Evolving paradigms in thymoma surgery and multidisciplinary care: a narrative review

Thymic epithelial tumors (TETs)-including thymomas and thymic carcinomas-are rare anterior mediastinal malignancies characterized by variable biology, frequent paraneoplastic syndromes, and high recurrence potential. Recent advances in pathologic classification, staging systems, imaging, surgical techniques, and systemic therapies have led to significant changes in clinical management. Complete R0 surgical resection remains the cornerstone of curative treatment; however, the increasing adoption of minimally invasive approaches, refinement of multimodal therapy for advanced disease, and emerging molecular profiling are reshaping contemporary clinical practice. This narrative review aims to provide a comprehensive overview of evolving surgical approaches and multidisciplinary management strategies for thymoma, highlighting recent advances and clinical challenges.

This review synthesizes literature published from 2010 to 2025 on the management of thymoma. Key areas assessed include updates to World Health Organization (WHO) histopathologic classification and Tumor-Node-Metastasis (TNM) staging; diagnostic strategies and imaging modalities; comparisons of open, video-assisted thoracoscopic surgery (VATS), and robotic-assisted surgical techniques; multimodal therapy, including neoadjuvant and adjuvant chemotherapy and radiotherapy; management of recurrent and metastatic disease; and evolving molecular and immunologic treatment approaches. Evidence from international databases and institutional outcomes was incorporated to evaluate the role of multidisciplinary management and treatment at high-volume centers.

Modern thymoma management has shifted toward more individualized, multidisciplinary decision-making. Minimally invasive surgery, particularly robotic-assisted thoracic surgery, provides safe and oncologically equivalent outcomes for early-stage tumors with reduced perioperative morbidity. For locally advanced or initially unresectable disease, neoadjuvant chemotherapy increases the likelihood of achieving R0 resection, while adjuvant radiotherapy improves local control in high-risk cases. Recurrent disease, often detected years after initial treatment, benefits most from repeat surgical resection when feasible. Molecular profiling has identified potential genomic alterations in selected subtypes, supporting the use of targeted agents and, more cautiously, immunotherapy, although thymoma's autoimmune biology increases the risk of severe immune-related toxicities. Across studies, treatment at specialized, high-volume centers consistently correlates with better outcomes.

Evolving surgical techniques, improved staging systems, and expanding systemic therapies have transformed the management of thymoma into a highly individualized, multimodal discipline. While complete resection remains central to curative intent, optimal outcomes require coordinated multidisciplinary care, careful patient selection for minimally invasive approaches, and personalized systemic strategies for advanced or recurrent disease. Continued international collaboration and molecularly informed research will be essential to refining future standards of care for this rare malignancy.