Thymic Surgery for Neoplasm: Perspectives on the Optimal Approach

Thymic epithelial tumors require tailored surgical strategies to optimize outcomes. This review synthesizes current evidence on surgical approaches, emphasizing the critical roles of tumor stage, anatomy, and multidisciplinary planning. For early-stage thymic epithelial tumors (Stage I/II), minimally invasive techniques (video-assisted thoracic surgery, robotic-assisted) demonstrate equivalent oncologic outcomes to open surgery, with reduced morbidity, shorter hospitalization, and faster recovery. Recent propensity-matched studies highlight robotic thymectomy's advantages, including lower blood loss and complication rates, though operative times may be longer. Locally advanced tumors (Stage IIIA-B) demand meticulous R0 resection, often necessitating open approaches for complex resections involving pericardium, phrenic nerves, or great vessels. Induction therapy shows promise in converting borderline resectable tumors and improving R0 rates. For Stage IVA disease, surgery within multimodal regimens may enhance survival, though benefits depend on pleural burden and histology, underscoring the need for individualized management. Emerging debates focus on refining resection extent. Lymphadenectomy gains traction for thymic carcinomas and advanced thymomas due to nodal metastasis risks, while partial thymectomy for early-stage tumors remains controversial, requiring randomized trials to balance oncologic efficacy against long-term immunologic consequences. Thymic surgery continues to evolve, prioritizing R0 resection while integrating minimally invasive advancements and multimodal therapies. Centralized, high-volume centers and international collaboration remain pivotal to addressing these rare malignancies. Future research must clarify lymphadenectomy's role, validate partial thymectomy, and optimize induction strategies through prospective trials.