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==Overview==
==Overview==


Staging of thymic epithelial tumors was initially proposed by Bergh and his colleagues in 1978,<ref name="Bergh-1978">{{Cite journal  | last1 = Bergh | first1 = NP. | last2 = Gatzinsky | first2 = P. | last3 = Larsson | first3 = S. | last4 = Lundin | first4 = P. | last5 = Ridell | first5 = B. | title = Tumors of the thymus and thymic region: I. Clinicopathological studies on thymomas. | journal = Ann Thorac Surg | volume = 25 | issue = 2 | pages = 91-8 | month = Feb | year = 1978 | doi =  | PMID = 626543 }}</ref> modified by Wilkins and Castleman in 1979,<ref name="Wilkins-1979">{{Cite journal  | last1 = Wilkins | first1 = EW. | last2 = Castleman | first2 = B. | title = Thymoma: a continuing survey at the Massachusetts General Hospital. | journal = Ann Thorac Surg | volume = 28 | issue = 3 | pages = 252-6 | month = Sep | year = 1979 | doi =  | PMID = 485626 }}</ref> and advanced by Masaoka et al. in 1981 and became widely adopted.<ref name="Masaoka-1981">{{Cite journal  | last1 = Masaoka | first1 = A. | last2 = Monden | first2 = Y. | last3 = Nakahara | first3 = K. | last4 = Tanioka | first4 = T. | title = Follow-up study of thymomas with special reference to their clinical stages. | journal = Cancer | volume = 48 | issue = 11 | pages = 2485-92 | month = Dec | year = 1981 | doi =  | PMID = 7296496 }}</ref><ref name="Kondo-2005">{{Cite journal  | last1 = Kondo | first1 = K. | title = Invited commentary. | journal = Ann Thorac Surg | volume = 80 | issue = 6 | pages = 2000-1 | month = Dec | year = 2005 | doi = 10.1016/j.athoracsur.2005.08.053 | PMID = 16305832 }}</ref> In 1999, World Health Organization (WHO) proposed
Staging of thymic epithelial tumors was initially proposed by Bergh and his colleagues in 1978,<ref name="Bergh-1978">{{Cite journal  | last1 = Bergh | first1 = NP. | last2 = Gatzinsky | first2 = P. | last3 = Larsson | first3 = S. | last4 = Lundin | first4 = P. | last5 = Ridell | first5 = B. | title = Tumors of the thymus and thymic region: I. Clinicopathological studies on thymomas. | journal = Ann Thorac Surg | volume = 25 | issue = 2 | pages = 91-8 | month = Feb | year = 1978 | doi =  | PMID = 626543 }}</ref> modified by Wilkins and Castleman in 1979,<ref name="Wilkins-1979">{{Cite journal  | last1 = Wilkins | first1 = EW. | last2 = Castleman | first2 = B. | title = Thymoma: a continuing survey at the Massachusetts General Hospital. | journal = Ann Thorac Surg | volume = 28 | issue = 3 | pages = 252-6 | month = Sep | year = 1979 | doi =  | PMID = 485626 }}</ref> and advanced by Masaoka et al. in 1981.<ref name="Masaoka-1981">{{Cite journal  | last1 = Masaoka | first1 = A. | last2 = Monden | first2 = Y. | last3 = Nakahara | first3 = K. | last4 = Tanioka | first4 = T. | title = Follow-up study of thymomas with special reference to their clinical stages. | journal = Cancer | volume = 48 | issue = 11 | pages = 2485-92 | month = Dec | year = 1981 | doi =  | PMID = 7296496 }}</ref><ref name="Kondo-2005">{{Cite journal  | last1 = Kondo | first1 = K. | title = Invited commentary. | journal = Ann Thorac Surg | volume = 80 | issue = 6 | pages = 2000-1 | month = Dec | year = 2005 | doi = 10.1016/j.athoracsur.2005.08.053 | PMID = 16305832 }}</ref> Modified Masaoka staging grouped with TNM classification is the most widely adopted system for thymic epithelial tumors currently in use.


