Role of radiotherapy in thymoma and thymic carcinoma: a narrative review

Introduction

Thymic epithelial tumors, encompassing thymomas and thymic carcinomas, are rare neoplasms arising in the anterior mediastinum. Although they represent the most common tumors of the thymus, their overall incidence remains low (1). Thymomas are typically indolent and often detected at localized stages. They are notable for their associations with paraneoplastic autoimmune syndromes, including myasthenia gravis, pure red cell aplasia, and systemic lupus erythematosus (2).

Histologically, thymomas are classified by the World Health Organization (WHO) into types A, AB, B1, B2, and B3, reflecting increasing atypia of thymic epithelium and decreasing lymphocyte richness (3). This histologic spectrum correlates with clinical behavior: type A/AB thymomas tend to be encapsulated and clinically least aggressive, whereas type B2/B3 thymomas demonstrate more invasive characteristics. Thymic carcinoma represents a distinct entity characterized by overt malignancy with cytologically malignant features and a propensity for early dissemination (4). Staging of thymic tumors has evolved from the Masaoka-Koga system to a tumor-node-metastasis (TNM)-based staging system adopted by the 8th edition American Joint Committee on Cancer staging manual (5,6). The most recent 9th edition introduced major revisions to the T categories and their definitions (7).

Complete surgical resection remains the primary treatment for localized disease, yielding excellent survival in early-stage thymoma (8-10). However, postoperative radiotherapy (PORT) plays an important role in reducing recurrence risk and possibly improving survival in higher-stage disease or when residual tumor remains. Radiotherapy field has greatly benefited from technological innovations over the past two decades (11). In particular, stereotactic body radiotherapy (SBRT) achieves high local control rates by delivering concentrated high doses to the tumor while minimizing impact on surrounding tissues (12,13). Moreover, advancements in imaging technology have enabled precise evaluation of positioning accuracy during radiation delivery (14,15).

This review synthesizes the latest clinical evidence on radiotherapy for thymoma and thymic carcinoma, covering indications, dose, and outcomes and prognosis, toxicity and late effects, and biological insights including tumor radiosensitivity and immune-related effects. Contemporary guidelines and studies from the past 5 years are emphasized to provide an up-to-date perspective. This article is presented in accordance with the Narrative Review reporting checklist (available at https://med.amegroups.com/article/view/10.21037/med-2025-1-64/rc).

Methods

A comprehensive literature search was conducted on 1 November 2025 using the PubMed database. The overall search process and inclusion criteria are summarized in Table 1. No restriction was placed on the publication date of the included articles, and only human studies published in English were considered eligible. Studies of any design were included, as the present work aimed to provide a comprehensive narrative overview rather than a quantitative systematic review. In addition to database searching, the reference lists of key articles and relevant review papers were manually screened to ensure inclusion of important and representative studies. This review followed a narrative approach; therefore, a formal PRISMA checklist was not applied, and the flow diagram is presented for transparency of the literature identification process (Figure 1). The literature selection was independently performed by A.K., who screened the titles and abstracts of all retrieved records to identify relevant studies. Full-text articles were then assessed for eligibility. Publications deemed irrelevant after full-text review were excluded. ChatGPT (version 5.0; OpenAI) was used for language refinement and structural editing. The scientific content, interpretation, and final decisions remained solely the responsibility of the author.

Figure 1 A simplified PRISMA-style flow diagram illustrating the identification, screening, and inclusion of studies for this narrative review.

