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Liou DZ, Berry MF, Brown LM, Demmy TL, Huang J, Khullar OV, Padda SK, Shah RD, Taylor MD, Toker SA, Weiss E, Wightman SC, Worrell SG, Hayanga JWA. The Society of Thoracic Surgeons Expert Consensus Document on the Surgical Management of Thymomas. Ann Thorac Surg 2024:S0003-4975(24)00338-2. [PMID: 38718878 DOI: 10.1016/j.athoracsur.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 04/02/2024] [Accepted: 04/07/2024] [Indexed: 07/14/2024]
Affiliation(s)
- Douglas Z Liou
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.
| | - Mark F Berry
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Lisa M Brown
- Division of General Thoracic Surgery, Department of Surgery, UC Davis Health, Sacramento, California
| | - Todd L Demmy
- Department of Thoracic Surgery, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - James Huang
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Onkar V Khullar
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Sukhmani K Padda
- Department Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Rachit D Shah
- Section of Thoracic and Foregut Surgery, VCU Health System, Richmond, Virginia
| | - Matthew D Taylor
- Division of Thoracic Surgery, Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Seyfi Alper Toker
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Elisabeth Weiss
- Department of Radiation Oncology, VCU Health, Richmond, Virginia
| | - Sean C Wightman
- Division of Thoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Stephanie G Worrell
- Thoracic Surgery Section, Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
| | - J W Awori Hayanga
- Division of Thoracic Surgery, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
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Patel G, Reddy BVK, Patil P. Maximal Thymectomy via Mini Sternotomy with Pleural Preservation. South Asian J Cancer 2022; 11:229-234. [PMID: 36620502 PMCID: PMC9822780 DOI: 10.1055/s-0042-1743162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Gaurav PatelBackground There are different surgical techniques used for maximal thymectomy. Each technique has its own advantages and disadvantages. We propose a mini sternotomy with pleural preservation approach for complete maximal thymectomy. Methods Over time range of 5 years, 32 patients with diagnosis of thymoma with or without myasthenia gravis (MG) underwent maximal thymectomy by mini sternotomy in our institute. Patient records were examined for the following parameters: age, sex, preoperative medication, symptoms of MG as per Myasthenia Gravis Foundation of America grading system, operating time, duration of postoperative ventilation, length of stay in the intensive care unit, overall length of hospitalization, and postoperative complications. Results The mean age of patients in our study was 43.66. Sex ratio in this study was almost equal. Sixty-nine percent of patients were stage I thymoma according to Masaoka staging. Size of the tumor ranged from 3 to 8 cm with mean size being 4.54 cm. Complete resection with negative tumor margins was possible in all the cases. Four patients had intraoperative pleural injury out of which two patients required intercostal tube insertion. We did not have any serious postoperative complications with no perioperative mortality. Conclusions Mini sternotomy allows maximal removal of thymus through a less invasive approach and is associated with a significantly smoother postoperative course, less overall complications, and good clinical outcome. It is a simple technique that can be performed by any thoracic and surgical oncologists especially in Indian subcontinent where facilities of video-assisted thoracoscopic surgery and robotic video-assisted thoracoscopic surgery are not available in all areas and are expensive.
