Videothoracoscopic Resection of Stage II Thymoma: Prospective Comparison of the Results Between Thoracoscopy and Open Methods

doi:10.1378/chest.128.4.3010

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Volume 128, Issue 4, October 2005, Pages 3010-3012

https://doi.org/10.1378/chest.128.4.3010 Get rights and content

Study objectives

Although videothoracoscopic (VTS) resection of Masaoka stage I thymoma has been reported to be a less invasive method than open thoracotomy and to achieve a comparable surgical outcome, the usefulness of this method in the treatment of stage II thymoma has not yet been prospectively evaluated. We therefore compared the VTS and open (median sternotomy) methods to see whether VTS resection could be used as successfully to treat stage II thymoma disease.

Design, setting, and patients

Patients (11 women and 11 men) with stage II thymoma were prospectively enrolled between November 1999 and September 2004. Of these, 12 patients (the VTS group) underwent tumor resection using a three-port endoscopic technique, and 10 patients (the open group) underwent tumor excision using a standard sternotomy approach. The diagnosis of all resected thymoma lesions and their stage were confirmed by histopathogic examination.

Measurements and results

Neither group experienced mortality or any major morbidity. The difference in mean age (± SD) between the VTS and open groups (40.2 ± 16.3 years and 47.7 ± 8.5 years, p = 0.202); mean operation time (193.3 ± 79.6 min and 207.5 ± 85.8 min, p = 0.692); mean duration of pleural drainage (4.2 ± 2.1 days and 4.6 ± 2.1 days, p = 0.702); and mean duration of postoperative hospital stay (6.8 ± 2.3 days and 8.9 ± 4.4 days, respectively; p = 0.157) were not statistically significant. However, mean intraoperative blood loss amounts were statistically different (119.2 ± 70.6 mL and 238.5 ± 110.2 mL, respectively; p = 0.006). During the mean follow-up period of 33.9 ± 19.7 months, all patients survived without sign of recurrence, and the mean survival time was not statistically significant (32.3 ± 22.0 months and 35.8 ± 17.5 months, respectively; p = 0.686).

Conclusion

Using careful and skillful technique, the VTS method is an effective treatment of stage II thymoma.

Section snippets

Methods and Materials

Between November 1999 and September 2004, 73 cases of primary mediastinal lesions were resected with curative intent. Of these, 22 patients (11 women and 11 men) with Masaoka stage II thymoma were prospectively enrolled. Twelve of these patients underwent complete thymoma resection using a three-port endoscopic technique (VTS group). The other 10 patients underwent standard medial sternotomy to excise the thymoma (open group). Diagnoses of all resected lesions and their stage were confirmed by

Results

There were no deaths or major complications in both groups and no conversion to thoracotomy in the VTS group. The mean age (± SD) in the VTS and open groups (40.2 ± 16.3 years and 47.7 ± 8.5 years, respectively) was not statistically different (p = 0.202). Mean intraoperative blood loss amounts were significantly different in the VTS and open groups (119.2 ± 70.6 mL and 238.5 ± 110.2 mL, respectively; p = 0.006). The VTS and open groups also did not have significantly different mean operation

Discussion

VTS surgery with the advantages of small incision and rapid recovery offers a better-tolerated approach to treat mediastinal lesions. The objective of VTS and open surgical treatment of thymoma, with or without myasthenia gravis, is the complete removal of the tumor and all involved structures.⁹¹⁰ The resection extent is almost the same for both the VTS and transsternal approaches.¹¹ With the benefit of minimal invasiveness and acceptable resection extent, we consider that resection of thymoma

Conclusion

This study has a limited number of cases because of its experimental intent, and follow-up duration is still not long enough. To our knowledge, this is the first prospective study on thoracoscopic resection of stage II thymoma. In careful and skillful hands, the thoracoscopic method can be performed in an effective way to treat stage II thymoma. The collection of more prospective data is needed to evaluate long-term effectiveness.