Clinical indication of radiotherapy

For stage I thymoma, surveillance or surgery alone is widely considered standard treatment, as robust evidence supporting adjuvant radiotherapy remains limited (16). The role of PORT in stage II thymoma remains controversial. In a retrospective study of 62 patients with completely resected Masaoka stage II thymoma, local recurrence was rare (3.2%) regardless of whether adjuvant radiotherapy was administered (17). While adjuvant radiotherapy was well tolerated, it did not significantly reduce local relapse, suggesting limited benefit in completely resected low-risk cases. Singhal et al. reported a retrospective series of 62 completely resected stage I–II thymomas in which adjuvant mediastinal radiotherapy (45–55 Gy) did not improve recurrence or survival outcomes compared with surgery alone (18). With a 5-year overall survival (OS) of 91% and only two recurrences, these findings support margin-negative surgical resection alone as sufficient treatment for stage I–II thymoma. Lim et al. conducted meta-analysis included seven retrospective studies comprising 1,724 patients with stage II–IV thymomas who underwent complete resection (19). PORT did not improve OS in stage II disease [hazard ratio (HR) =1.45; 95% confidence interval (CI): 0.83–2.55] but showed a significant survival benefit in stage III–IV disease (HR =0.63; 95% CI: 0.40–0.99). In completely resected, low-risk thymomas, PORT should be carefully weighed against the potential risk of late radiation-induced malignancies, and may reasonably be deferred until local recurrence (20).

However, some meta-analyses have yielded different insights. Tateishi et al. conducted a systematic review and meta-analysis of 4,746 patients with completely resected Masaoka/Masaoka-Koga stage II/III thymoma and found that PORT significantly improved OS (HR =0.68; 95% CI: 0.57–0.83; P<0.001), with consistent benefit observed in both stage II and III subgroups (21). Nevertheless, PORT did not improve disease-free survival, and the authors emphasized the need for randomized controlled trials to confirm these findings. He et al. performed a meta-analysis of 31 studies involving 10,543 patients, demonstrating that PORT significantly improved both OS (HR =0.73) and disease-free survival (HR =0.62) after complete resection of thymic epithelial tumors (22). Subgroup analyses indicated clear benefits for stage III–IV thymoma and thymic carcinoma, whereas no survival advantage was observed for stage II disease.

Thymic carcinoma demonstrates higher malignancy compared to thymoma, with elevated risks of recurrence and metastasis. Consequently, the benefit of adjuvant radiotherapy is more clearly established for thymic carcinoma than for thymoma. Mao et al. reported that in a retrospective study of 54 patients with completely resected thymic carcinoma, adjuvant radiotherapy significantly improved disease-free survival (P=0.041) but showed only a borderline association with OS (P=0.051) (23). Adjuvant chemotherapy provided no significant benefit, suggesting that PORT after complete resection enhances local disease control in thymic carcinoma. Rimner et al. conducted a large multi-institutional analysis of 462 patients with thymic carcinoma, demonstrating that PORT significantly improved OS (5-year OS 68% vs. 53%, P=0.002) (24). The survival benefit was most pronounced in patients with advanced-stage (III–IV) disease after R0 or R1/2 resection, while no significant advantage was observed in early-stage (I–II) cases. PORT did not significantly affect time to recurrence.

For unresectable locally advanced thymic carcinoma, Fukuda et al. conducted a phase II study that enrolled three patients treated with S-1 plus cisplatin concurrent with radiotherapy (60 Gy) (25). The median time to progression was 17.6 months, and the 1- and 3-year OS rates were 100% and 67%, respectively. Fan et al., who conducted a prospective phase II trial enrolling 56 patients with locally advanced unresectable thymic epithelial tumors. Patients received concurrent intensity-modulated radiotherapy with etoposide and cisplatin chemotherapy (26). The trial demonstrated an impressive objective response rate of 85.7%, with 1-, 2-, and 5-year OS rates of 91.0%, 76.2%, and 56.2%, respectively. As summarized in Table 2, single-institution series and meta-analyses report discordant survival effects of PORT in stage II thymoma, reflecting differences in study design, stage composition, and residual confounding.