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Affiliation(s)
- Gaurav Patel
- Department of Surgical Oncology, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, Maharashtra, India,Address for correspondence Gaurav Patel, MBBS, MS Department of Surgical Oncology, Bombay Hospital and Medical Research CentreMumbai-400020, MaharashtraIndia
| | - Bojja V. Kishore Reddy
- Department of Surgical Oncology, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, Maharashtra, India
| | - Prakash Patil
- Department of Surgical Oncology, Bombay Hospital and Medical Research Centre, Marine Lines, Mumbai, Maharashtra, India
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Zhang Q, Cao Y, Bi Z, Ma X, Yang M, Gao H, Gui M, Bu B. Childhood-Onset Myasthenia Gravis Patients Benefited from Thymectomy in a Long-Term Follow-up Observation. Eur J Pediatr Surg 2022; 32:543-549. [PMID: 35263776 PMCID: PMC9666056 DOI: 10.1055/s-0042-1744150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The effect of thymectomy on the treatment of childhood-onset myasthenia gravis (CMG) remains debatable. The objective of this study was to evaluate the clinical outcome and relevant prognostic factors of thymectomy for CMG patients. MATERIALS AND METHODS A total of 32 CMG patients who underwent thymectomy before 18 years of age were included in this retrospective study. Clinical state following thymectomy was assessed by quantified myasthenia gravis (QMG) scores, myasthenia gravis-related activities of daily living (MG-ADL) scores, and Myasthenia Gravis Foundation of America postintervention status. Repeated-measures analysis of variance (ANOVA) examined the changes in postoperative scores during the 5-year follow-up. Univariate logistic regression was applied to identify factors associated with short-term (1-year postoperation) and long-term (5-year postoperation) clinical outcomes. RESULTS Repeated-measures ANOVA showed that QMG scores (F = 6.737, p < 0.001) and MG-ADL scores (F = 7.923, p < 0.001) decreased gradually with time. Preoperative duration (odds ratio [OR] = 0.85, 95% confidence interval [CI]: 0.73-1.00, p = 0.043), gender (OR = 0.19, 95% CI: 0.04-0.94, p = 0.041), and MG subgroup (OR = 13.33, 95% CI: 1.43-123.99, p = 0.023) were predictors for 1-year postoperative prognosis. Shorter disease duration (OR = 0.82, 95% CI: 0.70-0.97, p = 0.018) and generalized CMG (OR = 6.11, 95% CI: 1.06-35.35, p = 0.043) were found to have more favorable long-term results. CONCLUSION Our results suggest that thymectomy is effective in treating CMG. Thymectomy could be recommended for CMG patients, especially for patients in the early course of GMG.
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Affiliation(s)
- Qing Zhang
- Department of Neurology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Yayun Cao
- Department of Radiology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei Province, China
| | - Zhuajin Bi
- Department of Neurology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Xue Ma
- Department of Neurology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Mengge Yang
- Department of Neurology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Huajie Gao
- Department of Neurology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Mengcui Gui
- Department of Neurology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Bitao Bu
- Department of Neurology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei Province, China,Address for correspondence Bitao Bu, MD, PhD Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and TechnologyWuhan, 430030, Hubei ProvinceChina
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Raza B, Dhamija A, Abbas G, Toker A. Robotic thymectomy for myasthenia gravis surgical techniques and outcomes. J Thorac Dis 2021; 13:6187-6194. [PMID: 34795970 PMCID: PMC8575861 DOI: 10.21037/jtd-2019-rts-10] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/10/2020] [Indexed: 11/30/2022]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder in which antibodies are produced against post-synaptic acetylcholine receptors, thereby causing impairment of neuromuscular transmission. Diagnosis of MG is confirmed with the AChR antibody test and via an Electromyography. Although medical treatment with acetylcholinesterase inhibitors remains the main treatment of MG, in recent years thymectomy has become an integral part of the treatment algorithm. Numerous factors such as the Patient’s age, presence of AChR antibodies, or MuSK antibody, the severity of disease affect the decision of preforming the thymectomy. Historically thymectomy was preformed via sternotomy associated with significant morbidity. Advancement in the minimally invasive approaches to thymic resection has led to more acceptance of thymectomy in the management of MG. Among these approaches, robotic thymectomy is gaining popularity across the globe due to the unique advantages of the robotic platform like 3D visibility, enhanced dexterity, and wrist like articulating movements of instruments. This has led to less post-operative pain and morbidity; faster recovery and shorter hospital stay. Successful treatment of MG requires a multi-modality approach, which has led to the formation of MG teams in most academic centers, comprising of a specialist neurologist, intensivist, and thoracic surgeon. In this article, we describe the techniques and outcomes of the robotic thymectomy for MG.
