Surgical Expert Consensus on Clinical Management of Advanced Thymoma and Thymic Carcinoma: A Beijing–Tianjin–Hebei Collaborative Initiative

ABSTRACT

Thymomas and thymic carcinomas represent rare epithelial‐derived thoracic neoplasms that, despite their low incidence, pose significant clinical challenges and impact patient survival. Through collaborative efforts among experts across the Beijing–Tianjin–Hebei region, this consensus seeks to provide guidance for the challenging management of advanced‐stage thymic epithelial tumors (Stages IIb–IV). Advanced thymic tumors frequently present with local invasion or distant metastases, necessitating multimodal therapeutic approaches incorporating surgery, radiotherapy, chemotherapy, and emerging immunotherapies. Treatment individualization remains paramount given tumor heterogeneity and variable clinical presentations. This regional consensus framework endeavors to offer evidence‐based guidance for thymic tumor management, promoting coordinated care through multidisciplinary teams that may help improve therapeutic outcomes and patient survival. Through collaborative efforts, we hope to foster greater consistency in treatment approaches across participating institutions, potentially contributing to enhanced regional oncological care via the careful integration of contemporary therapeutic strategies for patients with advanced thymic epithelial neoplasms.

Advanced thymoma/thymic carcinoma management requires multimodal strategies. Achieving R0 resection when feasible is critical, potentially requiring vascular reconstruction in locally invasive disease. Proactive screening for myasthenia gravis (RNS/EMG) and autoimmune comorbidities is critical.

1. Introduction

Thymic epithelial tumors, including thymomas and thymic carcinomas, are recognized as relatively uncommon thoracic malignancies that warrant careful clinical attention [1]. Despite their relatively low incidence, these neoplasms may present complex management considerations and could potentially affect patient prognosis [2, 3]. While recent advances in diagnostic techniques and multimodal treatment approaches have enriched our understanding of thymic tumors, achieving optimal clinical management remains an ongoing challenge, with various therapeutic questions still under investigation.

Advanced thymic neoplasms, defined by the Masaoka–Koga staging system, encompass locally invasive tumors including select Stage IIb lesions (involving pericardium, great vessels, or lung parenchyma), Stage III tumors (with adjacent organ invasion or mediastinal nodal involvement), and Stage IV disease (characterized by pleural/pericardial dissemination or distant metastases) [4, 5]. These locally advanced or metastatic tumors frequently demonstrate infiltration into surrounding structures, regional lymph node involvement, or systemic spread. Although thymomas typically exhibit indolent biological behavior with relatively slow progression and lower aggressive potential compared to thymic carcinomas, advanced disease presents formidable therapeutic challenges [6]. Consequently, standardized approaches to treatment selection, prognostic assessment, and quality‐of‐life preservation require urgent establishment for patients with advanced thymic tumors [7, 8].

The pathophysiology underlying thymic epithelial tumorigenesis remains poorly understood, likely involving complex interactions between genetic susceptibility, environmental exposures, and immune dysregulation [7]. Early‐stage disease often presents asymptomatically, complicating timely diagnosis. Once tumors reach advanced stages, accelerated progression significantly compounds treatment complexity [9]. The absence of standardized diagnostic and therapeutic protocols has resulted in institutional variations in patient management [8, 10], potentially exposing patients to unnecessary procedural risks and compromising treatment outcomes. Given the therapeutic complexity inherent to thymic epithelial tumors, effective regional collaboration and resource integration are fundamental to optimizing patient care [11].

The Beijing–Tianjin–Hebei metropolitan region represents a major economic and academic medical center in China, hosting numerous tertiary care institutions and specialized oncology teams. Aligned with national initiatives promoting regional healthcare integration, the Beijing–Tianjin–Hebei Myasthenia Gravis (MG) (Thymoma) Alliance was established to consolidate regional medical expertise, enhance collaborative care delivery, and standardize treatment protocols for advanced thymic tumors across participating institutions. Consensus development involved a systematic literature review across multiple databases, including PubMed and Web of Science for international publications. We prioritized high‐quality evidence directly applicable to clinical practice regarding advanced thymic tumor management. Through iterative expert panel discussions integrating clinical experience with evidence review, we established 15 consensus recommendations. Recommendation classifications are as follows: Grade 1A comprises strong recommendations supported by high‐quality evidence, including rigorous meta‐analyses or randomized controlled trials, and reflects unanimous expert agreement. Grade 1B includes strong recommendations based on high‐quality evidence that may exhibit minor expert disagreement. Grade 2A consists of moderate recommendations derived from lower‐quality evidence, accompanied by expert consensus, while Grade 2B includes moderate recommendations based on limited evidence with minor expert disagreement. Finally, Grade 3 encompasses weak recommendations that reveal substantial divergence in expert opinions.

2. Clinical Assessment of Advanced Thymic Tumors

2.1. Consensus 1

Initial assessment of advanced thymic tumors should incorporate comprehensive clinical evaluation, including medical history, symptomatology, physical examination, and appropriate diagnostic studies (Grade 1A).