In summary, the decision to use radiotherapy in the management of thymic epithelial tumors is critically governed by the pathological stage and the status of surgical margins. PORT may be safely omitted for patients with completely resected stage I thymoma with negative surgical margins (R0) where surveillance is the standard of care. Conversely, PORT is generally indicated and considered standard practice for invasive thymomas of stage III and is considered for high-risk stage II subtypes in selected patients. Furthermore, it is standard for virtually all thymic carcinomas beyond stage I, and for any case involving residual disease following surgery, specifically R1 or R2 resection. The role of PORT in stage II disease remains the primary point of contention. While several large meta-analyses suggest a potential OS advantage, individual retrospective series and subgroup analyses have not consistently demonstrated a clear benefit in this specific cohort. For unresectable tumors, definitive radiotherapy, usually delivered concurrently with chemotherapy, is the established modality required to achieve local control.

Guideline recommendations

Multiple international guidelines have addressed the role of radiotherapy in the management of thymic epithelial tumors. Table 3 summarizes key international recommendations on PORT for thymic epithelial tumors. The National Comprehensive Cancer Network (NCCN) (27), European Society for Medical Oncology (ESMO) (28), Spanish Group for Clinical Oncology and Radiation Oncology Societies (29), China Anti-Cancer Association (30), American Radium Society (31), and Ontario Health (Cancer Care Ontario)’s Program (32). All advocate a dose escalation strategy based on surgical margin status: typically, 45–50 Gy for microscopically negative margins (R0), 50–54 Gy for microscopically positive margins (R1), and 60–70 Gy for gross residual disease (R2).

PORT is consistently recommended for patients with positive margins or advanced-stage (stage III–IV) disease, whereas elective nodal irradiation is generally not advised. Recent multidisciplinary guidance emphasizes the importance of integrating surgery, radiotherapy, and systemic therapy within a coordinated multidisciplinary decision-making framework to optimize outcomes.

Hypofractionated radiotherapy and SBRT

Conventional fractionated radiotherapy for thymic epithelial tumors typically requires 5–7 weeks of treatment, representing a considerable time commitment. Reducing the number of radiotherapy sessions offers multiple benefits, including decreased hospital visits, less interruption to daily activities, and earlier initiation of systemic therapy when indicated. In recent years, hypofractionated radiotherapy—which increases the dose per fraction while reducing the total number of sessions and overall treatment duration—has demonstrated efficacy across multiple tumor types. Thymic epithelial tumors demonstrate marked heterogeneity in biological behavior and presumed radiosensitivity according to histologic subtype. Although subtype-specific data on radiosensitivity in thymic tumors remain limited, indolent tumors are generally thought to exhibit lower alpha-beta ratios compared with more aggressive malignancies (33). The alpha-beta ratio is a parameter reflecting radiosensitivity, and lower values are generally considered more suitable for higher doses per fraction from a normal organ preservation perspective. From this perspective, increasing the dose per fraction through hypofractionated radiotherapy or SBRT may offer theoretical and practical advantages in selected thymic tumors. In addition to these radiobiological considerations, increasing evidence from other malignancies suggests that high-dose-per-fraction radiotherapy can induce immunogenic cell death, enhance tumor antigen release, and modulate the tumor microenvironment in a manner that may augment antitumor immune responses (34).

Chu et al. conducted a prospective, single-arm phase II study (GASTO-1042) enrolling 50 patients with unresectable or recurrent thymic epithelial tumors who received hypofractionated intensity-modulated radiation therapy (45–51 Gy in 9–17 fractions) combined with weekly docetaxel/nedaplatin (35). The objective response rate was 83.7%, with 2-year progression-free and OS rates of 59.1% and 90.0%, respectively, and only 2% experienced grade ≥3 pneumonitis, indicating favorable efficacy and tolerability. Additionally, a case report described a patient with locally advanced type B2thymoma successfully treated with definitive hypofractionated radiotherapy (36).

Further treatment shortening through ultra-hypofractionation, specifically SBRT, has also demonstrated promising results. SBRT delivers very high doses per fraction over only a few sessions. Although it is not typically employed for primary thymomas due to their size and proximity to critical structures, SBRT may serve as an effective option for recurrent or metastatic disease.

