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Anti-dsDNA Is Associated with Favorable Prognosis in Myasthenia Gravis: A Retrospective Study. Acta Neurol Scand 2023. [DOI: 10.1155/2023/8939083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Objectives. To investigate the presence of serum antinuclear antibody (ANA) and anti-double-stranded DNA antibody (anti-dsDNA) in patients with myasthenia gravis (MG) and analyze the clinical characteristics and prognostic factors associated with MG. Methods. We retrospectively enrolled 363 patients with MG and analyzed the clinical characteristics and follow-up data between patients positive and negative for ANA and anti-dsDNA. We defined a Myasthenia Gravis Activities of Daily Living (MG-ADL) reduction as a main prognosis predictor and used logistic regression to determine independent factors associated with prognosis. We built a nomogram to predict prognosis and evaluate the internal validity of the model. Results. Ninety-eight (27.0%) patients were positive for ANA, and 51 (14.0%) were positive for anti-dsDNA. Patients positive for ANA and anti-dsDNA antibodies tended to be female and positive for acetylcholine receptor antibody (AChR-Ab). The rate of thymoma was higher in anti-dsDNA-positive patients with MG (p-dsDNA-MG) than in patients negative for anti-dsDNA (49.0% vs. 26.0%,
), and p-dsDNA-MG was associated with reduced MG-ADL score. Regression analysis showed that except for age of onset (
,
,
), anti-dsDNA (
,
,
), ptosis (
,
,
), and eye movement disorder (
,
,
) were independent predictive factors of a favorable prognosis of MG. These predictors were used to generate a nomogram with an excellent predictive value. Conclusions. Being female and the presence of AChR-Ab were features of ANA- or anti-dsDNA-positive MG. The presence of anti-dsDNA was associated with a favorable prognosis of MG.
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Chen K, Li Y, Yang H. Poor responses and adverse outcomes of myasthenia gravis after thymectomy: Predicting factors and immunological implications. J Autoimmun 2022; 132:102895. [PMID: 36041292 DOI: 10.1016/j.jaut.2022.102895] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
Abstract
Myasthenia gravis (MG) has been recognized as a series of heterogeneous but treatable autoimmune conditions. As one of the indispensable therapies, thymectomy can achieve favorable prognosis especially in early-onset generalized MG patients with seropositive acetylcholine receptor antibody. However, poor outcomes, including worsening or relapse of MG, postoperative myasthenic crisis and even post-thymectomy MG, are also observed in certain scenarios. The responses to thymectomy may be associated with the general characteristics of patients, disease conditions of MG, autoantibody profiles, native or ectopic thymic pathologies, surgical-related factors, pharmacotherapy and other adjuvant modalities, and the presence of comorbidities and complications. However, in addition to these variations among individuals, pathological remnants and the abnormal immunological milieu and responses potentially represent major mechanisms that underlie the detrimental neurological outcomes after thymectomy. We underscore these plausible risk factors and discuss the immunological implications therein, which may be conducive to better managing the indications for thymectomy, to avoiding modifiable risk factors of poor responses and adverse outcomes, and to developing post-thymectomy preventive and therapeutic strategies for MG.
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Affiliation(s)
- Kangzhi Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.
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Abstract
Background: Paraneoplastic gastroparesis is a gastrointestinal syndrome that rarely precedes a tumor diagnosis. To increase awareness of this rare clinical entity, we present a case of severe gastroparesis, which was later proven to be associated with a thymoma. Case report: A 55-year old man had the sudden onset of severe abdominal cramps and abdominal distension, early satiety with postprandial nausea, acid regurgitation, belching, and flatulence. He lost about 20 pounds. The physical and imaging examination revealed stomach distension, gastroparesis, and the presence of a solid mass in the anterior mediastinum. Radical surgery was performed to remove the thymoma and, given the high value of Mib-1, the patient was submitted to postoperative chest radiation therapy. After thymectomy, a diagnosis of paraneoplastic myasthenia gravis with subacute autonomic failure was made. Conclusion: Autoimmune gastroparesis should be considered as a potential paraneoplastic syndrome in patients with thymoma, myasthenia gravis, and delayed gastric emptying in the absence of mechanical obstruction.
