Extended Thymectomy With En Bloc Left Upper Lobectomy: A Combined VATS and Sternotomy Approach

This video is part of CTSNet’s 2025 Resident Video Competition. Watch all entries into the competition, including the winning videos.  

The authors present a case of extended thymectomy with en bloc left upper lobectomy, performed at Erasmus Medical Center in Rotterdam, The Netherlands.  

Thymomas are rare epithelial tumors that arise from the thymic gland. They usually grow slowly but are potentially invasive and may invade continuous structures such as the pleura, pericardium, great vessels, and lungs. The incidence is about 0.15 per 100,000 persons.  

Thymic tumors are often asymptomatic and frequently discovered incidentally on chest X-rays or computed tomography (CT) scans. In 30 to 40 percent of cases, there is an association with myasthenia gravis, so patients with thymomas at the authors’ center are routinely tested for antibodies. 

Since thymomas are rare and treatment strategies vary, treating these patients should always be discussed in a multidisciplinary team, preferably in expert centers. In general, treatment depends on resectability. In early-stage tumors, resection is the standard treatment. Locally advanced tumors may require a multimodal treatment approach with chemotherapy, radiation, and/or surgery. 

The authors present the case of a 53-year-old woman with no significant medical history. She visited her general practitioner with a prolonged cough, fever, and myalgia. A chest X-ray suggested a mediastinal mass, so the surgeons proceeded with a positron emission tomography-computed tomography (PET-CT) scan. Imaging revealed a large anterior mediastinal mass, suspicious for invasion of the pericardium and the aortic arch. Two pleural lesions were noted, suspicious for thymoma, and there was encasement of the brachiocephalic vein. She tested positive for myasthenia gravis (MG) antibodies, thus requiring a complete thymectomy in case or resection. 

A CT-guided biopsy confirmed a B1 thymoma. After a multidisciplinary discussion, the tumor was considered irresectable, and the patient received four cycles of induction chemotherapy with carboplatin and etoposide, followed by restaging. Unfortunately, the tumor showed only minimal reduction in size, and surgery was reconsidered. After reivew by a national multidisciplinary team, the patient was accepted for surgery at a center of expertise, with the possibility of performing aortic arch surgery. 

Preoperative CT showed suspected invasion of the aortic arch, especially near the brachiocephalic artery and left carotid artery, as can be seen in the transverse and coronal planes. 

The surgical plan was a combined approach. First, the surgeons started with a left-sided video-assisted thoracoscopic surgery (VATS). This allowed the authors to evaluate pleural lesions, check for invasion of the apical thoracic wall, and assess adhesions or involvement of the left upper lobe. The authors could also determine the margins for adequate resection.  

Next, a median sternotomy allowed for the removal of the mediastinal and pericardial mass and exploration of the aortic arch. If needed, aortic arch replacement could be performed under deep hypothermia with circulatory arrest. All team members, including surgical assistants, anesthesiologists, perfusionists, and dedicated aortic and thoracic surgeons, were briefed on the plan. The patient was motivated and wanted maximum treatment for the best possible prognosis. 

Anesthesia followed the standard cardiac protocol: general anesthesia, central venous line, bilateral radial arterial lines, urinary catheter, and two large-bore peripheral intravenous lines (IV). A double-lumen endotracheal tube was placed to allow for one-lung ventilation. The patient was positioned supine, with the left hemithorax slightly elevated to optimize thoracoscopic access. Transesophageal echocardiography (TEE) suggested no tumor invasion of the aortic arch, with smooth vessel margins and separate movement of the aorta and surrounding structures. 

The surgeons began with VATS inspection of the left hemithorax. Apical adhesions and indurated parenchyma in the left upper lobe were immediately apparent, consistent with tumor involvement. An additional port was placed, and pleural metastases were resected using diathermy, with an extended utility incision to improve access. Pleural dissection created safe margins around the tumor, extending cranially and caudally. The pericardium was then opened. The phrenic nerve could not be preserved due to tumor invasion. 

The surgeons proceeded with median sternotomy. Using the left internal mammary artery (LIMA) retractor, the surgeon resected the tumor toward laterally, removing adherent pleura under the sternum and ribs; no invasion of the ribs was seen. The LIMA was sacrificed. The assistant monitored margins via VATS to ensure complete resection. Once cranial and caudal margins were addressed, the authors started dissecting the mediastinal side.  

The pericardium was opened toward the ascending aorta, and extensive diathermy resection of the thymoma was performed. The tumor could be dissected from the ascending aorta, but the brachiocephalic vein was completely encased and divided using staples, providing step-by-step exposure of the aortic arch.  

Dissection around the aortic arch preserved critical structures, including the brachiocephalic artery, left carotid artery, left subclavian artery, and recurrent laryngeal nerve. The cranial pleural apex and adhesions to the left upper lobe were carefully mobilized. 

Due to the central tumor’s location near major pulmonary vessels, a wedge resection could not be performed, and an en bloc left upper lobectomy was performed. A small wedge of segment 6 was also removed due to a suspicious lesion. 

The en bloc specimen was marked accordingly and sent for pathological analysis. This provided an overview of the thorax at the end of the operation, which included division of the brachiocephalic vein, a clear aortic arch, extensive pericardial resection, and left upper lobectomy.  

Closure included a pericardial patch to prevent cardiac luxation. The diaphragm was not plicated because of the concomitant lobectomy, which required the upward mobilization of the diaphragm. 

Postoperatively, the patient spent one night in the intensive care unit (ICU), which was uneventful, before being transferred to the ward. Drains remained for five days due to persistent clear output, consistent with the extensive resection. On day five, she developed a cough and increased inflammatory markers. Intravenous antibiotics were started for suspected pneumonia, leading to subsequent improvement. She was discharged on day 14.  

Anticoagulation was initiated for the divided brachiocephalic vein, initially with vitamin K antagonists and later switched to a non-vitamin K oral anticoagulant (NOAC). Lifestyle advice included elevation and compression of the left arm to prevent swelling. The pathology report showed complete resection of the pleural nodes and wedge of segment 6. The en bloc thymoma and lobectomy showed clear margins everywhere, except for a small region around the left subcostal vein. A national multidisciplinary team recommended postoperative radiotherapy. 

Key Takeaways 

1. Management of thymomas requires a specialized multidisciplinary team due to their rarity and the multiple treatment options. 
2. Careful surgical planning and coordinated teamwork are essential for large invasive tumors. 
3. Clear patient counseling and informed consent are vital. 
4. Recognition of anatomical structures and careful intraoperative navigation are key technical considerations. 

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.