Hao et al. reported a prospective single-institution study of 32 patients (39 lesions) with thymoma or thymic carcinoma treated with SBRT, achieving a 96.9% response rate and 81.3% local control, with a median gross tumor volume (GTV) dose of 56 Gy (37). Similarly, Pasquini et al. described a retrospective series of 22 patients with pleural metastases from thymoma, reporting 1- and 2-year local control rates of 92% and 78%, respectively, and a median progression-free survival of 20.4 months (38). In addition, SBRT has demonstrated efficacy even in rare histologic subtypes. A patient with sacral bone metastasis from recurrent type A thymoma achieved complete pain relief and marked regression 2 years after receiving SBRT with 35 Gy delivered in five fractions using volumetric-modulated arc therapy (39). The application of SBRT in thymic epithelial tumors requires particular caution. Organ-at-risk constraints in SBRT are highly dependent on dose per fraction, prescription and normalization methods, and target location; therefore, a single universal set of constraints cannot be specified. In clinical practice, thoracic SBRT constraints established for lung cancer are often used as a pragmatic reference and adapted on an individualized basis with strict prioritization of critical mediastinal organs (40). Potential risks include radiation pneumonitis, especially with increased lung dose, as well as rare but potentially severe airway or vascular injury when high-dose regions involve the proximal bronchial tree or great vessels. These considerations explain why SBRT is generally unsuitable for large primary thymomas in the mediastinum, where target volumes are extensive and adjacent to multiple serial organs at risk. In contrast, SBRT may be more appropriately applied to limited-volume recurrences or pleural oligometastatic disease.

Limitations and future directions

Despite notable progress in the management of thymic tumors, major challenges persist. Owing to the rarity of thymic epithelial tumors, high-level evidence from randomized trials remains limited, and most conclusions rely on retrospective studies that are inherently prone to selection bias and confounding. Interpretation of outcomes after PORT is further complicated by several key factors, including heterogeneity in staging systems across eras (Masaoka, Masaoka-Koga vs. TNM classifications), which particularly affects risk stratification in stage II disease. Moreover, many studies pool biologically distinct entities—ranging from indolent thymoma subtypes to aggressive B2/B3 thymomas and thymic carcinoma—thereby obscuring true treatment effects. Margin status is inconsistently reported and variably incorporated into analyses, despite its strong prognostic relevance. Finally, treatment selection bias is unavoidable in retrospective datasets, as PORT is more often administered to patients with adverse pathological features. The ongoing, French-led RADIORYTHMIC randomized trial is specifically investigating PORT vs. observation in Masaoka stage IIb/III thymomas following R0 resection (41). The results of such trials are highly anticipated, as they will be critical for definitively quantifying the impact of radiotherapy on survival in this setting. Other weaknesses remain: data interpretation is further complicated by the heterogeneity across histological subtypes and stages, as many studies aggregate thymoma and thymic carcinoma, making individual interpretation difficult. Furthermore, confirming the true late benefits of modern techniques like intensity-modulated radiation therapy or proton therapy, such as reduced cardiopulmonary morbidity, will require decades of follow-up, as long-term toxicity data are still immature. Evidence for managing recurrence or reirradiation is minimal, with clinical practice often guided only by small case series. Similarly, the optimal integration of radiotherapy with chemotherapy, targeted therapy, or immunotherapy lacks standardized protocols. Preclinical and translational experience has revealed that radiotherapy remodels the tumor microenvironment, potentially enhancing immunotherapeutic sensitivity (42). A final critical consideration is that, despite the long survival of many patients with thymic epithelial tumors, patient-reported outcomes and quality-of-life assessments are rarely incorporated into clinical studies. Although international guidelines are largely concordant regarding PORT for high-risk disease, they diverge in intermediate-risk settings. As summarized in the table, the NCCN and Chinese guidelines favor broader use of PORT for stage II thymoma with high-risk features, whereas the ESMO guidelines adopt a more conservative approach after complete resection, with the Spanish/Spanish Society of Radiation Oncology recommendations emphasizing individualized, risk-based decision-making. In clinical practice, these discrepancies should be addressed through multidisciplinary discussion that integrates pathological risk factors, patient comorbidity, and anticipated long-term toxicity.