The evaluation protocol encompasses detailed history‐taking with emphasis on autoimmune symptoms and medication history, systematic physical examination focusing on superior vena cava (SVC) syndrome and myasthenic manifestations, contrast‐enhanced chest and upper abdominal CT as primary imaging, and specialized testing including electromyography for MG assessment [12]. Laboratory evaluation should include routine hematologic and biochemical studies, autoimmune markers (acetylcholine receptor and anti‐muscle‐specific kinase [anti‐MuSK] antibodies), and tumor markers to exclude other malignancies [13]. PET‐CT provides valuable information for systemic disease assessment and treatment response monitoring. This standardized approach, as outlined in Tables 1, 2, 3, aims to facilitate more accurate disease characterization and may serve as a useful foundation for evidence‐based multidisciplinary treatment planning.

TABLE 1.

Comprehensive clinical assessment protocol for advanced thymic tumors.

Assessment domain	Components	Key findings	Clinical significance
Clinical history	Disease progression, symptoms, autoimmune history	Chest pain, dyspnea, myasthenia gravis symptoms	Establishes disease timeline and associated conditions
Physical examination
Chest wall	Vascular pattern, mass palpation, percussion	Dilated veins, palpable masses, dullness	Vascular compression, direct tumor invasion
Head/neck	Facial edema, jugular distention	SVC syndrome signs	Superior vena cava obstruction
Upper extremities	Edema, muscle strength	Bilateral swelling, proximal weakness	Venous obstruction, myasthenia gravis
Cardiopulmonary	Heart sounds, breath sounds	Friction rub, diminished sounds	Pericardial/pleural involvement
Imaging studies
Primary	Contrast‐enhanced chest CT	Tumor size, invasion, staging	Essential for surgical planning
Supplementary	Upper abdominal CT, PET‐CT	Metastases, systemic disease	Disease extent assessment
Alternative	MRI	Soft tissue detail	When CT contraindicated
Laboratory studies
Routine	CBC, CMP, liver function	Organ function status	Baseline assessment, monitoring
Tumor markers	β‐hCG, AFP, CEA	Elevated levels	Differential diagnosis
Autoimmune	AChR antibodies, anti‐MuSK	Positive antibodies	Myasthenia gravis diagnosis
Specialized testing
Neurological	EMG, repetitive nerve stimulation	Abnormal responses	Confirms myasthenia gravis
Functional	Pulmonary function, echocardiography	Reduced capacity, cardiac dysfunction	Surgical risk assessment

Abbreviations: β‐hCG, beta‐human chorionic gonadotropin; AChR, acetylcholine receptor; AFP, alpha‐fetoprotein; anti‐MuSK, anti‐muscle‐specific kinase; CBC, complete blood count; CEA, carcinoembryonic antigen; CMP, comprehensive metabolic panel; CT, computed tomography; EMG, electromyography; MRI, magnetic resonance imaging; PET‐CT, positron emission tomography‐computed tomography; SVC, superior vena cava.

TABLE 2.

Diagnostic parameters and reference values.

Test category	Specific test	Normal range/cutoff	Abnormal findings	Clinical action
Hematology	Complete blood count	Age/gender appropriate	Cytopenias, leukocytosis	Monitor, investigate causes
	ESR	< 30 mm/h	Elevated	Assess inflammatory response
Biochemistry	Comprehensive metabolic panel	Laboratory reference	Electrolyte imbalance	Correct abnormalities
	Liver enzymes (ALT/AST)	< 40 U/L	Elevated	Evaluate hepatic involvement
Tumor markers	β‐hCG	< 5 mIU/mL (non‐pregnant)	Elevated	Rule out germ cell tumors
	Alpha‐fetoprotein	< 10 ng/mL	Elevated	Consider other malignancies
Autoimmune markers	AChR antibodies	< 0.4 nmol/L	Positive	Diagnose myasthenia gravis
	Anti‐MuSK antibodies	< 0.05 nmol/L	Positive	Seronegative MG variant
	Complement (C3/C4)	90–180/10–40 mg/dL	Low levels	Autoimmune activity
Imaging	CT enhancement pattern	Homogeneous enhancement	Heterogeneous/rim enhancement	Suggests malignancy
	PET‐CT SUVmax	< 2.5 (mediastinum)	> 4.0	Higher malignant potential
Functional tests	FEV1	> 80% predicted	< 60% predicted	Increased surgical risk
	LVEF	> 55%	< 40%	Cardiac risk stratification

Abbreviations: β‐hCG, beta‐human chorionic gonadotropin; AChR, acetylcholine receptor; ALT, alanine aminotransferase; anti‐MuSK, anti‐muscle‐specific kinase; AST, aspartate aminotransferase; C3, complement component 3; C4, complement component 4; CT, computed tomography; ESR, erythrocyte sedimentation rate; FEV1, forced expiratory volume in 1 s; LVEF, left ventricular ejection fraction; MG, myasthenia gravis; PET‐CT, positron emission tomography‐computed tomography; SUV_max, maximum standardized uptake value.

