging patients with thymoma
e. I approve/protocol it only in special circumstance
f. Not applicable

Rad_01e. Please elaborate in what circumstances you approve/protocol it

Rad_01f. If not applicable, please explain why

a. I do not order chest imaging studies for patients with myasthenia gravis
b. I usually approve/protocol a chest MRI and not a chest CT to screen for thymic lesions in patients with myasthenia gravis
c. I usually approve/protocol a chest MRI and not a chest CT to stage patients with thymoma
d. I employ chest CT and MRI equally when screening for thymic lesions in patients with myasthenia gravis
e. I employ chest CT and MRI equally when staging patients with thymoma

Mark all answers that apply

____________________________________________________________________________

Rad_02. What do you routinely emphasize in your report of imaging studies for a mediastinal lesion?

Mark all answers that apply

Rad_02. What do you routinely emphasize in your report of imaging studies for a mediastinal lesion?

a. Differential diagnosis (e.g. thymic tumor, germ cell tumor, lymphoma)
b. Which neighboring structure the mass abuts or invades
c. N staging with specific lymph node stations using the IASLC lymph node chart of involved lymph nodes
d. N staging, referencing the new TNM staging for TETs nodal staging chart
e. M staging (e.g. presence or absence of pleural metastases and distant metastases)
f. Whether additional imaging would be helpful for therapeutic decision making

____________________________________________________________________________

Rad_03. Regarding the imaging you usually interpret for SCREENING a myasthenia gravis patient for thymoma, which one do you most commonly interpret?

Rad_03. Which one do you most commonly interpret for SCREENING a myasthenia gravis patient for thymoma?

a. Chest CT WITHOUT intravenous contrast
b. Chest CT WITH intravenous contrast
c. MRI WITHOUT intravenous contrast
d. MRI WITHOUT AND WITH intravenous contrast injection

____________________________________________________________________________

Rad_04. Regarding the imaging you usually interpret for following TETs who have myasthenia gravis, which one do you most commonly interpret?

Rad_04. Which one do you most commonly interpret for following TET with myasthenia gravis?

a. Chest CT WITHOUT intravenous contrast
b. Chest CT WITH intravenous contrast
c. MRI WITHOUT intravenous contrast
d. MRI WITHOUT AND WITH intravenous contrast

____________________________________________________________________________

Rad_12. Please state the imaging modality used at your institution for following patients within the first three years after curative resection and what percentage use this modality

____________________________________________________________________________

Rad_13. Please state the imaging modality used at your institution for following patients five years after curative resection and what percentage use this modality.

____________________________________________________________________________

Rad_14. Please state how comfortable you are interpreting a chest MRI for evaluation of a new mediastinal mass in conjunction with a chest CT.

Rad_14. Please state how comfortable you are interpreting a chest MRI for evaluation of a new mediastinal mass in conjunction with a chest CT

a. Totally comfortable
b. Moderately comfortable
c. Uncomfortable

Rad_14c. Why are you uncomfortable (please mark all that apply)?

a. Insufficient training in thoracic MRI
b. Insufficient volume of MRI cases from which to gain experience
c. Scarcity of lectures at widely attended radiology conferences on Thoracic MRI
d. Insufficient recognition of MRI’s value for mediastinal mass evaluation
e. Other

Rad_14e. Please, explain other reasons you are uncomfortable

____________________________________________________________________________

Rad_15. Please state how comfortable you are interpreting a chest MRI alone for evaluation of a new mediastinal mass, without any other cross-sectional modality as a reference?

a. Totally comfortable
b. Moderately comfortable
c. Uncomfortable

Rad_15c. Why are you uncomfortable (please mark all that apply)?

a. Insufficient training in thoracic MRI
b. Insufficient volume of MRI cases from which to gain experience
c. Scarcity of lectures at widely attended radiology conferences on Thoracic MRI
d. Insufficient recognition of MRI’s value for mediastinal mass evaluation
e. Other

Rad_15e. Please, explain other reasons you are uncomfortable

____________________________________________________________________________

Rad_16. Please state how comfortable you feel interpreting a chest CT alone for evaluation of a new mediastinal mass without any other cross-sectional modality for reference?

a. Totally comfortable
b. Moderately comfortable
c. Uncomfortable

Rad_16c. Why are you uncomfortable (please mark all that apply)?

a. There is risk of misinterpreting benign proteinaceous and hemorrhagic mediastinal cysts as tumors on CT has insufficient soft tissue contrast, compared to MRI
b. CT is less sensitive for detection of small enhancing mural nodules and septations within cystic lesions than MRI
c. Other

Rad_16e. Please, explain other reasons you are uncomfortable

____________________________________________________________________________

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Surveys

Dear Colleague,

We would like to invite you to share your experience in your daily practice to identify areas of agreement and potential controversy in the current global clinical and pathology practice of the diagnosis and treatment of thymic epithelial tumors.

We appreciate you are taking the time to fill in the survey!

Part 1 - GENERAL

1. Name of person who completes survey (voluntary)

2. Country of person who completes survey

3. Years of practice since completion of training

4. Your main subspecialty (questions in the rest of the survey depend on your answer to this question)

5. How many new cases of thymic epithelial tumors (TETs) do you see per year?

6. Size of institution

7. Name of institution

8. Prior to treatment of a newly diagnosed TET, in which of these scenarios do you have a multidisciplinary discussion

9. Which of the following medical specialties are present at your multidisciplinary conference prior to treatment of TET?

10. Which staging system do you use

11. How did you find out about this survey?

THANK YOU FOR YOUR TIME AND CONTRIBUTION!

Part 2 - DETAILED

MEDICAL ONCOLOGY

Med_Onk_01. Do you communicate with your radiologist before starting treatment on locally invasive mediastinal lesion?