Conclusions

In conclusion, the field remains constrained by small cohorts and a lack of randomized controlled trials due to the rarity of thymic epithelial tumors. Future research should prioritize international collaboration to generate robust, high-quality evidence. Ultimately, the goal is to optimize cure rates while minimizing treatment-related toxicity, thereby improving both survival and long-term quality of life.

Acknowledgments

None.

Footnote

Reporting Checklist: The author has completed the Narrative Review reporting checklist. Available at https://med.amegroups.com/article/view/10.21037/med-2025-1-64/rc

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References

1. Roden AC, Szolkowska M. Common and rare carcinomas of the thymus. Virchows Arch 2021;478:111-28. [Crossref] [PubMed]
2. Blum TG, Misch D, Kollmeier J, et al. Autoimmune disorders and paraneoplastic syndromes in thymoma. J Thorac Dis 2020;12:7571-90. [Crossref] [PubMed]
3. Marx A, Chan JKC, Chalabreysse L, et al. The 2021 WHO Classification of Tumors of the Thymus and Mediastinum: What Is New in Thymic Epithelial, Germ Cell, and Mesenchymal Tumors? J Thorac Oncol 2022;17:200-13. [Crossref] [PubMed]
4. Alqaidy D, Moran CA. Thymic Carcinoma: A Review. Front Oncol 2022;12:808019. [Crossref] [PubMed]
5. Detterbeck FC, Nicholson AG, Kondo K, et al. The Masaoka-Koga stage classification for thymic malignancies: clarification and definition of terms. J Thorac Oncol 2011;6:S1710-6. [Crossref] [PubMed]
6. Chiappetta M, Lococo F, Zanfrini E, et al. The International Thymic Malignancy Interest Group Classification of Thymoma Recurrence: Survival Analysis and Perspectives. J Thorac Oncol 2021;16:1936-45. [Crossref] [PubMed]
7. Detterbeck F, Ruffini E. Updates on the Version 9 American Joint Committee on Cancer Staging System for Thymic Malignancies. Ann Surg Oncol 2025;32:7108-11. [Crossref] [PubMed]
8. Zhang Y, Lin D, Aramini B, et al. Thymoma and Thymic Carcinoma: Surgical Resection and Multidisciplinary Treatment. Cancers (Basel) 2023;15:1953. [Crossref] [PubMed]
9. Yuan ZY, Gao SG, Mu JW, et al. Long-term outcomes of 307 patients after complete thymoma resection. Chin J Cancer 2017;36:46. [Crossref] [PubMed]
10. Falkson CB, Vella ET, Ellis PM, et al. Surgical, Radiation, and Systemic Treatments of Patients With Thymic Epithelial Tumors: A Systematic Review. J Thorac Oncol 2023;18:299-312. [Crossref] [PubMed]
11. Fiorino C, Guckemberger M, Schwarz M, et al. Technology-driven research for radiotherapy innovation. Mol Oncol 2020;14:1500-13. [Crossref] [PubMed]
12. Katano A, Minamitani M, Ohira S, et al. Recent Advances and Challenges in Stereotactic Body Radiotherapy. Technol Cancer Res Treat 2024;23:15330338241229363. [Crossref] [PubMed]
13. Katano A. Exploring the Current Challenges and Pioneering Clinical Applications of Stereotactic Radiotherapy in Cancer Treatment. Technol Cancer Res Treat 2025;24:15330338251333658. [Crossref] [PubMed]
14. Katano A, Nozawa Y, Minamitani M, et al. Intrafractional Diaphragm Variations During Breath-Hold Stereotactic Body Radiotherapy for a Liver Tumor Based on Real-Time Registration Between Kilovoltage Projection Streaming and Digitally Reconstructed Radiograph Images: A Case Report. Cureus 2023;15:e48188. [Crossref] [PubMed]