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Surgical, Radiation, and Systemic Treatments of Patients With Thymic Epithelial Tumors: A Systematic Review
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Citation Excerpt :
The assessment of the ROB of these included studies can be found in Appendix D. The number of the included studies is reported in Table 1.22–127 All studies, except for one small RCT22 and an abstract of an RCT,23 were observational with low to very low certainty in the evidence.
Thymic epithelial tumors are rare and are classified as thymoma, thymic carcinoma, and thymic neuroendocrine tumors. The objective of this systematic review was to evaluate the treatment options for patients with thymic epithelial tumors.
This systematic review was developed by Ontario Health (Cancer Care Ontario)’s Program in Evidence-Based Care and by the Lung Cancer Disease Site Group. MEDLINE, EMBASE, and the Cochrane Library were searched for studies comparing surgical, radiotherapy, or systemic treatments against any combination of these treatments in patients with thymic epithelial tumors. Meta-analyses were conducted with clinically homogenous studies.
A total of 106 studies were included, mainly from observational studies. There was an overall survival benefit with postoperative radiotherapy for patients with thymic carcinoma (hazard ratio = 0.65, 95% confidence interval: 0.47–0.89) and for patients with thymoma (hazard ratio = 0.70, 95% confidence interval: 0.59–0.82), especially for those with a high risk for mortality. Patients with thymic carcinoma or thymoma had a response to chemotherapy. Selection bias affected the results for studies that evaluated neoadjuvant chemotherapy or minimally invasive surgical techniques. Furthermore, the overall survival benefit found for adjuvant chemotherapy may have been confounded by the administration of postoperative radiotherapy.
For patients with thymoma or thymic carcinoma, the literature is of low quality and subject to bias. There were overall survival benefits with postoperative radiotherapy. The results of this systematic review were used to inform treatment recommendations in a clinical practice guideline. Future large-scale prospective studies that control for confounders are needed.
Comparative effectiveness and cost-efficiency of surgical approaches for thymectomy
2020, Surgery (United States)
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Additionally, the long-term efficacy of VATS and RATS in resection of thymoma is unknown. Indeed, much of the surgical literature on the resection of thymus discusses outcomes with the traditional open approach, with limited studies investigating outcomes of minimally invasive surgical techniques (MIS).4–5,7–8,11–13,21–24 Hence, we sought to investigate the efficacy and safety of the different resection approaches used for thymectomy.
We compared the clinical outcomes and cost-efficiency of surgical approaches (sternotomy-open, video assisted thoracoscopic surgery, and robotic assisted thoracic surgery) for thymectomy.
This is a retrospective review of 220 consecutive patients who underwent thymectomy between January 1, 2007, and January 31, 2017. Surgical approach was determined by the surgeon, but we only included cases that could be resected using any of the 3 approaches.
Open approach was used in 69 patients, whereas minimally invasive technique was used in 151 (97, video assisted thoracoscopic surgery; 54, robotic assisted thoracic surgery). Open surgery was associated with greater total hospital cost ($22,847 ± $20,061 vs $14,504 ± $10,845, P < .001). Open group also revealed longer duration of intensive care unit (1.2 ± 2.8 vs 0.2 ± 1.3 days, P < .001) and hospital stay (4.3 ± 4.0 vs 2.0 ± 2.6 days, P < .001). There were no differences in major adverse clinical outcomes. Long-term recurrence-free survival after resection of thymoma was similar between the groups.
Minimally invasive techniques were equally efficacious compared with the open approach in the resection of the thymus. Additionally, their use was associated with decreased hospital duration of stay and reduced cost. Hence the use of minimally invasive approaches should be encouraged in the resection of thymus.
A national analysis of open versus minimally invasive thymectomy for stage I to III thymoma
2020, Journal of Thoracic and Cardiovascular Surgery
The oncologic efficacy of minimally invasive thymectomy for thymoma is not well characterized. We compared short-term outcomes and overall survival between open and minimally invasive (video-assisted thoracoscopic and robotic) approaches using the National Cancer Data Base.
Perioperative outcomes and survival of patients who underwent open versus minimally invasive thymectomy for clinical stage I to III thymoma from 2010 to 2014 in the National Cancer Data Base were evaluated using multivariable Cox proportional hazards modeling and propensity score–matched analysis. Predictors of minimally invasive use were evaluated using multivariable logistic regression. Outcomes of surgical approach were evaluated using an intent-to-treat analysis.
Of the 1223 thymectomies that were evaluated, 317 (26%) were performed minimally invasively (141 video-assisted thoracoscopic and 176 robotic). The minimally invasive group had a shorter median length of stay when compared with the open group (3 [2-4] days vs 4 [3-6] days, P < .001). In a propensity score–matched analysis of 185 open and 185 minimally invasive (video-assisted thoracoscopic + robotic) thymectomy, the minimally invasive group continued to have a shorter median length of stay (3 vs 4 days, P < .01) but did not have significant differences in margin positivity (P = .84), 30-day readmission (P = .28), 30-day mortality (P = .60), and 5-year survival (89.4% vs 81.6%, P = .20) when compared with the open group.
In this national analysis, minimally invasive thymectomy was associated with shorter length of stay and was not associated with increased margin positivity, perioperative mortality, 30-day readmission rate, or reduced overall survival when compared with open thymectomy.
Advances in treating myasthenia gravis