*There is no universally accepted system; no AJCC staging exists.
==Modified Masaoka Clinical Staging of Thymoma==
*Historically, a classifiaction system used both histological features and clinical behavior.
*Masaoka staging is the clinically used staging system, although it may not be predictive for thymic carcinoma.
*GETT staging is the surgical staging system, and may have better correlation with outcome.
*A meta-analysis from UCLA suggests that evaluation of transcapsular extension (Stage I vs. Stage IIa) is of no clinical value, as they have same DFS and OS outcomes.


==Historical Classification==
*Benign Thymoma (histologically and behaviorally benign)
*Malignant Thymoma (invasive)
:*Type I - histologically benign, but behaving aggressively with local invasion
:*Type II ("thymic carcinoma") - histologically malignant, aggresive behavior


{| style="border: 2px solid #696969;" align="center"
|+ <SMALL>''Modified Masaoka Clinical Staging of Thymoma (1994)''<ref name="Masaoka-1994">{{Cite journal  | last1 = Masaoka | first1 = A. | last2 = Yamakawa | first2 = Y. | last3 = Niwa | first3 = H. | last4 = Fukai | first4 = I. | last5 = Saito | first5 = Y. | last6 = Tokudome | first6 = S. | last7 = Nakahara | first7 = K. | last8 = Fujii | first8 = Y. | title = Thymectomy and malignancy. | journal = Eur J Cardiothorac Surg | volume = 8 | issue = 5 | pages = 251-3 | month =  | year = 1994 | doi =  | PMID = 8043287 }}</ref></SMALL>
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 15px;" | '''Stage'''
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 600px;" | '''Description'''
|-
| style="background: #F0F0F0;" align=center | '''I''' || Macroscopically and microscopically completely encapsulated
|-
| style="background: #F0F0F0;" align=center | '''II''' || A. Microscopic transcapsular invasion <BR> B. Macroscopic invasion into surrounding fatty tissue or grossly adherent to but not through <BR> mediastinal pleura or pericardium
|-
| style="background: #F0F0F0;" align=center | '''III''' || Macroscopic invasion into neighboring organs (ie, pericardium, great vessels, lung) <BR> A. Without invasion of great vessels <BR> B. With invasion of great vessels
|-
| style="background: #F0F0F0;" align=center | '''IV''' || A. Pleural or pericardial dissemination <BR> B. Lymphogenous or hematogenous metastasis
|-
|}
==TNM Classification of Thymic Epithelial Tumors==