15. Nozawa Y, Ohta T, Katano A, et al. Initial validation of a diaphragm tracking system for multiple breath-hold volumetric modulated arc therapy of abdominal tumors: A phantom study. Med Phys 2024;51:2378-85. [Crossref] [PubMed]
16. Zhang H, Lu N, Wang M, et al. Postoperative radiotherapy for stage I thymoma: a prospective randomized trial in 29 cases. Chin Med J (Engl) 1999;112:136-8.
17. Berman AT, Litzky L, Livolsi V, et al. Adjuvant radiotherapy for completely resected stage 2 thymoma. Cancer 2011;117:3502-8. [Crossref] [PubMed]
18. Singhal S, Shrager JB, Rosenthal DI, et al. Comparison of stages I-II thymoma treated by complete resection with or without adjuvant radiation. Ann Thorac Surg 2003;76:1635-41; discussion 1641-2. [Crossref] [PubMed]
19. Lim YJ, Kim E, Kim HJ, et al. Survival Impact of Adjuvant Radiation Therapy in Masaoka Stage II to IV Thymomas: A Systematic Review and Meta-analysis. Int J Radiat Oncol Biol Phys 2016;94:1129-36. [Crossref] [PubMed]
20. Okumura M, Fujimoto K, Hanaoka N, et al. Medical Practice Guidelines for Lung Cancers including malignant pleural mesotheliomas and thymic tumors according to evidence-based medicine. 2024. Edited by the Japan Lung Cancer Society. Chapter 3 Guidelines for thymic epithelial tumors - Summary of recommendations. Respir Investig 2025;63:1115-9.
21. Tateishi Y, Horita N, Namkoong H, et al. Postoperative Radiotherapy for Completely Resected Masaoka/Masaoka-Koga Stage II/III Thymoma Improves Overall Survival: An Updated Meta-Analysis of 4746 Patients. J Thorac Oncol 2021;16:677-85. [Crossref] [PubMed]
22. He T, Yao J, Chen J, et al. Postoperative radiotherapy for completely resected thymoma and thymic carcinoma: A systematic review and meta-analysis. PLoS One 2024;19:e0308111. [Crossref] [PubMed]
23. Mao Y, Wu S. Treatment and survival analyses of completely resected thymic carcinoma patients. Onco Targets Ther 2015;8:2503-7. [Crossref] [PubMed]
24. Rimner A, Ahmad U, Lobaugh SM, et al. Postoperative Radiation Therapy for Thymic Carcinoma: An Analysis of the International Thymic Malignancy Interest Group/European Society of Thoracic Surgeons Database. J Thorac Oncol 2024;19:626-35. [Crossref] [PubMed]
25. Fukuda M, Yamaguchi M, Yamazaki T, et al. Phase II study of S-1 plus cisplatin with concurrent radiotherapy for locally advanced thymic carcinoma: Results of the LOGIK1605/JART-1501 study. Thorac Cancer 2022;13:2499-506. [Crossref] [PubMed]
26. Fan XW, Yang Y, Wang HB, et al. Intensity Modulated Radiation Therapy Plus Etoposide/Cisplatin for Patients With Limited Advanced Unresectable Thymic Epithelial Tumors: A Prospective Phase 2 Study. Int J Radiat Oncol Biol Phys 2020;107:98-105. [Crossref] [PubMed]
27. Riely GJ, Wood DE, Loo BW, et al. Thymomas and Thymic Carcinomas, Version 2.2025, NCCN Clinical Practice Guidelines In Oncology. J Natl Compr Canc Netw 2025;23:255-69. [Crossref] [PubMed]
28. Girard N, Ruffini E, Marx A, et al. Thymic epithelial tumours: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015;26:v40-55. [Crossref] [PubMed]