TABLE 3.

Clinical decision algorithm and management pathways.

Clinical scenario	Initial assessment	Diagnostic priority	Treatment consideration
Anterior mediastinal mass	Contrast CT chest/abdomen	Rule out lymphoma, germ cell tumor	Avoid biopsy if resectable
Mass + myasthenia symptoms	EMG, AChR antibodies	Confirm MG diagnosis	Optimize MG before surgery
SVC syndrome presentation	Urgent contrast CT	Assess vascular involvement	Emergency radiation if severe
Large mass (> 5 cm)	CT + PET‐CT	Evaluate resectability	Consider neoadjuvant therapy
Suspected metastases	PET‐CT, tissue confirmation	Confirm Stage IV disease	Systemic therapy primary
Poor surgical candidate	Comprehensive risk assessment	Evaluate alternatives	Medical management/RT
Recurrent disease	Cross‐sectional imaging	Determine extent	Multidisciplinary approach

Abbreviations: AChR, acetylcholine receptor; CT, computed tomography; EMG, electromyography; MG, myasthenia gravis; PET‐CT, positron emission tomography‐computed tomography; RT, radiation therapy; SVC, superior vena cava.

2.2. Consensus 2

Assessment of advanced thymic tumors should emphasize evaluation of concurrent autoimmune conditions (Grade 1B).

Autoimmune disorders, particularly MG, occur in 30%–50% of patients with thymomas and significantly influence surgical planning and perioperative management [14]. Systematic evaluation of these conditions is essential for optimizing treatment outcomes and minimizing complications [15]. Clinical assessment should prioritize MG screening through targeted history‐taking focusing on ptosis, diplopia, muscle fatigability, and respiratory symptoms. Physical examination must include detailed neurological evaluation assessing extraocular movements, eyelid function, proximal muscle strength, and bulbar symptoms [16]. Additional autoimmune conditions requiring evaluation include systemic lupus erythematosus, rheumatoid arthritis, and Sjögren's syndrome, which may present with characteristic skin manifestations, joint involvement, or sicca symptoms [15]. Laboratory evaluation should encompass autoantibody testing, including anti‐acetylcholine receptor antibodies (AChR‐Abs), anti‐MuSK antibodies, antinuclear antibodies (ANAs), and disease‐specific markers such as anti‐dsDNA and anti‐CCP antibodies. Immunological assessment through immunoglobulin levels (IgG, IgA, and IgM) and complement components (C3 and C4) provides additional insight into immune system status [17, 18].

Multidisciplinary collaboration with neurology and rheumatology specialists is recommended for patients with confirmed or suspected autoimmune disorders to optimize preoperative management and develop coordinated treatment strategies. Current immunosuppressive medications, including corticosteroids, anticholinesterase agents, and disease‐modifying therapies, require careful documentation and perioperative adjustment [19, 20]. Individualized treatment planning must account for autoimmune disease severity, medication requirements, and potential impact on surgical candidacy and postoperative recovery [21]. This comprehensive approach ensures appropriate risk stratification and facilitates evidence‐based treatment decision‐making for patients with advanced thymic tumors and concurrent autoimmune conditions.

2.3. Consensus 3

In cases of locally advanced thymic tumors or those deemed unresectable based on evaluation, minimally invasive thoracoscopic or mediastinoscopic biopsy may be considered as an alternative when fine‐needle aspiration is unfeasible or fails to provide definitive diagnostic information. However, when clinical characteristics and radiological findings strongly suggest resectability of the thymic tumor, surgical biopsy should be prudently avoided due to the high risk of metastatic dissemination following capsular invasion (Grade 2A).

Obtaining tumor tissue through fine‐needle aspiration or surgical biopsy for pathological examination is essential to determine tumor type, grade, and stage [22]. This is crucial for formulating subsequent treatment strategies and prognostic assessment. Although biopsy plays a vital role in guiding therapeutic approaches, relying solely on initial morphological evaluation from biopsy specimens to predict clinical outcomes is insufficient [23]. In clinical practice, we frequently utilize comprehensive disease staging to more accurately predict patient prognosis [22].

3. Surgical Treatment Principles for Advanced Thymic Tumors

Advanced thymic epithelial tumors demonstrate distinct biological behavior characterized by relatively indolent growth patterns, differentiating them from more aggressive thoracic malignancies [24, 25]. This characteristic growth behavior suggests that patients with advanced‐stage disease may achieve meaningful clinical outcomes through appropriate therapeutic intervention, with potential for improved quality of life and prolonged survival despite locally advanced presentation [26].

3.1. Consensus 4

Treatment of advanced thymic tumors should prioritize surgical resection within a multidisciplinary treatment framework (Grade 2A).

