Surgical Outcomes of VATS Versus Open Approaches in Thymic Epithelial Tumors: A Retrospective Single-Center Study

Öz

Objective: Thymic epithelial tumors (TETs) are rare and heterogeneous neoplasms located in the anterior mediastinum, and surgical resection remains the most significant prognostic determinant of survival. The aim of this study was to evaluate the perioperative and oncologic outcomes of patients with TET according to radiologic and clinical staging, comparing two surgical approaches: video-assisted thoracoscopic surgery (VATS) and open surgery. Material and Method: Medical records of 36 patients who underwent surgery for pathologically confirmed TET between June 2013 and December 2020 were reviewed retrospectively. Patients were divided into two groups based on the surgical technique employed: VATS (n=22) and open surgery (n=14). Demographic characteristics, tumor diameter, Masaoka staging, histopathological subtype, duration of drainage, length of hospital stay, postoperative complications, and recurrence rates were analyzed. Results: The mean tumor diameter was 3.58 ± 0.24 cm in the VATS group and 7.34 ± 0.33 cm in the open surgery group (p<0.001). The mean drainage duration and hospital stay were significantly shorter in the VATS group (2.31 ± 0.22 days and 3.68 ± 0.39 days, respectively) compared with the open surgery group (both p<0.001). The proportion of Masaoka stage I disease was significantly higher in the VATS cohort (p<0.05). Postoperative complications were observed exclusively in the open surgery group. During follow-up, recurrence occurred in 1 patient in the VATS group and in 2 patients in the open surgery group. Conclusion: When appropriate patient selection and staging are applied, minimally invasive surgery represents a safe and effective treatment modality for TET. VATS offers advantages such as reduced morbidity and shorter hospitalization in early-stage disease, while maintaining oncologic outcomes comparable to open surgery.

Anahtar Kelimeler

• Thymic epithelial tumor
• VATS
• minimally invasive surgery
• Masaoka staging
• myasthenia gravis.

Timik Epitelyal Tümörlerde VATS ve Açık Yaklaşımların Cerrahi Sonuçları: Retrospektif Tek Merkezli Bir Çalışma

Öz

Amaç: Timik epitelyal tümörler (TET), nadir görülen ve anterior mediastende yerleşim gösteren heterojen neoplazmlardır. Cerrahi rezeksiyon, sağkalım üzerinde belirleyici olan başlıca prognostik faktördür. Bu çalışmanın amacı, TET tanılı hastalarda radyolojik ve klinik evrelemeye göre tercih edilen cerrahi yaklaşımın (VATS vs. açık cerrahi) perioperatif sonuçlar ve uzun dönem onkolojik sonuçlar üzerindeki etkilerini değerlendirmektir. Gereç ve Yöntem: Haziran 2013 – Aralık 2020 tarihleri arasında kliniğimizde opere edilen ve histopatolojik tanısı TET olan 36 hastanın kayıtları retrospektif olarak analiz edildi. Hastalar uygulanan cerrahi teknik esas alınarak VATS (n=22) ve açık cerrahi (n=14) olmak üzere iki gruba ayrıldı. Demografik özellikler, tümör boyutu, Masaoka evresi, histopatolojik alt tip, drenaj süresi, hastanede kalış süresi, postoperatif komplikasyonlar ve nüks oranları karşılaştırıldı. Bulgular: Ortalama tümör çapı VATS grubunda 3,58 ± 0,24 cm iken açık cerrahi grubunda 7,34 ± 0,33 cm idi (p<0,001). Ortalama drenaj süresi ve hastanede kalış süresi VATS ile opere edilen hastalarda sırasıyla 2,31 ± 0,22 gün ve 3,68 ± 0,39 gün olup açık cerrahi grubuna kıyasla anlamlı derecede daha kısaydı (her ikisi için p<0,001). Masaoka evre I hastalık oranı VATS grubunda belirgin olarak yüksekti (p<0,05). Postoperatif komplikasyon yalnızca açık cerrahi grubunda görüldü. Takip sürecinde VATS grubunda 1, açık cerrahi grubunda ise 2 hastada nüks gelişti. Sonuç: Minimal invaziv yaklaşım, uygun evreleme ve hasta seçimi ile TET cerrahisinde güvenli ve etkili bir yöntemdir. VATS, erken evre olgularda daha düşük morbidite ve daha kısa hastanede yatış süresi gibi avantajlar sunmakta; onkolojik sonuçlar açısından ise açık cerrahi ile karşılaştırılabilir performans göstermektedir.

Anahtar Kelimeler

• Timik epitelyal tümör
• VATS
• minimal invaziv cerrahi
• Masaoka evreleme
• myastenia gravis.

