Robotic-assisted thymectomy for locally advanced thymic malignancy: technical refinement and oncologic outcomes from...

Robotic-assisted thymectomy (r-ThX) is commonly performed for early-stage thymic malignancies, but its use in advanced-stage disease has not been well studied. This study evaluated the safety and oncological outcomes of r-ThX in patients diagnosed with locally advanced thymic malignancies, particularly those with partial invasion of major vessels, pericardium, pleura, or phrenic nerve.

In a single-center cohort study from January 2003 to January 2024, 41 consecutive patients with tumor-node-metastasis (TNM) stage II-IV thymic malignancies underwent thymectomy (r-ThX: 20, sternotomy: 21). We assessed the technical feasibility and clinical outcomes of r-ThX and proposed a decision algorithm describing patient selection of r-ThX and criteria of conversion to open surgery.

Patients in the sternotomy group had more advanced disease compared to those in the r-ThX group in terms of tumor size (8.0 vs. 5.3 cm, P=0.03), Masaoka-Koga stage (P=0.006), and TNM stage (P=0.006). Compared with sternotomy group, r-ThX group had a numeric lower R1 resection rate (32% vs. 55%, P=0.14), a shorter drainage duration (4.5 vs. 5.1 days, P=0.80) and a lower > grade I complication rate (20% vs. 42.9%, P=0.12). The decision algorithm reduced unplanned conversions, with only 15% of non-emergent conversions being due to underestimated local invasion or minor bleeding. After a median follow-up of 34.4 months, 15% (3/20) of the r-Thx group had recurrence, and no deaths occurred.

r-ThX is a viable alternative to sternotomy for selected patients with locally advanced thymic malignancies with partial invasions. Conversion to open surgery is crucial for major vessel involvement.