Aims and Scope Mediastinum (ISSN 2522-6711) is an open access and peer-reviewed medical journal aiming at better understanding and management of mediastinal diseases. It is a professional platform for the sharing of knowledge and experience between interested peers so as to finally benefit the patients. As a unique journal, it is not limited to diseases primary to this narrow space, but encompassing all disorders related to or affecting the mediastinum (including metastatic lesions from other parts of the body, local manifestation of systemic changes, as well as disease extension from neighboring organs or compartments). By allocating most up-to-date clinical and basic researches, state-of-the-art therapeutic approaches, and rich material for education, Mediastinum aims to provide high level evidence and useful resources for all healthcare professionals engaged in delivering quality care to their mediastinal patients. MED is published by AME Publishing Company, with support from Wolters Kluwer (the journal content will be made available on Wolters Kluwer Health’s Lippincott and Ovid platforms). Currently, MED has been indexed by Web of Science [Emerging Sources Citation Index (ESCI)], PubMed/PubMed Central and Scopus. Mediastinum is the official publication of: International Thymic Malignancy Interest Group (ITMIG) Indexing Mediastinum is indexed and covered by Web of Science [Emerging Sources Citation Index (ESCI)] SCOPUS PubMed PubMed Central Google Scholar Ovid Information for Authors Mediastinum is a member of Committee on Publication Ethics (COPE) and it follows the Committee on Publication Ethics (COPE)'s guidelines and the ICMJE recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journal. Manuscripts submitted must be the original work of the author(s) and must not be published previously or under consideration for publication elsewhere. 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Example of statements in published articles: https://actr.amegroups.org/article/view/8875; https://med.amegroups.org/article/view/8358/html. Contact with Editorial Office Aisling Luo, Corresponding Editor, Mediastinum Email: med@amegroups.com Publisher Information Mediastinum is published by AME Publishing Company. Address: Hong Kong branch office: Flat/RM C 16F, Kings Wing Plaza 1, NO. 3 on Kwan Street, Shatin, NT, Hong Kong, China. Updated on July 10, 2026
A real-world cohort study comparing chemotherapy and surgery in the treatment of stage IVA thymomas with pleural dissemination
Pathobiology of thymic epithelial tumours and the treatment strategy based on immuno-oncological characteristics: a narrative review
Background and Objective: Thymic epithelial tumours (TETs), including thymomas and thymic carcinomas, are relatively rare anterior mediastinal malignancies. Thymomas are well known to be associated with various autoimmune diseases, such as myasthenia gravis (MG), pure red cell aplasia, and hypogammaglobulinemia. The mainstay of treatment for all TETs is complete surgical resection, although recent advances in irradiation and anti-tumour drug therapies are increasingly indicated for advanced or recurrent disease. The pathobiology of TETs was reviewed to consider optimal treatment strategies based on their immuno-oncological characteristics. Methods: A comprehensive literature search was conducted using PubMed, focusing on the biology and treatment of TETs, along with integration of our original research data. Key Content and Findings: Pathobiology is different between thymoma and thymic carcinoma. Incomplete T cell development is observed in thymoma, which may affect patient autoimmunity. Type AB, B1, and B2 thymomas harbour abundant immature T cells, which cannot act as effector T cells in treatment using immune checkpoint inhibitors (ICIs). Neoplastic thymic epithelial cells (TECs) express programmed cell death-ligand 1 (PD-L1) at varying levels, and frequent genetic aberrations are observed according to the World Health Organization (WHO) classification. Germinal centre formation in the surrounding thymus may have a clinical role in thymoma-associated MG. Regarding treatment strategies, radical minimally invasive thymectomy using robotic technology is now available for MG. Effective molecular-targeted and ICI therapies have recently been introduced, and further novel targeted therapies are currently under development. WHO histological subtypes and inflammatory biomarkers are practically useful for determining the treatment strategy. Conclusions: A fundamental understanding of pathobiology and immuno-oncology is crucial for the appropriate management of TETs.
