Stage IVa thymoma: optimizing surgical management according to anatomical boundaries of the pleural space

Figures

• 

  Figure 1. Metaphorical comparison of surgical strategies for pleural metastases from Stage IV thymoma. (A) Pleural metastases are analogous to weeds growing between paving tiles, spreading along the anatomical boundaries. (B) Removing only the macroscopic nodules, as performed in a partial pleurectomy, corresponds to cutting only the visible part of the weeds, leaving the underlying disease process intact. (C) To prevent recurrence, is required to eradicate the roots. Similarly, to ePD, involving diaphragm and pericardium resection, is required. (D) Just as herbicide is applied after root extraction to eliminate risk of re-growth, HITHOC serves as an essential adjunctive ‘herbicide’, addressing the hidden risk of residual microscopic disease across the pleural space. ePD, extended pleurectomy/decortication; HITHOC, hyperthermic intrathoracic chemotherapy.

• 

  Figure 2. Surgical workflow and intraoperative management for Stage IVa thymoma. (A) CT scan of a patient with pleural metastasis from thymoma within the fissure. (B) Surgical outcome of ePD. (C) En-bloc resection of the parietal and visceral pleura, diaphragm and pericardium. (D) HITHOC setup following Leuven protocol. (E) Pericardial reconstruction using an NVRF allograft. CT, computed tomography; ePD, extended pleurectomy/decortication; HITHOC, hyperthermic intrathoracic chemotherapy; NVRF, non-vascularized rectus fascia.