Advanced thymic epithelial tumours after neoadjuvant therapy: a narrative review of surgical challenges and strategies.

Background and Objective: Thymic epithelial tumours, including thymoma and thymic carcinoma, are rare anterior mediastinal neoplasms. Complete surgical resection remains the strongest prognostic determinant, yet locally advanced disease frequently involves critical mediastinal structures and requires multimodality treatment. Neoadjuvant therapy is commonly used to improve resectability, although it alters operative anatomy in ways that can complicate subsequent surgery. This narrative review offers an updated appraisal of the surgical challenges that arise after neoadjuvant therapy, and of contemporary strategies for complex post-induction resection. Methods: A targeted literature search was carried out in PubMed, MEDLINE, Embase, Scopus, Web of Science and Google Scholar for English-language publications from January 1990 through January 2026. Search terms combined thymic malignancies, induction and chemoradiotherapy strategies, surgical resection, vascular reconstruction, pleural disease and survival. Emphasis was placed on contemporary literature (2010 to 2026) to reflect advances in imaging, multimodality therapy and surgical reconstruction. Key Content and Findings: Neoadjuvant therapy produces dense fibrosis and obscures tissue planes, which complicates the dissection of critical structures. Imaging often underestimates stromal remodelling and residual viable tumour, so unexpected intraoperative difficulty is common. Vascular involvement is a major driver of operative complexity and frequently calls for resection and reconstruction, with contemporary graft patency of roughly 85% to 90% at five years in specialised series. In stage III disease, reported five-year survival after complete resection is approximately 70% to 90% for thymoma and 30% to 50% for thymic carcinoma. In stage IVa disease, cytoreductive surgery remains a treatment option when macroscopic complete resection is feasible, but the balance between aggressive procedures such as extrapleural pneumonectomy and more conservative pleurectomy/decortication must be weighed very carefully, since high-quality comparative evidence is lacking. Emerging data suggest that neoadjuvant chemoradiotherapy may yield higher R0 rates than chemotherapy alone, albeit at the cost of more pronounced fibrosis, although a matching survival benefit has not yet been proven. Molecular profiling (including GTF2I and TP53/KIT alterations) and AI-assisted imaging biomarkers are increasingly informing patient selection and surgical planning. Conclusions: Surgery after neoadjuvant therapy is feasible and safe in experienced centres, and in selected patients the oncologic outcomes appear to approach those of upfront resection with acceptable postoperative morbidity. Given the rarity of these tumours and the retrospective nature of most of the evidence, however, any comparison with upfront surgery should be interpreted with caution. Future progress will depend on international collaboration, prospective registries, validated molecular and imaging biomarkers, and standardisation of multimodality strategies.