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BACKGROUND Thymectomy is required for the treatment of thymoma-associated myasthenia gravis (MG). However, MG may develop only after thymectomy, a condition known as post-thymectomy MG. This study aimed to investigate the risk factors for post-thymectomy MG in patients with thymoma. METHODS We retrospectively identified 235 patients with thymoma who underwent thymectomy at a single hospital from January 2008 to December 2017: 44 with preoperatively diagnosed MG were excluded, leaving 191 patients in the final analysis. Univariable survival analyses using Cox proportional hazards regression model and Kaplan-Meier estimate were conducted to identify risk factors for post-thymectomy MG. RESULTS Post-thymectomy MG developed in 4.2% (8/191) of the patients with thymoma between 18 days and 108 mo after surgery. Hazard ratios (HRs) of pre- and postoperative anti-acetylcholine receptor antibody (AChR-Ab) titers were 2.267 (P = .002) and 1.506 (P

The patient presented to our hospital with systemic eruptions and scalp hair loss. Six years ago, he underwent extended thymectomy for a diagnosis of thymoma complicated by myasthenia gravis. Three years post-surgery, recurrence manifested as left-sided pleural dissemination and liver metastasis.

Thymoma is a rare epithelial tumor of the thymus gland. Despite rarity, it is the most common tumor of the anterior mediastinum. Surgical resection in the form of extended thymectomy is the gold standard operation. Conventionally and even in the current era of significant advances in the minimally invasive surgery, open transsternal extended thymectomy is considered the gold standard, particularly for advanced-stage tumors. There is however significant evidence now available for the use of minimally invasive approaches for early-stage thymomas. This article aims to discuss the various minimally invasive approaches currently being employed for thymomas.

BACKGROUND: Approaches of thoracoscopic thymectomy for myasthenia gravis (MG) are debatable. The subxiphoid approach is widely utilized recent years for its better visualization of the anterior mediastinum. In the present study, we compared perioperative outcomes and mid-term effects of the extended thymectomy for MG between the subxiphoid approach and the routine right-thoracic approach. METHODS: One hundred and thirty-one MG patients treated with thoracoscopic extended thymectomy were analyzed. Among them, 68 patients were operated on via the subxiphoid approach and the other 63 via the conventional right-side unilateral approach. The patient outcomes were retrospectively reviewed and evaluated. Mid-term clinical outcome was assessed according to the classification system proposed by the Myasthenia Gravis Foundation of America (MGFA). Clinical efficacy and variables influencing outcome were evaluated by the Kaplan-Meier method and Cox proportional hazards regression analysis. RESULTS: Compared with the right thoracic approach, the duration of the procedure via the subxiphoid approach was significantly shorter (P=0.035), the rates of total thymectomy were higher (P=0.028), and the pain scores on postoperative days 1, 3, and 7 were significantly lower (P

We herein report a 63-year-old rippling muscle disease (RMD) patient who presented with painless stiffness, muscle hypertrophy and muscle contractions elicited by mechanical stimulation. He also showed irregular toe jerks and a slightly elevated level of anti-acetylcholine receptor antibody (AChR-Ab). Since he had a mediastinal mass mimicking thymoma, which was later revealed to be a bronchial cyst, he underwent extended thymectomy. The irregular toe jerks disappeared within a week after the operation. The other muscle symptoms completely remitted 27 months after the onset. This is the first report of a sporadic case of RMD with irregular toe jerks that resolved after extended thymectomy.

Introduction Stiff-person syndrome (SPS) is a rare autoimmune neurological disorder. Paraneoplastic SPS associated with malignant tumors such as thymoma occurs in approximately 5% of all SPS cases. We present a rare case of thymoma accompanied by SPS successfully treated using surgery. Presentation of case A 26-year-old woman presented with lower limbs convulsions and gait disturbance and complained of leg pain. Cerebrospinal fluid and blood test results showed a high level of anti-glutamic acid decarboxylase (GAD) antibodies. Computed tomography showed anterior mediastinal tumor suggestive of a thymoma. She underwent extended thymectomy, and her symptoms gradually improved after surgery. No evidence of recurrent thymoma and SPS has been observed over 44 months. Conclusion Surgical treatment would be effective for patients with SPS and thymoma.

This report was about a 60‐year‐old asymptomatic female patient who presented to our clinic with an anterior mediastinal mass found on routine chest computed tomography (CT). Chest CT revealed an irregular poorly enhanced anterior mediastinal mass which showed signs of infiltration to adjacent structures with sparse calcifications. The preliminary diagnosis was thymic carcinoma. The patient underwent extended thymectomy via median sternotomy and complete excision of the tumor. A small draining vein to the left brachiocephalic vein and phleboliths were identified in the tumor. A definitive diagnosis was made of mediastinal venolymphatic malformation (VLM). The patient had an uneventful clinical course and was discharged without further complication. This report highlights that it is possible to misdiagnose mediastinal VLM as thymic carcinoma and could serve as a useful reminder to physicians in the future.

La Timectomía es parte del tratamiento de la Miastenia Gravis debido a que puede producir remisiones de la sintomatología. Los parámetros que determinan el éxito de la cirugía son únicamente cuantitativos: cantidad de medicación o presencia/ausencia de síntomas, sin tomar en consideración los cambios del campo psicosocial. Este estudio, de tipo cualitativo retrospectivo, determina los cambios psicosociales en los pacientes que han sido tratados con Timectomía por Miastenia Gravis no Timomatosa. Variables como sexo, edad, medicación, grupo de Osserman pre y post quirúrgico, escala de Oosterhuis, escala de Millichap y escala de la Fundación Americana de MG, fueron recolectadas de las fichas médicas de los pacientes entre 2003 al 2013. Diecisiete personas cumplieron los criterios de inclusión: Ser mayores de 18 años con diagnóstico de Miastenia Gravis no Timomatosa a los que se les realizó timectomía extendida. Estas personas fueron encuestadas telefónicamente mediante el cuestionario SF-36. Los datos recopilados se analizaron con SPSS 22.0. La calidad de vida, antes y después de la cirugía, fue comparada mediante la prueba no paramétrica de Wilcoxon. El resultado quirúrgico de los pacientes fue: 52.9% tuvo una mejoría clínica significativa de acuerdo a la escala Oosterhuis (remisión total = 5, síntomas leves = 3, discapacidad leve = 1), de estos, el 17.6% presentó una remisión completa estable, sin medicación, y el 35.2% presentó remisión farmacológica con dosis bajas. Los resultados del cuestionario SF-36 indican que los pacientes tratados mejoraron su nivel medio de vida (p

