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Open in new tab Download slide OBJECTIVES Our goal was to compare the oncological outcomes and efficacy between minimally invasive thymectomy (MIT) and open thymectomy (OT) in patients with early or locally advanced thymoma using a multicentre study database. METHODS We retrospectively collected data from 1,239 patients who underwent thymectomy between January 2000 and December 2013, as recorded in the database of the Korean Association for Research on Thymus. We compared the postoperative outcomes of the MIT and OT groups using unmatched and propensity score (PS) matched data. RESULTS We excised the thymoma using MIT and OT in 455 and 784 patients, respectively. We matched 378 patients with Masaoka-Koga stage I or II thymoma by their PS. The operative time, duration of hospital stay and complications were significantly shorter in the MIT group than in the OT group (all P  <   0.005). In the PS matched data, the groups did not show significant differences in the 10-year survival rate (87.7% in OT vs 85.5% in MIT, stage II, mean follow-up duration: 12.9 years in OT vs 11.1 years in MIT), recurrence-free survival (94.0% in OT vs 86.4% in MIT) and R0 resection (97.35% in OT and MIT, P  =   0.59). CONCLUSIONS Compared with OT, MIT was associated with shorter operative times, shorter durations of hospital stay and fewer complications. Long-term survival, recurrence-free survival and complete resection were not significantly different between the OT and MIT groups. Our findings may help physicians track the progress of patients with early or locally advanced thymomas and design treatment plans for them. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Thymectomy is the treatment of choice for thymomatous myasthenia gravis (MG) for both oncological and neurological aspects. However, only a few studies comprising small numbers of patients have investigated post-thymectomy neurological outcomes. We examined post-thymectomy long-term neurological outcomes and predictors of thymomatous MG using a multi-institutional database. METHODS In total, 193 patients (47.3 ± 12.0 years; male:female = 90:103) with surgically resected thymomatous MG between 2000 and 2013 were included. Complete stable remission (CSR) and composite neurological remission (CNR), defined as the achievement of CSR and pharmacological remission after thymectomy, were evaluated. Predictors for CSR and CNR were examined by Cox regression analysis. RESULTS The median duration between MG and thymectomy was 3.1 months. In addition, 161 patients (83.4%) had symptoms less than Myasthenia Gravis Foundation of America clinical classification III. All patients underwent an extended thymectomy; there were no perioperative deaths. The 10-year cumulative probability of CSR and CNR was 36.9% and 69.1%, respectively. Mild preoperative symptoms were a significant predictor for CSR (P  = 0.040), and a large tumour was a predictor for CNR (P  < 0.001). Patients with a large tumour were associated with early MG onset and no steroid treatment. Surgical methods, thymoma stage and histological subtypes were not associated with long-term neurological remission. CONCLUSIONS Large tumour size and preoperative mild symptoms were predictors for long-term neurological outcome in thymomatous MG. Considering that patients with early onset of MG and no immunosuppressive treatment tend to have large tumours, early surgical intervention for patients with thymomatous MG having mild symptoms might be beneficial for controlling neurological outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Thymectomy is a recognized treatment for myasthenia gravis (MG), but the optimal surgical approach is yet to be determined. This study analysed the results in non-thymomatous MG patients treated at our institution using an extended transcervical access with partial upper sternotomy (TC-US), in order to describe cumulative incidence of remission and its predictors. METHODS: In the period 1988-2012, 215 non-thymomatous MG patients underwent thymectomy using the TC-US approach. There were 61 males and 154 females (median age: 33 years). Primary end points were complete stable remission (CSR) and pharmacological remission (PR). Clinico-pathological predictors of CSR/PR were analysed including age, gender, preoperative MG symptom duration, preoperative immunosuppression therapy and disease severity. RESULTS: The median follow-up period was 127 months. The median preoperative duration of MG symptoms was 9 months (interquartile range 4-13). The median operative time was 65 min (range: 45-135). There was no postoperative death. Morbidity rate was 7% (14 patients, no major complication). Ten patients died at the follow-up (3 of MG). MG symptoms improved in 85% (150/176) of the patients. CSR rate was 34%, PR rate was 4%. Cumulative incidence of CSR/PR was 27, 37 and 46% at 5, 10 and 15 years, respectively. Independent predictors of increased CSR/PR rate were age (P = 0.028) and MG symptom duration <6 months (P = 0.013). CONCLUSIONS: Our data suggest that in patients with non-thymomatous MG, thymectomy by TC-US has a remission rate not inferior to those reported after trans-sternal or video-assisted thoracic surgery techniques. The short duration of MG symptoms before thymectomy is a predictor of remission. The technique strikes a reasonable balance between the extent of thymic resection, operative and anaesthesia time, patient acceptance, neurological outcome and costs. [ABSTRACT FROM AUTHOR]

