Outcome of an Original Video-Assisted Thoracoscopic Extended Thymectomy for Thymoma

doi:10.1016/j.athoracsur.2011.07.054

The Annals of Thoracic Surgery

Volume 92, Issue 6, December 2011, Pages 2000-2005

https://doi.org/10.1016/j.athoracsur.2011.07.054 Get rights and content

Background

Video-assisted thoracoscopic extended thymectomy (VATET) for a thymoma larger than 5 cm in size is still technically difficult.

Methods

Thirty-five patients with clinical Masaoka stage I thymoma underwent an original VATET procedure between November 1998 and December 2009.

Results

All patients successfully underwent VATET, and none required conversion to a median sternotomy. Two patients also underwent partial resection of the lung and pericardium. Although there were no perioperative deaths, 3 patients experienced minor complications. The average tumor size was 5.2 cm. Fifteen tumors were larger than 5 cm. Pathologically, 15 were Masaoka stage I, 19 were stage II, and one was stage III. There were no significant differences in the tumor size between stages I and II. There were two type A, eight type AB, 15 type B1, five type B2, and three type B3 tumors and two thymic carcinomas. Twenty tumors were located in the right side of the body, five were in the middle, and ten were on the left. There were no differences in tumor size or pathologic stage according to location. There were also no differences in pathologic stage according to tumor size. The average follow-up period was 65 months. One patient showed recurrence to the bilateral lung 3.5 years after the procedure. After resection, this patient was free of disease 5 years after the first procedure. There has been no recurrence in any of the other patients.

Conclusions

Our original VATET procedure may be indicated for patients with clinical Masaoka stages I and II thymoma and in those with tumors larger than 5 cm.

Section snippets

Patients and Methods

From November 1998 to December 2009, VATET was attempted at our department in 35 consecutive patients (27 women, 8 men) with clinical stage I tumors. The study was approved by our institutional review board. All procedures were performed after informed consent had been obtained from the patients. None of the patients had any symptoms, and in all cases the anterior mediastinal tumor was found by roentgenogram of the chest. Preoperative assessments included evaluation of pulmonary and cardiac

Results

The clinical stage was evaluated by computed tomography and magnetic resonance imaging of the chest, and the preoperative assessment showed that all the patients had clinical Masaoka stage I tumors. Two patients had myasthenia gravis, and 2 others had pure red aplasia. No patients received neoadjuvant therapy.

All the patients successfully underwent a complete VATET, and none required conversion to a median sternotomy between November 1998 and December 2009. The patient characteristics are shown

Comment

Owing to the recent advances in the instruments and techniques used for video-assisted endoscopic surgical procedures, video-assisted thymectomy is being increasingly used. Many authors [4, 5, 6, 7, 8, 9, 10, 11] have reported their results with minimally invasive surgical procedures by use of thoracoscopy in patients with thymoma, and they have stated that the videothoracoscopic surgical procedure is indicated for well-encapsulated benign mediastinal lesions and contraindicated in patients

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Cited by (38)

