How to obtain adequate biopsy specımen in suspected thymic tumors

Pathologic diagnosis of thymic tumors (TTs) can be made by surgical or nonsurgical procedures. About 20% of TTs had been diagnosed by pretreatment biopsy methods while the rest had gone to surgery for diagnosis and treatment. However, in the last two decades there was an increase in pretreatment procedures for optimal management of locally advanced or metastatic TTs. Pretreatment tissue diagnosis of a noninvasive TT is not a standard option but is required if there is suspect or atypical clinical presentation and imaging, an invasive tumor requiring a nonsurgical approach or preoperative chemotherapy or chemo-radiotherapy, strong possibility of lymphoma or unclear differential diagnosis between lymphoma or other solid tumor by imaging studies, or suspicion of a metastatic lesion. In surgical diagnosis anterior mediastinotomy, video-assisted thoracic surgery or mediastinoscopy can be chosen for invasive TTs whereas total resection is performed for small, noninvasive tumors. Nonsurgical diagnosis can be made by transthoracic fine or core needle biopsies (TTFNA, TTCNB), conventional bronchoscopy, endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or medical thoracoscopy depending on procedural amenability according to tumor extension. TTFNA and TTCNB have been the most frequently used nonsurgical methods. However, there is an upward trend in using conventional bronchoscopy, EBUS-TBNA, EUS-FNA and medical thoracoscopy recently. To increase the diagnostic performance of these procedures in TTs, recommendations are (I) obtaining histologic specimens, (II) combining smears or liquid based cytology preparations and cell blocks, (III) obtaining multiple sufficient samples, (IV) combining histologic and cytologic specimens, (V) performing morphologic, immunohistochemical and molecular analyses on all specimens, (VI) using rapid onsite evaluation for cytologic specimens, (VII) correlating pathologic, clinical and radiologic findings, (VIII) consulting experienced pathologists.