Researchers emphasized the appropriate surgical management of paraneoplastic syndromes secondary to myasthenia gravis (MG) and other thymic epithelial tumors (TETs) and published their results in Mediastinum.

The editorial commentary written by Akcelik and colleagues determined that complete resection of the totality of thymic structure, including the adjacent adipose tissue from the neck to the diaphragm, should become part of the standard treatment for MG. They even suggest a surgical approach in those patients without a detected TET.

Furthermore, for patients in myasthenic crisis, the healthcare team may also consider an extended thymectomy with extrapleural pneumonectomy, a procedure indicated for metastatic TETs with disseminated pleural disease.

Regarding preoperatory management, a complete diagnostic and staging workup is essential. The categorization of thymic tumors proposed by the World Health Organization considers the histological type and classifies them into either A, B, or C.

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Another classification is the anatomical staging that can be according to the Masaoka or the International Association for the Study of Lung Cancer and the International Thymic Malignancy Interest Group staging system; this is considered superior to the histological classification for determining prognosis and allows the surgeon to properly plan how extensive the tissue resection will be.

For patients with MG and tumors less than 4 cm in size, the patient’s preferred position is in lateral decubitus with a 30-degree elevation of the left half of the chest. This approach allows easier access to the ectopic thymic tissue mostly found on the lateral face of the left phrenic nerve. For surgeries where more structures are affected, posterior tilting is included to visualize all structures better.

The authors highlight that surgical management is the main pillar for treating paraneoplastic syndrome secondary to MG and other causes of TETs. “Completeness of the tumor resection is the strongest prognostic indicator for improved outcomes. Our experience demonstrates the advantage of the robotic approach for resection of thymic tumors even when locally advanced,” they concluded.

Reference

Akcelik A, Petrov R, Bakhos C, Abbas A. Surgical management of locally advanced thymic neoplasms. Mediastinum. Published online March 25, 2022. doi:10.21037/med-21-32