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Factors affecting improvement of neurologic status evaluated by Quantitative Myasthenia Gravis Score for patients with thymomatous myasthenia gravis after extended thymectomy. J Transl Med 2021; 19:413. [PMID: 34600541 PMCID: PMC8487513 DOI: 10.1186/s12967-021-03082-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background The length of time for clinical improvement of patients with thymomatous myasthenia gravis (MG) after extended thymectomy is not clear. The purpose of this study was to determine the length of time after thymectomy in patients with thymomatous MG to achieve a 3-point reduction of Quantitative Myasthenia Gravis Score (QMGS), and identify variables associated with a failure to achieve the reduction. Methods The records of patients with thymomatous MG who underwent extended thymectomy from January 2005 to December 2018 were retrospectively reviewed. The primary end point was a reduction of 3 points of QMGs and the secondary end point was another reduction of 3 points of QMGs. Results A total of 481 patients were included in the analysis, the mean age of the patients was 41.63 ± 8.55 years, and approximately 60% were male. The median time to achieve a 3 point decrease in QMGS was 6 months, and the median time to achieve another 3 point decrease was 30 months. Multivariable analysis indicated that age ≥ 42 years and Masaoka-Koga stage > I were associated with a lower probability of achieving a 3 point decrease in QMGS (HR = 0.55 and 0.65, respectively). Likewise, multivariable analysis indicated that age ≥ 42 years and Masaoka-Koga stage > I were associated with a lower probability of achieving a second 3 point decrease in QMGS (HR = 0.53 and 0.53, respectively). Conclusions In patients with thymomatous MG who receive thymectomy, age ≥ 42 years and Masaoka-Koga stage > I are associated with a worse prognosis and failure to achieve a 3 point decrease in QMGS.
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Shreedhara AS, Nair SS, Unnikrishnan M, Sandhyamani S, Sarma PS, Nair M, Sarada C. Determinants of Suboptimal Outcome Following Thymectomy in Myasthenia Gravis. Neurol India 2021; 69:419-425. [PMID: 33904466 DOI: 10.4103/0028-3886.314565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Response to thymectomy in myasthenia gravis (MG) is influenced by various patient-, disease-, and therapy-related factors. Methods Retrospective analysis of 128 patients with MG who underwent maximal thymectomy over 15 years was done to identify the determinants of suboptimal clinical outcome. Results Among the 128 patients, 62 (48.4%) were females with a mean age of 38.97 (12.29) years. Thymomatous MG occurred in 66 (51.6%). Overall improvement from preoperative status was noted in 88 (68.8%) patients after mean follow-up of 51.68 (33.21) months. The presence of thymoma was the major predictor of suboptimal clinical outcome (P = 0.001), whereas age, gender, preoperative disease severity, and seropositive status did not attain significance. Patients with better outcome had received higher steroid dose preoperatively (P = 0.035). Conclusions Suboptimal response after thymectomy occurred in one-third of MG patients, more commonly with thymomatous MG. Relationship of preoperative steroid therapy to remission merits evaluation.
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Affiliation(s)
- A S Shreedhara
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sruthi S Nair
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Madathipat Unnikrishnan
- Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - S Sandhyamani
- Department of Pathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - P S Sarma
- Department of Pathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Muralidharan Nair
- Department of Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - C Sarada
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Menon D, Katzberg H, Barnett C, Pal P, Bezjak A, Keshavjee S, Bril V. Thymoma pathology and myasthenia gravis outcomes. Muscle Nerve 2021; 63:868-873. [PMID: 33675078 DOI: 10.1002/mus.27220] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 02/24/2021] [Accepted: 02/27/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION There is limited evidence regarding the impact of World Health Organization (WHO) subtype of thymoma on post-thymectomy outcome of thymoma-associated myasthenia gravis (TAMG). The objective was to determine if the pathological subtypes of thymoma were associated with post-thymectomy outcomes of myasthenia gravis (MG), in patients with TAMG. METHODS We performed a retrospective study of consecutive patients with TAMG who attended the neuromuscular clinic between January 2018 and December 2019 with a minimum follow-up of 1 y after thymectomy. Outcome measures were MG Impairment Index (MGII), single-simple question (SSQ), Myasthenia Gravis Foundation of America post-intervention status (MGFA PIS) and non-responder MG status at last assessment. RESULTS Ninety-five patients were included; mean age at onset was 48.1 ± 12.1 y; 54(56.8%) were females. Thirteen patients developed MG post-thymectomy. The most common thymoma was WHO type B2 in 39 (41.1%). Most patients (40, 42.1%) had Masaoka stage II thymoma. There was no association of thymoma subtypes or Masaoka stage of disease with age, gender, MG phenotype, serology, post-thymectomy onset, interval from onset to thymectomy, MGII, SSQ, MGFA PIS, or non-responder status. Associations were found between positive serology and lower MGII (11.1 ± 14.2 vs 23 ± 12.9, P = .050), thymic follicular hyperplasia (TFH) and higher SSQ (89.3 ± 11.7 vs 80.1 ± 20.2, P-.043), and lack of recurrence and higher SSQ (84.1 ± 18 vs 72.5 ± 20, P = .037). DISCUSSION The WHO pathological subtype of thymoma did not correlate with MG outcomes. However, positive acetylcholine antibody serology, presence of TFH, and non-recurrence of thymoma predict a favorable outcome.