OBJECTIVES The aim of the study was to investigate the distribution of ectopic thymic tissue in the mediastinum and to evaluate the possible relevance of this distribution to the therapeutic yield of thymectomies in patients with myasthenia gravis. METHODS In this prospective autopsy study, mediastinal dissections were performed on 50 cadavers without any previously known intrathoracic pathology. The initial dissection was performed in the same way as during the maximal thymectomy. The second stage consisted of dissecting areas of fatty tissue located out of reach of the standard maximal thymectomy, such as the perithyroid, periaortic, peritracheal and retrotracheal areas, as well as the areas adjacent to the right and left phrenic and recurrent laryngeal nerves. Each specimen was independently examined by two pathologists for ectopic thymic tissue. RESULTS There were 41 (82%) male and 9 (18%) female cadavers, with a mean age of 44.3 years (range: 15–75). Ectopic thymic tissue was detected in 32 out of 50 cadavers (64%). In 10 (20%) cadavers thymic foci were found in locations accessible to the standard surgical intervention and in 22 (44%)—in inaccessible locations. Thymic tissue incidence in individual locations was as follows: retrothyroid, 3 (6%); peritracheal, 5 (10%); retrotracheal, 1 (2%); right phrenic nerve, 2 (4%); left phrenic nerve, 14 (28%); right recurrent laryngeal nerve, 2 (4%); left recurrent laryngeal nerve, 2 (4%) and periaortic, 0. CONCLUSIONS The incidence of ectopic thymic tissue in the mediastinum is common. Although some improvements in the results of thymectomies may be expected with more extensive dissection, the frequent presence of thymic foci in anatomical locations hardly accessible to surgical intervention may be the true limitation for surgical treatment of myasthenia. [ABSTRACT FROM PUBLISHER]

OBJECTIVE The aim of this study was to report a single referral centre experience in the exeresis of mediastinal lesions with robotic surgical system. The outcomes of all patients were retrospectively investigated with special regard to myasthenic and thymomatous patients. METHODS From February 2001 to December 2010, 69 patients (30 males, 39 females), with a mean age of 55.4 years (range 20–81), underwent robotic surgery for treatment of mediastinal lesions. There were 39 thymectomies, 13 paravertebral neurogenic tumour removals, 9 pleuropericardial cyst removals, 3 teratoma excisions, 4 lymphonodal removals and 1 enterogenous cyst excision. Operative time, conversion rate, morbidity and mortality were analysed. RESULTS There were no intra-operative complications, and no mortality. The mean operative time was 124.3 min (range 45–240). Conversion to open surgery occurred in three cases (4.3%). All post-operative complications (7.2%) were conservatively treated. The mean post-operative stay was 4.3 days (range 3–10). For the myasthenic patients (mean follow-up of 18 months), the Myasthenia Gravis Foundation of America change in status resulted improved in 18 (90%) patients and unchanged in 2 (10%) patients. In cases of thymoma, the pathological analysis revealed Masaoka stage I (seven cases), IIA (three cases), IIB (two cases) and III (one case). No disease recurrence occurred at a mean follow-up of 16 months. CONCLUSIONS Our experience suggests that the surgical system was safe in performing mediastinal mass resection, with low morbidity and conversion rate. The robotic system proved useful, especially in a tiny space such as the mediastinum, and appeared to be an effective treatment for myasthenia gravis and for early-stage thymoma. [ABSTRACT FROM AUTHOR]

Abstract: Objective: This study aims to analyse the effectiveness of treatment of myasthenia gravis with three different techniques of thymectomy. Methods: Results of complete remission rates after 5-year follow-up of 60 patients who underwent basic transsternal thymectomies (group A) from 1 January 1996 to 31 December 1997, 75 patients who underwent extended transsternal thymectomies (group B) from 1 January 1998 to 30 June 2000 and 291 patients who underwent transcervical-subxiphoid-videothoracoscopic ‘maximal’ thymectomy (group C) from 1 September 2000 to 31 January 2009 were compared. Results: There were no differences between groups according to patient''s characteristics and postoperative complications’ rate. Ectopic foci of the thymic tissue were discovered in the fat of the neck and the mediastinum in 53.9% of patients from the group B and in 65.9% patients from the group C. After 1, 2, 3, 4 and 5 years of follow-up, complete remission rates were 8.3%, 11.7%, 15.0%, 16.7% and 20.0%, respectively, in group A; 26.7%, 38.7%, 42.7%, 46.7% and 50.7%, respectively, in group B; and 31.5%, 39%, 45.8%, 46.3% and 53.1%, respectively, in group C. The differences between group A and the groups B and C after 1, 2, 3, 4 and 5 years were statistically significant. There were no significant differences between groups B and C. Conclusions: (1) The results of complete remission rates after 5-year follow-up were statistically better in patients with myasthenia gravis (MG), who were operated on with extended transsternal thymectomy and transcervical-subxiphoid-videothoracoscopic ‘maximal’ thymectomy than the patients who underwent basic transsternal thymectomy. (2) The difference can be explained by the removal of ectopic foci of the thymic tissue from the neck and the mediastinum in these patients. [Copyright &y& Elsevier]