Background: Myastenia gravis (MG) is a neuromuscular junction disorder that causes significant disability in the patient. Plasmaparesis and thymectomy are some therapeutic modalities in MG patients. Patients with MG of 10-15% had thymoma and 60% occurred thymic hyperplasia. Thymectomy may improve MG outcomes in 54-94% of patients (thymoma cases) or 21-42% of patients (cases of thymic hyperplasia). Plasmaparesis perioperatif still controversial. Case report: The 60-year-old man comes with a complaint both eyelids often close and both hands and feet experience fluctuating weakness, improved at rest. Patients with a history of DM and pulmonary TB. On the physical examination obtained eyelid twitch response and improved ptosis on ice test. Laboratory shows hyperglycemia and thrombocytopenia. Electrophysiological examination supports neuromuscular junction lesions. In thoracic and thoracic rectal images the mediastinal mass was obtained. Patients were diagnosed with myastenia gravis with suspected thyroid mediastinal mass. Treatment given mestinon 60 mg every 8 hours peroral, thymectomy plan, platelet transfusion, and plasmaparesis. Obtained a tumor with a large 10x8x7 cm with adhesions around the organ. Microscopic features support a thymoma A. Patients receive perioperative plasmaparesis 1 series (5x administration) divided, 2 preoperative and 3 postoperative times. The patient used mechanical ventilation for less than 24 hours and no residual symptoms. Conclusion: Myastenia gravis grade IIa (Osserman) with thymoma A performed extended thymectomy. Plasmaparesis given pre and post surgery showed clinical improvement and duration of short ventilator use. Good prognosis associated with mild MG degree, no myastenia crisis. Keywords: myastenia gravis, thymectomy, plasmaparesis

Compared to the intercostal approach, subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) is considered to be less invasive as it may cause minimal postoperative pain. Besides, it provides an excellent view of the bilateral pleural cavities. In this paper, we describe our technique and overview a 2-year experience results in this approach for the surgical treatment of anterior mediastinal and pulmonary lesions. In a retrospective study of data collected prospectively between October 2014 and December 2016, 38 patients underwent surgery for an anterior mediastinal tumor or myasthenia gravis at our institution. Intraoperative factors like duration of operation and amount of blood loss were analyzed as well as postoperative ones, including duration of chest drains, amount of postoperative fluid drainage, and length of hospital stay. The median age of patients was 59 years (36-80 years) with 19 females (50%). Overall, 28 patients (74%) underwent extended thymectomy. Seven patients (19%) experienced a combined lung resection and extended thymectomy, 3 (7%) a resection of pericardial (2) or bronchogenic (1) cysts. The median diameter of the lesions was 2.93 cm (1.2-7.7 cm). Postoperatively, 30-day mortality was 0%. Subxiphoid uniportal VATS is a convenient approach for minimally invasive mediastinal surgery. The excellent exposure of the anterior mediastinum and the possibility of conducting complex procedures, such as extended thymectomies and combined mediastinal and pulmonary resections with good results of minimal morbidity, represent the strong points of this technique. Thoracic surgeons experienced in VATS can safely perform subxiphoid uniportal VATS for mediastinal surgery.

Background: To describe a technique of non-intubated uniportal subxiphoid thoracoscopic extended thymectomy.Methods: Data were collected retrospectively. A single 3-cm transverse incision was made below the xiphoid process. This method for extended thymectomy entails adoption of uniportal subxiphoid VATS combined with use of non-intubated anaesthesia for thymoma associated with myasthenia gravis.Results: 10 consecutive patients underwent this procedure successfully. Mean operative time was 102.5 minutes. Conversion to intubated ventilation or thoracotomy was not required. Mean chest tube duration was 3.5 days. Mean postoperative hospital stay was 4.7 days. Histologic examination showed early-stage thymomas. Complications were rare. Quantitative MG scores decreased during follow-up. Conclusions: Patients were uneventfully discharged with fast recovery. This technique may merge the potential benefits of a subxiphoid incision and the non-intubated anesthesia protocol.

Background Myasthenia gravis (MG) is an autoimmune disease and early thymectomy has been recommended. After the introduction of VATS, the safety and effectiveness of carbon dioxide (CO2) insufflation in thoracic cavity (capnothorax) has been continuously controversial. This study aimed to compare the safety and effectiveness of ventilation methods in bilateral video-assisted thoracoscopic extended thymectomy (BVET) with capnothorax.Methods We retrospectively investigated the medical records of MG patients who underwent BVET between August 2016 and January 2018.Patients were divided into two groups: group D (n=26) for one-lung ventilation and group S (n=28) for two lung-ventilation. We set nine anesthesia time points (T0–T8) and collected respiratory and hemodynamic variables including arterial O2 index (PaO2/FiO2).Results The EtCO2 at T0, T1–T4, and T7 were insignificantly higher in group D than those in group S. The SpO2 at T1–T3 and T8 were significantly lower in group D than those in group S. The FiO2 in group S was lower than that in group D at all-time points. The number of PaO2/FiO2 ≤ 300 and PaO2/FiO2 ≤ 200 were significantly higher in group D than those in group S. Hemodynamic variables were not insignificantly different between the two groups at all-time points. The duration of surgery and anesthesia was shorter in group S than that in group D. Conclusions This retrospective study suggests that anesthesia using two-lung ventilation during BVET with capnothorax was a safe and effective method to improve lung oxygenation and reduce the operation and anesthesia time.

The recent increase in robotic thymectomy research has been met with great enthusiasm and expectation. Previous studies with substantial number of cases have shown that robotic extended thymectomy is a safe and alternative approach to open thymectomy, providing patients with myasthenia gravis (MG) and/or thymoma less postoperative pain, quicker postoperative recovery, and improved cosmesis. Besides, retrospective evidence has suggested efficacy of robotic extended thymectomy on MG in terms of improving symptoms and inducing remission. At present, no consensus on the ideal approach for robotic extended thymectomy has been reached. The left-sided approach might be preferable because of anatomical considerations, including better visualization of the contralateral phrenic nerve, easier management of the upper poles, and more comprehensive access to the common sites of ectopic thymic tissue. After accumulating enough experience, we have also adopted this elegant approach in some special care conditions, such as juvenile MG, elderly MG, relapse MG, and MG with a high BMI (≥30 kg/m2). In this chapter, we describe our technique of robotic extended thymectomy via the left-sided approach and discuss on patient selection, perioperative management, and current evidence and controversies.