Outcomes of extended resection for locally advanced thymic malignancies
2023, Respiratory Medicine and Research
Thymic malignancies are rare tumors about which data are limited. Our objective here was to evaluate the outcomes and risk factors for complications and death in patients who underwent extended surgery to remove thymic malignancies.
We retrospectively included patients who underwent extended resection of locally advanced, nonmetastatic thymic malignancies at our institution. Patients were deemed eligible for resection by a multidisciplinary team. During surgery, priority was given to achieving complete resection rather than to sparing organs.
The 108 patients had a mean age of 53 ± 15 years (range, 9–83); among them, 91 had thymoma, 12 thymic carcinoma, and 5 neuroendocrine tumor. The Masaoka stage was III or higher in 86 patients; examination of operative specimens resulted in downstaging of 22 patients. Tumor-free resection margins were achieved in 98 patients. Overall 5- and 10-year survival rates were 80% and 68%, respectively. Myasthenia gravis, present in 36 patients, was the only independent significant risk factor for major postoperative complications. Age older than 70 years, thymic carcinoma or neuroendocrine tumor, pT3 or pT4 stage, and R1 or R2 resection margins independently predicted death. The number of resected structures was not associated with survival. Thymic carcinoma or neuroendocrine tumor was independently associated with shorter disease-free survival.
In an expert center, extended resection targeting complete resection rather than organ preservation provided good outcomes in patients with locally advanced thymic malignancies. The risk/benefit ratio of surgery should be assessed with special care in patients who are elderly or have myasthenia gravis.
A case of atypical thymic carcinoid mimicking a paraganglioma
2020, International Journal of Surgery Case Reports
Citation Excerpt :
However, concerns regarding the chances of tumour capsule rupture and risk of pleural dissemination using the MIT approach have been raised. Most investigators accept that MIT is technically safe and feasible for TETs with diameters <5 cm [7]. During the last decade, MIT, including robotic thymectomy, tends to be increasing in proposal for larger tumour and more advanced stage patients [1,8].
Thymic atypical carcinoid has high recurrence and metastasis rates due to frequent lymph node metastases. The aim of the study is to report a case of atypical thymic carcinoid mimicking a paraganglioma and to further explain the benefits of using median sternotomy (MS) approach even in thymic epithelial tumours (TETs) sized less than 5 cm.
The patient was a 59-year-old asymptomatic man. During a medical check-up, positron emission tomography/computed tomography (PET/CT) showed a 4.5 cm-diameter thymus with remarkable uptake. Thoracic surgery was performed to completely remove the tumour with lymph node dissection using MS because of possible malignancy. Although MS is accepted as the standard approach for TETs, minimally invasive thoracotomy (MIT) has emerged over recent decades. Maintaining surgical safety is priority; MIT is generally selected in <5-cm-diameter tumours. Here, we considered that the tumour could be resected using MIT. However, because PET/CT showed marked uptake, we selected the MS approach. Thus, MS can be applied even for small-sized TETs.
Thymic atypical carcinoid should be considered when PET/CT shows high-uptake tumours in the anterior mediastinum. Clinicians should consider using the MS approach, even if the tumour is <5 cm.
Thymic Tumors
2018, IASLC Thoracic Oncology
Video-Assisted Thoracic Surgery Thymectomy Versus Sternotomy Thymectomy in Patients With Thymoma
2017, Annals of Thoracic Surgery
This study was designed to evaluate the feasibility of video-assisted thoracoscopic surgery (VATS) and to compare the oncologic outcomes of VATS with those of sternotomy in patients with thymoma.
The clinical outcomes of 2,835 patients with thymic epithelial tumors treated between 1991 and 2010 in 32 Japanese institutions were collected retrospectively. The study compared postoperative complications, positive surgical margins, location of recurrence, and survival in 140 of 142 VATS-treated patients (VATS group) matched with 140 of 1,294 sternotomy-treated patients (ST group) by using propensity scores.
Postoperative complications were observed in 8 patients in the VATS group. The morbidity rate in the VATS group was not different from that of the ST group (p = 0.25). Positive surgical margins were noted in 4 patients (3 in the VATS group; 1 in the ST group). There was no statistically significant difference in the recurrence rate between groups (median follow-up period: 3.7 years in the VATS group; 5.2 years in the ST group). In total the most frequent site of recurrence was pleural dissemination. In the VATS group, the 5-year recurrence-free survival rate was 93.8%, and the 5-year overall survival rate was 97.9%. There was no difference in the recurrence-free survival and overall survival rates between the VATS group and the ST group (p = 0.91 and p = 0.74, respectively).
VATS thymectomy was feasible and comparable to sternotomy for the treatment of patients with thymoma with regard to morbidity, incomplete resection rate, and prognosis. However, additional follow-up is required to evaluate long-term outcomes.