2020, Neurotherapeutics in the Era of Translational Medicine
Myasthenia gravis (MG) is a prototypical antibody-mediated autoimmune disease affecting various targets at the postsynaptic membrane of the neuromuscular junction. Conventional treatments including pyridostigmine, immunosuppression, immunomodulation, and thymectomy have dramatically reduced mortality and improved disease control. However, the conventional approach is not always successful in reducing the burden of disease and minimizing side effects among MG patients. In the past 10 years, there have been major advances in the therapeutic approach to myasthenia gravis regarding thymectomy, eculizumab, and rituximab that already impact clinical practice. We also review ongoing investigations of novel treatment approaches including neonatal Fc receptor inhibition, subcutaneous immunoglobulin, and 3,4-diaminopyridine that will further advance the management of MG in the next decade.
Comparison of perioperative outcomes of videothoracoscopy and robotic surgical techniques in thymoma
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Citation Excerpt :
Some authors have also compared VATS thymectomy with transsternal thymectomy in their studies but did not identify recurrence for stage II thymoma in the transsternal or VATS groups.15 Another study reported no significant difference in disease recurrence or overall survival between the two groups.18 However, the risks of tumor capsule rupture and the spread of tumor cells to the pleura during thymoma resection reflect the controversial suitability of the VATS approach.19
In this study, the perioperative outcomes of video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) were compared in patients with clinical stage I and stage II thymoma.
The outcomes of 24 patients (10 males and 14 females; mean age: 42.5 years; range: 18–65 years) with diagnoses of clinical stage I and stage II thymoma who underwent VATS in our clinic between April 2010 and March 2018 were compared with the outcomes of 21 patients (8 males and 13 females; mean age: 41.2 years; range: 19–63 years) with the same clinical stages of thymoma who underwent RATS between March 2013 and May 2018. The operative times, postoperative complications, lengths of hospital stay, and total amounts of chest tube drainage of the patients were evaluated.
No postoperative mortality was observed in either group. In general, VATS was performed from the right side, and RATS was performed from the right hemithorax. The operative time was significantly longer in the VATS group than in the RATS group (106.5 min versus 75.7 min, respectively; p < 0.001). In the VATS group, the total amount of postoperative drainage from the chest tubes was greater than that in the RATS group (210 ml versus 325 ml, respectively), and the drainage time was longer in the VATS group than in the RATS group (3 days versus 5 days, respectively; p < 0.001). The length of hospital stay was longer for the patients in the VATS group than for those in the RATS group (5.3 days versus 4.1 days, respectively; p < 0.001). The levels of pain were similar in both groups. No difference in the complication rates was found between the 2 groups.
In the treatment of clinical stage I and stage II thymoma patients, the robotic approach and excision with VATS are techniques with equal reliability. However, the use of robot-assisted thoracoscopic thymectomy technique is advantageous in terms of decreasing the total amount of postoperative drainage and shortening the length of hospital stay.
Utilization of Minimally Invasive Thymectomy and Margin-Negative Resection for Early-Stage Thymoma
2019, Annals of Thoracic Surgery
Minimally invasive thymectomy (MIT) has demonstrated improved short-term outcomes compared with open thymectomy (OT). Although adoption of MIT for thymoma is increasing, oncologic outcomes have not been well characterized.
This was a retrospective cohort study of adult patients from the National Cancer Database who underwent MIT or OT for Masaoka stage I to II thymoma between 2010 and 2014. The primary outcome was R0 resection. Secondary outcomes included MIT use, perioperative mortality, and length of stay.
Nine hundred forty-three patients from 395 hospitals underwent thymectomy for stage I to II thymoma. MIT was performed in 31.3% (59.7% robotic, 40.3% thoracoscopic). Over the study period MIT utilization increased from 21.0% to 40.2% (trend test, p < 0.001). R0 resection was achieved in 83.1% of MITs (86.6% stage I, 72.7% stage II) and 79% of OTs (85.5% stage I, 65.8% stage II). In multivariable analyses, the likelihood of incomplete resection (R1/2) was associated with stage II tumors (odds ratio, 2.51) and World Health Organization B3 histology (odds ratio, 3.66). R0 resection was not associated with surgical approach (p = 0.17) and did not vary with tumor size (trend test, p = 0.90). Mortality rates at 30 and 90 days were 0% and 0.5%, respectively. MIT was associated with significantly shorter lengths of stay than OT (–1.03 days [95% confidence interval, –1.68 to –0.38]).
The use of MIT for resection of early-stage thymoma is increasing and is not associated with lower rates of R0 resection than OT. Reasons for the relatively low rates of R0 resection among all thymectomies requires further investigation, and long-term outcomes data are needed to better define the oncologic effectiveness of MIT.

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Minimally Invasive TechniquesVideothoracoscopic Resection of Stage II Thymoma: Prospective Comparison of the Results Between Thoracoscopy and Open Methods

Study objectives

Design, setting, and patients

Measurements and results

Conclusion

Section snippets

Methods and Materials

Results

Discussion

Conclusion

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

Ann Thorac Surg

Application of videothoracoscopy in surgical treatment of thymoma and histological characteristics of the tumor[in Japanese]

Klinicheskaia Khirurgiia

Minimally Invasive Techniques
Videothoracoscopic Resection of Stage II Thymoma: Prospective Comparison of the Results Between Thoracoscopy and Open Methods