29. Rico M, Flamarique S, Casares C, et al. GOECP/SEOR radiotherapy guidelines for thymic epithelial tumours. World J Clin Oncol 2021;12:195-216. [Crossref] [PubMed]
30. Fang W, Yu Z, Chen C, et al. China Anti-Cancer Association Guidelines for the diagnosis, treatment, and follow-up of thymic epithelial tumors (2023). Mediastinum 2024;8:27. [Crossref] [PubMed]
31. Chun SG, Rimner A, Amini A, et al. American Radium Society Appropriate Use Criteria for Radiation Therapy in the Multidisciplinary Management of Thymic Carcinoma. JAMA Oncol 2023;9:971-80. [Crossref] [PubMed]
32. Falkson CB, Vella ET, Ellis PM, et al. Surgical, Radiation, and Systemic Treatments of Patients With Thymic Epithelial Tumors: A Clinical Practice Guideline. J Thorac Oncol 2022;17:1258-75. [Crossref] [PubMed]
33. Santacroce A, Kamp MA, Budach W, et al. Radiobiology of radiosurgery for the central nervous system. Biomed Res Int 2013;2013:362761. [Crossref] [PubMed]
34. Demaria S, Guha C, Schoenfeld J, et al. Radiation dose and fraction in immunotherapy: one-size regimen does not fit all settings, so how does one choose? J Immunother Cancer 2021;9:e002038. [Crossref] [PubMed]
35. Chu C, Liang Y, Lin X, et al. Hypofractionated Radiation Therapy Combined With Weekly Chemotherapy in Patients With Unresectable or Recurrent Thymic Epithelial Tumor: A Prospective, Single-Arm Phase 2 Study (GASTO-1042). Int J Radiat Oncol Biol Phys 2022;114:89-98. [Crossref] [PubMed]
36. Katano A, Kasuga Y, Ohira S, et al. Hypofractionated Radiotherapy as a Standalone Treatment Modality for Locally Advanced Type B2 Thymoma in an Octogenarian Patient: 45 Gy in 15 Fractions. Cureus 2024;16:e51528. [Crossref] [PubMed]
37. Hao XJ, Peng B, Zhou Z, et al. Prospective Study of Stereotactic Body Radiation Therapy for Thymoma and Thymic Carcinoma: Therapeutic Effect and Toxicity Assessment. Sci Rep 2017;7:13549. [Crossref] [PubMed]
38. Pasquini G, Menichelli C, Pastore G, et al. Stereotactic body radiation therapy for the treatment of pleural metastases in patients with thymoma: a retrospective review of 22 patients. J Thorac Dis 2021;13:6373-80. [Crossref] [PubMed]
39. Katano A, Sugahara D, Yasui A, et al. Stereotactic Ablative Radiation Therapy for Sacral Bone Metastasis in Recurrent Type A Thymoma: A Two-Year Follow-Up Demonstrating Pain Reduction and Local Control. Cureus 2024;16:e67142. [Crossref] [PubMed]
40. Fleming C, Cagney DN, O'Keeffe S, et al. Normal tissue considerations and dose-volume constraints in the moderately hypofractionated treatment of non-small cell lung cancer. Radiother Oncol 2016;119:423-31. [Crossref] [PubMed]
41. Basse C, Botticella A, Molina TJ, et al. RADIORYTHMIC: Phase III, Opened, Randomized Study of Postoperative Radiotherapy Versus Surveillance in Stage IIb/III of Masaoka Koga Thymoma after Complete Surgical Resection. Clin Lung Cancer 2021;22:469-72. [Crossref] [PubMed]
42. Xu Y, Chen J, Qiu Y, et al. Radiotherapy and immune microenvironment crosstalk in pancreatic cancer: a comprehensive review of current insights and future directions. Front Immunol 2025;16:1619946. [Crossref] [PubMed]