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Ann Thorac Surg 2004;77:1878
© 2004 The Society of Thoracic Surgeons

Correspondence

Video-assisted extended thymectomy in patients with thymoma by lifting the sternum: is it safe?

Axel Aubert, MD, Philippe Chaffanjon, MD, Pierre-Yves Brichon, MD

Service de Chirurgie Thoracique et Générale, Chu de Grenoble, BP 217 - 38043 Grenoble Cedex 09, France

To the Editor:

In an article by Dr Takeo and colleagues [1], readers were encouraged to perform complete extended thymectomy for thymoma by video thoracoscopy (VT) with a sternum-elevating method. In a previous article Dr Roviaro and colleagues reported VT excision of 20 mediastinal masses including 8 thymic tumors [2].

In view of two cases of tumor chest wall implantation in our experience we disagree with these propositions. These previously reported [3, 4] implantations occured either on the parietal pleura or on the chest wall despite the use of extraction bags and trocars (contamination of the trocars by the instruments seeding tumor cells). A 25-year-old women sustained VT resection of a well-encapsulated thymic tumor, which was a liposarcoma. She died 24 months later from pleural and parietal metastatic extension beginning at the port sites. A 47-year-old woman was operated in another center in which a VT biopsy of a well encapsulated thymoma was followed by extended thymectomy through median sternotomy. She presented 4 years later with pleural and parietal tumoral implantations at the port sites without any recurrence in the thymic area.

Well-encapsulated thymic tumors must be primarily resected. Even if benign thymic tumors could be resected by VT, malignancy or aggressiveness is not known before the histopathologic study (as in the first patient). Furthermore the prognosis of thymoma depends on the quality of the resection. Some surgeons estimate that VT resection has the same quality compared with thoracotomy. We think that VT does not permit the same quality in completion and extension of the resection because of work in two dimensions. Moreover, protective measures that are reassuring (protection bag, introduction trocars) may be responsable for pleural and parietal implantations by seeding cells.

In conclusion, even if malignant tumors are rare in the mediastinum, we believe that VT thymic biopsy and VT thymectomy are dangerous and should not be performed for well-encapsulated thymic tumors. Technical displays and esthetism do not supplant good oncologic management. Cancer resections must be performed through incisions that provide good exposure (median sternotomy or thoracotomy). VT now has well codified indications but thymoma are excluded.

References

  1. Takeo S., Sakada T., Yano T. Video-assisted extended thymectomy in patients with thymoma by lifting of the sternum. Ann Thorac Surg 2001;71:1721-1723.[Abstract/Free Full Text]
  2. Roviaro G., Rebuffat C., Varoli F., Vergani C., Maciocco M., Scalambra S.M. Videothoracoscopic excision of mediastinal masses: indications and technique. Ann Thorac Surg 1994;58:1679-1683.[Abstract]
  3. Aubert A., Chaffanjon P., Peoc'h M., Brichon P.Y. Chest wall implantation of a mediastinal liposarcoma after videothoracoscopy. Ann Thorac Surg 2000;69:1579-1580.[Abstract/Free Full Text]
  4. Aubert A, Chaffanjon P, Brichon PY, Implantations pariétales de deux tumeurs de la loge thymique après vidéo-thoracoscopie. Journal de Chirurgie Thoracique et Cardio-Vasculaire 2002; VI (n°1):63–5




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