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Affiliation(s)
- Deepak Menon
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Hans Katzberg
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Barnett
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Prodipto Pal
- Department of Laboratory Medicine and Pathology, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Bezjak
- Department of Radiation Oncology, University Health Network, Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Department of Surgery, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vera Bril
- Ellen and Martin Prosserman Centre for Neuromuscular Diseases, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Chen J, Shang W, Chen Y, Li Y, Huang X, Su C, Zhu K, Zhang J, Liu W, Feng H. Thymomatous myasthenia gravis: 10-year experience of a single center. Acta Neurol Scand 2021; 143:96-102. [PMID: 32762063 DOI: 10.1111/ane.13332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/16/2020] [Accepted: 08/02/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To summarize the clinical features of thymomatous myasthenia gravis (T-MG), examine the association between MG and thymoma, and identify the related factors or predictors for long-term prognosis of T-MG. METHODS A retrospective, observational study was conducted on 100 patients with T-MG and 96 patients with non-T-MG (NT-MG) between January 1, 2009 and December 31, 2019. The baseline characteristics were recorded for each patient. Logistic regression was used to measure the association between all clinical variables and T-MG prognosis. RESULTS Between the T-MG and NT-MG groups, age at onset (45.66 ± 11.53 years vs 39.06 ± 14.39 years); age >40 years (72.0% vs. 40.6%); AChR-Ab positive rate (100.0% vs. 83.3%); Myasthenia Gravis Foundation of America (MGFA) classification at the worst condition (≥grade III, 61.0% vs. 33.0%); thyroid dysfunction (7.0% vs. 20.8%); and outcome (complete stable remission + pharmacologic remission + improvement, 74.0% vs. 93.7%) were statistically significant (P < .05). Presence of thymoma (OR = 0.196, 95%CI = 0.076-0.511, P = .001) was a risk factor for MG. Male sex, post-operative complications, higher grade of MGFA classification, and thymoma Masaoka-Koga pathological stage were risk predictors for long-term prognosis of T-MG (P < .1). Use of preoperative anticholinesterase drugs (OR = 5.504, 95%CI = 1.424-21.284, P = .013) was identified as an independent predictor for T-MG. CONCLUSION T-MG is clinically different from NT-MG, and thymoma is considered a risk factor for MG. Preoperative anticholinesterase drug use is a protective factor for long-term prognosis of T-MG. A comprehensive understanding of the characteristics of T-MG will likely help improve its prognosis.
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Affiliation(s)
- Jiaxin Chen
- Department of Neurology The First Affiliated Hospital of Sun Yat‐sen UniversitySun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Disease Guangzhou China
| | - Wenjin Shang
- Department of Neurology The First Affiliated Hospital of Sun Yat‐sen UniversitySun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Disease Guangzhou China
| | - Yin Chen
- Department of Neurology The First Affiliated Hospital of Sun Yat‐sen UniversitySun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Disease Guangzhou China
| | - Yan Li
- Department of Neurosurgical Intensive Care Unit The First Affiliated Hospital of Sun Yat‐sen UniversitySun Yat‐sen University Guangzhou China
| | - Xin Huang
- Department of Neurology The First Affiliated Hospital of Sun Yat‐sen UniversitySun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Disease Guangzhou China
| | - Chunhua Su
- Department of Thoracic Surgery The First Affiliated Hospital of Sun Yat‐sen UniversitySun Yat‐sen University Guangzhou China
| | - Kai Zhu
- Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Disease Guangzhou China
| | - Jieni Zhang
- Department of Neurology The First Affiliated Hospital of Sun Yat‐sen UniversitySun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Disease Guangzhou China
| | - Weibin Liu
- Department of Neurology The First Affiliated Hospital of Sun Yat‐sen UniversitySun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Disease Guangzhou China
| | - Huiyu Feng
- Department of Neurology The First Affiliated Hospital of Sun Yat‐sen UniversitySun Yat‐sen University Guangzhou China
- Guangdong Provincial Key Laboratory for Diagnosis and Treatment of Major Neurological Disease Guangzhou China
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Tomschik M, Hilger E, Rath J, Mayer EM, Fahrner M, Cetin H, Löscher WN, Zimprich F. Subgroup stratification and outcome in recently diagnosed generalized myasthenia gravis. Neurology 2020; 95:e1426-e1436. [PMID: 32641537 DOI: 10.1212/wnl.0000000000010209] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 03/16/2020] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To describe disease outcomes of myasthenia gravis (MG) subgroups and which factors influence outcomes by reviewing individual patient records of a representative cohort. METHODS We performed a retrospective analysis of 199 patients with generalized MG and disease onset after the year 2000 who were treated at 2 tertiary referral centers in Austria. We stratified patients as early- and late-onset acetylcholine receptor antibody-positive, muscle-specific tyrosine kinase (MuSK) antibody-positive, and seronegative patients and patients with thymoma regardless of antibody status. We evaluated patients' symptom severity and treatment regimens and the occurrence of life-threatening events at yearly time points for up to 10 years. RESULTS Minimal manifestation status or better was eventually achieved and sustained for >1 year by 125 (63%) patients. Forty percent (66 of 165 patients) showed an early response to treatment, which predicted a benign disease course later on. In contrast, 19% of patients, who remained symptomatic for 2 years after disease onset despite immunosuppressive therapy, were more treatment resistant in the following years. The strongest predictor of outcome was the diagnostic subgroup. Patients with MuSK-MG had a much better outcome than previously reported. CONCLUSION Our data give an update on the disease course of generalized MG in the new century. Diagnostic subgroups and response to treatment within the first 2 years help to predict the long term outcome.