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Affiliation(s)
| | - Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ghulam Abbas
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
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Alqarni F, Almalki D, Aljohani Z, Ali A, AlSaleem A, Alotaibi N, Odeh S, Dalbhi SA. Prevalence and risk factors of myasthenia gravis recurrence post-thymectomy. ACTA ACUST UNITED AC 2021; 26:4-14. [PMID: 33530037 PMCID: PMC8015504 DOI: 10.17712/nsj.2021.1.20190041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 08/30/2020] [Indexed: 12/13/2022]
Abstract
Objectives: To evaluate the prevalence and the factors associated with recurrence of myasthenia gravis following thymectomy. Methods: Six electronic databases which reported on recurrence of myasthenia gravis following thymectomy and/or its risk factors from 1985 to 2018 were searched. Summary prevalence and risk values obtained based on the random effect models were reported. Results: Seventy (70) papers containing 7,287 individuals with myasthenia gravis who received thymectomy as part of their management were retrieved. The patients had a mean follow-up of 4.65 years post-thymectomy. The prevalence of myasthenia gravis recurrence post-thymectomy was 18.0% (95% CI 14.7–22.0%; 1865/7287). Evident heterogeneity was observed (I2=93.6%; p<0.001). Recurrence rate was insignificantly higher in male compared with female patients (31.3 vs. 23.8%; p=0.104). Pooled recurrence rates for thymomatous (33.3%) was higher than the rate among non-thymomatous (20.8%) myasthenia gravis patients (Q=4.19, p=0.041). Risk factors for recurrence include older age, male sex, disease severity, having thymomatous myasthenia gravis, longer duration of the myasthenia gravis before surgery, and having an ectopic thymic tissue. Conclusion: A fifth of individuals with myasthenia gravis experience recurrence after thymectomy. Closer monitoring should be given to at-risk patients and further studies are needed to understand interventions to address these risks.
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Affiliation(s)
- Fatmah Alqarni
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Daifallah Almalki
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Ziyad Aljohani
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Abdulrahman Ali
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Alanood AlSaleem
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Noura Alotaibi
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Shahla Odeh
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Sultan Al Dalbhi
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
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Padilla Londoño N, Martínez-Ruiz D, Sánchez ÁJ, Velásquez M. Descripción de las características clínicas y la respuesta a tratamiento en pacientes con miastenia grave sin timoma sometidos a timectomía en una institución de alta complejidad de Cali, Colombia, 2010-2017. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La miastenia grave es una enfermedad autoinmunitaria con una prevalencia mundial de 150 a 250 casos por 1´000.000 de habitantes. El tratamiento recomendado para la miastenia grave sin timoma es la timectomía total, la cual es la única alternativa de curación.
Métodos. Se llevó a cabo un estudio descriptivo y retrospectivo de una serie de casos de pacientes adultos con miastenia grave sin timoma sometidos a timectomía, durante el periodo de 2010 a 2017. En el análisis estadístico descriptivo, se utilizaron frecuencias absolutas y porcentajes para las variables cualitativas y, para las variables cuantitativas, se utilizaron la mediana y el rango intercuartílico.
Resultados. Veintiocho pacientes con miastenia grave sin timoma se sometieron a timectomía desde el año 2010 hasta el 2017. Se categorizaron según la clasificación del estado posterior a la intervención de la Myasthenia Gravis Foundation of America y se evidenció que 4 (14,3 %) pacientes presentaban remisión completa y el grado 3 de manifestaciones clínicas mínimas fue el más frecuente en 19 (67,9 %); 26 (92,9 %) tuvieron mejoría con respecto al cambio del estado clínico, en 2 (7,1 %) no se documentaron cambios y en ningún paciente hubo empeoramiento, exacerbación o muerte secundaria a la enfermedad.
Conclusiones. A lo largo de siete años se practicó timectomía a 28 pacientes con diagnóstico de miastenia grave sin timoma, aproximadamente, en el 15 % de los pacientes hubo remisión completa, el grado 3 de manifestaciones mínimas fue el más frecuente y el 93 % presentó mejoría de su estatus clínico.