Surgical resection remains the cornerstone of curative therapy for advanced thymic tumors, with complete resection offering optimal oncologic outcomes even in locally advanced disease [26, 27]. The majority of patients with advanced thymic tumors remain candidates for complete surgical resection, which provides effective disease control, reduces tumor burden, and establishes favorable conditions for adjuvant therapies [28]. Contemporary surgical approaches have demonstrated that aggressive resection, including en bloc removal of involved adjacent structures, can achieve R0 resection in appropriately selected patients [29].

However, surgical management of advanced thymic tumors presents significant technical challenges due to frequent involvement of critical mediastinal structures, including great vessels, pericardium, lung, and chest wall [30]. The intimate relationship between advanced tumors and vital anatomical structures necessitates meticulous surgical planning and expertise in complex thoracic reconstructive techniques. Additionally, the frequent association with autoimmune disorders, particularly MG, compounds perioperative complexity and requires specialized perioperative management protocols. Given these complexities, surgical intervention for advanced thymic tumors should be performed at high‐volume centers with dedicated thoracic surgical expertise and robust multidisciplinary support systems [31]. Optimal outcomes require coordinated care involving thoracic surgery, medical oncology, radiation oncology, neurology, and critical care medicine to address the unique challenges presented by these patients and minimize perioperative morbidity while maximizing oncologic efficacy [26, 27, 32].

3.2. Consensus 5

Comprehensive preoperative evaluation should guide the selective use of neoadjuvant therapy to optimize R0 resection rates (Grade 2A).

Achieving complete resection (R0) represents the primary goal in surgical management of advanced thymic tumors, with neoadjuvant therapy playing a crucial role in select patients to enhance resectability [11, 32]. The approach to induction therapy differs significantly between thymomas and thymic carcinomas, requiring histology‐specific treatment protocols [24, 30]. Neoadjuvant strategies aim to reduce tumor volume, decrease adherence to critical structures, and facilitate complete resection in cases where initial assessment suggests marginal resectability [32, 33]. Comprehensive preoperative planning must incorporate detailed imaging assessment, multidisciplinary consultation, and individualized surgical strategy development. This includes determination of optimal surgical approach, extent of resection required, and anticipated reconstructive needs. Patient‐specific factors such as performance status, comorbidities, and autoimmune disease activity significantly influence surgical planning and risk assessment [15, 18, 19].

Surgical technique must adhere to oncologic principles emphasizing en bloc resection with tumor‐free margins to prevent cellular dissemination. However, surgery alone may be insufficient in advanced disease, particularly in thymic carcinoma with nodal involvement or distant metastases, and thymomas with pleural dissemination. These scenarios necessitate integrated multimodal approaches combining surgical resection with systemic therapies [31].

Postoperative management requires vigilant monitoring for complications, particularly in patients with MG who may experience respiratory compromise. Adjuvant therapy decisions should be guided by pathologic findings, including histologic subtype, staging, and resection margins. Radiotherapy may be indicated for incompletely resected disease [34], while chemotherapy consideration depends on histologic subtype and stage [8]. The psychological burden associated with thymic tumor diagnosis and treatment necessitates comprehensive supportive care throughout the treatment trajectory. Patients face uncertainties related to surgical outcomes, treatment toxicities, and potential disease recurrence, making psychological support and rehabilitation essential components of care. Optimal management of advanced thymic tumors requires integration of surgical expertise with medical oncology, radiation oncology, and supportive care services within a multidisciplinary framework [35]. This comprehensive approach, delivered at experienced centers, provides the foundation for achieving optimal oncologic outcomes while maintaining quality of life in this complex patient population [31].

4. Surgical Management of Vascular Invasion in Advanced Thymic Tumors

Advanced thymic epithelial tumors frequently demonstrate local invasion of critical mediastinal structures, including lung parenchyma, pericardium, and major venous structures such as the SVC and brachiocephalic veins [36]. Vascular involvement significantly increases surgical complexity and requires specialized reconstructive techniques to achieve complete oncologic resection.

4.1. Consensus 6

Advanced thymic tumors with major vessel invasion should undergo complete resection with appropriate vascular reconstruction techniques (Grade 2B).

Successful management of thymic tumors with vascular invasion requires en bloc resection of the tumor and involved vessels, followed by immediate vascular reconstruction [27, 37]. The choice of reconstructive technique depends on the extent of vascular involvement, with options including unilateral prosthetic graft replacement for limited involvement or bilateral Y‐shaped graft reconstruction for complex multi‐vessel invasion [32, 38]. Vascular reconstruction techniques for advanced thymic tumors involving the SVC include unilateral prosthetic graft replacement and bilateral Y‐shaped graft reconstruction, with selection dependent upon the extent of vascular involvement. Unilateral prosthetic graft replacement utilizing a single conduit with end‐to‐end anastomotic reconstruction is appropriate when tumor involvement is confined to the SVC and a single brachiocephalic vein, offering reduced operative complexity, shorter procedural time, and fewer anastomotic sites with correspondingly lower complication rates [27]. Complex cases requiring simultaneous reconstruction of the SVC and both brachiocephalic veins necessitate Y‐shaped prosthetic graft replacement employing a bifurcated graft with the main trunk replacing the SVC and bilateral limbs anastomosed to the respective brachiocephalic veins [32]. While technically demanding and associated with higher procedural risk, this approach enables comprehensive reconstruction of extensively involved venous anatomy. Successful implementation requires detailed preoperative assessment of tumor‐vessel relationships through high‐resolution imaging, meticulous intraoperative attention to anastomotic integrity, and intensive postoperative monitoring with particular emphasis on hemodynamic stability and anticoagulation protocols to maintain graft patency [39]. These complex procedures should be performed at experienced centers with expertise in both thoracic oncology and vascular reconstruction to optimize patient outcomes and minimize perioperative morbidity.