Kaynakça

1. Prays J, Ortiz-Villalón C. Molecular landscape of thymic epithelial tumors. Semin Diagn Pathol 2022;39(2):131-136.
2. Suster S. Diagnosis of thymoma. J Clin Pathol 2006;59(12):1238-1244.
3. Rich AL. Epidemiology of thymoma. J Thorac Dis 2020;12(12):7531-7535.
4. Su XY, Wu WL, Liu N, Zhang SF, Li GD. Thymic epithelial tumors: a clinicopathologic study of 249 cases from a single institution. Int J Clin Exp Pathol 2014;7(11):7760-7767.
5. Iorio R, Lennon VA. Paraneoplastic autoimmune neurologic disorders associated with thymoma. Handb Clin Neurol 2024;200:385-396.
6. Koo CW, Lo YC. Good's syndrome: thymoma with acquired immunodeficiency. Am J Respir Crit Care Med 2023;208(3):322-324.
7. Hsu CH, Chan JK, Yin CH, Lee CC, Chern CU, Liao CI. Trends in the incidence of thymoma, thymic carcinoma, and thymic neuroendocrine tumor in the United States. PLoS One 2019;14(12):e0227197.
8. Masaoka A. Staging system of thymoma. J Thorac Oncol 2010;5(10 Suppl 4):304-312.

9. Detterbeck FC, Stratton K, Giroux D, et al. The IASLC/ITMIG Thymic Epithelial Tumors Staging Project: proposal for an evidence-based stage classification system for the forthcoming (8th) edition of the TNM classification of malignant tumors. J Thorac Oncol 2014;9(9 Suppl 2):65-72.
10. Koyasu S. Imaging of thymic epithelial tumors - a clinical practice review. Mediastinum 2024;8:41.
11. Liou DZ, Berry MF, Brown LM, et al. The Society of Thoracic Surgeons expert consensus document on the surgical management of thymomas. Ann Thorac Surg 2024;118(5):975-1004.
12. O'Sullivan KE, Kreaden US, Hebert AE, Eaton D, Redmond KC. A systematic review of robotic versus open and video-assisted thoracoscopic surgery (VATS) approaches for thymectomy. Ann Cardiothorac Surg 2019;8(2):174-193.
13. Chiappetta M, Grossi U, Sperduti I, et al. Which is the best treatment in recurrent thymoma? A systematic review and meta-analysis. Cancers (Basel) 2021;13(7):1559.
14. Marx A, Chan JKC, Chalabreysse L, et al. The 2021 WHO classification of tumors of the thymus and mediastinum: what is new in thymic epithelial, germ cell, and mesenchymal tumors? J Thorac Oncol 2022;17(2):200-213.
15. Patel G, Reddy BVK, Patil P. Maximal thymectomy via mini sternotomy with pleural preservation. South Asian J Cancer 2022;11(3):229-234.
16. Engels EA. Epidemiology of thymoma and associated malignancies. J Thorac Oncol 2010;5(10 Suppl 4):260-265.
17. Zhang Y, Lin D, Aramini B, et al. Thymoma and thymic carcinoma: surgical resection and multidisciplinary treatment. Cancers (Basel) 2023;15(7):1953.
18. Gilhus NE, Tzartos S, Evoli A, Palace J, Burns TM, Verschuuren JJGM. Myasthenia gravis. Nat Rev Dis Primers 2019;5(1):30.
19. Giaccone G, Kim C, Thompson J, et al. Pembrolizumab in patients with thymic carcinoma: a single-arm, single-centre, phase 2 study. Lancet Oncol 2018;19(3):347-355.
20. Kondo K, Monden Y. Therapy for thymic epithelial tumors: a clinical study of 1,320 patients from Japan. Ann Thorac Surg 2003;76(3):878-884.
21. Vaidya Y, Polycarpou A, Gibbs S, et al. Surgical approaches for thymectomy: a narrative review. Mediastinum 2025;9:5.
22. Podobed AV, Kurchin VP, Bambiza AV, Savchenko OG, Malkevich VT. Comparative analysis of thoracoscopic and open thymectomy for thymoma stage I-II. Khirurgiia (Mosk) 2021;(7):31-35.
23. Detterbeck FC, Nicholson AG, Kondo K, Van Schil P, Moran C. The Masaoka-Koga stage classification for thymic malignancies: clarification and definition. J Thorac Oncol 2011;6(7):1710-1716.
24. Xie A, Tjahjono R, Phan K, Yan TD. Video-assisted thoracoscopic surgery versus open thymectomy for thymoma: a systematic review. Ann Cardiothorac Surg 2015;4(6):495-508.
25. Zhang X, Gu Z, Fang W. Minimally invasive surgery in thymic malignancies: the new standard of care. J Thorac Dis 2018;10(Suppl 14):1666-1670.
26. Zahid I, Sharif S, Routledge T, Scarci M. Video-assisted thoracoscopic surgery or transsternal thymectomy in the treatment of myasthenia gravis? Interact Cardiovasc Thorac Surg 2011;12(1):40-46.
27. Cata JP, Lasala JD, Williams W, Mena GE. Myasthenia gravis and thymoma surgery: a clinical update for the cardiothoracic anesthesiologist. J Cardiothorac Vasc Anesth 2019;33(9):2537-2545.
28. Lee GD, Kim HR, Choi SH, Kim YH, Kim DK, Park SI. Prognostic stratification of thymic epithelial tumors based on both Masaoka-Koga stage and WHO classification systems. J Thorac Dis 2016;8(5):901-910.
29. Wright CD, Wain JC, Wong DR, et al. Predictors of recurrence in thymic tumors: importance of invasion, World Health Organization histology, and size. J Thorac Cardiovasc Surg 2005;130(5):1413-1421.
30. Girard N. Therapeutic management of metastatic thymoma and thymic carcinoma. Curr Oncol Rep 2025;27(7):906-914.