Anne Lu1, Alisha Huang1, Conrad Falkson2
1Mediastinum Editorial Office, AME Publishing Company; 2Division of Radiation Oncology, The Kingston Health Sciences Center and Queen’s University, Kingston, ON, Canada
Editor's Note: Tumors of the thymus gland are a group of rare diseases, on which both patients and doctors lack of knowledge and information. International Thymic Malignancy Interest Group (ITMIG) has launched the initiative: May – Thymic Malignancy Awareness Month. ITMIG aims to increase the knowledge of these rare neoplasms among patients and their families, as well as among doctors of various specialties with a series of events including the interviews with mediastinal disease experts released on the journal Mediastinum. Prof. Conrad Falkson, as a prominent expert in the field of thymic diseases, was invited for the interview.
Mediastinum: Would you please highlight the value of radiotherapy in treatment of thymic malignancies (if postoperative radiation therapy can improve overall survival)?
Prof. Falkson: One has to recognize that thymic tumors are epithelial tumors, which arise from the epithelial component of the thymus. We used to talk about benign and malignant tumors. There is no clear distinction. The question of radiation therapy comes in as an adjunct to surgery. The ideal approach is complete resection. But there are patients who have higher risk of recurrence, and this is primarily where the role of radiation is. We would recommend radiation for all the patients with locally advanced tumors. There's a subcategory of more aggressive tumors called thymic carcinomas, which are a different entity. For all the patients in this group, I would also recommend radiation. The primary function of the radiation is to reduce the risk of local recurrence where complete surgical resection has not been achieved.
Mediastinum: What is the role of radiation oncologist in the management of thymic tumors? How to cooperate with experts from other disciplines?
Prof. Falkson: A team approach is the ideal way to manage almost all oncology patients. Radiation oncologists have to work as part of the team. Ideally, all of the patients with thymic tumors should be presented at a tumor board with multi-disciplinary representation. Radiology input is required to help delineate extent of disease and determine resectability of the tumor. Pathologists are needed to look at the histology to confirm the features of the tumor. Surgeons are needed to discuss the surgical options. Radiation oncologists and the medical oncologists are also needed to give input to the discussion. There should not be a haphazard approach, but a team approach with a planned strategy from the beginning.
Radiation oncologists are very much a part of the team, and ideally those who have experience in dealing with thymic tumors are needed. Thymic tumors are different from lung cancer and the approach is different. Specific expertise is needed to help determine when the addition of radiation may benefit the patient and when not.
Mediastinum: What do you think are the biggest challenge for current treatment, especially radiation therapy of thymic malignancies?
Prof. Falkson: Thymic tumors are what we call an orphan or rare tumor site. We lack good, robust prospective studies to clearly define which patients benefit from radiation and exactly what dose is required. The technology in radiation is improving rapidly. Our ability to deliver treatment very accurately has increased significantly over the last decade or two. The questions are: Firstly which patient population will benefit from the addition of radiation? Secondly what exactly is our target, and then what dose should we aim to deliver? Without proper trials and large studies, we won't get definitive answers on this. The next best solution is to employ a collaborative group approach and try to pool data from different centers and different countries around the world. Standardizing of data and nomenclature is vitally important.
Mediastinum: What will be trends of the further clinical practice and research on radiotherapy in treatment of thymic malignancies?
Prof. Falkson: I think I approached that a little earlier when I said our technology is evolving. The trend is toward the delivery of effective treatment while minimizing toxicity and without causing severe side-effects. I think along the lines of 3D CRT (Three Dimensional Conformal Radiation Therapy), IMRT (Intensity Modulated Radiation Therapy), VMAT (Volumetric Modulated Arc Therapy) techniques, as well as possibly proton therapy to reduce heart dose. We do need to identify the patient population that would benefit from treatment and avoid treatment and possible toxicities for those who will not benefit.
Mediastinum: Besides of clinical practice and research, you are also actively participating in teaching. Would you please give some recommendations in training medical students?
Prof. Falkson: I think that medical students need to recognize that thymic tumors are a relatively rare but defined entity. I think what's happening more and more in medicine and rightly so is the awareness of rare tumors, recognizing them and then referring rapidly to a center or at least collaborating with that has specific expertise in managing the rare disease. This should be greatly facilitated by the improved communication using electronic media. ITMIG hosts a monthly virtual tumor board with participation from all disciplines by physicians with specific interest and experience in managing thymic tumors. This tumor board allows anyone anywhere in the world to gain the benefit of expert opinion and these tumor boards comply with international ethics and privacy expectations. Details of how to present a patient and participate are on the ITMIG website itmig.org. I strongly encourage learners to join these meetings. There is a lot to learn.
Mediastinum: Would you please provide some suggestions for junior radiation oncologist in achieving excellent academic performance?