{| style="border: 2px solid #696969;" align="center"
{| style="border: 2px solid #696969;" align="center"
|+ <SMALL>''Masaoka Staging System (1981)''<ref name="Masaoka-1981">{{Cite journal  | last1 = Masaoka | first1 = A. | last2 = Monden | first2 = Y. | last3 = Nakahara | first3 = K. | last4 = Tanioka | first4 = T. | title = Follow-up study of thymomas with special reference to their clinical stages. | journal = Cancer | volume = 48 | issue = 11 | pages = 2485-92 | month = Dec | year = 1981 | doi =  | PMID = 7296496 }}</ref></SMALL>
|+ <SMALL>''TNM Classification of Thymic Epithelial Tumors by Yamakawa and Masaoka (1991)''<ref name="Yamakawa-1991">{{Cite journal  | last1 = Yamakawa | first1 = Y. | last2 = Masaoka | first2 = A. | last3 = Hashimoto | first3 = T. | last4 = Niwa | first4 = H. | last5 = Mizuno | first5 = T. | last6 = Fujii | first6 = Y. | last7 = Nakahara | first7 = K. | title = A tentative tumor-node-metastasis classification of thymoma. | journal = Cancer | volume = 68 | issue = 9 | pages = 1984-7 | month = Nov | year = 1991 | doi =  | PMID = 1913546 }}</ref></SMALL>
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 15px;" | '''Stage'''
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px;" colspan=2 | '''T/N/M Stage'''
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 500px;" | '''Description'''
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 520px;" | '''Description'''
|-
| style="background: #F0F0F0; width:75px;" rowspan=4 align=center | '''T factor''' || style="background: #F0F0F0; width: 50px;" align=center | '''T1''' || Macroscopically completely encapsulated and microscopically no capsular invasion
|-
| style="background: #F0F0F0;" align=center | '''T2''' || Macroscopically adhesion or invasion into surrounding fatty tissue or mediastinal pleura, <BR> or microscopic invasion into capsule
|-
| style="background: #F0F0F0;" align=center | '''T3''' || Invasion into neighboring organs, such as pericardium, great vessels, and lung
|-
| style="background: #F0F0F0;" align=center | '''T4''' || Pleural or pericardial dissemination
|-
|-
| align=center | '''I''' ||Macroscopically completely encapsulated and microscopically no capsular invasion
| style="background: #F0F0F0;" rowspan=4 align=center | '''N factor''' || style="background: #F0F0F0;" align=center | '''N0''' || No lymph node metastasis
|-
|-
| align=center | '''II1''' ||Macroscopic invasion into surrounding fatty tissue or mediastinal pleura
| style="background: #F0F0F0;" align=center | '''N1''' || Metastasis to anterior mediastinal lymph nodes
|-
|-
| align=center | '''II2''' ||Microscopic invasion into capsule
| style="background: #F0F0F0;" align=center | '''N2''' || Metastasis to intrathoracic lymphnodes except anterior mediastinal lymph nodes
|-
|-
| align=center | '''III''' ||Macroscopic invasion into neighboring organ, ie, pericardium, great vessels, or lung
| style="background: #F0F0F0;" align=center | '''N3''' || Metastasis to extrathoracic lymphnodes
|-
|-
| align=center | '''IVa''' ||Pleural or pericardial dissemination
| style="background: #F0F0F0;" style="background: #F0F0F0;" rowspan=4 align=center | '''M factor''' || style="background: #F0F0F0;" align=center | '''M0''' || No hematogenous metastasis
|-
|-
| align=center | '''IVb''' ||Lymphogenous or hematogenous metastasis
| style="background: #F0F0F0;" align=center | '''M1''' || Hematogenous metastasis
|-
|-
|}
|}
Line 42: Line 58:


{| style="border: 2px solid #696969;" align="center"
{| style="border: 2px solid #696969;" align="center"
|+ <SMALL>''Clinical Stage Systems by Bergh (1978) and Wilkins (1979)''<ref name="Bergh-1978">{{Cite journal  | last1 = Bergh | first1 = NP. | last2 = Gatzinsky | first2 = P. | last3 = Larsson | first3 = S. | last4 = Lundin | first4 = P. | last5 = Ridell | first5 = B. | title = Tumors of the thymus and thymic region: I. Clinicopathological studies on thymomas. | journal = Ann Thorac Surg | volume = 25 | issue = 2 | pages = 91-8 | month = Feb | year = 1978 | doi =  | PMID = 626543 }}</ref><ref name="Wilkins-1979">{{Cite journal  | last1 = Wilkins | first1 = EW. | last2 = Castleman | first2 = B. | title = Thymoma: a continuing survey at the Massachusetts General Hospital. | journal = Ann Thorac Surg | volume = 28 | issue = 3 | pages = 252-6 | month = Sep | year = 1979 | doi =  | PMID = 485626 }}</ref></SMALL>
|+ <SMALL>''Combined Masaoka Staging/TNM Classification (1994)''<ref name="Tsuchiya-1994">{{Cite journal  | last1 = Tsuchiya | first1 = R. | last2 = Koga | first2 = K. | last3 = Matsuno | first3 = Y. | last4 = Mukai | first4 = K. | last5 = Shimosato | first5 = Y. | title = Thymic carcinoma: proposal for pathological TNM and staging. | journal = Pathol Int | volume = 44 | issue = 7 | pages = 505-12 | month = Jul | year = 1994 | doi =  | PMID = 7921194 }}</ref></SMALL>
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 100px;" | '''Author'''
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 150px;" | '''Masaoka Stage'''
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 15px;" | '''Stage'''
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 150px;" | '''T factor'''
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 500px;" | '''Description'''
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 150px;" | '''N factor'''
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 150px;" | '''M factor'''
|-
| style="background: #F0F0F0;" align=center | '''Stage I''' ||align=center| T1 ||align=center| N0 ||align=center| M0
|-
|-
| rowspan=3 align=center | Bergh et al.|| align=center | '''I''' ||Intact capsule or growth within the capsule
| style="background: #F0F0F0;" align=center | '''Stage II''' ||align=center| T2 ||align=center| N0 ||align=center| M0
|-
|-
| align=center | '''II''' ||Pericapsular growth into the mediastinal fat tissue
| style="background: #F0F0F0;" align=center | '''Stage III''' ||align=center| T3 ||align=center| N0 ||align=center| M0
|-
|-
| align=center | '''III''' ||Invasive growth into the surrounding organs and/or intrathoracic metastases
| style="background: #F0F0F0;" align=center | '''Stage IVa''' ||align=center| T4 ||align=center| N0 ||align=center| M0
|-
|-
| rowspan=3 align=center | Wilkins et al.|| align=center | '''I''' ||Intact capsule or growth within the capsule
| style="background: #F0F0F0;" align=center rowspan=2 | '''Stage IVb''' ||align=center| Any T ||align=center| N1, N2, or N3 ||align=center| M0
|-
|-
| align=center | '''II''' ||Pericapsular growth into the mediastinal fat tissue or adjacent pleura or pericardium
|align=center| Any T ||align=center| Any N ||align=center| M1
|-
|-
| align=center | '''III''' ||Invasive growth into the surrounding organs and/or intrathoracic metastases
|}
|}




