Case report
A challenging case of a giant thymoma resected using the clamshell approach
Extensive intrathoracic tumours demand an aggressive surgical approach due to their size and proximity to vital structures, thereby increasing procedural risks. A thymoma can expand substantially before detection and affect surrounding tissues. An operation is the primary therapy, sometimes supplemented by chemotherapy or radiation. In this case report, we present the case of a giant thymoma managed with the clamshell approach.
Large endothoracic tumours present a significant challenge in general thoracic surgery due to their considerable size and proximity to critical anatomical structures [1].
These features often necessitate the use of highly invasive surgical approaches, such as a clamshell or a hemi-clamshell thoracotomy, to achieve complete resection [2, 3]. The procedures are technically demanding, requiring meticulous dissection to avoid injury to vital structures [4]. Moreover, the invasiveness of these approaches contributes to prolonged recovery periods, elevated rates of postoperative complications and not negligible perioperative mortality risks.
A thymoma is a rare tumour that can grow slowly, often reaching considerable dimensions before being diagnosed [5]. It can invade adjacent structures, including the lungs, pleura and mediastinal great vessels, making its treatment more complex [6]. Symptoms may be nonspecific, such as chest pain or shortness of breath. Surgical resection is the main treatment option, although additional therapies like chemotherapy or radiation may be necessary, depending on the extent of the invasion.
This case report illustrates a complex case of a thymoma operated on in our centre using a clamshell approach.
1 - Patient presentation (0:13)
The patient is a 57-year-old male, former smoker, with a medical history significant only for hypertension. He presented to the emergency department with asthenia and palpitations, prompting a chest X-ray and a subsequent computed tomography (CT) scan.
The CT scan showed a large, solid mass measuring approximately 17 x 10 cm, causing posterior displacement of the aorta and pulmonary arteries and significant compression of the trachea at the level of the main carina. The lesion exhibited annular calcifications. Additionally, a small pleural effusion and pericardial effusion were noted.
A CT-guided core needle biopsy confirmed the diagnosis of thymic carcinoma. Following a multidisciplinary evaluation, the patient underwent three cycles of chemotherapy with carboplatin and paclitaxel. Subsequent imaging, including a CT scan and cardiac magnetic resonance imaging, was performed to assess the treatment response and to plan for surgical intervention. The CT scan demonstrated that the diameters of the mass remained unchanged. The cardiac magnetic resonance images showed that both the heart and the major mediastinal vessels, although compressed, in the kinetic sequences move adjacent to the mass without exhibiting fibro-retractile phenomena due to invasion by contiguity/continuity.
2 - Surgical procedure (1:49)
The patient was placed in a supine position with his arms alongside the body. A clamshell incision was performed at the third intercostal space. The mass was progressively separated from the thoracic wall and the right lung. A longitudinal section of the body of the sternum was made to extend the surgical field and better dissect the lower portion of the mass. The pericardium was opened and dissected up to the left brachiocephalic vein, identifying and preserving the left phrenic nerve. The same procedure was performed for the right brachiocephalic vein.
3 - Mass excision (3:58)
The lung was completely separated from the mass using six parenchymal staplers. Because the mass infiltrated the left brachiocephalic vein, the vein was distally isolated at its junction with the superior vena cava.
The left brachiocephalic vein was cross-clamped proximally and distally to the neoplasm after the administration of 2500 international units of heparin and dissected with a scalpel; the mass was freed from the supra-aortic trunks and removed.
4 - Vascular reconstruction of the left brachiocephalic vein (6:03)
The left brachiocephalic vein was reconstructed with a 3-0 Prolene single running suture using a polytetrafluoroethylene prosthesis. Before completing the anastomosis, de-airing was performed. TachoSil (Corza Medical, Westwood, MA, USA) was applied to enhance haemostasis. A lymphadenectomy was carried out in the paratracheal station.
5 - Haemostasis and closure (8:06)
Haemostasis was further secured with the application of TachoSil and Glubran 2 (GEM, Viareggio, IT). The sternum was closed with a parasternally crossed closure technique.
6 - Postoperative course and follow-up (8:43)
The postoperative course was uneventful. The pleural drain was removed on postoperative day 4, and the patient was discharged on postoperative day 5. Postoperatively, we added antiplatelet therapy (acetylsalicylic acid 100 mg daily). Contrary to the initial determination, the final histological diagnosis was changed to thymoma AB. Due to the closeness of the neoplasm to the surgical margins, the patient received adjuvant radiotherapy.
According to our experience, a clamshell procedure represents a highly effective and versatile surgical approach for managing large thoracic masses that involve the mediastinum, both lungs and the great vessels and/or neoplasm located in the posterior mediastinum. This incision provides excellent bilateral exposure of the thoracic cavity, facilitating access to critical mediastinal structures and enables precise dissection of bulky lesions [2].
In this case, we opted for an operation because the lesion did not respond to chemotherapy and because the preoperative images showed no signs of infiltration of the heart chambers.
However, one of the most complex aspects of these cases is the question of when surgery should be indicated and when the tumour should be considered inoperable. As far as we are concerned, the indication for surgery in these cases is based on the good general condition of the patient and the absence of infiltration of the heart by the lesion. Of course, our recommendation is to refer such patients to high-volume, experienced centres.
Case Report Follow-up
The postoperative course was uneventful. The patient did not experience any late complications following the surgical procedure.
1. Slinger P, Karsli C. Management of the patient with a large anterior mediastinal mass: recurring myths. Curr Opin Anaesthesiol 2007;20:1–3.
PubMed Abstract | Publisher Full Text
2. Bains MS, Ginsberg RJ, Jones WG, McCormack PM, Rusch VW, Burt ME et al. The clamshell incision: an improved approach to bilateral pulmonary and mediastinal tumor. Ann Thorac Surg 1994;58:30–2; discussion 33.
PubMed Abstract | Publisher Full Text
3. Fujiwara A, Funaki S, Ose N, Kanou T, Kanzaki R, Minami M et al. Surgical resection for advanced thymic malignancy with pulmonary hilar invasion using hemi-clamshell approach. J Thorac Dis 2018;10:6475–81.
PubMed Abstract | Publisher Full Text
4. Park BJ, Bacchetta M, Bains MS, Downey RJ, Flores R, Rusch VW et al. Surgical management of thoracic malignancies invading the heart or great vessels. Ann Thorac Surg 2004;78:1024–30.
PubMed Abstract | Publisher Full Text
5. Minervini F, Kocher GJ. When to suspect a thymoma: clinical point of view. J Thorac Dis 2020;12:7613–8.
PubMed Abstract | Publisher Full Text
6. Girard N, Ruffini E, Marx A, Faivre-Finn C, Peters S, ESMO Guidelines Committee. Thymic epithelial tumours: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015;26 Suppl 5:v40–55.
The authors would like to thank Emma Tavelli for the drawings.
Authors
Giulia Pagliarini, Vincenzo Verzeletti, Alessandro Bonis, Gianluca Canu, Marco Mammana, Samuele Nicotra, Andrea Dell’Amore & Federico Rea
Affiliations
Thoracic Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public-Health, Padua University Hospital, Padua, Italy
Corresponding Author
Vincenzo Verzeletti
Thoracic Surgery Unit
Department of Cardiac, Thoracic, Vascular Sciences and Public Health
Padua University Hospital
Padua
Italy
Email: vverzeletti@gmail.com
Keywords
© The Author 2025. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