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Affiliation(s)
- Matthias Tomschik
- From the Department of Neurology (M.T., E.H., J.R., M.F., H.C., F.Z.), Medical University of Vienna; and Department of Neurology (E.-M.M., W.N.L.), Medical University of Innsbruck, Innsbruck, Austria
| | - Eva Hilger
- From the Department of Neurology (M.T., E.H., J.R., M.F., H.C., F.Z.), Medical University of Vienna; and Department of Neurology (E.-M.M., W.N.L.), Medical University of Innsbruck, Innsbruck, Austria
| | - Jakob Rath
- From the Department of Neurology (M.T., E.H., J.R., M.F., H.C., F.Z.), Medical University of Vienna; and Department of Neurology (E.-M.M., W.N.L.), Medical University of Innsbruck, Innsbruck, Austria
| | - Eva-Maria Mayer
- From the Department of Neurology (M.T., E.H., J.R., M.F., H.C., F.Z.), Medical University of Vienna; and Department of Neurology (E.-M.M., W.N.L.), Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Fahrner
- From the Department of Neurology (M.T., E.H., J.R., M.F., H.C., F.Z.), Medical University of Vienna; and Department of Neurology (E.-M.M., W.N.L.), Medical University of Innsbruck, Innsbruck, Austria
| | - Hakan Cetin
- From the Department of Neurology (M.T., E.H., J.R., M.F., H.C., F.Z.), Medical University of Vienna; and Department of Neurology (E.-M.M., W.N.L.), Medical University of Innsbruck, Innsbruck, Austria
| | - Wolfgang N Löscher
- From the Department of Neurology (M.T., E.H., J.R., M.F., H.C., F.Z.), Medical University of Vienna; and Department of Neurology (E.-M.M., W.N.L.), Medical University of Innsbruck, Innsbruck, Austria
| | - Fritz Zimprich
- From the Department of Neurology (M.T., E.H., J.R., M.F., H.C., F.Z.), Medical University of Vienna; and Department of Neurology (E.-M.M., W.N.L.), Medical University of Innsbruck, Innsbruck, Austria.