==TNM Staging (1999)==
==Previously Reported Staging System==
{|
 
| [[File:ttt1.png|800px|thumb]]
 
|}<ref name="www.ncbi.nlm.nih.gov">{{Cite web | last = | first = | title = Thymectomy and malignancy. [Eur J Cardiothorac Surg. 1994] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/8043287 | publisher = | date =  | accessdate = }}</ref>
{| style="border: 2px solid #696969;" align="center"
|+ <SMALL>''Masaoka Staging (1981)''<ref name="Masaoka-1981">{{Cite journal | last1 = Masaoka | first1 = A. | last2 = Monden | first2 = Y. | last3 = Nakahara | first3 = K. | last4 = Tanioka | first4 = T. | title = Follow-up study of thymomas with special reference to their clinical stages. | journal = Cancer | volume = 48 | issue = 11 | pages = 2485-92 | month = Dec | year = 1981 | doi =  | PMID = 7296496 }}</ref></SMALL>
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 15px;" | '''Stage'''
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 600px;" | '''Description'''
|-
| style="background: #F0F0F0;" align=center | '''I''' || Macroscopically completely encapsulated and microscopically no capsular invasion
|-
| style="background: #F0F0F0;" align=center | '''II''' || 1. Macroscopic invasion into surrounding fatty tissue or mediastinal pleura <BR> 2. Microscopic invasion into capsule
|-
| style="background: #F0F0F0;" align=center | '''III''' || Macroscopic invasion into neighboring organ (ie, pericardium, great vessels, or lung)
|-
| style="background: #F0F0F0;" align=center | '''IVa''' || Pleural or pericardial dissemination
|-
| style="background: #F0F0F0;" align=center | '''IVb''' || Lymphogenous or hematogenous metastasis
|-
|}


==Original Masaoka Staging (1991)==
*Stage I - Macroscopically and microscopically completely encapsulated
*Stage II - Macroscopic invasion into surrounding fatty tissues or mediastinal pleura or microscopic invasion into the capsule
*Stage III - Macroscopic invasion into adjacent organs or intrathoracic metastases
*Stage IVA - Pleural or pericardial implants/dissemination
*Stage IVB - Nodal or hematogenous metastases