Background: infiltration of superior vena cava (SVC) is not rare. The extent of SVC resection depends on the width of the area of neoplastic invasion. Aims: To evaluate the safety of extended thymectomy for Thymic Epithelial Neoplasm (TEN) with SVC resection. Methods: Retrospectively review of thymectomy for TEN in the last twenty years according to STROBE methodology. Disease-free survival (DFS) and overall survival (OS) were calculated using the Kaplan – Meier method. A backward stepwise Cox regression multivariate analysis was performed to determine factors associated with long-term outcomes. Results: 78 patients underwent surgery for advanced-stage TEN (1998 - 2019). 17.9% underwent thymectomy with resection of SVC. Thymic carcinoma was a negative prognostic factor (HR = 2.26; 95% CI = 1.82 – 6.18; p = 0.038) at the multivariate analysis. The median OS and the DFS of SVC resected patients were 50 months (range: 5 – 207) and 31 months (range: 5 – 151). There was no significant difference in OS and DFS between SVC resected and not resected patients. Conclusions: SVC resection is a safe and effective procedure and does not seem to affect survival and disease recurrence. This surgical approach is oncologically reliable to allow radical resection of locally advanced TEN.

A 63‐year‐old man presented with bilateral ptosis, and detailed evaluation confirmed ocular myasthenia gravis with three anterior mediastinal masses on computed tomography (CT) of the chest. Extended thymectomy was performed, and pathology revealed two thymic carcinoma and one thymoma. After surgery, the patient is free from recurrence. Synchronous triple thymic carcinomas and thymoma have not been reported. The finding of this case report supports the hypothesis of malignant transformation of thymoma to thymic carcinoma. Thymic carcinoma should be considered in the differential diagnosis of multiple thymic tumours, and extended thymectomy should be the treatment of choice., Synchronous triple thymic carcinomas and thymoma have not been reported. The finding of this case report supports the hypothesis of malignant transformation of thymoma to thymic carcinoma.

Objectives: We examine the therapeutic efficacy of extended thymectomy with blood vessel resection and reconstruction in thymic carcinoma patients with great vessel invasion.Methods: In total 26 patients diagnosed as clinical stage III thymic carcinoma with severe great vessel invasion were enrolled in this retrospective study. Among these patients, 14 cases received adjuvant chemo- and radiotherapy (non-operation subgroup, NOG), the other 12 patients received extended thymectomy with vessel resection and reconstruction followed by the adjuvant treatment (operation subgroup, OG).Results: All surgical procedures went smoothly with no perioperative death. R0 resection was obtained in all surgical cases, and we also observed a lymph node metastasis rate of 38.8%. The overall survival (OS) was 36 months for the whole cohort, 48 and 26 months for the OG and NOG respectively (p = 0.013). The median disease metastasis free survival (DMFS) was 47 months for the OG and 18 months for the NOG (p = 0.019).Conclusion: Extended thymectomy with vessel resection is feasible for patients with clinical stage III thymic carcinoma. Surgery significantly improves the overall survival and the prognosis of clinical stage III thymic carcinoma.

The continuous evolvement of minimally invasive thymectomy over the last decades has potential advantages over trans-sternal thymectomy with similar oncologic outcomes of thymoma and complete remission for myasthenia gravis patients. A variety of different minimally invasive approaches have been described previously. The aim of this article is to present our subxiphoid and subcostal approaches in thymectomy for patients with myasthenia gravis and thymomas and to investigate the early surgical outcomes of these patients. A retrospective analysis was performed of 95 patients who underwent thymectomy via a subxiphoid and subcostal approach for MG and/or thymoma at our department during the period of 2015 to 2017. The clinical characteristics and early surgical outcomes of these patients were reviewed and analyzed. Complete thymectomy and extended thymectomy was accomplished through the subxiphoid and subcostal approach in 93 of the 95 (97.9%) patients. Two patients (3.2%) required conversion to sternotomy for the invasion of a thymoma. The mean operative time was 109 min (range 70–170 min), with the mean estimated blood loss of 47 ml (range 20–350 ml). Postoperative complications included two cases of myasthenic crisis: one case of pleural effusion and one case of wound infection. In a mean follow-up of 31 months no patients showed recurrence of the tumor. In 41 MG patients followed up for 31 months, the improvement rate was 87.8% and the rate of complete remission was 29.3%. Subxiphoid and subcostal thoracoscopic thymectomy may be a safe and feasible approach for treating MG and anterior mediastinal tumors

Thymectomy plays an important role in patients with myasthenia gravis (MG) and video-assisted thoracoscopic (VATS) extended thymectomy has been widely used in recent years. The traditional thoracoscopic procedure requires three intercostal incisions. Our study improved the surgical approach and operation method by using single-utility port thoracoscopy. The aim of this study was to evaluate the effect of single-utility port VATS extended thymectomy for MG.A retrospective analysis was performed in 45 patients with MG who underwent single-utility port VATS extended thymectomy in Beijing Hospital from July 2017 to December 2018. The safety and effectiveness of this surgical approach were summarized.All operations were accomplished successfully, without conversion to thoracotomy, requirement of additional incisions or postoperative death. The mean operation time was (141.3±39.2) min; the mean intraoperative blood loss was (64.2±45.5) mL; the median thoracic drainage duration was 3 days (range 2 days to 8 days); the mean pleural drainage was (890.4±439.1) mL, and the median postoperative hospital stay was 6 days (range 3 days to 91 days). There were 13 cases (28.9%) with postoperative complications, including 5 cases (11.1%) with myasthenia crisis, 6 cases (13.3%) with pulmonary complications, 4 cases (8.9%) with poor incision healing, 4 cases (8.9%) with atrial fibrillation, and 1 case (2.2%) with delayed pericardial hemorrhage. The median follow-up time was 18.5 months (range 12.5 months to 29.2 months). According to the effect of 1 year after surgery, 1 case (2.2%) showed pharmacologic remission; 18 cases (40.0%) showed minimal manifestations; 23 cases (51.1%) got improvement; 1 case (2.2%) showed no changs and 2 cases (4.4%) were worse.Single-utility port VATS extended thymectomy is a safe and feasible minimally invasive procedure for MG. During the perioperative period, special attention should be paid to prevent myasthenic crisis, pulmonary complications, and incision complications.【中文题目：单操作孔胸腔镜胸腺扩大切除治疗重症肌无力：附45例报告】 【中文摘要：背景与目的 胸腺切除已成为重症肌无力（myasthenia gravis, MG）治疗的重要组成部分，近年来，经电视胸腔镜（video-assisted thoracoscopic surgery, VATS）胸腺扩大切除得到广泛应用。传统VATS术式多需3个经肋间切口，本研究改良了手术入路和操作方式，现总结单操作孔VATS胸腺扩大切除治疗MG的效果。方法 回顾性分析2017年7月-2018年12月北京医院胸外科应用单操作孔VATS行胸腺扩大切除术的45例MG患者资料，总结其手术安全性和疗效。结果 本组45例均顺利完成胸腺扩大切除，无中转开胸、增加切口和围术期死亡，平均手术时间（141.3±39.2）min，平均术中出血量（64.2±45.5）mL，中位胸腔引流管留置时间3 d，平均胸腔引流量（890.4±439.1）mL，中位术后住院时间6 d。围术期并发症13例（28.9%），其中肌无力危象5例（11.1%），肺部并发症6例（13.3%），切口愈合不良4例（8.9%），房颤4例（8.9%），迟发性心包积血1例（2.2%）。中位随访时间18.5个月，统计术后1年的疗效，药物缓解1例（2.2%），微小症状表现18例（40.0%），改善23例（51.1%），无变化1例（2.2%），加重2例（4.4%）。结论 单操作孔胸腔镜下胸腺扩大切除术治疗MG的手术安全性和疗效良好，围术期应注意预防肌无力危象、肺部并发症和切口并发症。】 【中文关键词：重症肌无力；胸腺扩大切除；电视胸腔镜；单操作孔】.

