PMC:5848821 / 32198-41143 JSONTXT

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CONFERENCE DISCUSSION\nDr M. Okumura (Osaka, Japan): I congratulate Dr Moser and colleagues for creating this large database of 152 patients undergoing surgical treatment for pleural dissemination of thymic epithelial tumours. I also agree with the indication of surgery for Stage IVA thymomas and resectable recurrent thymomas. I hope that the authors’ tremendous efforts will lead to an adequate treatment strategy for dissemination of thymic epithelial tumours. But I have 3 points that I need to clarify.\nThe first question is on the indication of surgery for thymic carcinoma. Thymic carcinoma was shown to be an independent significant factor for poor outcome in overall survival, cause-specific survival and freedom from recurrence in this study. The hazard ratio was 6.5, 13.1 and 2.4, respectively, in each of the analyses. Five-year freedom from recurrence is approximately 10%. These results might suggest that surgery is not indicated for pleural dissemination of thymic carcinoma.\nI would like to know the authors’ opinion about the indication for pleural dissemination of thymic carcinoma. If you think that operative indication is still justified, then please let us know the condition in which surgery for dissemination of thymic carcinoma can be chosen.\nThe next question concerns completeness of resection. In the present study, cases undergoing R0 resection were shown to have better survival compared with R1/R2 resection. In resection of pleural lesions, it is sometimes difficult to discriminate R0 resection from R1 resection and to predict whether R0 resection can be obtained before surgery. I would like to know whether even R1 resection shows a significant difference compared with R2 resection or not.\nThe final question relates to operative procedures to resect pleural dissemination. There was no significant difference in either overall survival or freedom from recurrence among extrapleural pneumonectomy, total pleurectomy and local pleurectomy. If so, the least invasive procedure, local pleurectomy, should be chosen for any patient. As you mentioned, I guess that this result was obtained depending on the surgeon’s adequate selection of patients and operative procedures. If the present study is able to suggest the choice of operative procedure in specific situations, please let me know.\nDr Moser: You have read the study very closely. The first question was about thymic carcinoma. It is correct. We found (and this is not surprising as we saw this in other studies) that in thymic carcinoma, overall survival, cause-specific survival and freedom from recurrence are also worse in this study.\nI am not giving guidelines: all the data are here, and I cannot give a recommendation for individual patients. But as a surgeon, I still treat patients, not statistics. I have this data in my mind, and my goal in every patient with thymic carcinoma is to achieve an R0, a complete resection, preferring surgery, because the data show that these people will have prolonged survival. So I would go for surgery also in thymic carcinoma patients with the goal of achieving a complete resection. If this is not possible, incompletely resected patients do much worse.\nThe second question concerned the resection status. To make this feasible for the study, we did it like others before. We only took patients with pathologically confirmed complete resections. So when the pathologist stated in one of the multiple centres, in Canada, Italy, Austria, that this was a complete resection, then we took this for the analysis of freedom from recurrence. We did not include patients who had incomplete resection after R1 resection, and who may have had a complete remission after postoperative therapy, in the analysis of freedom from recurrence. We wanted to have this as clean as possible, so we only took the pathologically confirmed complete resections in this study. We thought this would be the cleanest approach.\nAnd your third question was about the procedures. I showed you a comparison of extrapleural pneumonectomy with the procedures of total pleurectomy and local pleurectomy. There is an obvious bias in the choice of these procedures. EPP is only chosen by the surgeon if there is metastasis to the lung, to the pleural surfaces, the pericardium, the diaphragm. Then, the patient needs an EPP. And a local pleurectomy is only chosen if there is smaller metastatic or oligometastatic disease.\nThis is not a randomized comparison of surgical procedures. This is not the message. But the message for me is that even with this invasive surgery, EPP, you can achieve as good a result if you do a complete resection as after such a local pleurectomy where you just resect one or two nodules from the pleura. That is really surprising to me. So it is really worth going for radical surgery in advanced disease. This is the message that I get out of it. I don’t want to say that patients who have local pleurectomy get the same result as EPP. This is not what this figure tells us. This tells us patients had the right operation and it had a good outcome.\nDr A. Oliaro (Torino, Italy): You have reported 5 plications of the diaphragm for phrenic nerve involvement. In the Torino experience, we never suture the phrenic nerve after resection, because we don’t believe in suture of the phrenic nerve. But last month, we resected the nerve and we sutured the nerve, and the phrenic nerve now functions; the diaphragm is functional. What do you think about that? Is it necessary to have a study if we must suture the nerve or we cut the nerve and we plicate the diaphragm?\nDr Moser: This is very interesting. You are talking about phrenic nerve reconstruction, as I understand it. I never did a phrenic nerve reconstruction. In these patients with extensive disease, the phrenic nerve was obviously involved. I don’t know the length of the phrenic nerve that was resected or whether there was a possibility for phrenic nerve reconstruction, but in non-EPP patients it is maybe worth following this concept.\nDr J. Schirren (Wiesbaden, Germany): It would be interesting for me to know how many patients you looked at in the beginning of the ’70s. I think the surgical technique in the ’70s was not the same as in the ’90s or in the 2000s. Therefore, it would be interesting to know how many patients were from this era.\nDr Moser: As I showed on one of the introductory slides, 90% of the patients had their pleural surgery between 2001 and 2014. There were just a few patients from back then.\nDr Schirren: But how many had an EPP in the beginning of the ’70s?\nDr Moser: I cannot tell you, but, as I said, most patients, 90% of them, were from between 2001 and 2014. So it is just a couple of patients, maybe 1 or 2 EPPs, from the period you mention.\nDr Schirren: The chemotherapy that patients get for this extended disease is different between the ’70s and the ’80s and the ’90s and nowadays, and, therefore, I can’t believe that there is no difference between an EPP and a pleurectomy, and the patients get carboplatin and etoposide. This is very aggressive chemotherapy. I think we all know from mesothelioma that there are differences.\nDr Moser: Of course the chemotherapy changes, but I have to say that the most predominant chemotherapeutic scheme was the PAC scheme, so the cisplatin-based scheme. This was more than 80%. There is not much change over the years in this. You saw that about 60% had neoadjuvant therapy, so multimodality therapy was quite frequent here.\nBut this is not a study on chemotherapy. This is a surgical study. This is just data that we collected to have a detailed picture. There was no complete remission. There were partial remissions for the neoadjuvant therapy in about half of the patients, but not one complete remission. We have all this data, but I can’t show it. You just gave me 8 mins here.\nDr A. Toker (Istanbul, Turkey): We have pleural involvement with thymoma, around 40 cases, and according to our experience, which we reviewed very recently, it is not uncommon that lymph node metastases occurred in these patients.\nI would like to know the number of obtained lymph node metastases in these patients and your attitude towards the lymph node in pleurectomy situations. Do you also do lymph node dissections in those patients who have recurred?\nDr Moser: I think in open surgery you always do lymph node dissection. I cannot tell you the extent of lymph node dissection in this multicentre retrospective collection of data, but just a handful of lymph node metastases were reported. As you would expect in thymomas, there are not many lymph node metastases.\nDr S. Bölükbas (Wuppertal, Germany): I have a comment. If you have lymph node metastases, then it is upstaging to IVB, not IVA, therefore you have to exclude those patients.\nDr Moser: Absolutely, but this is not a study just on IVA. This is a study on all patients with pleural disease and their recurrences."}