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Kaba E, Cosgun T, Ayalp K, Toker A. Robotic thymectomy for myasthenia gravis. Ann Cardiothorac Surg 2019; 8:288-291. [PMID: 31032216 DOI: 10.21037/acs.2019.02.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Erkan Kaba
- Department of Thoracic Surgery, Medicine Faculty, Bilim University, Istanbul, Turkey
| | - Tugba Cosgun
- Department of Thoracic Surgery, Medicine Faculty, Bilim University, Istanbul, Turkey
| | - Kemal Ayalp
- Department of Thoracic Surgery, Group Florence Nightingale Hospitals, Istanbul, Turkey
| | - Alper Toker
- Department of Thoracic Surgery, Group Florence Nightingale Hospitals, Istanbul, Turkey
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Abstract
OBJECTIVE To evaluate transcervical and transsternal thymectomy benefits in large myasthenia gravis (MG) cohort. METHOD We retrospectively evaluated MG patients (n = 184) who had undergone thymectomy between 2004 and 2015 at National Institute of Mental Health and Neurosciences, Bangalore (India). Myasthenia gravis foundation of America guidelines were followed to assess clinical outcome. Anti-acetylcholine receptors (AChR) antibodies, repetitive nerve stimulation (RNS) and Neostigmine tests were performed at pre and post-thymectomy stage. RESULTS Most of the patients were fell under MG grade IIA (82 of 184, 44.56%) and grade IIB (61 of 184, 33.15%). Thymoma and thymic hyperplasia was established in 64 (34.78%) and 89 (48.37%) patients respectively. Other thymic abnormalities such thymic atrophy, cysts and lipoma were established in 31 (16.85%) patients. MG patients were treated either with transcervical (n = 79) or (n = 105) transsternal thymectomy. At the pre-thymectomy stage, the majority of the patients were positive for anti-AChR antibodies (179 of 184, 97.28%), RNS (170 of 184, 92.4%), and Neostigmine (175 of 184, 95.11%). At the post-thymectomy stage, a significant reduction observed in anti-AChR antibodies positivity (p < 0.022) and RNS positivity (p < 0.015). Overall, benefits were observed in 61.41% (113 of 184) of patients. Clinical benefits (complete stable remission, pharmacological remission, minimal manifestation, and improvement) of transcervical and transsternal thymectomy observed in 69.62% (55 of 79) and 55.24% (58 of 105) of patients respectively. MG patients with thymoma showed the least improvement compared to thymic hyperplasia. DISCUSSION Transcervical and transsternal thymectomy showed clinical benefits, however, there was no significant difference between them.
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Affiliation(s)
- Suresh C Bokoliya
- a Department of Neuromicrobiology , National Institute of Mental Health and Neurosciences , Bangalore , India
| | - Shripad A Patil
- a Department of Neuromicrobiology , National Institute of Mental Health and Neurosciences , Bangalore , India
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Muhammed J, Chen CY, Wan Hitam WH, Ghazali MZ. Thymectomy for Myasthenia Gravis: A 10-year Review of Cases at the Hospital Universiti Sains Malaysia. Malays J Med Sci 2016; 23:71-8. [PMID: 27660548 DOI: 10.21315/mjms2016.23.4.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 06/20/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND A thymectomy is considered effective for patients with myasthenia gravis (MG). Although a few studies have described the role of a thymectomy in the treatment of MG in Asians countries, there are no published data on the application of this surgical approach for MG in Malaysia. We aimed to describe the clinical outcomes of MG patients who underwent a thymectomy and the factors affecting these outcomes. METHODS This was a retrospective study involving 16 patients with MG who underwent a thymectomy at the Hospital Universiti Sains Malaysia (HUSM) from January 2002 until December 2012, with a follow-up period ranging from 3-120 months. RESULTS The study consisted of 16 patients aged 22-78 years, 10 of whom were males. The overall remission/improvement rate was 87.5%, and the rate of clinical outcomes classified as unchanged/worsened was 12.5%. Thymomamatous or non-thymomamatous MG, histology features, Osserman stage and the duration of follow-up were not significant prognostic factors. Post-operative mortality was 6.2% (1 of 16 patients died of septic shock). CONCLUSION A thymectomy seems to be an effective treatment for MG, with low surgical morbidity. Patients with a lower Osserman stage and those with/without thymomas had favourable outcomes.