The surgical approach commences with median sternotomy followed by systematic tumor mobilization through careful dissection of the thymic mass from surrounding mediastinal structures while preserving cardiac and major vascular integrity, with precise assessment of tumor‐vessel relationships to determine the optimal reconstructive strategy [39]. Vascular control is achieved through strategic placement of atraumatic clamps on uninvolved vessel segments with continuous monitoring of internal jugular venous pressure (maintained < 30 mmHg) to ensure adequate cerebral venous drainage during temporary occlusion, followed by en bloc resection of the tumor with involved vascular segments to maintain oncologic principles [38]. When invasion is limited to the SVC and one brachiocephalic vein, unilateral graft reconstruction employs precise measurement of vessel diameter and length to guide appropriate graft selection, followed by end‐to‐end anastomosis using 5‐0 polypropylene sutures to create tension‐free reconstruction with meticulous attention to graft positioning to prevent kinking or excessive angulation. Complex cases requiring reconstruction of the SVC and both brachiocephalic veins utilize Y‐shaped prosthetic grafts, typically with an 18–20 mm main trunk and 10 mm bilateral limbs, with the main graft anastomosed to the proximal SVC or right atrial appendage following systemic heparinization (1 mg/kg) and bilateral limbs connected to respective brachiocephalic stumps using continuous 5‐0 polypropylene sutures [32]. When SVC invasion involves less than 50% of the vessel circumference without brachiocephalic involvement, pericardial patch reconstruction offers an alternative approach utilizing autologous pericardial tissue fashioned to match the defect geometry and secured with 5‐0 polypropylene sutures, preserving native vessel endothelium while providing durable repair with reduced thrombogenicity [39]. Throughout all reconstructive techniques, protective lung ventilation strategies and preservation of critical structures, including phrenic nerves and pulmonary vessels, remain paramount, with completion assessment confirming hemostasis, absence of air embolism, and maintenance of internal jugular pressure < 30 mmHg to ensure adequate venous drainage [27, 38].

4.2. Consensus 7

Emphasize long‐term management and follow‐up after surgery for advanced thymic tumors, including regular imaging examinations to assess reconstructed vascular patency and monitor tumor recurrence (Grade 2A).

Following surgical intervention for advanced thymic tumors, patients require long‐term postoperative management and follow‐up. This includes regular imaging examinations to assess the patency of reconstructed vessels and monitor for tumor recurrence [35, 36]. Concurrently, attention should be directed toward patients' quality of life, providing necessary rehabilitation guidance and psychological support. For patients who develop complications, prompt diagnosis and treatment should be initiated to ensure patient safety and well‐being. Through standardized postoperative management and follow‐up, surgical success rates can be improved, patient survival prolonged, and quality of life enhanced [27, 37, 39].

Postoperative management requires comprehensive monitoring of vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, with particular attention to hemodynamic stability, alongside regular laboratory examinations encompassing routine blood tests, coagulation parameters, hepatorenal function, and electrolyte levels. Early postoperative ultrasound or CT angiography should be performed to evaluate reconstructed vascular patency and anastomotic status, with patients experiencing respiratory insufficiency receiving short‐term mechanical ventilation support followed by gradual reduction of ventilatory assistance, encouragement of spontaneous breathing, and early implementation of respiratory function training to promote lung re‐expansion and improve pulmonary ventilation [27, 37, 39]. Effective postoperative pain control is achieved through the implementation of multimodal analgesic strategies incorporating both opioid and non‐opioid analgesics, with consideration for patient‐controlled analgesia pumps to provide continuous analgesic effects and reduce patient discomfort while facilitating early mobilization and recovery.

4.3. Consensus 8

When surgically treating advanced thymic tumors invading major vessels, attention should be directed toward anticipating and preventing potential complications (Grade 2B).

Surgical management of advanced thymic tumors invading major vessels poses multiple complications, including thrombosis, infection, venous reconstruction failure, hemorrhage, pulmonary complications, and venous return dysfunction. To reduce the incidence of these complications, thorough preoperative assessment and preparation, meticulous intraoperative technique, close postoperative monitoring, and appropriate preventive measures are necessary [38]. For example, anticoagulants may be administered to prevent thrombosis, antibiotics to prevent infection, and regular imaging examinations performed to monitor venous reconstruction efficacy. Through these measures, complications can be minimized, ensuring patient safety and surgical effectiveness [27, 39].