==GETT Staging==
{| style="border: 2px solid #696969;" align="center"
*Stage IA - Encapsulated, completely resected.
|+ <SMALL>''Clinical Staging by Bergh (1978) and Wilkins (1979)''<ref name="Bergh-1978">{{Cite journal  | last1 = Bergh | first1 = NP. | last2 = Gatzinsky | first2 = P. | last3 = Larsson | first3 = S. | last4 = Lundin | first4 = P. | last5 = Ridell | first5 = B. | title = Tumors of the thymus and thymic region: I. Clinicopathological studies on thymomas. | journal = Ann Thorac Surg | volume = 25 | issue = 2 | pages = 91-8 | month = Feb | year = 1978 | doi =  | PMID = 626543 }}</ref><ref name="Wilkins-1979">{{Cite journal | last1 = Wilkins | first1 = EW. | last2 = Castleman | first2 = B. | title = Thymoma: a continuing survey at the Massachusetts General Hospital. | journal = Ann Thorac Surg | volume = 28 | issue = 3 | pages = 252-6 | month = Sep | year = 1979 | doi =  | PMID = 485626 }}</ref></SMALL>
*Stage IB - Macroscopically completely resected but suspicion of mediastinal adhesions or potential capsular invasion at surgery.
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 100px;" | '''Author'''
*Stage II - Invasive tumor, completely resected.
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 15px;" | '''Stage'''
*Stage IIIA - Invasive tumor, subtotal resection.
! style="background: #F0F0F0; border: 0px solid #696969; padding: 0 5px; width: 500px;" | '''Description'''
*Stage IIIB - Invasive tumor, biopsy alone.
|-
*Stage IVa - Supraclav or pleural met.
| style="background: #F0F0F0;" rowspan=3 align=center | Bergh et al. || style="background: #F0F0F0;" align=center | '''I''' || Intact capsule or growth within the capsule
*Stage IVb - Distant metastases.<ref name="www.ncbi.nlm.nih.gov">{{Cite web | last = | first = | title = Seventeen years of surgical treatmen... [Eur J Cardiothorac Surg. 1991] - PubMed - NCBI | url = http://www.ncbi.nlm.nih.gov/pubmed/2025438 | publisher = | date =  | accessdate = }}</ref>
|-
| style="background: #F0F0F0;" align=center | '''II''' || Pericapsular growth into the mediastinal fat tissue
|-
| style="background: #F0F0F0;" align=center | '''III''' || Invasive growth into the surrounding organs and/or intrathoracic metastases
|-
| style="background: #F0F0F0;" rowspan=3 align=center | Wilkins et al. || style="background: #F0F0F0;" align=center | '''I''' || Intact capsule or growth within the capsule
|-
| style="background: #F0F0F0;" align=center | '''II''' || Pericapsular growth into the mediastinal fat tissue or adjacent pleura or pericardium
|-
| style="background: #F0F0F0;" align=center | '''III''' || Invasive growth into the surrounding organs and/or intrathoracic metastases
|-
|}


==References==
==References==
{{Reflist|2}}
{{reflist|2}}


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Latest revision as of 12:10, 28 August 2015

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amr Marawan, M.D. [2]

Overview

Staging of thymic epithelial tumors was initially proposed by Bergh and his colleagues in 1978,[1] modified by Wilkins and Castleman in 1979,[2] and advanced by Masaoka et al. in 1981.[3][4] Modified Masaoka staging grouped with TNM classification is the most widely adopted system for thymic epithelial tumors currently in use.

Modified Masaoka Clinical Staging of Thymoma

Modified Masaoka Clinical Staging of Thymoma (1994)[5]
Stage Description
I Macroscopically and microscopically completely encapsulated
II A. Microscopic transcapsular invasion
B. Macroscopic invasion into surrounding fatty tissue or grossly adherent to but not through
mediastinal pleura or pericardium
III Macroscopic invasion into neighboring organs (ie, pericardium, great vessels, lung)
A. Without invasion of great vessels
B. With invasion of great vessels
IV A. Pleural or pericardial dissemination
B. Lymphogenous or hematogenous metastasis


