En bloc Extended Total Thymectomy and Extrapleural Pneumonectomy in Masaoka stage IVA Thymomas

BACKGROUND: Surgical excision is the primary treatment for a thymoma. However, for advanced thymoma that extends to within the thoracic cavity and for recurrent cases with pleural dissemination (Masaoka stage IVA), the appropriate treatment is controversial. We evaluated the safety of surgery and outcomes of seven patients that underwent an en bloc extended total thymectomy and extrapleural pneumonectomy for stage IVA thymomas. METHODS: From 1994 to 2009, five patients initially diagnosed with pleural dissemination and two patients with recurrent tumors in the pleura and lungs after a total thymectomy, were identified. Seven patients had an extrapleural pneumonectomy performed. For the first operation, five patients underwent additional en bloc extended total thymectomy. RESULTS: Two recurrent cases were identified 55.2 and 12.3 months after first operation. Two patients had WHO type B1-B2 tumors, two had B2, two had B2-B3, and one had a B3 tumor. The mean hospital stay was 15.3 days (range: 7-29). There was no operative mortality. Four patients had neoadjuvant chemotherapy and five were treated with adjuvant chemotherapy. The median survival was 30.6 months and the Kaplan-Meier 2-year survival was 100% (95% confidence interval: 24.6-36.6 months). One patient, who did not receive induction chemotherapy, had distant metastases after surgery. CONCLUSIONS: En bloc extended total thymectomy and extrapleural pneumonectomy can be safely performed on selected patients with stage IVA thymomas and is expected to achieve complete local control. Although the treatment strategy has yet to be standardized, complete resection with appropriate systemic therapy may improve survival in otherwise fatal disease.