Narrative review of descending necrotizing mediastinitis, focusing on the etiology, classification-guided surgical management, treatments, and prognosis
Background and Objective: Descending necrotizing mediastinitis (DNM) is a rare, life-threatening infection characterized by the rapid spread of deep neck infection (DNI) along the continuous fascial planes into the mediastinum. Although diagnostic and therapeutic advances have improved patient outcomes, the prognosis remains unsatisfactory in advanced cases or in the absence of timely and appropriate treatment, mainly due to delayed diagnoses and difficulty in selecting an appropriate surgical approach. This review summarizes the current knowledge on the pathophysiology, anatomical classification, and surgical treatment of DNM, with particular emphasis on a recently proposed classification for surgical planning. Methods: A literature search was conducted using PubMed/MEDLINE for the period from January 1999 to June 2025 with the term “descending necrotizing mediastinitis”. Full texts were retrieved through the Oita University Library. No restrictions were placed on article type. Eligible studies were English-language reports (written in English at least in abstract) addressing the etiology, pathophysiology, anatomical classification, surgical approach and treatment, or outcome of DNM. Conference proceedings and animal experimental studies were excluded. For quantitative tabulations, only articles reporting ≥4 patients were included, and less than 4 patients case-reports were excluded from the quantitative summaries. Key Content and Findings: Over time, disease classification has become more common, and the proportion of Type I disease has been increasing, reflecting improvements in the early diagnosis. Mortality rates have improved from 24.7% in the 2000s to 17.8% in the 2010s and to 14.1% in the 2020s, in our descriptive rates derived from registry cohorts. Type II disease extending below the carina, is associated with worse outcomes than Type I disease. In particular, Type IIC disease descending through the retrovisceral space, is often unsuitable for traditional anterior approaches and requires a posterior mediastinal approach via video-assisted thoracic surgery (VATS). Optimal outcomes depend on a multidisciplinary treatment strategy that includes early airway management, broad-spectrum antimicrobial therapy, and precise targeted surgical drainage. Conclusions: Improved treatment outcomes for DNM require a rapid diagnosis, accurate anatomical assessment, and prompt, case-appropriate surgical intervention. Recognizing the correct classification enables the selection of the most suitable drainage approach and is expected to further improve the prognosis.
Systemic therapy for advanced thymic epithelial tumors: a narrative review of current evidence and perspectives
Background and Objective: Thymic epithelial tumors (TETs), including thymoma and thymic carcinoma, are rare tumors. Although systemic therapy is commonly used for unresectable advanced or recurrent TETs, establishing robust evidence remains challenging. This narrative review summarizes current evidence and incorporates the latest clinical trial data, reporting outcomes separately for thymoma and thymic carcinoma whenever possible. We also highlight practical considerations relevant to clinical practice, including dosing strategies and toxicity management. Methods: We searched PubMed and Google Scholar for prospective and retrospective original studies, meta-analyses, review articles, and case studies published up to November 2025 using terms including “thymoma”, “thymic carcinoma”, “thymic cancer”, “thymic tumors”, “thymic epithelial tumors”, “chemotherapy”, “systemic treatment”, “immunotherapy”, and “targeted therapy”. Ongoing trials were identified via ClinicalTrials.gov and the Japan Registry of Clinical Trials. Retrospective studies enrolling fewer than 15 participants were excluded. Key Content and Findings: Systemic therapy for advanced TETs continues to include cytotoxic chemotherapy as a major component. In selected settings, particularly in thymic carcinoma, targeted therapy and immune checkpoint inhibitors (ICIs) represent additional active options. Emerging trials suggest that combination strategies may enhance efficacy. Novel drugs, including bispecific antibodies and antibody–drug conjugates, are being evaluated in ongoing phase II trials. Conclusions: Despite the rarity of TETs, systemic treatment options have gradually expanded through the accumulation of evidence from small phase II studies. Future advances will require collaborative prospective trials to validate predictive biomarkers and support biomarker-enriched trial designs.
Preoperative and anesthetic management of high-risk cardiovascular complications of mediastinal masses: a narrative review
Background and Objective: The mediastinum is a complex anatomical region that includes the heart, aorta, superior vena cava, trachea, and mainstem bronchi. Mediastinal masses, while relatively uncommon, can cause life-threatening cardiovascular symptoms from mass effect, including cardiac tamponade, superior vena cava syndrome, mediastinal mass syndrome, and right ventricular outflow tract obstruction, requiring prompt identification and management. Currently, there are no guidelines that discuss the optimal management of these cardiovascular complications, and our review aims to address this. Methods: A database search in PubMed was conducted from September 2025 to November 2025, including articles related to mediastinal masses and the various cardiovascular complications that can arise. Selected articles were compiled and reviewed to help compose this review. Key Content and Findings: This review aims to outline the incidence and etiology of different mediastinal masses, review the presentation and diagnostic workup, highlight key life-threatening syndromes related to mass effect, and discuss definitive management of these lesions. Given the complexity of the mediastinum and potential for several life-threatening complications without appropriate identification, timely diagnosis is needed to guide management. Conclusions: A multidisciplinary approach is crucial in the stabilization and management of these patients with mediastinal masses and should be considered the standard of care in all patients. This review aims to summarize current literature for the management of cardiovascular complications related to mediastinal masses.
