Total Thymectomy Is Oncologically Superior to Partial Thymectomy in Patients with Thymic Carcinoma

Reviewed by Dr Reza Lankarani, General SurgeonFounder | Surgical Pioneering Newsletter and Podcast Series Editorial Board Member | @Genesis Journal of Surgery and Medicine------------------------------------------------------------International Journal of Surgery October 15, 2025 DOI: 10.1097/JS9.0000000000003600------------------------------------------------------------1. Overview: The study investigates whether partial thymectomy is oncologically acceptable for thymic carcinoma, a rare and aggressive subtype of thymic epithelial tumors (TETs). Using real-world multicenter data from 19 Japanese institutions (2010–2021), the authors analyzed 92 patients who underwent curative-intent resection—73 with total thymectomy and 19 with partial thymectomy. Key Methods: - Retrospective comparative cohort design. - Primary endpoints: overall survival (OS) and recurrence-free survival (RFS). - Statistical adjustment via overlap weighting to mitigate selection bias. - Central pathological review for diagnostic consistency. Key Findings: - 79.3% of clinical stage I cases were upstaged postoperatively, highlighting limitations of preoperative imaging. - In unadjusted analyses, partial thymectomy showed a trend toward worse OS and RFS (p ≈ 0.055–0.057). - After propensity-weighted adjustment, partial thymectomy was significantly associated with: - Worse OS (p = 0.0027) - Higher recurrence risk (p < 0.0001), especially early postoperative recurrence. - Local and distant recurrences were significantly more common in the partial group after weighting. Conclusion: Total thymectomy is oncologically superior for thymic carcinoma. Given the difficulty in preoperative differentiation from thymoma, total thymectomy should remain the standard for all resectable TETs unless a definitive benign diagnosis is confirmed.--- 2. Critical Assessment: Strengths and WeaknessesStrengths:- Multicenter real-world data: Enhances generalizability beyond single-institution bias.- Central pathological review: Ensures diagnostic uniformity—critical given histological complexity of TETs.- Advanced statistical methodology: Use of overlap weighting (superior to traditional propensity matching in preserving sample size and reducing variance) effectively balances baseline imbalances (e.g., age, stage, performance status).- Clinically relevant question: Addresses a growing dilemma as minimally invasive partial resections gain popularity for early thymoma.- Clear staging discrepancy demonstration: The Sankey diagram powerfully illustrates the high rate of understaging in clinical practice.Weaknesses:- Small sample size in partial group (n=19): Limits statistical power for subgroup analyses and increases vulnerability to outliers.- Retrospective design: Inherent selection bias—partial thymectomy patients were older, frailer, and had smaller tumors, suggesting surgeon preference for less aggressive surgery in higher-risk patients.- Lack of standardized partial resection definition: “Partial” included hemi-thymectomy and tumor-only resection, introducing heterogeneity.- No intraoperative frozen section use: While realistic (as noted in discussion), this reflects a missed opportunity to explore adaptive surgical strategies.- Limited external validation: All centers are in Japan; biological or practice-pattern differences may limit global applicability.--- 3. Comparison with Recent StudiesRecent literature largely supports partial thymectomy for early-stage thymoma but remains cautious for thymic carcinoma.Graphical Insight (Conceptual):Key Contribution: This is among the first robust multicenter studies to demonstrate that partial thymectomy is inadequate for thymic carcinoma, even when tumors appear early-stage. It cautions against extrapolating thymoma data to carcinoma.--- Academic Significance: This study makes a timely and clinically vital contribution. As minimally invasive surgery expands, there is a real risk of undertreating thymic carcinoma due to preoperative misclassification. The authors provide strong real-world evidence that total thymectomy is non-negotiable for optimal oncologic control in carcinoma.Impact: - Likely to influence guidelines (e.g., NCCN, ITMIG) to explicitly discourage partial resection when carcinoma cannot be ruled out.- Reinforces the need for caution in adopting partial thymectomy outside rigorously confirmed early thymoma.--- Plain-Language Summary for Patients and the Public If a tumor is found in the thymus (a small organ behind the breastbone), doctors often can’t tell before surgery whether it’s a slow-growing type (thymoma) or a more aggressive cancer (thymic carcinoma). Some surgeons have started doing smaller operations (partial thymectomy) for what looks like early, harmless tumors. But this study shows that if the tumor turns out to be thymic carcinoma, the smaller surg