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Hoffman CR, Green MS. Anesthesia for Thymectomy. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zheng Y, Cai YZ, Shi ZY, Qiu Y, Zhang HL, Wang ZH, Li WB, Wang Y. Different neurologic outcomes of myasthenia gravis with thymic hyperplasia and thymoma after extended thymectomy: A single center experience. J Neurol Sci 2017; 383:93-98. [DOI: 10.1016/j.jns.2017.10.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 09/24/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022]
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Xie X, Gan X, Chen B, Shen Z, Wang M, Zhang H, Xu X, Chen J. Left- and right-sided video-assisted thoracoscopic thymectomy exhibit similar effects on myasthenia gravis. J Thorac Dis 2016; 8:124-32. [PMID: 26904220 DOI: 10.3978/j.issn.2072-1439.2016.01.40] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Unilateral video-assisted thoracoscopic (VATS) thymectomy features less operative trauma, improved cosmesis, and similar efficiency compared with transsternal (TS) thymectomy for treatment of patients with myasthenia gravis (MG). Unilateral VATS thymectomy can be easily performed from either side of the thorax, because thymus is located in the middle of mediastinum. Nevertheless, the side that provides better outcomes remains controversial. This study presents our experience on treatments for MG and reveals the differences between the unilateral VATS thymectomy performed on each side. METHODS Eighty-one consecutive patients with MG who underwent TS or VATS thymectomy on either side between January 2003 and December 2012 were enrolled in the study. Clinicopathologic data and surgical outcomes were retrospectively analyzed and compared among different surgical approaches. RESULTS TS thymectomy was administered in 50 patients, whereas unilateral VATS approaches were performed on the remaining 31 patients, 15 on the left side and 16 on the right side. The VATS group exhibited a significantly shorter surgery duration (P<0.001), less intraoperative blood loss (P=0.009), shorter postoperative hospital stay (P=0.025), smaller thoracic drainage volume (P=0.033), shorter thoracic drainage duration (P=0.006), and less postoperative complications (P<0.001) compared with the TS group. However, disease remission rates did not significantly differ among the groups (P=0.988). The left-sided group exhibited considerably longer thoracic drainage duration than the right-sided group (P=0.041). Moreover, surgical time (P=0.736), intraoperative blood loss (P=0.281), postoperative hospital stay (P=0.599), thoracic drainage volume (P=0.571), postoperative complications (P=0.742) and therapeutic effect (P=1.000) did not significantly differ among the groups. Multivariate analysis revealed that the ocular type of MG is the only independent factor for clinical remission (P=0.002). CONCLUSIONS Unilateral VATS thymectomy can reduce surgical risks and shorten hospitalization duration without threatening the therapeutic effect. This technique can be safely and effectively performed by experienced surgeons in either side of the thorax.
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Affiliation(s)
- Xuan Xie
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Xiangfeng Gan
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Baishen Chen
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Zhuojian Shen
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Minghui Wang
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Huizhong Zhang
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Xia Xu
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Ju Chen
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
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Nazarbaghi S, Amiri-Nikpour MR, Mahmodlou R, Arjmand N, Rezaei Y. Clinical Outcomes of Myasthenia Gravis with Thymoma and Thymic Hyperplasia Undergoing Extended Transsternal Thymectomy: A Single-Center Experience. NORTH AMERICAN JOURNAL OF MEDICAL SCIENCES 2015; 7:503-8. [PMID: 26713298 PMCID: PMC4683805 DOI: 10.4103/1947-2714.170608] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Despite the widespread use of thymectomy in myasthenia gravis (MG) patients, it has remained controversial as to whether this procedure is of a similar efficacy and clinical outcome among MG patients with thymoma and thymic hyperplasia. AIM We sought to determine the long-term clinical outcomes of MG patients who received extended transsternal thymectomy associated with pyridostigmine and prednisolone postoperatively. MATERIALS AND METHODS In a retrospective study from January 1999 to December 2013, MG patients who underwent thymectomy were followed up. Out of 41 MG patients admitted in our center, 25 patients had undergone thymectomy adjunctive to pyridostigmine and prednisolone therapy postoperatively. The primary endpoints included improvement in individual diplopia, ptosis, dysphagia, dysarthria, dyspnea, and limb weakness. In addition, according to the MG Foundation of America (MGFA) criteria, response to therapy was defined as complete stable remission (CSR), pharmacologic remission (PR), and minimal manifestation (MM) as secondary endpoints. RESULTS Majority of the patients were male (60%) and the mean age of the patients was 32.2 ± 13.9 years. Fifteen (60%) and 10 patients (40%) had thymoma and thymic hyperplasia, respectively. All the patients were followed up during a mean period of of 86.9 ± 50.3 months (minimum 10 months and maximum 168 months). The rates of CSR, PR, and MM were comparable between the thymoma and thymic hyperplasia groups (P = 0.584). Based on the Kaplan Meier analysis, the probabilities of CSR, PR, and MM were not significantly different between patients with thymoma and thymic hyperplasia. CONCLUSION The extended transsternal thymectomy, along with the postoperative regimen of pyridostigmine and prednisolone was associated with a high rate of clinical improvement among MG patients with thymoma or thymic hyperplasia.
