Anti-angiogenic therapy in thymic carcinoma: a narrative review of current evidence and emerging combinations.

BACKGROUND AND OBJECTIVE: Thymic carcinoma (TC) is a rare and aggressive malignancy with limited systemic treatment options. Although platinum-based chemotherapy has historically been the first-line standard, anti-angiogenic therapy has emerged as an important therapeutic strategy across treatment settings. This review synthesizes current evidence on anti-angiogenic therapies, as monotherapy and in combination with chemotherapy or immunotherapy, and defines their evolving role in TC management. METHODS: A targeted narrative review was conducted using PubMed/MEDLINE, Embase, Google Scholar, ClinicalTrials.gov, conference proceedings, and reference list screening to identify clinical studies of anti-angiogenic therapy in TC published from January 2000 to January 2026. KEY CONTENT AND FINDINGS: Anti-angiogenic therapy demonstrates clinical activity across treatment settings in TC. Yet the magnitude and durability of benefit vary by agent, treatment line, and prior vascular endothelial growth factor (VEGF) exposure. In the first-line setting, VEGFR-2 inhibition with ramucirumab combined with platinum-based chemotherapy has achieved encouraging response rates and prolonged progression-free survival (PFS), though findings require cautious interpretation given small sample sizes and early termination of the trials without phase III confirmation. Multikinase inhibitors, such as sunitinib and lenvatinib, provide durable disease control in previously treated patients, with benefit closely linked to maintaining adequate dose intensity. Anti-angiogenic agents combined with immunotherapy have further expanded therapeutic options, particularly in anti-angiogenic-naïve patients; however, superiority over sequential use of these agents is unproven and additive toxicity is substantial. No validated predictive biomarkers currently guide treatment selection or sequencing. CONCLUSIONS: Anti-angiogenic therapy has emerged as a clinically active component of TC management across treatment lines and in rational combinations. The evidence base nevertheless rests on small phase II studies without confirmatory phase III data or broad regulatory approval. Future progress will depend on optimizing treatment sequencing, improving toxicity management, and advancing biomarker-driven patient selection through collaborative, multi-institutional efforts.