Objectives Extended thymectomy is a treatment option for myasthenia gravis (MG), but the surgical indications are controversial. Pathologic features of the thymus can be used to predict surgical outcomes, but there is no reliable method for evaluating these characteristics preoperatively. The purpose of this study was to determine whether anterior mediastinal tissue volume, as measured via 3-dimensional computed tomography (3DCT) volumetry, correlates with serum anti-acetylcholine receptor antibody (AChRAb) levels in patients undergoing thymectomy for myasthenia gravis. Therefore, we investigated the relationships among anterior mediastinal tissue volume determined by 3DCT volumetry and AChRAb levels. Methods The subjects were 28 patients who underwent extended thymectomy and were enrolled retrospectively. We measured volume of the anterior mediastinum and calculated the volumes of more than −30 Hounsfield units (V −30 ) by using 3DCT volumetry and compared them with perioperative AChRAb levels. The significance of their volumes in MG was examined by comparison with 53 patients without MG. Results V −30 values were related to age and were significantly greater in patients with MG than in patients without MG ( P −30 values were correlated positively with preoperative AChRAb levels (ρ = 0.505, P = .006) and inversely with the post/preoperative AChRAb ratio (ρ = −0.453, P = .018). The histologic nonadipose tissue ratio was correlated with the V −30 /volume of the anterior mediastinum (ρ = 0.700, P Conclusions This method for evaluation of the anterior mediastinal tissue volume and AChRAb production may be helpful in establishing a treatment plan for MG.

The approaches to thoracoscopic thymectomy in myasthenia gravis (MG) are debatable. We developed a novel approach via subxiphoid and subcostal arch, with a significantly shorter duration of operation and hospital stay, less estimated blood loss, and lower postoperative pain.From December 2012 to December 2014, 77 myasthenia gravis patients with or without thymoma underwent thoracoscopic extended thymectomy at our hospital. Among them, 41 patients were operated via the subxiphoid and subcostal arch approach and the other 36 via the conventional unilateral approach. The patient outcomes were retrospectively reviewed and evaluated.The thoracoscopic extended thymectomy was performed safely via the subxiphoid and subcostal arch approach. In this approach, no drainage tube was inserted after operation except in the first two patients. Two of the 41 patients were switched to trans-sternal approach due to the tight adhesion between the thymoma and the left innominate vein. No major complications occurred. Compared with the unilateral approach, the duration of the procedure via subxiphoid and subcostal arch was significantly shorter, with less estimated blood loss, shorter hospital-stay and lower postoperative pain (P0.001). The cosmetic scores were comparable between the two groups (P=0.369).The novel subxiphoid and subcostal arch approach is technically feasible and safe. It is an acceptable alternative to conventional thoracoscopic extended thymectomy.

Background: Complete resection is the mainstay of treatment for thymoma, but few studies have investigated the extent of resection on normal thymus. Extended thymectomy is considered the treatment of choice for myasthenic patients with thymoma, while the optimal therapy for non-myasthenic patients is still a matter of debate. The aim of this retrospective study was to compare extended thymectomy vs. thymomectomy in non-myasthenic thymoma patients for (I) oncological outcome, (II) multicentric thymoma occurrence and (III) postoperative myasthenia gravis (MG) development. Methods: A retrospective comparative study was conducted on 92 non-myasthenic patients with completely resected thymoma, according to the extent of resection: extended thymectomy (70 patients) vs. R0-mediastinal thymomectomy (22 patients). Clinical and pathological characteristics, oncological outcome and postoperative MG occurrence were compared between the two study groups. Results: We did not observe any significant differences in gender, age, symptomology, preoperative chemotherapy, histology, tumour size, adjuvant therapy or complications. There were no recorded postoperative mortalities. Stage distribution was different between the two groups: similar percentages of early stage thymoma for both groups were present, but there was a prevalence of stage III for extended thymectomy and stage IV for thymomectomy (P < 0.01). At a median follow-up of 77.4 months (range 1-255 months), no statistically significant differences were recorded in local recurrence (P=0.396), thymoma related deaths (P=0.504), multicentric thymoma occurrence (P=0.742) and postoperative MG development (P=0.343). A high preoperative anti-acetylcholine receptor antibodies (ARAb) serum titer assay was statistically correlated with postoperative MG occurrence (r=0.49, P < 0.05). Conclusions: Thymomectomy appears to be a valid treatment option for non-myasthenic thymoma patients, as this procedure was associated to the same 5-year oncological results, compared to extended thymectomy, for both stage I-II small thymomas and patients with giant unilateral masses, as well as advanced diseases. Moreover, thymomectomy was not associated to an increased rate of postoperative MG.

We adopted a bilateral approach to complete robotic extended thymectomy with the excision of the pericardial fat tissue from both sides and analyzed the initial outcomes. The patient cart was docked first from the left shoulder side. After dissection of the thymus and right pericardial fat tissue, the cart was temporarily rolled out, and the bed was rotated approximately 90° clockwise. The cart was then re-docked from the right-side shoulder, and extended thymectomy was performed via the left-side approach. The outcomes were compared with four cases of unilateral approach performed for mediastinal tumor in the same term. Four patients with myasthenia gravis (two of whom had stage I thymoma) underwent extended thymectomy by the bilateral approach. The mean operative time was 288 min, and the console time was 146 min in the right side and 67 min in the left side. The resected thymus and surrounding adipose tissue were almost symmetrical, in contrast with those obtained via the unilateral approach. No remarkable events were noted. Bilateral extended thymectomy for myasthenia gravis patients was safe and reasonable based on the initial outcomes.

