What would your approach be to treatment in a patient with stage IV thymic squamous cell carcinoma who received neoadjuvant carboplatin, paclitaxel, and ramucirumab and underwent R1 resection?  

Would the high PD-L1 level influence your treatment approach?

This case involves a male patient in his 20s with stage IVB primary mediastinal thymic squamous cell carcinoma with lymphogenous spread, who received 6 cycles of neoadjuvant chemotherapy and had a strong radiographic response. He subsequently underwent an R1 resection with one positive lymph node identified. He is now recovering postoperatively and will be presented at the local cardiothoracic tumor board to discuss adjuvant radiation and systemic therapy. Molecular testing revealed high PD-L1 expression (TPS/CPS >70%) and a TP53 mutation (VAF 7.7%).

Case has been complicated by paraneoplastic myasthenia gravis that presented in crisis and required IVIG and steroids.