5. Pleural Dissemination in Advanced Thymic Epithelial Tumors

The complexity of treating thymic tumors stems from their diverse biological behaviors and propensity for local invasion and distant metastasis, particularly within the thoracic cavity [40]. In advanced thymic tumors, pleural implantation metastasis is common and often indicates a poor prognosis and increased treatment difficulty [41, 42]. Tumor cells can shed from the primary site and implant on the pleura or other thoracic structures, such as major blood vessels, the heart, lungs, or diaphragm, facilitated by various biological characteristics of the tumor cells, including the expression of adhesion molecules and the activation of matrix metalloproteinases [43].

Clinically, pleural implantation metastasis in advanced thymic tumors presents a wide range of symptoms. Early on, patients may be asymptomatic; however, with increasing tumor burden, symptoms like chest pain, persistent cough, and dyspnea may arise. When metastasis involves the pleura, pleural effusion is a common imaging finding [40, 43]. Diagnosis primarily relies on imaging studies and pathological confirmation. CT and/or MRI can provide details on tumor size, shape, and its relationship with surrounding tissues, while video‐assisted thoracoscopic surgery and pleural biopsy are often employed to obtain pathological samples. Given that preoperative imaging may not detect small pleural metastases, surgeons should routinely explore the entire thoracic cavity and parietal pleura during surgery to avoid missing small metastatic sites [44].

5.1. Consensus 9

For patients with thymic tumors displaying limited local advancement and pleural metastatic involvement, surgical management should be prioritized. Complete resection remains the cornerstone of therapy, aiming for maximal tumor clearance and potential cure. Surgical intervention offers a substantial reduction in tumor burden, which not only facilitates the effectiveness of subsequent treatments but also contributes to improved local disease control and reduction in recurrence risk. Moreover, surgery is particularly beneficial for patients with bulky or symptomatic lesions, providing significant symptom relief and enhancing overall quality of life. In cases of recurrence or isolated metastatic disease, repeat surgical resection may be considered on an individual basis, provided the patient's clinical status is sufficient to tolerate further procedures (Grade 2B).

Surgical resection is recommended as the primary approach for thymic tumors with restricted local invasion and pleural metastasis, striving for complete tumor removal. This approach has demonstrated clear advantages in diminishing tumor burden and enhancing the impact of adjunctive therapies, while also serving to limit local disease progression and recurrence. Although thymic tumors have a propensity for local relapse, timely surgical management is associated with a significant reduction in recurrence rates [9, 32].

For patients with high tumor volumes or metastatic lesions resulting in symptoms such as chest discomfort or dyspnea, surgery is an effective means to palliate symptoms and improve life quality [45, 46]. Repeat surgical intervention should be considered for select patients presenting with recurrent or solitary metastatic lesions, contingent on adequate functional reserve [41, 47]. Observational data reported in the literature indicate that in cases of recurrence or metastasis, active surgical rescue can provide meaningful survival benefits [48]. Additional studies reinforce the positive impact of prompt and assertive surgical management on both overall and disease‐free survival in cases of initially advanced or relapsed thymic tumors [42, 49]. Resected tumor specimens facilitate comprehensive pathologic and molecular evaluation, which are essential for biological characterization of the disease and inform tailored postoperative treatment strategies [50].

5.2. Consensus 10

Hyperthermic intrathoracic chemotherapy (HITOC) represents a valuable adjunctive treatment for advanced thymic tumors with pleural metastatic disease. While this approach extends operative duration and increases procedural complexity, appropriate patient selection and meticulous perioperative management ensure acceptable safety profiles (Grade 2B).

HITOC leverages the synergistic effects of localized hyperthermia and chemotherapeutic agents to achieve enhanced antitumor activity. The hyperthermic component directly induces tumor cell death, modifies the local tumor microenvironment, and increases chemosensitivity while improving drug penetration into tumor tissue. This regional approach maximizes local drug concentration while minimizing systemic exposure and associated toxicity. The technique involves circulating heated chemotherapy solution (42°C–43°C) throughout the pleural cavity for approximately 60 min immediately following tumor resection. This protocol targets residual microscopic disease and aims to prevent local recurrence and metastatic progression. Beijing Tongren Hospital first reported the successful application of HITOC for thymic tumor pleural metastasis in 2013, demonstrating promising clinical outcomes [44].

Current evidence suggests that HITOC effectively controls pleural implantation in advanced thymic tumors and may provide therapeutic benefit even in chemotherapy‐resistant thymic carcinoma [49, 51]. Although the procedure increases operative complexity, published series demonstrate acceptable safety and feasibility [51]. Reported complications include postoperative pain, transient pulmonary dysfunction, and infrequent infectious complications [51, 52].

