Advanced thymic epithelial tumour resection: vascular resection and reconstruction strategy

Thymic epithelial tumors (TETs) represent the predominant primary malignancy of the anterior mediastinum, often necessitating complex surgical interventions due to their invasive nature. The prognosis of advanced TET relies significantly on achieving complete resection with microscopically clear margins (R0). This frequently entails resection and reconstruction of major vascular structures like the superior vena cava (SVC) and brachiocephalic veins, and in some cases, extra pleural pneumonectomy (EPP). The aim of the study is to interrogate our series of advanced TET resections.

We analysed our experience with vascular resection and reconstruction in 14 patients with advanced stage III/IV TET undergoing extensive resection post-neoadjuvant chemotherapy. A comprehensive preoperative evaluation was performed, including computed tomography (CT), positron emission tomography (PET), biopsy, and exercise testing. We describe our surgical approach and the details of our series.

From 2015 to 2023, 31 patients underwent surgery for advanced TET at our centre, with major vessel reconstruction performed in 14 cases. This included resection of SVC and innominate veins with subsequent reconstruction using polytetrafluoroethylene (PTFE) grafts. The median operative time was 350 minutes, with a median blood loss of 1,300 mL. Cardiopulmonary bypass (CPB) was required in 2 cases. The rate of R0 resection was 78.6%, with a recurrence rate of 14.3% at a median follow-up of 1,700 days. Postoperative complications occurred in 42.9% of patients, with an in-hospital mortality rate of 7.1%.

Multi-disciplinary management, meticulous preoperative planning, and advanced surgical techniques are essential for the successful treatment of advanced TET. Complex vascular resections should be reserved for high-volume centres to optimize outcomes.