Objective:We performed propensity score (PS) models to compare the outcome of patients with myasthenia gravis (MG) submitted to 2 different surgical approaches: extended transsternal (T-3b) or thoracoscopic extended thymectomy (VATET).Methods:Patients' clinical data were retrieved from the MG database of the C. Besta Neurologic Institute Foundation. In the PS analysis, a matching ratio of 1:1 of the main clinical variables was obtained for the 2 groups of patients and treatment effect was estimated by comparing their outcome.Results:A total of 210 patients met the inclusion criteria, by having a complete set of clinical data, and were included in the PS model; a matched dataset of 122 participants (61 per group) showed an adequate balance of all the covariates. Our analysis demonstrated that 68.9% of patients who had thymectomy by the VATET technique reached the pharmacologic remission/remission status at 2 years from thymectomy compared to 34.4% of those operated on by the T-3b technique (p < 0.001), had a lower INCB-MG score (p < 0.001), and had less muscle fatigability (p = 0.004). Similar results were found considering only nonthymomatous patients with MG. Results were also confirmed by paired statistical tests.Conclusions:Our PS matching analysis showed that VATET is a reliable and effective surgical approach alternative to T-3b in patients with MG who are candidates for thymectomy.Classification of evidence:This study provides Class IV evidence that for patients with MG, VATET is more effective than T-3b thymectomy.

Thymic small cell cancer is a very rare type of thymic epithelial tumor. Lambert-Eaton myasthenic syndrome is a rare paraneoplastic syndrome associated with thymic epithelial tumors. We report an extremely rare case of Lambert-Eaton myasthenic syndrome associated with thymic small cell carcinoma. A 71-year-old man was referred to our institution for a mediastinal tumor and a 2-month history of ptosis, fatigue, and gait disorder. Based on radiologic findings thymoma associated with Lambert-Eaton myasthenic syndrome was diagnosed, and extended thymectomy was performed. After surgery the patient's symptoms had not improved. Anticholinesterase treatment alleviated his symptoms.

We developed a new minimally invasive thoracoscopic technique of extended thymectomy for myasthenia gravis by combining a subxiphoid incision with dual costal margin incisions. In our experience of 31 consecutive cases, this procedure provides a good operative view in the neck region and makes verification of the bilateral phrenic nerves easy. All the patients recovered smoothly with less trauma, less bleeding, less complication, and good cosmetic results. This modified transsubxiphoid approach is a satisfactory procedure for performing extended thymectomy in patients with myasthenia gravis.

Background: Extended thymectomy is indicated for patients with myasthenia gravis (MG) when drug-resistance or dependence is seen. We have employed a technique for subcostal thoracoscopic extended thymectomy (STET) on patients with MG. Methods: Clinical data of 15 eligible patients who underwent STET in our department from February 2015 to November 2015 by the same surgical team were retrospectively analyzed. The operation time, blood loss, duration of postoperative hospital stay, thoracic drainage periods were concerned. Results: All the surgeries were finished successfully without conversion to sternotomy. Mean operation time was 157.53±40.31 min (range, 73–275 min). Mean blood loss was 56.33±7.07 mL (range, 10–200 mL). Mean pleural drainage volume in the first 24 hours was 72.67±17.68 mL (range, 0–250 mL). Mean postoperative thoracic drainage periods were 1.20±0.71 days (range, 0–3 days). Mean duration of postoperative hospital stay was 6.13±0.71 days (range, 3–22 days). Conclusions: This procedure showed satisfactory results for patients with MG. Moreover, the STET approach is more easily for surgeons to fully reveal the bilateral phrenic nerve and the upper thymic poles. We believe that STET is a satisfactory procedure for performing extended thymectomy in well selected patients.

Background Thymectomy is indicated in patients with seropositive myasthenia gravis (SPMG) in patients under the age of 50 and in patient with myasthenia gravis (MG) associated with thymoma. Methods 345 patients with MG who underwent an extended thymectomy from April 1990 to December 2010. Patients were separated into the 4 groups: group with a complete stable remission, pharmacological remission group, group of patients with significant improvement and the group with mild improvement of symptoms. Results In our study, we observed 345 patients with MG and thymectomy. 137 patients (39.71 %) attained the complete stable remission (CSR) and 92 patients (26.67 %) the pharmacological remission (PR). The significant improvement of MG symptomatology was achieved in 95 patients (27.54 %). The rest of 21 patients from total 345 (6.08 %) have reached only a mild improvement. Patients after thymectomy with CSR were in the clinical stage I and IIA, in accordance to the modified Osserman classification and most benefited from the thymectomy. Conclusions The extended thymectomy combined with immunotherapy is the preferred treatment with an expected satisfactory long-term remission rate. Despite the recent improvements in MG medical therapy, thymectomy plays an important role in the otherwise complex treatment of the disease. Because of early diagnosis with thymectomy performed without a delay, patients can achieve significantly more often favorable outcomes and even stable remissions (Tab. 4, Fig. 7, Ref. 17).

Myasthenia gravis (MG) is an autoimmune disease that affects the neuromuscular junction causing fluctuating weakness of skeletal muscles. It is considered a rare disease with an estimated prevalence of 7.77/100,000. Surgical treatment is done by simple or extended thymectomy. Although thymectomy has been used in the treatment of MG since 1941, the role of thymectomy for MG is not completely understood. Perhaps, one of the longest unresolved issues in thoracic surgery is the role of thymectomy in the treatment of MG. Persistent questions and issues involve not only the surgical approach to thymectomy, but also the role of thymectomy itself in the treatment of MG. This article focuses on the review of thymectomy in MG patients.

Background: Minimally invasive thymectomy is fast becoming the preferred approach for myasthenia gravis and non-invasive thymoma. The most commonly employed approach for minimally invasive thymectomy is the lateral thoracic approach. Safe achievement of radical resection requires adequate visualisation of both the phrenic nerves along their entire course. In our experience, such visualisation is rather difficult with unilateral transthoracic approaches. We herein describe our technique and initial experience of 25 cases with subxiphoid robotic thymectomy (SRT) for myasthenia gravis with or without thymoma. To the best of our knowledge, this is the first such report from India. Subjects and Methods: We retrospectively analysed data of patients who underwent SRT at our centre from June 2017 to September 2018. Twenty-five consecutive patients were analysed, and demographic data, total duration of the procedure, console time, blood transfusion requirement, duration of chest drainage, length of hospital stay, pain score on post-operative day (POD) 1 and day of discharge and post-operative morbidity and mortality within 90 days were recorded. Results: A total of 25 patients underwent SRT. All our patients had myasthenia gravis with 4 of them having thymoma. There were 11 males and 14 females with mean age of 29.30 years (range 23–48). The mean console time was 102.85 min (range 88–120) while the mean total operative time was 199.14 (range 180–220). On first POD 1, visual analogue scale score average was 5, and at discharge, it was 2. There was no 30-day or 90-day mortality. All cases of thymoma had a complete R0 resection. Conclusion: Our experience suggests that subxiphoid approach offers a good operative view of the thymus in cervical region along with easy identification of bilateral phrenic nerves. Thus, SRT can be performed safely with comparable results.