HITOC offers particular advantages for patients with intrathoracic metastatic disease not amenable to complete surgical resection. By delivering concentrated chemotherapy locally, this approach can improve regional disease control, extend survival, and reduce systemic toxicity compared to conventional systemic chemotherapy regimens [44]. While HITOC represents a promising therapeutic option for advanced thymic tumors, particularly in patients with suboptimal responses to standard treatments, broader clinical adoption requires validation through prospective clinical trials to establish definitive efficacy and safety parameters.

6. Management of Advanced Thymic Tumors With Concurrent MG

MG occurs in 30%–50% of patients with advanced thymoma, substantially increasing perioperative risk and procedural complexity [14]. Comprehensive preoperative evaluation and optimization, including specialized neurological assessment and targeted immunotherapy such as intravenous immunoglobulin (IVIG) or complement inhibitors, are essential for minimizing surgical morbidity and improving outcomes [53].

6.1. Consensus 11

Patients with advanced thymic tumors and concurrent MG require comprehensive preoperative evaluation with mandatory neurological consultation (Grade 1B).

Preoperative neurological evaluation is essential for thymic tumor patients with MG and encompasses comprehensive disease assessment, medical optimization, and perioperative planning. Neurologists must thoroughly evaluate current MG activity, including severity and variability of muscle weakness with particular attention to bulbar and respiratory muscle involvement, to establish baseline functional status and identify patients at increased perioperative risk [54]. Concurrent medical optimization focuses on adjusting anticholinesterase therapy and immunosuppressive regimens to achieve maximal symptom control while minimizing surgical risk, which may include modifying pyridostigmine dosing and considering pulse steroid therapy or plasmapheresis for patients with unstable disease. Additionally, neurological consultation establishes protocols for perioperative medication management, respiratory monitoring requirements, and strategies for preventing and managing postoperative myasthenic exacerbations or crises, including determination of postoperative intensive care monitoring needs and respiratory support thresholds [55]. The complexity of managing concurrent MG necessitates coordinated interdisciplinary care between thoracic surgery and neurology teams with clearly defined perioperative management protocols to optimize both oncologic and neurologic outcomes.

6.2. Consensus 12

IVIG therapy should be utilized in patients with advanced thymoma and concurrent MG to optimize symptom control and minimize perioperative risk. The combination of specialized neurological consultation and IVIG treatment provides optimal preoperative preparation for this high‐risk patient population (Grade 2A).

IVIG exerts therapeutic benefit through multiple mechanisms: modulation of autoimmune responses via immune complex binding and inflammatory mediator regulation; provision of passive immunity through broad‐spectrum immunoglobulin supplementation; and clearance of pathogenic autoantibodies responsible for neuromuscular junction dysfunction. For patients at elevated surgical risk, IVIG therapy is recommended 1–2 weeks preoperatively using a standard regimen of 0.4 g/kg daily for five consecutive days [56]. This protocol aims to stabilize MG symptoms and reduce the likelihood of perioperative myasthenic crisis.

Preoperative IVIG administration provides rapid symptom improvement, particularly valuable during periods of disease exacerbation or surgical stress. The therapy offers a stable therapeutic window for patients with generalized MG, reducing perioperative complications related to neuromuscular dysfunction. Long‐term benefits include decreased postoperative MG recurrence and improved functional recovery [14, 53]. The complexity of managing advanced thymoma with concurrent MG necessitates coordinated care combining neurological expertise with targeted immunotherapy. This integrated approach ensures comprehensive preoperative optimization, reduces perioperative morbidity, and facilitates postoperative recovery, ultimately improving both oncologic and neurologic outcomes [56]. Successful management of this challenging patient population requires meticulous preoperative planning, with neurological consultation and IVIG therapy serving as essential components of the perioperative care strategy.

7. Management of Advanced Thymic Tumors With Concurrent Autoimmune Diseases

Beyond MG, thymomas are associated with diverse autoimmune conditions, including autoimmune myocarditis, hepatitis, enteritis, Good's syndrome, and dermatomyositis [57, 58, 59]. Management of these patients requires careful attention to medication selection, optimal surgical timing, and radiation therapy considerations with appropriate toxicity monitoring.

7.1. Consensus 13

Treatment strategies for patients with advanced thymoma and concurrent autoimmune diseases must be individualized based on disease activity and overall clinical status. Immunosuppressive therapy requires cautious application, with agent selection tailored to individual patient circumstances (Grade 2B).

Surgery remains the treatment of choice for advanced thymoma patients without distant metastases, even in the presence of autoimmune comorbidities. However, surgical planning must account for autoimmune disease activity and its impact on perioperative risk. Active autoimmune disease may necessitate preoperative immunomodulation to achieve disease stability [58].

Immunosuppressive therapy presents unique challenges in this population, as these agents may potentially promote tumor progression. Careful selection of immunosuppressants and chemotherapeutic agents is essential, requiring individualized treatment regimens [57, 59]. Eculizumab, an FcRn inhibitor that reduces pathogenic IgG antibody levels, has demonstrated efficacy in MG with favorable safety profiles [60, 61, 62]. This agent represents a valuable option for patients with inadequate response to conventional immunosuppression.