Prof. Conrad Falkson: I think it is very important to have standardized practice at a center and describe policies for this. This allows for data collection within your own center and then the ability to monitor and audit real life outcomes. Ideally this should be done prospectively. I strongly recommend collaboration with other centers to help determine what data should be collected and look to collaborate in existing trials. Data can be pooled with that of other centers allowing for more robust data and considered contributing to national and international databases. We do need to collect data on our patients prospectively. Even a relatively small number of patients on per center basis will help contribute numbers to a much larger database. We do need to collect the data prospectively and then collaborate. There's a lots of opportunities for research at a more basic level and including molecular analyses and studies. Thymic tumors are fascinating tumors as they often have unique features impacting the host immune system and can present with varied paraneoplastc phenomena.
Mediastinum: ITMIG has been continuing its mission to promote the advancement of clinical and basic science pertaining to thymic and other mediastinal malignancies and related conditions. What are your expectations to the future development of ITMIG?
Prof. Falkson: I think ITMIG is a very exciting organization. One has to give recognition to Frank Detterbeck and the group of dedicated people, who founded the ITMIG group 13 years ago. It was a novel concept to create awareness and gain information on a rare tumor. Individual centers and even collaboration of centers within a single country would not provide definitive information in such a rare tumor. International collaboration is what is required. ITMIG brought together a group of people with a common interest in thymic tumors and has since been working to define diagnostic and therepeutic standards which ultimately allow for collection of data sets large enough to draw meaningful conclusions and to inform our treatment making decisions.
ITMIG has taken us from a place where data from less than 100 patients from a single institution was used to devise a staging system for thymic tumors to where we are today able to refer to data collected from more than 10,000 patients from all over the world. I foresee that ITMIG will continue to play a leading role in helping to define and refine the appropriate diagnostic and management parameters for this rare tumor site. Similar groups need to be formed for other rare disease sites and can learn form the experience gained by ITMIG. ITMIG has been growing for more than 10 years, and I think it is going to continue to grow as people recognize the benefit of an organization like this for gathering and pooling international data on rare tumors to get robust data.
Figure 1. Prof./Dr. Conrad Falkson
Dr. Conrad Falkson (Figure 1) is Head of the Division of Radiation Oncology at the Kingston Health Sciences Center and Queen’s University in Kingston, Ontario, Canada. He has practiced as an Academic Radiation Oncologist, Associate Professor at the Department of Oncology, Cancer Center of Southeastern Ontario at the Kingston General Hospital and Queen’s University, Kingston, Ontario since 2004. He the Head of the Radiation Treatment Program at the Cancer Center of Southeastern Ontario and Regional Radiation Clinical Lead, for the Southeast LHIN.
He has manages a busy clinical practice while actively participating in research and teaching. Fields of interest include treatment of thoracic malignancies with a specific interest in mediastinal tumors, breast cancer, GI malignancies, and sarcomas. He has expertise in brachytherapy and has established a comprehensive High Dose Rate Brachytherapy program in Kingston which includes and active lung brachytherapy program and an interstitial Accelerated Partial Breast Irradiation Program.
Always active in Clinical Research and Clinical trials, he is the Kingston PI for the NRG (previously NSABP and RTOG) and served on the GI subcommittee of the NSABP. He was a foundation member of the Ontario Cancer Research Ethics Board. He is a member of the CTG Canada audit and monitoring committee. He is a member of the Cancer Care Ontario (CCO) Gastrointestinal Cancers Advisory Committee, the CCO Sarcoma Services Steering Committee and an active member of the PEBC Lung Disease Site and has been active in the development of evidence-based guidelines.
Dr. Falkson graduated as a medical doctor from the University of Pretoria (South Africa) in 1983. After a short rotation in medical oncology, he entered a training program in surgery at the University of Pretoria. Planning to pursue a career in Surgical Oncology, he spent a year as Senior Research Associate in Oncology learning clinical trials methodology before moving to the United Kingdom to further his surgical training.
While in the UK he realized his interest was oncology and not surgery and enrolled in the training program in Clinical Oncology of the Royal College of Radiology and accepted a registrar position at St. Bartholomew’s and The Royal London Hospitals in London, UK.
In 1996, he returned to South Africa and subsequently joined the academic staff of the Department of Radiation Oncology at the University of the Witwatersrand and the Johannesburg General Hospital. In 2001 he moved his family to Canada. They spent 3 happy years in Thunder Bay before he accepted his current appointment in Kingston.
Provenance and Peer Review: This article was commissioned by the editorial office, Mediastinum for the series “Meet the Professor”. The article did not undergo external peer review.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form. The series “Meet the Professor” was commissioned by the editorial office without any funding or sponsorship. AL reports that she is a full employee of AME Publishing Company. AH reports that she was an intern editor of AME Publishing Company from February 17, 2022 to April 17, 2022. CF reports that he was lead author on the Cancer Care Ontario evidence based guideline for the management of thymic tumors and he has no financial gain or support obtained from this.
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