Early Postoperative Results after Thymectomy for Thymic Cancer: A Single-Institution Experience

Prognostic impact of surgery on thymic malignancies with concurrent or previous extrathymic malignancies: a retrospective analysis from 1998 to 2021

OBJECTIVE

There is limited research on the impact of surgery on the cancer-specific survival (CSS) of patients with malignant thymoma and concurrent or previous extrathymic malignancies (PMTEMs). This retrospective analysis evaluated the prognostic value of surgery in PMTEMs.

METHODS

Data were sourced from the SEER database, encompassing PMTEMs aged 20-90 with confirmed diagnoses and comprehensive clinical information. Patients were categorized into surgical (n = 105) and nonsurgical (n = 25) groups. Propensity score matching (PSM) was employed to mitigate selection bias, resulting in well-balanced baseline characteristics between the groups. Kaplan-Meier curves and the log-rank test were used to investigate the prognostic value of surgery in PMTEMs.

RESULTS

Using PSM, the matching of characteristics between the surgical and nonsurgical groups was well-balanced, ensuring the reliability of subsequent analyses. Pre-PSM, the CSS in the surgical group was significantly better than that in the nonsurgical group (p <.001). Similarly, according to the post-PSM data, the CSS for PMTEMs in the surgical group remained superior to that in the nonsurgical group, which indicates that the survival advantage of the surgical group persisted after PSM (p =.030). Additionally, PMTEMs with smaller thymomas (≤ 5 cm) had a significant advantage in CSS compared to those with larger thymomas (p = .046).

CONCLUSIONS

In conclusion, this study shows that surgery may significantly improve the survival rate of PMTEMs.

A Smartphone App for the Management of Postoperative Home Recovery After Thoracic Surgery Procedures: A Pilot Study Using the Care4Today™ App

Background/Objectives: In recent years, the use of smartphones has significantly increased among populations of almost every age. The aim of our work is to analyze the impact of an application (app) that follows up with the progress of a patient who underwent a thoracic surgery procedure in the first 30 days after discharge. Methods: We prospectively analyzed all the patients included in the pilot study from March 2023 to September 2023. The Care4Today™ app was downloaded and activated by the patient preoperatively. From the day of discharge, the app sent questions related to pain perception, breathing capacity, general clinical conditions, problems with surgical wound and quality of life. In the case of negative responses, clinical staff received an email with an orange (medium problem) or red (serious problem) alert. Results: Among the 96 patients who were included, 82 eventually downloaded and used the app. The mean age of the patients was 60.7 years (range 19-80), and 43 (52.4%) were female. Minimally invasive techniques (VATS or RATS) were used in 76 cases (92.7%). The mean length of in-hospital stay was 5.3 days. Malignancy was the reason for surgery in 66 cases (80.5%). The answer rate was 75.8%. A total of 698 orange alerts and 52 red alerts were sent by the app. Re-hospitalization was needed in two cases (only one case related to our surgical procedure). The app was globally judged as useful in the management of convalescence (with an average rating of 7.4 out of 10). Age was not related to the completion rate of answers. Conclusions: The use of the app Care4Today could prevent unexpected re-hospitalization and possible complications. The patients appreciated the use of this tool, and they found it useful for safer postoperative recovery. No difference according to the patients' age was found regarding the use of the app.

Perioperative outcomes comparison of robotic and video-assisted thoracoscopic thymectomy for thymic epithelial tumor: a single-center experience

BACKGROUND

The advent of robot-assisted thoracoscopic surgery (RATS) has completely revolutionized the modality of thymectomy, which could reportedly achieve equivalent efficacy compared with a minimally invasive approach. This study was conducted to further compare the perioperative outcomes between these two modalities.

METHODS

A retrospective single-center study that included patients receiving either a robotic or video-assisted thoracoscopic (VAT) thymectomy between February 2021 and January 2023 was conducted. All the patients were pathologically confirmed with thymic epithelial tumors. Clinical and pathological characteristics and perioperative outcomes were collected and compared between these two cohorts.

RESULTS

A total of 190 patients were included in this study, with 61 (32.1%) and 129 (67.9%) receiving robotic and video-assisted thymectomy, respectively. The clinicopathological characteristics were not significantly different between these 2 groups. The size of the resected specimens in the RATS cohort was larger than the VATS cohort [median (IQR), 13.0 (8.0-16.0) vs. 9.0 (6.7-12.0) cm, p < 0.001], while the procedural duration was longer for the RATS group than its counterpart [median (IQR), 105 (85-143) vs. 85 (69-115) min, p = 0.001]. Moreover, no other significant difference was observed between these two groups. Since more than half of the robotic thymectomy was performed using a subxiphoid approach, a subgroup analysis was further conducted. Similarly, the robotic group through a subxiphoid approach harbored a longer procedural duration, and the size of the specimens obtained was larger than the VATS group [median (IQR), 14.0 (11.0-16.5) vs. 12.5 (8.5-15.0) cm, p = 0.061].

CONCLUSIONS

The early clinical efficacy of robotic thymectomy was proven comparable to the established VATS approach, and such a modality might have strength when obtaining larger specimens, which could contribute to improving long-term efficacy. Despite the longer procedural duration recorded in the early stage of conducting robotic thymectomy, further accumulation would help decrease the time.

Thymoma resection and myasthenia gravis: what is the neurological outcome in patients older than 65 years?