Tóm tắt Đặt vấn đề: Phẫu thuật nội soi lồng ngực đã được sử dụng rộng rãi trong điều trị các khối u trung thất trước trong đó có u tuyến ức. Xu hướng hiện nay là ngày càng giảm số “lỗ” và hạn chế độ dài đường rạch nhằm mục tiêu giảm đau sau mổ, giảm dị cảm thành ngực và giảm thời gian nằm viện. Trong báo cáo này, chúng tôi thông báo một trường hợp cắt tuyến ức mở rộng ở một người bệnh nhược cơ bằng phẫu thuật nội soi một lỗ. Phương pháp nghiên cứu: Người bệnh nam 55 tuổi, được chẩn đoán nhược cơ, trên CT: khối u tuyến ức đường kính (ĐK) 3cm. Các thăm dò khác trước mổ bình thường. Người bệnh được chỉ định mổ cắt tuyến ức nội soi lồng ngực một lỗ hai bên. Người bệnh được gây mê toàn thân, sử dụng ống nội khí quản hai nòng. Người bệnh nằm ngửa được cố định vững vào bàn mổ, nghiêng bàn khoảng 600 sang bên phải khi thao tác. Rạch da 3cm khoang liên sườn 4 đường nách giữa, qua đường rạch đưa ống kính nội soi 300 và dụng cụ vào để thao tác, không sử dụng banh sườn. Tiến hành phẫu tích từ bên phải trước, sau khi tuyến ức và tổ chức mỡ trung thất được giải phóng, mở màng phổi trung thất đối bên và qua đó đẩy bệnh phẩm sang bên trái. Sau đó, nghiêng bàn mổ sang bên đối diện. Tương tự như bên phải, rạch da ở vị trí khoang liên sườn 4 dài 3cm. Phẫu tích lấy toàn bộ tổ chức mỡ trung thất và thùy trái tuyến ức và lấy bệnh phẩm. Kết quả: Không gặp biến chứng trong và sau mổ. Người bệnh xuất viện sau 5 ngày. Giải phẫu bệnh Thymoma typ A (Masaoka I). Không có tái phát sau 18 tháng theo dõi. Kết luận: Phẫu thuật nội soi lồng ngực một lỗ hai bên có thể áp dụng hiệu quả trong cắt tuyến ức mở rộng điều trị nhược cơ. Giảm đau sau mổ, giảm thời gian nằm viện và tốt hơn về mặt thẩm mỹ là những ưu điểm của phương pháp này so với các phẫu thuật truyền thống. Abstract Introduction: Video-assisted thoracoscopy is become a widely accepted approach for the resection of anterior mediastinal masses, including thymoma. The current trend is to reduce the number of ports and to minimize the length of incision in order to decrease postoperative pain, chest wall paraesthesia and length of hospitalization. Herein, we reported an extended thymectomy in a patient with myasthenia gravis with bilateral single-port thoracoscopy approach. Material and Methods: A 55-years-old woman with myasthenia gravis was referred to our attention for management of a 3.5 cm, well-capsulated thymoma. All laboratory and cardio-pulmonary tests were within the normal limit; thus, thymoma resection with bilateral single-port thoracoscopy approach was scheduled. Under general anaesthesia and selective intubation, the patient was placed in 600 right lateral decubitus position. A 3cm skin incision was performed in the fourth right intercostal space and through that, a 300 camera and working instruments were inserted without rib spreading. After complete dissection of the thymus and mediastinal fat, the contralateral pleura was opened and through that, the specimen was pushed into the left pleural cavity. Then, the patient was placed in the left lateral decubitus position. Similarly to the right side, a 3-cm incision was performed in the fourth left intercostal space to complete thymoma dissection and the specimen was retrieved. Results: No intra- and post-operative complications were found. The patient was discharged of the hospital in 4th days. Pathological examination revealed a thymoma of type A (Masaoka stage I). No recurrence was found in 18 months of follow-up Conclusion: Bilateral single-port thoracoscopy is an available procedure for management of thymoma associated with myasthenia gravis. Less postoperative pain, reduction of hospital stay and better aesthetic results are the potential advantages of this approach in comparison with traditional technique. Obviously, our results should be validated by larger studies in terms of long-term oncological outcomes. Keyword: Single-port thoracoscopic surgery, thymoma, myasthenia gravis.

Background: The co-existence of myasthenia gravis (MG) and thymoma makes the surgical treatment more complicated and adjuvant radiation more controversial. The aim of this study was to investigate adjuvant radiotherapy for thymoma with MG after extended thymectomy. Methods: A total of 181 patients with both MG and thymoma were recruited between 2003 and 2014 at Tongren Hospital, China. Among all the patients, 157 patients received radiation therapy after surgery (Group A); whereas the other 24 patients did not receive radiation therapy (Group B). According to the time that patients started mediastinal radiation therapy, we subdivided the 157 patients in Group A into subgroups (1-month subgroup, n = 98; 2-month subgroup, n = 7; and 3-month subgroup, n = 52). We then compared the effect of the mediastinal radiation therapy across these different groups using the survival rate, the rate of postoperative myasthenic crisis, and the complete stable remission (CSR) rate as the primary endpoints. Results: There was a significant difference in the occurrence of postoperative myasthenic crisis between 1-month subgroup and Group B (χ2 = 4.631, P = 0.031). The rates of reaching CSR were 32.6% in 1-month subgroup, 25% in 3-month subgroup, and 22.7% in Group B, respectively. The overall survival rates of 1-month subgroup, 3-month subgroup, and Group B were 88.8%, 83.3%, and 77.3%, respectively. Analysis on the Kaplan-Meier survival curves demonstrated that within 8 years after surgery, there was no significant difference in aspects of overall survival and disease-free survival between 1-month subgroup and Group B, and between 3-month subgroup and Group B; over 8 years after surgery, the disease-free survival rates in 1-month subgroup, 3-month subgroup and Group B were 79.4%, 70.6%, and 55.3%, respectively. Conclusions: Adjuvant radiation within 1 month after extended thymectomy may be helpful in controlling postoperative MG, such as decreasing the possibility of postoperative myasthenic crisis, and raising cumulative probabilities of reaching CSR. Key words: Myasthenia Gravis; Prognosis; Radiotherapy; Thymectomy; Thymoma

OBJECTIVES: Video-assisted thoracoscopic extended thymectomy (VATET) is commonly performed bilaterally to remove all the thymic tissue in the mediastinum for the surgical treatment of myasthenia gravis. We hypothesize that the therapeutic efficacy of unilateral thoracoscopic thymectomy (right-sided) is comparable to that of bilateral VATET. METHODS: We retrospectively reviewed 103 consecutive patients who received VATET for non-thymomatous myasthenia gravis (NTMG), with a minimum follow-up period of 36 months. RESULTS: Bilateral VATET was performed in the first 31 patients and right-sided VATET in the following 72. No patients died perioperatively. The operating time in the right-sided VATET group was significantly shorter than that in the bilateral VATET group (169.3 ± 19.3 vs 152.6 ± 20.7 min, P

Background: To present the technique of minimally invasive extended thymectomy performed through the uniportal subxiphoid approach, with double elevation of the sternum for nonthymomatous myasthenia gravis (MG). Methods: Operative technique: the whole dissection was performed through the 4–7 cm transverse or longitudinal subxiphoid incision with use of videothoracoscope. The sternum was elevated with two hooks connected to the sternal frame (Rochard bar, Aesculap-Chifa, Nowy Tomysl, Poland). The lower hook was inserted through the subxiphoid incision and the superior hook was inserted percutaneously, after the mediastinal tissue including the major mediastinal vessels were dissected from the inner surface of the sternum. The fatty tissue of the anterior mediastinum and the aorta-pulmonary window was completely removed. Results: There were four patients in the period 1.1.2017–30.4.2017. There was no mortality and morbidity. Conclusions: The uniportal subxiphoid approach combined with double elevation of the sternum enabled very extensive thymectomy in case of thymoma.