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Affiliation(s)
- Julieana Muhammed
- Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia; Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Chui Yin Chen
- Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia; Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Wan Hazabbah Wan Hitam
- Department of Ophthalmology, School of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia; Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Mohamad Ziyadi Ghazali
- Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia Health Campus, 16150 Kubang Kerian, Kelantan, Malaysia; Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
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El-Medany Y, Hajjar W, Essa M, Al-Kattan K, Hariri Z, Ashour M. Predictors of Outcome for Myasthenia Gravis after Thymectomy. Asian Cardiovasc Thorac Ann 2016; 11:323-7. [PMID: 14681093 DOI: 10.1177/021849230301100411] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The aim of this study was to assess the clinical outcome of patients with myasthenia gravis treated with maximal thymectomy and to identify prognostic variables that predict the outcome. Over 15 years, from 1986 to 2001, we collected data on 100 patients with myasthenia gravis who underwent maximal thymectomy and retrospectively reviewed their outcome. Women comprised 63% and the median age was 25 years (range, 4 to 61). The median duration of the disease was 26 months (range, 1 to 240). According to the Osserman classification, there were seven patients in class I, 31 in class II, 47 in class III, and 15 in class IV. In non thymomatous patients (93 patients), complete remission rate progressively increased from 37.4% to 58.2% and 75% at 3, 10 and 15 years of follow-up respectively. These findings suggest that the complete remission rate is prone to increase with time after maximal thymectomy. The total benefit rate achieved was estimated to be 86% while 14% did not improve at a mean follow-up period of 7.6 years (range, 8 to 180 months). Univariate analysis ( p < 0.05) showed that age, thymic histology and ectopic thymic tissue are significant prognostic factors for outcome.
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Affiliation(s)
- Yasser El-Medany
- Thoracic Surgery Unit, Department of Surgery, King Khalid University Hospital, King Saud University, Riyadh 11472, Kingdom of Saudi Arabia
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Aghajanzadeh M, Khoshrang H, Mohammadzadeh A, Roudbari SA, Ghayeghran AR. Thymectomy for Myasthenia Gravis: Prognostic Factors in 70 Patients. Asian Cardiovasc Thorac Ann 2016; 15:371-5. [PMID: 17911062 DOI: 10.1177/021849230701500503] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Thymectomy has become increasingly accepted as an efficacious procedure for myasthenia gravis, with high rates of complete clinical remission. Predictors of the response to thymectomy for myasthenia gravis vary in the literature. We retrospectively reviewed the clinical records of 70 patients (63% female; mean age, 38 years) diagnosed with myasthenia gravis from August 1993 to August 2004, to determine the factors predicting outcome. Complications occurred in 20%, but there was no hospital mortality. Complete clinical remission was obtained postoperatively in 47%. Our results indicate that patients with less than 1 year's duration of disease have a better prognosis, and Osserman stages I, IIa, and IIb are also associated with higher clinical remission rates. Female patients have a better prognosis than males, and the younger the patient the better the outcome. Thymectomy is indicated for myasthenia gravis as early as possible in the course of the disease.
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Affiliation(s)
- Manucher Aghajanzadeh
- Department of Thoracic Surgery, Razi and Poorsina Teaching Hospital, Guilan University of Medical Sciences, 37 Yalda Building, 100 Street, Golsar Avenue, Rasht, Iran.
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Minato H, Kinoshita E, Nakada S, Nojima T, Tanaka M, Usuda K, Sagawa M, Iwao H, Tanaka M, Doai M, Takahashi T, Shibata N. Thymic lymphoid hyperplasia with multilocular thymic cysts diagnosed before the Sjögren syndrome diagnosis. Diagn Pathol 2015; 10:103. [PMID: 26173602 PMCID: PMC4502560 DOI: 10.1186/s13000-015-0332-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 06/18/2015] [Indexed: 11/22/2022] Open
Abstract
Background Thymic lymphoid hyperplasia is often present with myasthenia gravis as well as other autoimmune diseases such as systemic lupus erythematosus and rheumatoid arthritis. Of the 4 cases of thymic lymphoid hyperplasia associated with Sjögren syndrome that have been reported, no case with a thymic lesion diagnosis that led to the diagnosis of Sjögren syndrome has been reported. We herein report a case of thymic lymphoid hyperplasia with multilocular thymic cysts, diagnosed before Sjögren syndrome. Case presentation A 37-year-old Japanese woman had an approximate 5-cm anterior mediastinal mass detected by chest imaging. The resected lesion revealed multilocular thymic cysts that were filled with colloid-like material. Histology showed lymph follicular hyperplasia with many epithelial cysts. The epithelium consisted of thymic medullary epithelium, and no epithelial proliferation was seen in the lymphoid tissue. Lymphocytes were composed of an organized mixed population of mature T and B cells without significant atypia. The infiltrated B cells did not reveal light chain restriction or immunoglobulin heavy chain gene rearrangement. After the pathological diagnosis of thymic lesion, tests for the presence of autoantibodies were positive for antinuclear antibodies, rheumatic factor, and anti-SSA/Ro antibodies. The Schirmer’s, chewing gum, and Saxon tests showed decreased salivary and lacrimal secretion. Lip biopsy showed focal lymphocytic sialadenitis. The signs and symptoms of Sjögren syndrome had not resolved, without aggravation, 1 year after the thymectomy. Conclusion When a case with thymic lymphoid hyperplasia without myasthenia gravis is encountered, it is essential to consider the presence of another autoimmune disease including Sjögren syndrome.