To increase the neurological results in patients older than 65 years with myasthenia gravis after thymectomy, we retrospectively analysed this outcome in a large bicentric cohort of patients with myasthenia gravis (MG)years, for which surgery was indicated for a concurrent thymoma. From 1/2000 to 2/2022, 502 patients underwent thymectomy for thymic epithelial tumours (TETs) in two high-volume Institutions (167aged more than 65 years). Among them, 66 patients were affected by TET and MG, representing our final study group. The mean age for MG onset was 68.3 ± 6 years.At surgery, the Osserman score 2 was the most diffuse in our cohort (43, 65.1%), followed by 1 (20, 30.3%). In 11 cases, the MG diagnosis coincided with thymoma diagnosis. In the other cases, the interval between MG diagnosis and surgery was 1.7 years ± 1.9. The most common surgical approach was sternotomy (41,62.1%), followed by RATS (14,21.2%). The most frequent TNM stage was T1N0 (75.7%) and most patients had WHO type-B tumour. After radical thymectomy, 58 patients (88%) reported a significant neurological improvement. According to MGFA-PIS, after surgery we had 4 (6%) complete stable remission, 11 (16.7%) pharmacological remission, 43 (65.2%) minimal manifestation, 2 (3%) worsening/death for MG, and 5 (7.6%) unchanged. No association was found between neurological outcome and age of MG onset, kind of pharmacological therapy before surgery, surgical approach (sternotomy vs others), tumour dimension, the ITMIG stage and the preoperative Osserman score. For MG and thymoma-afftected patients over 65 years, thymectomy seems to be an effective treatment to improve neurological symptoms. We suggest to set up clinical trials to explore the neurological efficacy of mini-invasive thymectomy in clinically selected MG patients aged over 65 years.

Perspectives on surgical treatment for thymic epithelial tumors: a narrative review

Background and Objective

Thymic epithelial tumors are relatively rare; thus, mostly retrospective studies and a few prospective randomized controlled trials have been conducted on the treatment and the biomarkers, with no standard therapy established. Indications for extended thymectomy, robot-assisted thoracic surgery, and multidisciplinary treatment are controversial. Here, we considered the prospects of surgical treatment and the possibility of immune checkpoint inhibitor (ICI) treatment for thymic epithelial tumors.

Methods

This is a narrative review; PubMed was searched using a set of keywords related to thymoma and its proposed treatments over the last 5 years.

Key Content and Findings

Thymic epithelial tumors are associated with autoimmune diseases. They are relatively rare, and their pathology remains unclear. Therefore, accumulating more case reports is important. Surgical resection is generally considered for both diagnosis and treatment. If the tumor has a strong tendency to invade surrounding areas, such as thymic carcinoma/thymoma, the diagnosis may be confirmed preoperatively by needle biopsy, and induction chemotherapy may be selected. Surgical resection is the most effective treatment, and complete resection is important. In cases where complete resection is difficult, multidisciplinary treatment is performed. Although there are various obstacles, using ICIs may prove effective for treatment both as preoperative and postoperative chemotherapy in the future, as shown for other cancers. Programmed cell death-ligand 1 (PD-L1) is an immunoinhibitory molecule that suppresses T cells activation, leading to tumor progression. Overexpression of PD-L1 in some cancers is associated with poor clinical outcomes. However, the role of PD-L1 expression as a prognostic factor remains controversial. Therefore, various biomarkers other than PD-L1 have been identified.

Conclusions

We reviewed the latest treatments for thymic epithelial tumors. If new therapeutic agents such as ICIs and molecular-targeted drugs are developed, this review suggests that surgery will become more important not only as therapy but also as part of multidisciplinary treatment that includes tissue collection.

Stage III-IV thymic squamous cell carcinoma in complete pathological remission achieved with thymic cancer resection after immunotherapy combined with chemotherapeutic conversion therapy: a report of two cases from real-world data

Background

Thymic carcinoma, a rare malignancy in the mediastinum, currently lacks standardized treatment options. Although surgery remains a crucial component among traditional therapeutic approaches, the potential benefits of radiotherapy and chemotherapy remain controversial. Nevertheless, a substantial number of patients are diagnosed with advanced tumor growth, posing challenges for achieving complete resection through surgical intervention and resulting in a poor prognosis. In light of the promising antitumor effects demonstrated by immunotherapy in various prevalent cancers, certain studies have shown favorable efficacy in advanced or recurrent thymic cancer cases. However, the incidence of adverse effects induced by immunotherapy in thymic cancer is notably higher compared to other tumor types, with severe and fatal complications being particularly significant. Consequently, there is an urgent need to address the crucial issue of patient selection for immunotherapy in thymic cancer.

Case Description

In this study, we report on the treatment with programmed cell death protein 1 (PD-1) inhibitor therapy combined with chemotherapy conversion therapy for two patients diagnosed with stage III-IV thymic squamous cell carcinoma according to the Masaoka-Koga staging system. The aim of this study was to assess the effectiveness and safety of PD-1 inhibitor combined with chemotherapy conversion therapy in patients with thymic squamous cell carcinoma. Two patients in this cohort, one with stage III and another with stage IV disease, were deemed ineligible for upfront surgical resection. Puncture pathology confirmed the diagnosis of thymic squamous cell carcinoma. Both patients underwent transformation therapy using a combination of PD-1 inhibitors and chemotherapy. Tumor shrinkage was observed in both patients, enabling successful completion of surgery. Postoperative pathology revealed no residual tumor cells, indicating complete pathological remission. Notably, none of the patients experienced grade 3 or higher immunotherapy-related adverse reactions following immunotherapy.

Conclusions

A combination of PD-1 inhibitors and chemotherapy followed by surgery demonstrated improved efficacy and enhanced safety for treating patients with Masaoka-Koga stage III-IV thymic squamous carcinoma and represents a potential novel therapeutic alternative for this disease.