TNM Classification of Thymic Epithelial Tumors

TNM Classification of Thymic Epithelial Tumors by Yamakawa and Masaoka (1991)[6]
T/N/M Stage Description
T factor T1 Macroscopically completely encapsulated and microscopically no capsular invasion
T2 Macroscopically adhesion or invasion into surrounding fatty tissue or mediastinal pleura,
or microscopic invasion into capsule
T3 Invasion into neighboring organs, such as pericardium, great vessels, and lung
T4 Pleural or pericardial dissemination
N factor N0 No lymph node metastasis
N1 Metastasis to anterior mediastinal lymph nodes
N2 Metastasis to intrathoracic lymphnodes except anterior mediastinal lymph nodes
N3 Metastasis to extrathoracic lymphnodes
M factor M0 No hematogenous metastasis
M1 Hematogenous metastasis


Combined Masaoka Staging/TNM Classification (1994)[7]
Masaoka Stage T factor N factor M factor
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0 M0
Stage IVa T4 N0 M0
Stage IVb Any T N1, N2, or N3 M0
Any T Any N M1


Previously Reported Staging System

Masaoka Staging (1981)[3]
Stage Description
I Macroscopically completely encapsulated and microscopically no capsular invasion
II 1. Macroscopic invasion into surrounding fatty tissue or mediastinal pleura
2. Microscopic invasion into capsule
III Macroscopic invasion into neighboring organ (ie, pericardium, great vessels, or lung)
IVa Pleural or pericardial dissemination
IVb Lymphogenous or hematogenous metastasis


Clinical Staging by Bergh (1978) and Wilkins (1979)[1][2]
Author Stage Description
Bergh et al. I Intact capsule or growth within the capsule
II Pericapsular growth into the mediastinal fat tissue
III Invasive growth into the surrounding organs and/or intrathoracic metastases
Wilkins et al. I Intact capsule or growth within the capsule
II Pericapsular growth into the mediastinal fat tissue or adjacent pleura or pericardium
III Invasive growth into the surrounding organs and/or intrathoracic metastases

References

  1. ↑ 1.0 1.1 Bergh, NP.; Gatzinsky, P.; Larsson, S.; Lundin, P.; Ridell, B. (1978). "Tumors of the thymus and thymic region: I. Clinicopathological studies on thymomas". Ann Thorac Surg. 25 (2): 91–8. PMID 626543. Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 Wilkins, EW.; Castleman, B. (1979). "Thymoma: a continuing survey at the Massachusetts General Hospital". Ann Thorac Surg. 28 (3): 252–6. PMID 485626. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 Masaoka, A.; Monden, Y.; Nakahara, K.; Tanioka, T. (1981). "Follow-up study of thymomas with special reference to their clinical stages". Cancer. 48 (11): 2485–92. PMID 7296496. Unknown parameter |month= ignored (help)
  4. ↑ Kondo, K. (2005). "Invited commentary". Ann Thorac Surg. 80 (6): 2000–1. doi:10.1016/j.athoracsur.2005.08.053. PMID 16305832. Unknown parameter |month= ignored (help)
  5. ↑ Masaoka, A.; Yamakawa, Y.; Niwa, H.; Fukai, I.; Saito, Y.; Tokudome, S.; Nakahara, K.; Fujii, Y. (1994). "Thymectomy and malignancy". Eur J Cardiothorac Surg. 8 (5): 251–3. PMID 8043287.
  6. ↑ Yamakawa, Y.; Masaoka, A.; Hashimoto, T.; Niwa, H.; Mizuno, T.; Fujii, Y.; Nakahara, K. (1991). "A tentative tumor-node-metastasis classification of thymoma". Cancer. 68 (9): 1984–7. PMID 1913546. Unknown parameter |month= ignored (help)
  7. ↑ Tsuchiya, R.; Koga, K.; Matsuno, Y.; Mukai, K.; Shimosato, Y. (1994). "Thymic carcinoma: proposal for pathological TNM and staging". Pathol Int. 44 (7): 505–12. PMID 7921194. Unknown parameter |month= ignored (help)
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