Thymoma and Thymic Carcinoma: Surgical Resection and Multidisciplinary Treatment

Abstract

Thymoma and thymic carcinoma are the most common tumors of the anterior mediastinum and a relatively rare type of thoracic cancer. The prerequisite for surgery is clinical staging and operative evaluation, both of which are based on medical imaging. The best strategy for treating a thymic epithelial tumor is surgical resection of the organ and surrounding tissue. Thymectomy modalities vary, including open surgery and minimally invasive surgery, and surgeons have used various innovations to better meet the needs of the procedure; therefore, it is critical to select the appropriate procedure based on the patient's characteristics. Evaluation of resectability is the first step of surgical resection for thymic tumors without distant metastasis. The decision regarding unresectability should be made carefully. During subsequent chemotherapy or chemoradiotherapy, reevaluation of whether an area is resectable or not remains essential. Despite numerous technological advances in the surgical treatment of thymic tumors, several contentious issues remain, including the selection of surgical approaches for difficult cases, the selection of video-assisted thoracoscopic approaches, the evaluation of resectability, minimally invasive surgery for locally advanced thymic tumors, lymphadenectomy in thymic tumors, neoadjuvant therapy for thymic tumors, debulking surgery, and salvage surgery. In solving these problems, the surgeon's judgment, surgical experience, and surgical skills are especially important.

Keywords: multidisciplinary treatment; resectability; subxiphoid thymectomy; surgery; thymic carcinoma; thymoma.

Figure 1

Picture of surgical approach. (a). Median sternotomy with a high vascular anastomosis (b). Clamshell incision.

Figure 2

Increased retrosternal space is created by our sternum-lifting system. The relevant anatomy is easily identified, and more complex dissection can be achieved. (a) The right phrenic nerve; (b) The right internal mammary vein; (c) The left phrenic nerve; (d) The left internal mammary vein; (e) Superior vena cava, brachiocephalic trunk, inferior thyroid vein, left innominate vein.

Figure 3

CT scan of 32-year-old patient with thymoma. (a) The relationship of tumor to the top of SVC, which is tumor free. The left innominate vein joins the SVC; (b) The relationship of tumor and the top of superior vena cava which is tumor free; (c) The relationship of tumor and the aorta arch which is potentially tumor free; (d) The relationship of tumor and the aorta branches, which are potentially tumor free.

Figure 4

Subxiphoid approach with double sternal elevation for locally advanced thymic tumors. (a,b) resection of left innominate vein; (c) plasty of left innominate vein; (d) plasty of SVC; (e,f) resection and reconstruction of pericardium; (g) resection of involved lung; (h) prophylactic plication of the diaphragm.