Abstract: Background: We sought to evaluate factors influencing long-term survival in 19 patients with primary neuroendocrine tumours of the thymus. Methods: From January 1990 to December 2004, 19 patients (14 males, 5 females; mean age 48.6 years) were surgically treated for a primary neuroendocrine tumour of the thymus. Results: All patients underwent radical R0 thymomectomy and were followed up for a total of 1459 months (median: 69 months; range: 8–180). Nine patients had associated paraneoplastic syndrome. No operative mortality occurred. Two patients underwent re-do surgery because of local recurrence, respectively, 25 and 35 months after surgery. Five patients died of disease, respectively, 51, 70, 95, 131 and 153 months after surgery. One patient died of myocardial infarction with no evidence of disease. Thirteen patients are alive, of which 10 are free from disease and three with disease. The overall 5-year and 10-year actuarial survival rates were 91.6% and 69.8%, respectively (median survival: 153 months). The 10-year survival was evaluated according to histology (typical carcinoid 100%; atypical carcinoid: 66.6%; large cell neuroendocrine tumours: 0%), Masaoka staging (stage I: 100%; stage II: 50%; stage III: 66.6%; stage IV: 0%), presence of paraneoplastic syndrome (no: 87.5%; yes: 0%) and postoperative radiotherapy (yes: 40%; no: 83.3%). Conclusions: The prognosis of primary neuroendocrine tumours of the thymus is related to the grading of the neoplasm, the presence of a paraneoplastic syndrome and to the Masaoka staging but not to the postoperative radiotherapy. [Copyright &y& Elsevier]

Objective: Effects of preoperative steroids on morbidity and mortality after transsternal thymectomy are analyzed. Methods: There were 620 transsternal thymectomies for myasthenia gravis performed in the period 1973–2002. There were 547 patients with nonthymomatous myasthenia, including 17 patients submitted to repeated thymectomy (rethymectomy) and 46 patients with thymoma. There were 522 upper median sternotomies performed in the period 1973–1997 and 98 complete median sternotomies performed in the period 1998–2002 (74 patients without thymoma, 7 thymomas and 17 rethymectomies). One hundred and seventeen of these 620 patients were taking steroids preoperatively. The impact of steroids use on postoperative respiratory insufficiency (ventilator), need for tracheostomy, superficial wound dehiscence, superficial wound suppuration, sternal dehiscence and mortality was analyzed. Results: The rate of morbidity and mortality in the steroids and the no-steroids groups included respiratory insufficiency necessitating the use of a ventilator in 46/503 patients from the no-steroids group (9.1%) and 8/117 patients from the steroids group (6.8%; P=0.4260), need for tracheostomy in 14/503 patients from the no-steroids group (2.8%) and 3/117 patients from the steroids group (2.6%; P=0.9054). Complications with wound healing (including sternal dehiscence, superficial wound dehiscence and superficial wound suppuration) occurred in 47/503 (9.3%) patients from the no-steroids group and in 1/117 (0.9%) patient from the steroids group (P=0.0023). The overall complications rate was 30.6% (154/503) in the no-steroids group and 11.1% (13/117) in the steroids group (P=0.0001). Mortality rate in the no-steroids group was 0.4% (2/503 patients) and none in the steroids group. Morbidity in patients with complete sternotomy was low, respiratory insufficiency in three patients (3.1%), and superficial wound suppuration in one patient (1.0%), no other morbidity and no mortality. Changing morbidity in periods 1973–1980, 1981–1990 and 1991–2002 is analyzed. Conclusions: Preoperative use of steroids for transsternal thymectomy in patients with myasthenia gravis had no negative impact on morbidity and mortality, conversely, the results in patients taking steroids were better, with significant difference of results regarding the overall complication rates and the overall complication rates of wound healing. [Copyright &y& Elsevier]

The author focuses on the surgical management of thymic conditions and the importance of gathering data to standardize the surgical approach for thymic diseases. Topics include the dichotomy between thymectomy and thymomectomy, the importance of determining the size of tumour before adopting a surgical approach to the thymoma, and the efficacy of using Masaoka staging system.

OBJECTIVES The aim of this study was to report a single referral centre experience in robotic extended thymectomy for clinical early-stage thymomas, evaluating its safety, feasibility and efficacy, with special regard to oncological outcomes. METHODS Between April 2002 and February 2011, we retrospectively selected all those patients who underwent robotic thymectomy for clinical early-stage thymomas. Operative time, morbidity, mortality, duration of hospitalization and overall and disease-free survival were analysed. RESULTS There were 14 patients (8 males, 6 females) with a mean age of 65.2 years (range 23–81). One patient suffered from myasthenia gravis. The WHO classifications were: A in two cases, AB in four cases, B1 in three cases, B2 in two cases and B3 in three cases. The Masaoka stages were: I in seven cases, IIA in four cases, IIB in two cases and III in one case. The mean operative time was 139 min. No intra-operative complication or death occurred. Conversion to open surgery was required in two cases. Minor complications occurred in two patients (14.2%) due to pleural effusion. The mean hospitalization was 4.0 days. Five patients underwent adjuvant radiotherapy. All patients were alive with no disease recurrence, with a median follow-up of 14.5 months (range 1–98). CONCLUSIONS Robotic thymectomy is a safe and feasible technique, with a short operative time and low morbidity. Even on a small series with short follow-up, robotic extended thymectomy for thymoma appeared to be an effective treatment for early-stage thymomas. [ABSTRACT FROM AUTHOR]