The author, however, shows perhaps insufficient recognition that there are points of conflict between the new TNM system and the way thymoma resections are actually performed today. For example, should surgeons really alter their current thoracoscopic approaches to stage I/II TEMs to allow N2 (middle mediastinal) lymph node dissection, when only 2% of thymomas have involved nodes? Anterior port sites used for thymectomy do not allow good access to level 7; unilateral video-assisted thoracoscopic surgery (VATS)/robotic approaches will always leave contralateral lymph node stations unexplored. It would be more appropriate to suggest an aggressive search for lymph nodes only with frankly invasive tumors and known thymic carcinomas. 然而，作者可能没有充分认识到新的TNM系统与当今胸腺瘤切除术的实际方式之间存在冲突。例如，当只有2%的胸腺瘤累及淋巴结时，外科医生真的应该改变目前的胸腔镜方法，将其改为I/II期TEMs，以允许N2（中纵隔）淋巴结清扫吗？用于胸腺切除术的前端口部位不能很好地进入7级；单侧电视胸腔镜手术（VATS）/机器人技术总是会遗漏对侧淋巴结区。建议只对侵袭性肿瘤和已知胸腺癌进行积极的淋巴结干预更为合适。
Finally, I do have concern that since the majority of tumors used to create the TNM system were resected “open,” before the wide adoption of thoracoscopy for TEMs, that the system may only be appropriately applied to “open” resections. For example, if one performs a VATS/robotic “thymomectomy”rather than the “total thymectomy/thymomectomy” typically performed “open,”one may be more likely to have a recurrence with a Masaoka stage II tumor invading extracapsular fat. That risk may not be reflected, however, in a staging system developed from data derived from “open” operations. Might the aforedescribed stage-shift downward from Masaoka stage II to TNM stage I tumors be inappropriate for VATS/robotic resections? 最后，我确实担心的是，由于用于创建TNM系统的大多数肿瘤都是在胸腔镜广泛应用于TEMs之前“开放式”切除的，因此该系统可能仅适用于“开放性”切除。例如，如果进行VATS/机器人“胸腺切除术”，而不是通常“开放式”进行的“全胸腺切除术/胸腺切除术“，则Masaoka II期肿瘤侵犯瘤周脂肪的复发可能性更大。然而，这种风险可能不会反映在根据“开放”行动的数据开发的分期系统中。上述阶段从Masaoka II期向下转移到TNM I期肿瘤是否不适合VATS/机器人切除？
Overall, using a shared, worldwide staging system for TEMs will certainly accelerate progress in this disease, and thus surgeons should embrace it despite a few specific concerns about its current iteration. As cases are accumulated using the new system, including more minimally invasive cases, the staging will be progressively refined. 总的来说，使用一个共享的全球TEMs分期系统肯定会加速这种疾病诊疗的进步，因此外科医生应该接受它，尽管目前对它的迭代有一些具体的担忧。随着使用新系统积累病例，包括更多的微创病例，分期将逐步完善。
Shrager JB. Commentary: Progress, or just movement, on thymoma staging? J Thorac Cardiovasc Surg. 2021 Apr;161(4):1530-1531. doi: 10.1016/j.jtcvs.2020.11.009. Epub 2020 Nov 6. PMID: 33293061.