7.2. Consensus 14

Radiotherapy protocols must be precisely tailored to individual patient tolerance and clinical circumstances. Multidisciplinary team collaboration is essential to optimize therapeutic outcomes and maintain quality of life (Grade 2A).

Adjuvant radiotherapy plays a critical role following incomplete resection of invasive thymomas or in cases of local recurrence, requiring more stringent dose control and frequent monitoring in patients with autoimmune diseases to prevent exacerbation of existing conditions or induction of new autoimmune responses. The complexity of managing invasive thymomas with concurrent autoimmune diseases necessitates comprehensive multidisciplinary coordination involving thoracic surgeons, subspecialist internists, pathologists, radiation oncologists, radiologists, and supportive care specialists, with treatment plans that must be individualized and continuously adjusted based on disease evolution and treatment response [8, 52, 57]. Regular comprehensive assessment is essential, including complete blood counts, hepatic and renal function, cardiac enzymes, electrocardiography, and electromyography to monitor disease progression and treatment‐related toxicity, while patient quality of life and psychological well‐being require ongoing attention, given that the burden of chronic disease management can significantly impact mental health [63].

8. Palliative Treatment Approaches for Advanced Thymic Tumors

8.1. Consensus 15

For advanced thymic tumors where complete resection (R0) is not feasible, palliative interventions should be considered to control symptoms, extend survival, and enhance quality of life (Grade 2A).

When thymic tumors involve critical mediastinal structures or patients are unsuitable for major surgical intervention, palliative approaches become essential components of comprehensive care, aiming to provide meaningful symptom relief while maintaining acceptable quality of life in patients with unresectable disease. Radiofrequency ablation (RFA) utilizes high‐frequency electrical currents to generate localized thermal energy, achieving precise tumor destruction while preserving adjacent normal tissues, and is particularly valuable for patients with prior surgical interventions or extensive thoracic adhesions as a minimally invasive alternative, though treatment efficacy depends on tumor characteristics including size, location, and vascular proximity requiring careful patient selection [64, 65, 66]. Additional thermal ablation techniques, including microwave and laser ablation, provide minimally invasive options for patients unable to tolerate major surgery, offering operational simplicity and expedited recovery while achieving local tumor control. Brachytherapy involves direct implantation of radioactive sources within tumor tissue to deliver concentrated radiation for local disease control, demonstrating particular efficacy for unresectable thymic tumors or localized metastatic disease, with clinical series reporting safe and effective outcomes for pleural recurrence, and combination chemotherapy showing promise for recurrent and metastatic disease [67]. Cryoablation employs argon–helium gas systems to induce rapid freeze–thaw cycles, resulting in tumor cell destruction through extreme temperature changes, providing meaningful tumor burden reduction and symptom palliation, particularly for pain control [68, 69].

9. Conclusion

The management of advanced thymoma and thymic carcinoma remains an evolving area of clinical practice, with several aspects of diagnosis and treatment continuing to generate debate among thoracic oncology specialists, as consensus on optimal management strategies has not been universally achieved despite significant advances in understanding thymic tumor biology and treatment approaches. This consensus document represents a collaborative effort among regional experts in the Beijing–Tianjin–Hebei area, developed through a comprehensive literature review and structured expert discussion, with primary objectives to establish a standardized framework for surgical decision‐making in advanced thymic tumors, promote consistent diagnostic and therapeutic protocols, and ensure uniform treatment quality across participating institutions.

The recommendations presented herein are based on available literature and expert clinical experience, compiled according to evidence‐based medicine principles, and are intended to serve as a clinical reference for healthcare professionals managing patients with advanced thymic tumors while acknowledging areas where clinical data remain limited or controversial. These guidelines do not constitute definitive standards for medical practice, and they should not be used as determinative criteria in medical disputes or legal proceedings. For topics with insufficient evidence or ongoing debate, we have identified research priorities and future investigational directions that represent important opportunities for prospective clinical studies. As our understanding of thymic tumor biology continues to evolve and new therapeutic modalities emerge, periodic revision of these recommendations will be necessary, with ongoing research efforts anticipated to provide additional evidence supporting more definitive consensus statements in areas currently characterized by clinical uncertainty.

Author Contributions

Zhen Yu, Peng Zhang, Guoyan Qi, Deruo Liu, Tao Yu, YunFeng Zhang, Ji Ke, Xingguo Yang, Baoxun Zhang, Xintao Yu, Jian Cui, Xiang Gao, and Lei Yu drafted this manuscript. All authors reviewed the final version of the manuscript.

Conflicts of Interest

The authors declare no conflicts of interest.

Yu Z., Zhang P., Qi G., et al., “Surgical Expert Consensus on Clinical Management of Advanced Thymoma and Thymic Carcinoma: A Beijing–Tianjin–Hebei Collaborative Initiative,” Thoracic Cancer 16, no. 14 (2025): e70133, 10.1111/1759-7714.70133.

Data Availability Statement

Data supporting this study's findings are available from the corresponding author upon reasonable request.