Robotic thymectomy for thymoma in patients with myasthenia gravis: neurological and oncological outcomes

Abstract

OBJECTIVES The goal of this study was to analyse the outcomes in 53 patients with thymoma, 34 of whom had myasthenia gravis (MG), who were treated with robotic surgery. The oncological outcomes of the whole series of patients were analysed. Furthermore, because consistent data are not yet available in the literature, the main focus was the analysis of the neurological results of the patients affected by MG and thymoma. METHODS The clinical outcomes of 53 patients with a diagnosis of thymoma who underwent robotic thymectomy between January 2014 and December 2019 in our institution were collected and evaluated; 34 of these patients had a concomitant diagnosis of MG. The neurological status of the patients was determined from a clinical evaluation according to the Osserman classification and on pre- and post-surgery Myasthenia Gravis Composite scores, whereas neurological clinical outcomes were assessed using the Myasthenia Gravis Foundation of America Post-Intervention Score. Reduction of steroid therapy was also considered. The recurrence rate, adjuvant radiotherapy and overall survival of the patients with a thymoma were evaluated. RESULTS Neurological outcomes: improvement of the clinical conditions was obtained in 26 patients (76.5%) following the operation: complete stable remission was observed in 5 patients (14.7%), pharmacological remission in 10 (29.4%) and minimal manifestation in 11 (32.3%). Four patients (11.8%) exhibited no substantial change from the pretreatment clinical manifestations or reduction in MG medication and 4 (11.8%) patients experienced worsening of clinical conditions. In 21 patients (61.7%) a reduction of the dosage of steroid therapy was obtained. Oncological outcomes: at an average follow-up of 36 months, the overall survival was 96%, 4 patients (7.5%) had pleural relapses and 12 patients (22.6%) underwent postoperative radiotherapy, according to their stage. In accordance with Masaoka staging, 34% were in stage I, 56.6% in stage II and 9.4% in stage III CONCLUSIONS Our results suggest that robotic surgical treatment of patients with thymoma and concomitant MG is effective in improving the neurological outcomes. Moreover, the oncological results obtained in this series confirm the efficacy of robotic surgery for the treatment of thymic malignancies, with results in line with those of open surgery. However, due to the indolent growth of thymomas, further observations with longer follow-up are necessary.

Robotic Mediastinal Tumor Resections: Position and Port Placement

“…An assistant suction device can be used between the camera port and left arm port if necessary. A right-side approach has a wider field of view and larger working space [ 14 , 15 , 16 , 17 , 18 , 19 ], whereas a left-side approach potentially accesses more thymic tissue and allows easier visualization of the contralateral phrenic nerve [ 20 , 21 , 22 , 23 , 24 , 25 , 26 ]. Although it is controversial whether a left-side or right-side approach is better, several recent studies have reported using the left-side approach for extended thymectomy in patients with MG because it provides enhanced visualization and reduces the probability of phrenic nerve injury [ 21 , 25 , 27 , 28 ].…”

Difficult Decisions in Minimally Invasive Surgery of the Thymus

“…The oncological and neurological outcomes of MG patients and thymoma have been studied after robotic surgery [ 14 ]. In a series by Romano et al, patients who had their thymus removed showed a complete stable remission (CSR) rate of 14.7% at three years and a clinical improvement in 77% of patients with MG. Conversely, 23.6% experienced either no substantial change or worsened symptoms.…”

“…In a series by Romano et al, patients who had their thymus removed showed a complete stable remission (CSR) rate of 14.7% at three years and a clinical improvement in 77% of patients with MG. Conversely, 23.6% experienced either no substantial change or worsened symptoms. The average operation duration was 126 min, and the average hospital stay was 5.1 days [ 14 ]. This length of stay (LOS) with robotic surgery is a clear example of the outcome of prolonged surgical time.…”

Neurological outcomes of extended thymectomy for thymomatous myasthenia gravis: Subxiphoid vs. trans-sternal approaches

“…Few studies have focused on whether minimally invasive surgery is effective in improving neurological outcomes in patients with MG-affected thymoma. Franca Melfi suggested that robotic surgery for patients with thymoma and concomitant MG could be effective in improving neurological prognosis ( 10 ).…”

“…In contrast to the unilateral approach, which makes it challenging to visualize the contralateral phrenic clearly, the subxiphoid approach allows adequate visualization of the entire anterior mediastinal space ( 11 , 12 ). Furthermore, it was reported that subxiphoid and subcostal arch thoracoscopic thymectomy appeared to be a safe and feasible procedure for early-stage thymoma and MG ( 10 , 13 ). However, they did not explore the neurological outcomes of MG under this approach.…”