Objective: Thymectomy via transsternal approach is the accepted standard surgical procedure within the treatment of myasthenia gravis (MG) cases for many years. In our study, minimally invasive thymectomy technique and its results are presented. Material and Method: Patients who were diagnosed myasthenia gravis by the neurology clinics and were performed extended thymectomy in our clinic between 2005 – 2016 are included to our study. Results: In our clinic 28 cases, diagnosed with non-thymomatous MG, underwent extended thymectomy; 11 patients were operated via sternotomy and 17 patients were operated via Video Assisted Thoracoscopic Surgery (VATS). The study group included 19 female and 9 male patients. While the sternotomy group included 5 male and 6 female patients; the VATS group had 4 male and 13 female patients (p=0,212). Whereas the median age for the sternotomy group was 40,82+16,1 years, the median age for the VATS group was 33,7+11,6 (48,05) years (p=0,082). Peroperative mortality was not seen in both groups, yet there was morbidity for 1 patient in each groups (p=0,833). The length of hospitalization in sternotomy group was 6,2+2,2 days and in VATS group it was 2,8+1,2 days. (p=0,019). Conclusion: Complete or extended thymectomy within the treatment of non-thymomatous is a safe and an effective method. In the experienced clinics minimally invasive techniques are appropriate choices for the patients upon with the lack of mortality and viable morbidity rates.

Purpose To depict the long-term outcome of patients with myasthenia gravis after thymectomy in combination with immunotherapy, and the factors that may potentially affect the outcome. Methods The 306 patients with myasthenia gravis who underwent extended thymectomy from January 1984 to December 2011 at Tongji Hospital were retrospectively evaluated. Results The patients consisted of 174 cases with thymoma and 132 cases without thymoma. Pharmaceutical treatment was tailored for each case during follow-up. Nine patients with thymomatous myasthenia gravis died during the perioperative period, and 297 patients were followed for 8.6 years. By their latest visits, 241 patients (81.1%) gained satisfactory efficacy, 24 cases died (8.1%), and 32 cases (10.8%) remained unchanged or deteriorated. Favorable factors for satisfactory efficacy included the presence of ocular myasthenia gravis before operation, no presence of thymoma, and lack of concomitant diseases. It is interesting to mention that, patients with non-thymomatous myasthenia gravis obtained significantly higher rates of complete stable remission and clinical remission than the patients with thymomatous myasthenia gravis. Conclusions Extended thymectomy combined with immunotherapy is a preferred treatment with a satisfactory long-term remission rate. Patients with non-thymomatous myasthenia gravis have a much more promising prognosis than the patients with thymomatous myasthenia gravis. However, appropriate caution must be taken to discontinue pharmaceutical therapy as relapse remains a major concern after a patient who has already undergone thymectomy becomes symptom-free.

Background The aim of this study was to report a single referral center experience in robotic extended thymectomy for clinical early stage thymomas, evaluating its safety, feasibility and efficacy, with special regard to oncological outcomes. Methods Between January 2009 and December 2012, we retrospectively selected patients who underwent robotic extended thymectomy for clinical early stage thymomas. Operative time, morbidity, mortality, duration of hospitalization, and overall and disease-free survival were analyzed. Results There were 23 patients (15 males, eight females) with a mean age of 49.3 years (range 20–66). There were no intra-operative complications, and no mortality. The mean operative time was 85.2 minutes (range 60–180). No patient underwent conversion to open surgery. All post-operative complications (4.3%) were conservatively treated. The mean post-operative stay was 3.6 days (range two to nine). The pathological analysis revealed Masaoka stage I (21 cases) and II (two cases). No disease recurrence occurred at a mean follow-up of 24.8 months. 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.

Background In thymoma patients without myasthenia gravis, it is debatable whether thymectomy should be performed in addition to thymomectomy, the procedure in which the thymoma alone is resected. In this study, we proposed to compare the surgical results in early-stage nonmyasthenic thymoma patients who underwent thymomectomy with and without extended thymectomy. Methods A total of 95 patients without clinical evidence of preoperative myasthenia gravis, who underwent surgery for early-stage thymoma (stages I and II), were selected for the study. Thymomectomy with extended thymectomy was performed through median sternotomy on 42 patients, whereas thymomectomy without thymectomy was carried out through video-assisted thoracoscopic surgery (VATS) or thoracotomy in 53 patients. Outcomes and surgical complications were compared between the two patient groups. Results The median duration of the follow-up was 57 months (6–121 months). Three patients, one in the thymomectomy group (1.9%) and two in the thymomectomy with thymectomy group (4.5%), developed tumor recurrences. Tumor recurrence rates between the two groups were not significantly different. During the follow-up period, we did not document the development of postoperative myasthenia gravis in any of the patients enrolled. Postoperative opioid use, the number of days of drainage, and hospitalization length were lower in patients undergoing thymomectomy through thoracotomy or VATS. Conclusions In early-stage nonmyasthenic thymoma patients, thymomectomy without thymectomy through thoracotomy or VATS was associated with lower morbidity and shorter hospitalization, than thymomectomy with extended thymectomy. Postoperative myasthenia gravis did not develop in any of the patients enrolled in our study during the 57-month median follow-up period. Overall tumor recurrence rates were not significantly different between these two patient groups. On the basis of our results, we conclude that thymomectomy without thymectomy through thoracotomy or VATS is justified for early-stage nonmyasthenic thymoma patients, and longer follow-up is needed to investigate the necessity of thymectomy in this group.

