Abstract
Simple SummaryThe trend for thymoma surgery has been to increase utilization of minimally invasive options for resection; however, the primary objective should be to perform an oncological resection. One must consider the stage of tumor, presence of myasthenia gravis, presence of lymphadenopathy, and size of thymoma prior to deciding optimum surgical strategy.A minimally invasive resection of thymomas has been accepted as standard of care in the last decade for early stage thymomas. This is somewhat controversial in terms of higher-staged thymomas and myasthenia gravis patients due to the prognostic importance of complete resections and the indolent characteristics of the disease process. Despite concerted efforts to standardize minimally invasive approaches, there is still controversy as to the extent of excision, approach of surgery, and the platform utilized. In this article, we aim to provide our surgical perspective of thymic resection and a review of the existing literature.
Highlights
When the thymus and thymoma are resected in their entirety, the operation is termed “thymothymectomy”
In 2010, Masaoka himself provided interesting anecdotal reports [8]. By comparing his previous experiences at two different hospitals, he observed that overall survival rates in patients with Stage I and II thymomas undergoing extended thymothymectomy was superior to patients in the thymomectomy series (10-year survival rates of Stage I: 87.1% vs. 66.0%, those of Stage II: 80.6% vs. 60.0%)
Post-thymectomy myasthenia gravis (MG) has been shown to correlate with higher levels of Acetylcholine Receptor antibodies (ARab), which tend to correlate with myasthenic symptoms [9,10]
Summary
Prior reports claim that extensive pleural adhesions, pericardial adhesions, great vessel involvement, and pericardial involvement are contraindications to minimally invasive thymoma resections [2]. Pericardial resection has been previously considered a contraindication to minimally invasive surgery for thymoma, but we have demonstrated technical feasibility despite pericardial involvement, using both the robotic console and VATS approach (Figure 1). The oncological and neurological outcomes of MG patients and thymoma have been studied after robotic surgery [14]. The average operation duration was 126 min, and the average hospital stay was 5.1 days [14] This length of stay (LOS) with robotic surgery is a clear example of the outcome of prolonged surgical time. When performing thymoma resection in MG patients with a robotic, minimally invasive approach, the LOS has been shown to be even shorter [16]. Kumar et al, analyzed outcomes after robotic thymoma resections and found that resection of surrounding structures, conversion to open surgery and postoperative complications were significantly higher in MG patients [17]. The operative approach is left to the discretion of the surgeon and is usually determined by level of expertise and severity of disease
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