Applying expertise: Extrapleural pneumonectomy and extended pleurectomy decortication in the management of Masaoka-Koga stage IV thymoma.

Objectives: The European Society of Medical Oncology supports the use of surgery with adjuvant radiotherapy in resectable Masaoka-Koga Stage IV thymomas. We explore the role of extended pleurectomy decortication (EPD) and extrapleural pneumonectomy (EPP) in the management of patients with Masaoka-Koga stage IV thymic tumors with pleural involvement from our single-center experience. Methods: We conducted a retrospective analysis of patients who had undergone extended resections over a 10-year period for Masaoka-Koga stage IV thymomas at our thoracic unit in the United Kingdom. Data was gathered from patient records and electronic databases. Results: Ten patients were included in our series; 90% with primary thymoma and 10% with metastatic recurrence. In total, 80% of patients had EPD and 20% EPP; 60% had pericardium resected and 50% the ipsilateral hemidiaphragm. Length of stay was 2 to 21 days (median, 7 days). There was no in-hospital or 90-day mortality. Histology subtypes were variable: World Health Organization type AB (20%), B1 (10%), B2 (50%), and B3 (20%). A total of 60% of patients had R1 resection. All patients had adjuvant therapy. In total, 70% of patients had disease recurrence with an average disease-free interval of 44 months (range, 8 months to 10 years). Five-year survival was 90% with an overall survival of 60%. Conclusions: This series supports the use of extended resections in selected patients with Masaoka-Koga stage IV thymoma as part of multimodality treatment. EPP and EPD are not part of routine thoracic surgery practice in the United Kingdom. We suggest these cases are referred to dedicated centers with required expertise.