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Giant thymoma successfully resected via median sternotomy and anterolateral thoracotomy: a case report
© The Author(s). 2018
Received: 2 February 2018
Accepted: 4 April 2018
Published: 10 April 2018
Some patients with thymoma present with a very large mass in the thoracic cavity. Although the most effective treatment for thymoma is surgical resection, it is difficult to perform because of the size of the tumor and the infiltration of tumor into the surrounding organs and vessels. We report a patient with a giant thymoma that was completely resected via a median sternotomy and left anterolateral thoracotomy.
A 63-year-old woman presented with a mass in the left thoracic cavity that was incidentally found on a chest X-ray. Chest computed tomography revealed a giant mass (16 × 10 cm) touching the chest wall and diaphragm and pressed against the heart and left upper pulmonary lobe. Complete resection was performed via a median sternotomy and left anterolateral thoracotomy. The tumor was histologically diagnosed as a WHO type B2 thymoma, Masaoka stage II.
Giant thymomas tend to grow expansively without invasion into surrounding organs and vessels. Surgical resection that employs an adequate approach must be considered, regardless of the size of the tumor.
Thymic epithelial neoplasms are commonly located in the anterior mediastinum. The tumors typically show slow-growing behavior. Patients present with various clinical signs and symptoms that are associated with expansion of the tumor; the most effective treatment modality is surgery . Giant thymomas are very rare and difficult to resect because of the size of the tumor and involvement of surrounding organs. Here, we report a case of giant thymoma that was completely resected via a median sternotomy and anterolateral thoracotomy.
Characteristics of patients with giant thymoma
Tumor size (cm)
13 × 10 × 10
median + right anterolateral
12 × 14 × 12
20 × 14 × 8
17 × 12 × 7
18 × 14 × 11
14 × 13 × 8
20 × 11 × 2
21 × 7 × 7
13 × 10
19 × 16 × 15
left hemic lamshell
16 × 10 × 7
median + left anterolateral
Surgical resection is generally accepted to be the most effective treatment for thymoma, and complete resection is an important prognostic indicator of long-term outcome . Large size is a poor prognostic factor in thymoma, and complete resection largely contributes to a successful treatment outcome for patients with giant thymoma. Although thymomas can present as huge masses, tumor stage may not always be correlated with tumor size . Interestingly, most giant thymomas have been found to be low grade histologically, without invasion into the surrounding organs and vessels, and have been completely resected (Table 1). The noninvasiveness of giant thymomas might account for their presentation as very large tumors.
A median sternotomy is the standard procedure for resecting a thymoma of normal size, but the procedure is controversial for giant thymoma (Table 1). A clamshell incision was used for an emergency operation for a patient with shock due to bleeding of a thymoma . This approach enables access to both hila and the pleural cavity. One patient underwent resection via a hemiclamshell approach, which allows access to the upper thoracic cavity . Both the clamshell and hemiclamshell incisions are more invasive than other approaches. A posterolateral approach was used for 2 patients [9, 11]. This approach is suitable for a tumor that extends to the inferior cavity, but a second surgery is needed to confirm complete thymectomy. A median sternotomy is suitable for patients with possible invasion of the innominate vein [7, 8], but access to the hila or posterior thorax can be difficult for cases of giant thymomas. Three patients with giant thymoma underwent resection via the anterolateral approach, which allows extension of the incision to include a posterolateral or hemiclamshell approach [6, 12, 14]. Only one patient with giant thymoma underwent resection via a median sternotomy and anterolateral thoracotomy , which was the approach we used for our patient. This approach allows wide access to the tumor and involved organs, regardless of their location in the thoracic cavity.
Some thymoma patients develop MG after thymectomy (“post-thymectomy MG”) regardless of whether or not they have a history or signs or symptoms of MG. Post-thymectomy MG develops in 1.0% to 28% of thymoma patients who have undergone thymectomy [18–23]. Previous reports showed that elevated preoperative serum AchR antibody levels and World Health Organization type B thymoma were risk factors for post-thymectomy MG [24, 25]. Our case corresponds to patients at high risk post-thymectomy MG, and requires careful follow-up for early detection of MG.
We reported a rare case of giant thymoma that was successfully resected via median sternotomy and left anterolateral thoracotomy. Giant thymomas tend to be low-grade tumors that do not infiltrate adjacent organs and vessels. For successful treatment of giant thymoma, curative surgical resection must be considered, regardless of tumor size.
This study was supported in part by JSPS KAKENHI Grant Number JP 15 K10272.
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The data supporting the conclusions of this article are included within the article.
All authors participated in the design of the case report and coordination, and helped to draft the manuscript. YA and AI wrote the manuscript. HO, SK, TM, HO, and YA collected and analyzed clinical data of the patient. SS, MW, and KS carried out the pathological diagnosis and provided images of the gross pathology and histopathology. All authors read and approved the final manuscript.
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Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of the Journal of Cardiothoracic Surgery.
The authors declare that they have no competing interests.
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