Abstract
BACKGROUND: Thymic tumor size has been frequently considered a factor limiting the indication for minimally invasive surgery. Robotic-assisted thoracic surgery (RATS) has been mainly offered to patients with limited thymoma up to 4 cm. However, considering increasing experience in the field and improved technical skills, RATS has proved to allow safe resection of larger lesions. To date, RATS thymectomy for large and advanced thymomas remains controversial and there is no a general consensus. The present retrospective study aims to evaluate the feasibility and the safety of RATS thymectomy for the treatment of large thymomas. METHODS: Between May 2021 and February 2025, 88 consecutive patients underwent RATS thymectomy in the Division of Thoracic Surgery of Sant’Andrea Hospital, Sapienza University of Rome, Italy. Patients older than 18 years old, with histology of thymoma, both myasthenic and non-myasthenic, with lesions larger than 5 cm were included (Figure 1), with a final sample of 70 patients. Data on lesions side, dimensions, associated resections, time of surgery, complications, conversion rate, final pathology, length of stay, adjuvant therapy and survival, were retrospectively analyzed. RESULTS: Mean tumor size in the study cohort was 6.69±1.92 cm (range, 5–10 cm). Five patients (7.14%) presented with myasthenia. The mean operative time excluding docking-undocking time was 52.31±16.52 minutes. Associated resections were 11 (15.71%): 3 pericardium portion, 3 pleura nodules, 4 lung resections, and 1 anonymous vein. No conversion rate was described and only 4 minor complications (atrial fibrillation, pleura effusion) were reported. Five patients received R1 resections and 3 of them underwent adjuvant radiation. A total of 7 patients (10%) received post-operative radiation. At the median follow-up of 36 months, no mortality was described. CONCLUSIONS: Previous studies reported that the optimum diameter of resected thymomas was 4 cm, thus aiming to reduce the risk of capsule rupture during excision. According to our results, larger thymomas were successfully excised using RATS. Most of them (42.86%) were classified as Masaoka stage I, followed by 32.85% showing microscopic invasion. Importantly, no capsule ruptures were observed at pathology. Follow-up data showed excellent overall survival. Based on our preliminary results, RATS can be considered safe and feasible for large thymomas.