Approach to mediastinal cytopathology: a diagnostic overview
The mediastinum contains a diverse array of tissues, giving rise to a wide spectrum of benign, inflammatory, and malignant lesions. Accurate diagnosis is essential for determining appropriate management strategies, ranging from observation to targeted therapy. Fine-needle aspiration (FNA) has become the cornerstone of mediastinal evaluation, particularly with the advent of endobronchial and endoscopic ultrasound-guided techniques [endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and endoscopic ultrasound-guided FNA (EUS-FNA)], which allow minimally invasive access to all mediastinal compartments. Cytologic evaluation of these specimens, however, presents diagnostic challenges due to overlapping morphologic features and limited material for ancillary testing. This comprehensive review outlines a systematic approach to mediastinal cytopathology, emphasizing specimen adequacy, cytomorphologic interpretation, and integration with ancillary studies. Key entities include reactive lymphoid hyperplasia, granulomatous inflammation, cystic lesions, and a range of neoplastic processes such as thymic epithelial tumors, lymphomas, germ cell tumors (GCTs), mesenchymal neoplasms, and metastatic malignancies. Ancillary techniques—immunocytochemistry (ICC), flow cytometry, and molecular testing—play pivotal roles in confirming lineage, assessing clonality, and enabling targeted therapeutic decisions. Advances in next-generation sequencing (NGS) have expanded the use of cytology specimens for molecular profiling, while digital cytology and artificial intelligence (AI) are emerging as promising tools to improve accuracy and reproducibility. The review also highlights common diagnostic pitfalls, including confusion between thymic lesions and metastatic carcinoma, lymphoma and thymoma, or GCTs and poorly differentiated carcinomas. An algorithmic diagnostic workflow that combines cytomorphology with clinical, radiologic, and molecular data enhances accuracy and efficiency.
The expanding role of robotic surgery in thymectomy: a narrative review
Surgical resection for thymic epithelial tumors has traditionally been performed via a median sternotomy or video-assisted thoracoscopic surgery (VATS). In recent years, however, robot-assisted thoracoscopic surgery (RATS) has been increasingly adopted as a minimally invasive alternative, with a growing number of reports. This review summarizes the progress achieved to date and outlines future perspectives in robot-assisted thymectomy.
Mediastinitis after cardiac surgery, from microbes to management: a systematic review
Background: Post-sternotomy mediastinitis is a complication of cardiac surgery associated with substantial morbidity, mortality, and healthcare burden. Despite advances in surgical technique, perioperative care, and infection control, patient risk profiles and surveillance methodologies continue to drive variation in reported incidence rates. The objective of this systematic review is to review the evidence on incidence, microbiology, risk factors, prevention, and management of mediastinitis after cardiac surgery. Methods: A systematic search of Ovid MEDLINE and EMBASE was performed from inception to October 2025 following PRISMA 2020 guidelines (registration CRD420251177438). Eligible studies included adult patients undergoing cardiac surgery with reported outcomes on mediastinitis incidence, mortality, microbiology, prevention, or management. Case reports, conference abstracts, and narrative reviews were excluded. Data were extracted on study design, population characteristics, pathogen distribution, preventive strategies, and management approaches. Due to heterogeneity in study designs and outcome definitions, a meta-analysis was not performed. Results: 60 studies met inclusion criteria. Across over 400,000 patients, the reported incidence of mediastinitis ranged from 0.2% to 11.0%, with contemporary series typically reporting 0.5–3%. Mortality ranged from 1.5% in contemporary early-treated cohorts to 40–60% in delayed, recurrent, or fungal mediastinitis complicated by sepsis. Staphylococcus aureus and coagulase-negative staphylococci (CoNS) remained predominant pathogens, alongside methicillin-resistant strains, gram-negative bacilli, and an emerging burden of fungal and biofilm-forming organisms. Consistent risk factors included diabetes, obesity, chronic kidney disease, chronic lung disease, prolonged cardiopulmonary bypass, bilateral internal thoracic artery (BITA) harvest, high transfusion burden, and re-exploration. Preventive strategies included well-timed, weight-adjusted antibiotic prophylaxis, optimized perioperative glycemic control, skeletonized internal thoracic artery harvest, rigid sternal fixation in high-risk patients, and closed-incision negative-pressure therapy. Effective management involved early radical debridement, vacuum-assisted closure therapy, culture-directed antimicrobials, and vascularized flap coverage within multidisciplinary teams. Conclusions: Post-sternotomy mediastinitis remains a preventable systemic complication. Bundled perioperative strategies, meticulous sternal technique, optimized perfusion and metabolic control, and coordinated multidisciplinary management offer the greatest potential to reduce incidence and improve outcomes. Future research should standardize definitions, refine prophylaxis bundles, optimize antimicrobial duration, and integrate advanced diagnostics for early detection of biofilm-mediated infection.