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Affiliation(s)
- Surena Nazarbaghi
- Department of Neurology, Urmia University of Medical Sciences, Urmia, Iran
| | | | - Rahim Mahmodlou
- Department of Surgery, Imam Khomeini Hospital, Urmia University of Medical Sciences, Urmia, Iran
| | - Nasim Arjmand
- Department of Neurology, Urmia University of Medical Sciences, Urmia, Iran
| | - Yousef Rezaei
- Seyyed-al-Shohada Heart Center, Urmia University of Medical Sciences, Urmia, Iran
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[Thymoma-associated myasthenia gravis: Clinical features and surgical results]. Rev Neurol (Paris) 2013; 169:879-83. [PMID: 23639728 DOI: 10.1016/j.neurol.2013.01.625] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2012] [Revised: 12/21/2012] [Accepted: 01/21/2013] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The aim of this study was to compare the characteristics of myasthenic patients with and without thymoma, and the results of thymectomy in both types of patients. MATERIAL AND METHODS A retrospective study was conducted among 66 patients who underwent thymectomy for myasthenia gravis in our department over a 10-year period (2000-2010). The surgical approach was sternotomy or anterolateral thoracotomy. Patients were divided into two groups according to the presence of thymoma: with (T-MG) and without (NT-MG) thymoma. Complete stable remission (CSR) was the primary endpoint. RESULTS Median age was 35.09±9.89 years. The NT-MG group had 38 patients (57.57%) and the T-MG group 28 patients (42.43%). There was no difference between the two groups regarding the surgical approach (P=0.52). T-MG patients were older (40.54±15.16 vs. 31.37±9.46) (P=0.008) and predominantly male. There were more generalized forms (P=0.01) and more bulbar involvement (P=0.02) in the T-MG group. The rate of CSR at 5 years was 7% and 17% in the T-MG and NT-MG patients respectively (P=0.70). At 10 years, it was 36% and 94.73% respectively (P=0.03). CONCLUSION Thymomatous myasthenia gravis is characterized by the severity of its clinical features. Remission rate at 10 years was significantly lower in the myasthenia with thymoma group.
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Mao ZF, Mo XA, Qin C, Lai YR, Hackett ML. Incidence of thymoma in myasthenia gravis: a systematic review. J Clin Neurol 2012; 8:161-9. [PMID: 23091524 PMCID: PMC3469795 DOI: 10.3988/jcn.2012.8.3.161] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2012] [Revised: 07/24/2012] [Accepted: 07/24/2012] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose Myasthenia gravis (MG) is usually comorbid with thymoma. More accurate estimates of the incidence thymoma in MG will help inform patients and their physicians, facilitate health policy discussions, provide etiologic clues, and optimize the management of MG. Methods We conducted a systematic review search of relevant English-language studies published between 1960 and 2012 using MEDLINE and Embase. We identified additional studies by reviewing the bibliographies of the retrieved articles and hand searched the main neurology journals. Only incidence studies and case series of unselected MG patients in which information about thymoma were included. Results Out of 2206 potentially relevant studies, 49 met the inclusion criteria. Although there was a considerable degree of heterogeneity, the pooled estimate of the incidence of thymoma in MG was 21% (95% confidence interval, 20-22%). The pooled incidence was significantly higher for surgery-based studies than for population- and hospital-based studies. A large proportion of the reported thymomas were noninvasive. Furthermore, thymoma appears to occur significantly more frequently among male MG patients and those older than 40 years at the onset of MG. Conclusions Thymoma is common in MG patients, but appears to be found more often in male MG patients and those older than 40 years at the onset of MG. Further research is needed to expand our understanding of these association conditions.
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Affiliation(s)
- Zhi-Feng Mao
- Institute of Neurology, First Affiliated Hospital, Guangxi Medical University, Nanning, Guangxi, People's Republic of China
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Vachlas K, Zisis C, Rontogianni D, Tavernarakis A, Psevdi A, Bellenis I. Thymoma and myasthenia gravis: clinical aspects and prognosis. Asian Cardiovasc Thorac Ann 2012; 20:48-52. [PMID: 22371942 DOI: 10.1177/0218492311433189] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Myasthenia gravis is present in a significant proportion of patients with thymoma. We investigated particular features of the clinical behavior of thymoma and its relationship to myasthenia in a retrospective study of 79 patients who underwent thymectomy for thymoma during the last 20 years. The presence of myasthenia gravis, Masaoka stage, World Health Organization histotype, myasthenia response, and survival were analyzed. The mean age of the patients was 56.1 ± 12.4 years, and 39 had myasthenia gravis. A significantly higher proportion of patients with myasthenia was found in B2 and B3 histotypes compared to A, AB, and B1. Among myasthenic patients, 33.3% had no response, 50% had a partial response, and 16.7% achieved complete remission. During the follow-up period, 16 (21.1%) patients died. Mean survival was 4.8 ± 1.4 years for patients with no myasthenia response, whereas those with a partial or complete myasthenia response had significantly better survival.
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Affiliation(s)
- Konstantinos Vachlas
- Department of Thoracic and Vascular Surgery, Evangelismos Hospital, Athens, Greece.