Med_Onk_02. How do you most commonly manage THYMOMAS at TNM stage cM1a/IVA patients in case of single metastasis?

Med_Onk_03. How do you most commonly manage THYMOMAS at TNM stage cM1a/IVA patients in case of oligometastatic (2-4 metastases) disease?

Med_Onk_04. How do you most commonly manage THYMOMAS at TNM stage cM1a/IVA patients in case of multiple (≥ 5) unilateral metastases?

Med_Onk_05. How do you most commonly manage THYMOMAS at TNM stage cM1a/IVA patients in case of multiple bilateral metastases?

Med_Onk_06. How do you most commonly manage THYMIC CARCINOMAS at TNM stage cM1a/IVA patients in case of single metastasis?

Med_Onk_07. How do you most commonly manage THYMIC CARCINOMAS at TNM stage cM1a/IVA patients in case of oligometastatic (2-4 metastases) disease?

Med_Onk_08. How do you most commonly manage THYMIC CARCINOMAS at TNM stage cM1a/IVA patients in case of multiple (≥ 5) unilateral metastases?

Med_Onk_09. How do you most commonly manage THYMIC CARCINOMAS at TNM stage cM1a/IVA patients in case of multiple bilateral metastases?

Med_Onk_10. What is your preoperative minimal clinical/neurological and laboratory test set in terms of:

a) myasthenia gravis and other autoimmune diseases

b) tumor markers, particularly germ cell tumors

Med_Onk_11. What is your preferred chemotherapy regimen in the neoadjuvant/adjuvant setting for patients with THYMOMA?

Med_Onk_12. What is your preferred chemotherapy regimen in the neoadjuvant/adjuvant setting for patients with THYMIC CARCINOMA?

Med_Onk_13. What is your preferred chemotherapy regimen for patients with patients with advanced, inoperable THYMOMA?

Med_Onk_14. What is your preferred chemotherapy regimen for patients with patients with advanced, inoperable THYMIC CARCINOMA?

Med_Onk_15. What is your preferred systemic therapy in the second line setting for patients with advanced, inoperable THYMOMA?

Med_Onk_16. What is your preferred systemic therapy in the second line setting for patients with advanced, inoperable THYMIC CARCINOMA?

Med_Onk_17. How would you describe your experience using immune checkpoint inhibitors in patients with THYMOMA?

Med_Onk_18. If you have not used immune checkpoint inhibitors for patients with THYMOMA, what would be the reasons?

Med_Onk_19. How would you describe your experience using immune checkpoint inhibitors in patients with THYMIC CARCINOMA?

Med_Onk_20. If you have not used immune checkpoint inhibitors for patients with THYMIC CARCINOMA, what would be the reasons?

Med_Onk_21. Do you consider using NGS testing for patients with thymic epithelial tumors?

Med_Onk_22. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis

THANK YOU FOR YOUR TIME AND CONTRIBUTION!

NEUROLOGY

Neu_01. How often do you observe associated neuromuscular junction diseases in patients with thymoma/thymic carcinoma?

Neu_02. In your clinical experience, have you observed cases of other paraneoplastic neurological diseases associated with thymoma?

Peripheral Nervous System (PNS) disorders

Central Nervous System (CNS) disorders

Neu_03. How frequently do you use thymoma classification systems (TNM staging, Masaoka Koga staging, etc.) in clinical practice in patients with associated neurological autoimmune diseases?

Neu_04. How often do you interact with other specialists (thoracic surgeons, radiologists, pathologists, oncologists, radiotherapists, etc.) in planning treatment of patients with thymoma and associated neurological autoimmune diseases?

Neu_05. What is your suggested preoperative minimal test set in patients with thymoma?

Neu_06. What is your approach to patients who are asymptomatic for neuromuscular plaque disorders but have positive autoantibodies and/or pathologic neurophysiological studies before thymoma resection?

Neu_07. What are the main clinical features of MYASTHENIA GRAVIS in your cohort of thymoma patients?

Neu_08. In your clinical experience what factors are most associated with the development of post-operative myasthenic crisis in patients undergoing surgical resection of thymoma?

Neu_09. What percentage of your myasthenic patients who underwent surgical resection of the thymoma required anytime post-operative immunomodulatory or immunosuppressive therapy?

Neu_10. Regarding a chest CT with iodinated intravenous contrast in patients WITH myasthenia gravis

THANK YOU FOR YOUR TIME AND CONTRIBUTION!

PATHOLOGY

Pat_01. If you have a multidisciplinary conference with the pathologist, which cases are reviewed?

Pat_02. In your institution, how often does the resection specimen come oriented and with additionally resected anatomical structures and surgical margins clearly marked to pathology?

Pat_03. How do surgeons and pathologists communicate in regards to resection specimens?

Pat_04. How often do you review the radiological report when taking samples from the resected tumor?

Pat_05. How often do you review the radiological report when analyzing mediastinal tumor biopsy?

Pat_06. In what material do you usually subtype thymomas?

Pat_07. How do you define lung invasion?

Pat_08. How do you define great vessels invasion?

Pat_09. How do you define neural invasion?

Pat_10. How do you report TET after neoadjuvant therapy?

Pat_11. Lymph node sampling on resection specimens

Pat_12. How do you evaluate margins?

Pat_13. In which situations do you usually use immunohistochemical tests?

Pat_14. Do you use digital pathology in thymic pathology?

Pat_15. Do you use artificial intelligence for the evaluation of thymic tumors?

Pat_16. Do you report micrometastases in lymph nodes?

Pat_17. Do you report isolated tumor cells in lymph nodes?

THANK YOU FOR YOUR TIME AND CONTRIBUTION!

THORACIC SURGERY

Sur_01. How often do you communicate with your radiologist before starting treatment on locally invasive mediastinal lesion