A review of robotic-assisted mediastinal surgery in the pediatric population
Advances in minimally invasive surgical techniques have greatly decreased the morbidity associated with large open thoracic operations. Robotic-assisted thoracic surgery is at the forefront of minimally invasive techniques and has been rapidly adopted in the adult population. However, the integration of robotic surgery in the pediatric population has been slower. Mediastinal resections are particularly well suited for a robotic approach as it offers precise motor control and dexterity within a confined space. The objective of this study is to clarify the feasibility and safety of a robotic approach to pediatric mediastinal pathology. We queried the online databases of PubMed, Web of Science, and Embase to identify studies and case reports regarding robotic-assisted mediastinal surgery in the pediatric population, defined as patients less than 18 years old. A total of 12 studies and case reports were utilized to synthesize a review of robotic-assisted mediastinal surgery in the pediatric population. While the available literature regarding the topic of pediatric robotic-assisted mediastinal surgery is sparse, the studies and case reports that do exist suggest that robotic-assisted mediastinal surgery within this population is both feasible and safe. The available literature identified in this review demonstrates low complication rates and low rates of conversion to open surgery speaking to the safety and feasibility of this approach. This review also suggests that a robotic approach offers superior flexibility, improved visualization, improved ergonomics and better alignment of hand motion when compared to traditional video-assisted thoracic surgery (VATS).
Acute mediastinitis, mediastinal granuloma, and fibrosing mediastinitis: a narrative review
Background and Objective: Acute mediastinitis, mediastinal granuloma (MG), and chronic fibrosing mediastinitis (FM) are distinct disease processes affecting the mediastinal structures. These diseases have variable etiologies, management strategies, and outcomes. The purpose of the manuscript is to present a narrative review of these distinct, albeit rare conditions affecting the mediastinum. Methods: We searched various databases such as PubMed and Google Scholar from the last 10 years for the various benign mediastinal disorders we wanted to discuss. Relevant articles that were written in English were shortlisted and used to help write this narrative review. Key Content and Findings: The most common causes of acute mediastinitis are post-operative infection, esophageal perforation, or deep neck space infection originating from the oropharynx. Acute mediastinitis is a life-threatening disease, is difficult to manage and is associated with high morbidity and mortality. MG is usually a sequela of chronic infection or inflammation that has an overall benign course and the possibility of spontaneous resolution. On occasion, an MG can cause pathophysiological consequences due to its mass effect. FM is caused by infectious, inflammatory, or malignant conditions and can also be idiopathic. This condition leads to extensive fibrosis throughout the mediastinum with invasion of mediastinal structures. It is difficult to treat, especially when complications arise from invasion or compression of mediastinal structures, and it carries a poor prognosis. Conclusions: In this review article, we will discuss each of these conditions in more detail, including epidemiology, pathophysiology, clinical features, imaging features, diagnosis, management, and prognosis.
Evolving paradigms in thymoma surgery and multidisciplinary care: a narrative review
Background and Objective: Thymic epithelial tumors (TETs)—including thymomas and thymic carcinomas—are rare anterior mediastinal malignancies characterized by variable biology, frequent paraneoplastic syndromes, and high recurrence potential. Recent advances in pathologic classification, staging systems, imaging, surgical techniques, and systemic therapies have led to significant changes in clinical management. Complete R0 surgical resection remains the cornerstone of curative treatment; however, the increasing adoption of minimally invasive approaches, refinement of multimodal therapy for advanced disease, and emerging molecular profiling are reshaping contemporary clinical practice. This narrative review aims to provide a comprehensive overview of evolving surgical approaches and multidisciplinary management strategies for thymoma, highlighting recent advances and clinical challenges. Methods: This review synthesizes literature published from 2010 to 2025 on the management of thymoma. Key areas assessed include updates to World Health Organization (WHO) histopathologic classification and Tumor-Node-Metastasis (TNM) staging; diagnostic strategies and imaging modalities; comparisons of open, video-assisted thoracoscopic surgery (VATS), and robotic-assisted surgical techniques; multimodal therapy, including neoadjuvant and adjuvant chemotherapy and radiotherapy; management of recurrent and metastatic disease; and evolving molecular and immunologic treatment approaches. Evidence from international databases and institutional outcomes was incorporated to evaluate the role of multidisciplinary management and treatment at high-volume centers. Key Content and Findings: Modern thymoma management has shifted toward more individualized, multidisciplinary decision-making. Minimally invasive surgery, particularly robotic-assisted thoracic surgery, provides safe and oncologically equivalent outcomes for early-stage tumors with reduced perioperative morbidity. For locally advanced or initially unresectable disease, neoadjuvant chemotherapy increases the likelihood of achieving R0 resection, while adjuvant radiotherapy improves local control in high-risk cases. Recurrent disease, often detected years after initial treatment, benefits most from repeat surgical resection when feasible. Molecular profiling has identified potential genomic alterations in selected subtypes, supporting the use of targeted agents and, more cautiously, immunotherapy, although thymoma’s autoimmune biology increases the risk of severe immune-related toxicities. Across studies, treatment at specialized, high-volume centers consistently correlates with better outcomes. Conclusions: Evolving surgical techniques, improved staging systems, and expanding systemic therapies have transformed the management of thymoma into a highly individualized, multimodal discipline. While complete resection remains central to curative intent, optimal outcomes require coordinated multidisciplinary care, careful patient selection for minimally invasive approaches, and personalized systemic strategies for advanced or recurrent disease. Continued international collaboration and molecularly informed research will be essential to refining future standards of care for this rare malignancy.