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Yu L, Zhang XJ, Ma S, Li F, Zhang YF. Thoracoscopic Thymectomy for Myasthenia Gravis With and Without Thymoma: A Single-Center Experience. Ann Thorac Surg 2012; 93:240-4. [DOI: 10.1016/j.athoracsur.2011.04.043] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Revised: 04/05/2011] [Accepted: 04/07/2011] [Indexed: 11/29/2022]
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17
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Prokakis C, Koletsis E, Salakou S, Apostolakis E, Baltayiannis N, Chatzimichalis A, Papapetropoulos T, Dougenis D. Modified Maximal Thymectomy for Myasthenia Gravis: Effect of Maximal Resection on Late Neurologic Outcome and Predictors of Disease Remission. Ann Thorac Surg 2009; 88:1638-45. [DOI: 10.1016/j.athoracsur.2009.07.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Revised: 07/21/2009] [Accepted: 07/23/2009] [Indexed: 10/20/2022]
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18
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Cheng C, Wu G, Yeung SCJ, Li R, Bella AE, Pang J, Zhong FT, Luo H, Jin Y, Pan J. Serum protein profiles in myasthenia gravis. Ann Thorac Surg 2009; 88:1118-23. [PMID: 19766792 DOI: 10.1016/j.athoracsur.2009.05.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 05/08/2009] [Accepted: 05/13/2009] [Indexed: 11/28/2022]
Abstract
BACKGROUND The diagnosis of myasthenia gravis (MG) remains challenging. We performed a proteome-wide search for potential serum protein diagnostic markers for MG using surface-enhanced laser desorption/ionization (SELDI) time-of-flight mass spectrometry (TOFMS). METHODS Proteomic spectra from 80 MG patients and 80 healthy individuals were generated by SELDI. Samples from 56 MG patients and 56 healthy individuals in the training set were analyzed to set up the decision tree. Samples from 24 MG patients and 24 healthy individuals were used for cross-validation testing. RESULTS The SELDI TOFMS analysis generated 101 peaks, representing differentially expressed proteins between 1000 and 20000 Da. Among them, 9 peaks were down-regulated and 30 others were up-regulated in the MG sera compared with the controls. The decision tree used the peak at M4168.94 Da and M1122.57 Da as splitters in the classification process. In the training set, 112 samples were classified as MG or control group, with a sensitivity of 100% and specificity of 89.3%; the 10-fold cross-validated analysis identified the optimal decision tree with the lowest relative cross-validated cost of 0.080. In the test set, the decision tree generated was able to identify 20 of 24 MG patients and 21 of 24 healthy individuals with a sensitivity of 83.3% and a specificity of 87.5%. CONCLUSIONS SELDI TOFMS is a useful tool for the detection and identification of potential serum biomarkers that can diagnose MG with high sensitivity and specificity.
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Affiliation(s)
- Chao Cheng
- Department of Thoracic Surgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
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Agrifoglio M, Barili F, Dainese L, Cappai A, Cheema FH, Biglioli P. An occasional diagnosis of myasthenia gravis--a focus on thymus during cardiac surgery: a case report. J Cardiothorac Surg 2009; 4:55. [PMID: 19811646 PMCID: PMC2764702 DOI: 10.1186/1749-8090-4-55] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2009] [Accepted: 10/07/2009] [Indexed: 12/02/2022] Open
Abstract
Background Myasthenia gravis, an uncommon autoimmune syndrome, is commonly associated with thymus abnormalities. Thymomatous myasthenia gravis is considered to have worst prognosis and thymectomy can reverse symptoms if precociously performed. Case report We describe a case of a patient who underwent mitral valve repair and was found to have an occasional thymomatous mass during the surgery. A total thymectomy was performed concomitantly to the mitral valve repair. Conclusion The diagnosis of thymomatous myasthenia gravis was confirmed postoperatively. Following the surgery this patient was strictly monitored and at 1-year follow-up a complete stable remission had been successfully achieved.
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Affiliation(s)
- Marco Agrifoglio
- Department of Cardiovascular Surgery, University of Milan, Via Parea 4, 20138 Milan, Italy.
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Castle SL, Kernstine KH. Robotic-assisted thymectomy. Semin Thorac Cardiovasc Surg 2009; 20:326-31. [PMID: 19251172 DOI: 10.1053/j.semtcvs.2008.11.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2008] [Indexed: 11/11/2022]
Abstract
Thymectomy is an established therapy for myasthenia gravis. Minimally invasive surgery for thymectomy has been reported, but not clearly shown to be equivalent to open resection. Robotic-assisted thymectomy may provide the benefit of a full resection of thymic tissue and anterior mediastinal tissue for the treatment of myasthenia gravis by a minimally invasive approach. We present a review of the experience of robotic thymectomy.