Background Complete open surgical resection is the standard treatment for thymoma and myasthenia gravis. We evaluated the feasibility of bilateral video-assisted thoracoscopic extended thymectomy, and compared it to surgery via sternotomy. Methods From 2011 to 2014, 43 patients undergoing thymectomy were divided into 2 groups: 23 underwent video-assisted thoracoscopic extended thymectomy, and 20 had thymectomy via sternotomy. The primary outcomes were postoperative pain score (visual analog scale) at 6, 12, 24, 48, and 72 h, and 1-month postoperatively, and morphine consumption in the first 48 h. Secondary outcomes were surgical and clinical results. Results There were no significant differences between the 2 groups in terms of demographics and preoperative clinical data. Compared to the sternotomy group, the video-assisted thoracoscopic thymectomy group had lower pain scores and morphine consumption at all time points, significantly less operative blood loss and chest drainage volume, and shorter hospital stay. The rates of improvement in myasthenia gravis were 85% and 86% in the video-assisted thoracoscopic thymectomy and sternotomy groups, respectively. No recurrence of thymoma was found in either group (median follow-up 27 months). Conclusions Our results seem to confirm that in selected cases, video-assisted thoracoscopic thymectomy allows complete resection of thymus and perithymic tissue, similar to sternotomy but with the known advantages of minimally invasive surgery including less pain and a good cosmetic result.

Background: To present the technique of single-port video-assisted thoracoscopic mediastinal tumor resection, which includes limited thymectomy, extended thymectomy, cyst excision and posterior mediastinal tumor excision, and the early results of resection with the use of this technique. Methods: Forty patients with mediastinal tumors were treated with single-port thoracoscopic mediastinal resection at Chang Gung Memorial Hospital between April 2014 and September 2015. The surgical intervention was performed through the fourth or fifth intercostal space at the anterior axillary line. A 5 or 10 mm 30 degree video camera and working instruments were employed simultaneously at this incision site throughout the surgery. Results: Among the 40 cases included in the final analysis, 10 extended thymectomies, 7 limited thymectomies, nine cyst excisions and 14 tumor excisions were performed successfully without the need for conversion. For the 40 patients who underwent single-port video-assisted thoracoscopic surgery (VATS), the mean operation time was 97.3±31.2 min and the average blood loss was 29.75±39.77 mL. The average length of the incision wound was 3.22±0.79 cm and the average length of postoperative hospital stay was 3.72±1.63 days. There were no mortalities and mobility was achieved within 30 days postoperatively. Conclusions: Our preliminary report suggests that uniportal VATS for mediastinal tumor resection is a promising and safe technique within a short-term period.

Background Video-assisted thoracoscopic extended thymectomy (VATET) for a thymoma larger than 5 cm in size is still technically difficult. Methods Thirty-five patients with clinical Masaoka stage I thymoma underwent an original VATET procedure between November 1998 and December 2009. Results All patients successfully underwent VATET, and none required conversion to a median sternotomy. Two patients also underwent partial resection of the lung and pericardium. Although there were no perioperative deaths, 3 patients experienced minor complications. The average tumor size was 5.2 cm. Fifteen tumors were larger than 5 cm. Pathologically, 15 were Masaoka stage I, 19 were stage II, and one was stage III. There were no significant differences in the tumor size between stages I and II. There were two type A, eight type AB, 15 type B1, five type B2, and three type B3 tumors and two thymic carcinomas. Twenty tumors were located in the right side of the body, five were in the middle, and ten were on the left. There were no differences in tumor size or pathologic stage according to location. There were also no differences in pathologic stage according to tumor size. The average follow-up period was 65 months. One patient showed recurrence to the bilateral lung 3.5 years after the procedure. After resection, this patient was free of disease 5 years after the first procedure. There has been no recurrence in any of the other patients. Conclusions Our original VATET procedure may be indicated for patients with clinical Masaoka stages I and II thymoma and in those with tumors larger than 5 cm.

OBJECTIVES: Thymoma is a relatively rare tumour and is uniquely associated with autoimmune diseases such as myasthenia gravis (MG). However, the factors involved in the prognosis of thymoma remain under discussion. METHODS: We retrospectively reviewed 162 patients who underwent extended thymectomy via median sternotomy for thymoma at our institute from 1976 to 2009. The histological subtype was classified according to the World Health Organization (WHO) histological classification system. Survival analysis was performed using the Kaplan–Meier method and the Cox proportional hazards model. RESULTS: Tumours comprised 7 Type A tumours, 38 Type AB, 49 Type B1, 45 Type B2 and 23 Type B3. Various types of autoimmune diseases were comorbid in 66 patients. The median follow-up period was 94 months, and 14 patients experienced recurrence. Seven patients died of recurrent tumour, and 18 patients died of causes other than thymoma. The 10-year overall survival was 85.7%, and the 10-year disease-free survival (DFS) was 76.8%. The 10-year DFS was 62.5% for Type A, 86.3% for Type AB, 91.5% for Type B1, 77.1% for Type B2 and 26.3% for Type B3. In multivariate analysis, age, Type B3 and MG were determined as prognostic factors for survival. On the other hand, Masaoka’s stage did not influence survival. CONCLUSIONS: Type B3 classified by the WHO histological classification system is a poor prognostic factor for survival of thymoma after extended thymectomy. Association with MG is possibly an indicator of poor survival. Age is an independent prognostic factor, suggesting favourable prognosis of thymoma after surgical treatment. Considering thymoma is a rare tumour, it would be necessary to build a multi-institutional database as soon as possible.

To clarify the efficacy of a right-sided video-assisted thoracoscopic extended thymectomy (RtVATET) as a surgical alternative for myasthenia gravis (MG) and to determine the optimal timing for a thymectomy.Thirty-three patients who underwent RtVATET in two institutes were enrolled in this study. Another 66 paired, traditional trans-sternal extended thymectomy (TET) patients from the registered database were used to compare these two surgical modalities for MG.Mean blood loss was 88.5 ml in RtVATET and 226.8 ml in TET group patients (P0.001). Mean operation duration was 207.3 min for RtVATET and 172.8 min for TET patients (P = 0.003). Complete stable remission (CSR) rates and total improvement rates for the RtVATET and TET patients were 42.4% vs 60.6% (P = 0.087) and 87.9% vs 90.1% (P = 0.637), respectively. Furthermore, when we focused on the minor grades (classes I and IIa), TET groups showed significantly better CSR than the RtVATET groups (P = 0.012), but there was no statistically significant difference for the more severe grades (classes IIb and III, P = 0.827).Both RtVATET and TET are effective for treating MG, although this study does indicate an advantage for TET. We suggest that a thymectomy should therefore be performed earlier, or that the procedures should be extensive enough to remove all of the tissue that contains thymic tissue.

A method of videothoracoscopy-assisted extended thymectomy procedure performed through a movable small access window is introduced. The access window can be moved stepwise and longitudinally alongside full sternotomy to be upon the dissection site. The majority of the thymectomy procedure can be directly viewed and operated from the moving window. However, partial and complete thoracoscopic maneuvers are required for dissection of the lateral-most region near the phrenic nerve and the upper poles of the thymus, respectively.