Primary hyperparathyroidism is commonly caused by parathyroid adenomas, hyperplasia, or, rarely, carcinoma. In up to 20% of cases, parathyroid tissue may be ectopic, often located in the mediastinum due to aberrant embryologic migration. Ectopic parathyroid glands pose a diagnostic and therapeutic challenge, and an accurate preoperative localization is essential for an effective and safe resection. Imaging modalities such as CT scan, TC-sestamibi scintigraphy, PET/CT, ultrasonography and MRI are routinely employed, whereas combined techniques offer improved diagnostic accuracy. Emerging approaches, however, including PET/CT with choline tracers, have shown promise in enhancing sensitivity in complex or recurrent cases. When ectopic glands are in the mediastinum, thoracic surgical intervention is required. Traditional open approaches, such as sternotomy or thoracotomy, are associated with significant morbidity. The development and evolution of minimally invasive surgery (MIS) has become the preferred approach in selected cases. When MIS is performed, intraoperative assessment and parathyroid identification are crucial to ensure complete gland removal. Intraoperative parathyroid hormone (ioPTH) monitoring provides real-time confirmation of surgical success. The integration of advanced imaging, intraoperative monitoring, and minimally invasive techniques significantly improves surgical outcomes while minimizing complications and accelerating patient recovery. Ultimately, the effective treatment of ectopic parathyroid glands relies on a personalized approach, adapting both diagnostic and surgical strategies to the unique anatomical and clinical context of each patient. Integration of advanced imaging, intraoperative monitoring, and minimally invasive techniques, combined with a multidisciplinary team involving endocrinologists, radiologists, and thoracic surgeons, is key to optimizing outcomes and reducing patient morbidity.

Background: De novo stage IVa thymomas, characterised by plural or pericardial dissemination at diagnosis, pose significant management challenges. The purpose of this article is to describe our experience with a two-step surgical strategy in the management of de novo stage IVa thymomas, and to evaluate its impact on oncological outcomes. Methods: Clinical and oncological data were retrospectively collected for all patients with pleural de novo stage IVa thymoma, classified according to the 9th tumor-node-metastasis (TNM) staging system, who underwent surgical treatment at the University Hospital of Pisa between January 2005 and December 2024. Variables included clinical and surgical characteristics, histological subtype [per World Health Organization (WHO) classification], and adjuvant treatments. Overall survival (OS) and disease-free survival (DFS) were analysed, stratifying patients based on surgical timing: single-step surgery (primary tumour and metastases treated simultaneously) versus two-step surgery (procedures performed 3–6 months apart). Results: Thirty patients (14 males, 16 females; median age 47 years, range 29–82 years) were included, 13 (43.3%) of whom had myasthenia gravis. All patients had pleural dissemination at diagnosis: 33% had a single metastasis, while one-third of patients had more than 10 implants. Neoadjuvant chemotherapy was administered in 63.3% of cases when judged potentially resectable. Nineteen patients (63.3%) underwent single-step surgery with radical intent on the primary tumour and pleural metastases. Eleven patients (36.7%) underwent two-step surgery, with the first procedure addressing the primary tumour, with a lower rate of post-operative complications and an earlier discharge, followed by a second operation targeting pleural metastases. The most common histological subtypes were B3 (36.7%), B2 (23.3%), and combined B2/B3 (23.3%). Twenty-five patients received adjuvant therapy, 8 of whom were prior to the second surgical procedure. Conclusions: Managing de novo stage IVa thymomas usually requires a multimodal approach. Given the typically indolent behavior of the disease, a two-step surgical strategy does not compromise the oncological outcomes, compared to single-step surgery, but may reduce the post-operative complication rate.

Background: Thymomas typically demonstrate an indolent growth pattern, showing a non-infiltrative behaviour and displacing adjacent structures, even when they reach a great size. However, high-grade thymomas may invade the capsule and directly extend into neighbouring organs. Airway involvement is exceedingly rare, with only a few cases documented in the literature. Case Description: We report an uncommon case of invasive thymoma with endobronchial growth in a 75-year-old female. The patient initially presented with hemoptysis. Chest computed tomography imaging revealed a calcified mass in the anterior mediastinum with invasion of the left upper pulmonary lobe. Due to the extent of bronchial obstruction to a subsegmental bronchus of the left upper lobe, the radiological findings were initially interpreted as being most consistent with a primary lung neoplasm. Flexible bronchoscopy confirmed the presence of a polypoid lesion originating from the subsegmental bronchus of the left upper lobe (Figure 1). Histopathological examination of endobronchial biopsies revealed a B2 thymoma. Following multidisciplinary evaluation and staging investigations that excluded distant metastases, the patient was initially referred for neoadjuvant chemotherapy due to suspected involvement of the left main pulmonary artery and mediastinal lymph nodes. However, owing to significant toxicity after the first cycle, an upfront surgical approach was considered more appropriate. The patient subsequently underwent an en-bloc extended thymectomy with left upper lobectomy via a left posterolateral thoracotomy. Histopathological analysis of the surgical specimen confirmed tumour invasion into the pulmonary parenchyma and the bronchial lumen. All surgical margins, including the bronchial stump, were negative, and no lymph node metastases were identified [pT3N0, stage IIIa according to the 9th dedicated tumor-node-metastasis (TNM) classification, although the latest system does not yet consider bronchial involvement]. The postoperative course was uneventful, and the patient was discharged on postoperative day 6. She was subsequently enrolled in a pulmonary rehabilitation program to support recovery. Adjuvant radiotherapy targeting the anterior mediastinum was administered without complications. Follow-up bronchoscopies showed no abnormalities, and the patient remains disease-free on initial post-surgical surveillance imaging. Conclusions: In conclusion, this rare case of invasive thymoma with endobronchial involvement emphasises the significance of prompt diagnosis, effective multidisciplinary treatment, and successful surgical management, leading to a favourable post-treatment outcome.