Minimally invasive versus open thymectomy for thymic malignancies: Systematic review and meta-analysis
2016, Journal of Thoracic Oncology
Complete resection is the standard of care for treatment of thymic malignancies. The use of minimally invasive surgery remains controversial. We searched online databases and identified studies from 1995 to 2014 that compared minimally invasive to open thymectomy for thymic malignancies. Study end points included operative blood loss, operative time, respiratory complications, cardiac complications, length of hospital stay, R0 resection, and recurrence. We summarized outcomes across studies using random-effects meta-analysis to account for study heterogeneity. We calculated ORs for binary outcomes and standardized mean differences for continuous outcomes. We calculated incidence rate ratios for the number of recurrences, accounting for total person-time observed in each study. Of 516 potential reference studies, 30 with a total of 2038 patients met the inclusion criteria. Patients with Masaoka stage I or II thymic malignancy constituted 94.89% of those in the minimally invasive surgery (MIS) group and 78.62% of those in open thymectomy (open) group. Mean tumor size was 4.09 cm (MIS) versus 4.80 (open). Of the 1355 MIS cases, 32 were converted to open cases. Patients in the MIS group had significantly less blood loss; however, no significant differences in operating time, respiratory complications, cardiac complications, or overall complications were identified. Length of stay was shorter for patients in the MIS group. When patients with Masaoka stage I and II thymic malignancy only were analyzed, there was no difference in rate of R0 resection or overall recurrence rate. One postoperative death occurred in the open group. The results of this unadjusted meta-analysis of published reports comparing minimally invasive with open thymectomy suggest that in selected patients with thymic malignancy, minimally invasive thymectomy is safe and can achieve oncologic outcomes similar to those of open thymectomy.
Intermediate-term oncologic outcomes after video-assisted thoracoscopic thymectomy for early-stage thymoma
2014, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Factors such as tumor size and invasion should be considered when determining the indications for VATS thymectomy. Thoracoscopic resection of bulky or invasive thymoma remains technically challenging and controversial.10,30 There is currently no consensus regarding the tumor size limit for VATS thymectomy.
To evaluate the impact on patient survival of video-assisted thoracoscopic surgery (VATS) thymectomy for the treatment of early-stage thymoma, by comparing the intermediate-term oncologic outcomes with outcomes after open thymectomy.
Eighty-two patients who underwent complete resection of a Masaoka stage I or II thymoma between November 1998 and December 2011 were reviewed.
The patients included 32 men and 50 women (median age, 57 years; range, 20-90 years), of whom 44 had stage I thymoma and 38 had stage II thymoma. Seventy-one patients underwent VATS, of whom 4 (5.6%) underwent conversion to open thymectomy; the remaining 11 patients underwent planned open thymectomy. Thirty-six patients underwent total thymectomy and 46 underwent partial thymectomy. Operative mortality was nil. The tumor stage, tumor size, and proportion of patients who underwent total thymectomy were not significantly different between the open and VATS thymectomy groups. The median follow-up period was 49 months (VATS, 48 months; open, 52 months). There was a significant difference between the 2 groups for the estimated 5-year overall survival (VATS, 97.0%; open, 79.5%; P = .041) but not in the estimated 5-year recurrence-free survival.
Our findings indicate that the intermediate-term oncologic outcomes after VATS thymectomy for early-stage thymoma are as favorable as outcomes after open thymectomy. Further follow-up is still required to evaluate the long-term outcomes after VATS thymectomy.

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Original articleGeneral thoracicOutcome of an Original Video-Assisted Thoracoscopic Extended Thymectomy for Thymoma

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Comment

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Int J Radiat Oncol Biol Phys

J Thorac Cardiovasc Surg

Follow-up study of thymomas with special reference to their clinical stages

Cancer

World Health Organization histological classification of tumoursHistological typing of tumours of the thymus

Thymoma: the use of minimally invasive resection techniques

Chest Surg Clin North Am

Video-assisted thoracoscopic thymectomy

Ann Thorac Cardiovasc Surg

Technique of transcervical-subxiphoid-VATS “maximal” thymectomy in treatment of myasthenia gravis

Przegl Lek

Early experience with robot-assisted surgery for mediastinal masses

Ann Thorac Surg

[Comparative assessment of the effectiveness of traditional and videothoracoscopic thymectomies in complex treatment of myasthenic thymomas]

Vestn Khir Im I I Grek

Original article
General thoracic
Outcome of an Original Video-Assisted Thoracoscopic Extended Thymectomy for Thymoma