Mediastinal epithelial neoplasms with recurrent molecular alterations
A wide variety of benign and malignant epithelial tumors arise in the mediastinum. This review sheds light on recurrent molecular genetic alterations of mediastinal epithelial tumors to help the surgical pathologist become aware of molecularly defined entities that one may encounter in practice and understand relevant genetic underpinnings, with an emphasis on diagnostically useful immunohistochemical targets. We discuss the molecular landscape of thymoma, including World Health Organization (WHO) types as well as micronodular and metaplastic thymoma, and introduce current concepts in the molecular subtyping of thymic carcinoma. We present an overview of proposed molecular classification schemes of thymic epithelial neoplasms that focuses on commonly occurring molecular alterations described in The Cancer Genome Atlas and original data sources, and relate them to longitudinal prognostic and therapeutic implications. Poorly differentiated epithelial neoplasms of the mediastinum defined by recurrent molecular alterations can display diagnostically challenging morphologic and immunohistochemical profiles and are critically important to recognize due to their aggressive behavior. We conclude with a discussion of NUT carcinoma and switch/sucrose non-fermentable (SWI/SNF) complex deficient tumors, including thoracic SMARCA4-deficient undifferentiated tumor, reviewing salient histopathologic and immunohistochemical features that allow their recognition from histologic mimics and tumors with overlapping immunoprofiles. We lastly outline the current understanding of genetic events that give rise to these destructive tumors.
Small biopsy diagnosis of anterior mediastinal masses: histologic, immunohistochemical, and molecular considerations
Salvage resection via a trans-manubrial approach after definitive chemoradiotherapy for initially unresectable thymic carcinoma in the superior mediastinum: a case report
Aberrant malignant invasive thymoma presenting as isolated left internal jugular vein thrombosis.and resected by VATS thymectomy: a case report
Cryoablation as a downsizing strategy enabling R0 resection in a giant mediastinal desmoid tumor: a case report
Background: Endothoracic desmoid tumors are rare, locally aggressive soft-tissue neoplasms whose intrathoracic location often precludes safe surgical resection. The historical paradigm of upfront radical surgery has shifted toward a more conservative and stepwise approach, prioritizing active surveillance and non-surgical treatments whenever feasible. Surgical resection is now typically reserved for selected cases. Percutaneous cryoablation (PCA) has emerged as a promising minimally invasive treatment and valid therapeutic alternative for selected patients, although its role as a tumor downsizing strategy remains poorly defined. Case Description: We report the case of a 64-year-old woman presenting with a giant anterior mediastinal desmoid tumor causing progressive respiratory symptoms and pain. Initial systemic therapies were associated with disease progression, and despite second-line treatment, tumor control was not achieved, leading to surgical contraindication. Within the framework of the prospective CRYODESMO-O1 trial, the multidisciplinary team proposed PCA, resulting in a significant reduction in tumor size and improved anatomical relationships. This evolution allowed reconsideration of surgical resection, which was subsequently performed via a left sternothoracotomy approach. Final pathological examination demonstrated less than 10% residual desmoid tissue with complete (R0) resection. At the last follow-up at 8 months after surgery the patient was well and without recurrence. Conclusions: In this case, cryoablation was associated with marked tumor downsizing and a major pathological response, facilitating reconsideration of surgical resection in a tumor initially deemed unresectable. This approach may represent a potential component of multimodal management in carefully selected patients, although further evidence is needed to confirm its role.
Thymolipoma and lipofibroadenoma, two sides of the same coin?