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Affiliation(s)
- Shannon L Castle
- Department of Surgery, University of California-San Diego, San Diego, California, USA
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Abstract
BACKGROUND Paraneoplastic neurologic syndromes (PNS) constitute a rare group of disorders resulting from damage to the nervous system in the setting of cancer physically unrelated to the tumor site. PNS are believed to result from an autoimmune attack of normal neuronal tissue, spurred by similar neuronal antigens ectopically expressed by tumor cells. REVIEW SUMMARY The most common PNS are reviewed and also their association with specific onconeural antibodies, some directly pathogenic, others whose role in the disease process is less clear-cut. This diversity in pathogenesis is likely due to the relative role of humoral versus cellular immunity in PNS. Virtually any cancer may result in PNS but certain tumors, small cell lung cancer, gynecologic cancers (breast and ovarian), thymoma, and plasma cell tumors are more frequently encountered. In most instances, immunosuppressive therapy is unhelpful and outcome is poor. CONCLUSIONS PNS have diverse presentations, affecting both the central and peripheral nervous system and commonly, it is the PNS, not cancer that is the presenting symptom. Only subsequently, after onconeural antibodies are discovered or cancer is found, is PNS diagnosed. Neurologists should familiarize themselves with these rare syndromes and treatment principles, as rapid detection and treatment of the underlying tumor offer the best chance for recovery or prevention of further neurologic deterioration.
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Affiliation(s)
- Thomas B Toothaker
- Department of Neurology and Neuroscience, Weill Medical College of Cornell University, New York-Presbyterian Hospital, New York, NY 10021, USA.
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Thymoma-associated myasthenia gravis: Outcome, clinical and pathological correlations in 197 patients on a 20-year experience. J Neuroimmunol 2008; 201-202:237-44. [DOI: 10.1016/j.jneuroim.2008.07.012] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Revised: 07/17/2008] [Accepted: 07/17/2008] [Indexed: 11/17/2022]
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Zamecnik J, Vesely D, Jakubicka B, Cibula A, Pitha J, Schutzner J, Mazanec R. Atrophy of type II fibres in myasthenia gravis muscle in thymectomized patients: steroid-induced change with prognostic impact. J Cell Mol Med 2008; 13:2008-2018. [PMID: 18657229 DOI: 10.1111/j.1582-4934.2008.00431.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Selective atrophy of type II muscle fibres has been long recognized as an enigmatic but consistent feature of myasthenia gravis (MG) muscle; however, the pathophysiology and the mechanism of that change have remained obscure. In the present study, the results of histomorphometric analysis performed on muscle biopsies from 207 thymectomized seropositive MG patients were correlated with clinical features of MG to demonstrate possible pathophysiological associations and potential prognostic impact. The atrophy of type II fibres was verified in 35 cases (16.9%), being more pronounced in fibres of IIB subtype. It was neither significantly associated with the duration and severity of MG nor with the age of the patients. On the other hand, we demonstrated that the atrophy associated with long-term treatment with corticosteroids, and correlated with increasing doses. Thus, we suppose that the atrophy of type II muscle fibres in seropositive MG is steroid induced rather than MG-associated event. Although the MG patients with atrophy of type II fibres did not differ from the remaining MG cases in terms of improvement in the disease during the follow-up period, our analysis provides clear evidence that they presented a significantly slower tendency to reach an asymptomatic state after thymectomy. Therefore, the steroid-induced atrophy of type II fibres in MG muscle might be considered to be an unfavourable prognostic factor.
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Affiliation(s)
- Josef Zamecnik
- Department of Pathology and Molecular Medicine, Charles University, 2nd Medical Faculty and University Hospital Motol, Prague, Czech Republic
| | - Dan Vesely
- Department of Pathology and Molecular Medicine, Charles University, 2nd Medical Faculty and University Hospital Motol, Prague, Czech Republic.,1st Department of Infectious Diseases, Charles University, 2nd Medical Faculty and University Hospital Bulovka, Czech Republic
| | - Branislav Jakubicka
- Department of Pathology and Molecular Medicine, Charles University, 2nd Medical Faculty and University Hospital Motol, Prague, Czech Republic
| | - Adrian Cibula
- Department of Pathology and Molecular Medicine, Charles University, 2nd Medical Faculty and University Hospital Motol, Prague, Czech Republic
| | - Jiri Pitha
- Department of Neurology, Charles University, 1st Medical Faculty, Prague, Czech Republic.,Department of Neurology, Charles University, 3rd Medical Faculty, Prague, Czech Republic
| | - Jan Schutzner
- 3rd Department of Surgery, Charles University, 1st Medical Faculty and University Hospital Motol Prague, Czech Republic
| | - Radim Mazanec
- Department of Neurology, Charles University, 2nd Medical Faculty and University Hospital Motol, Prague, Czech Republic
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