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Affiliation(s)
- Hiroshi Minato
- Department of Pathology and Laboratory Medicine, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 9200293, Japan.
| | - Eriko Kinoshita
- Department of Pathology and Laboratory Medicine, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 9200293, Japan.
| | - Satoko Nakada
- Department of Pathology and Laboratory Medicine, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 9200293, Japan.
| | - Takayuki Nojima
- Department of Pathology and Laboratory Medicine, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 9200293, Japan.
| | - Makoto Tanaka
- Department of Thoracic Surgery, Kanazawa Medical University, Uchinada, Ishikawa, Japan.
| | - Katsuo Usuda
- Department of Thoracic Surgery, Kanazawa Medical University, Uchinada, Ishikawa, Japan.
| | - Motoyasu Sagawa
- Department of Thoracic Surgery, Kanazawa Medical University, Uchinada, Ishikawa, Japan.
| | - Haruka Iwao
- Department of Hematology and Immunology, Kanazawa Medical University, Uchinada, Ishikawa, Japan.
| | - Masao Tanaka
- Department of Hematology and Immunology, Kanazawa Medical University, Uchinada, Ishikawa, Japan.
| | - Mariko Doai
- Department of Radiology, Kanazawa Medical University, Uchinada, Ishikawa, Japan.
| | - Tomoko Takahashi
- Department of Radiology, Kanazawa Medical University, Uchinada, Ishikawa, Japan.
| | - Naoko Shibata
- Department of Ophthalmology, Kanazawa Medical University, Uchinada, Ishikawa, Japan.
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Kadota Y, Horio H, Mori T, Sawabata N, Goto T, Yamashita SI, Nagayasu T, Iwasaki A. Perioperative management in myasthenia gravis: republication of a systematic review and a proposal by the guideline committee of the Japanese Association for Chest Surgery 2014. Gen Thorac Cardiovasc Surg 2015; 63:201-15. [PMID: 25608954 DOI: 10.1007/s11748-015-0518-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Indexed: 01/21/2023]
Abstract
Thymectomy is regarded as a useful therapeutic option for myasthenia gravis (MG), though perioperative management in MG patients is largely empirical. While evidence-based medicine is limited in the perioperative management of MG patients, treatment guidelines are required as a benchmark. We selected issues faced by physicians in clinical practice in the perioperative management of extended thymectomy for MG, and examined them with a review of the literature. The present guidelines have reached the stage of consensus within the Japanese Association for Chest Surgery.
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Affiliation(s)
- Yoshihisa Kadota
- Guidelines Committees of Japanese Association for Chest Surgery, Kyoto, Japan,
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14
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Prognostic factors of remission in myasthenia gravis after thymectomy. Eur J Cardiothorac Surg 2014; 48:18-24. [DOI: 10.1093/ejcts/ezu309] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 07/07/2014] [Indexed: 01/05/2023] Open
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Berrih-Aknin S, Le Panse R. Myasthenia gravis: a comprehensive review of immune dysregulation and etiological mechanisms. J Autoimmun 2014; 52:90-100. [PMID: 24389034 DOI: 10.1016/j.jaut.2013.12.011] [Citation(s) in RCA: 232] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 12/12/2013] [Indexed: 12/31/2022]
Abstract
Autoimmune myasthenia gravis (MG) is characterized by muscle weakness caused by antibodies directed against proteins of the neuromuscular junction. The main antigenic target is the acetylcholine receptor (AChR), but the muscle Specific Kinase (MuSK) and the low-density lipoprotein receptor-related protein (LRP4) are also targets. This review summarizes the clinical and biological data available for different subgroups of patients, who are classified according to antigenic target, age of onset, and observed thymic abnormalities, such as follicular hyperplasia or thymoma. Here, we analyze in detail the role of the thymus in the physiopathology of MG and propose an explanation for the development of the thymic follicular hyperplasia that is commonly observed in young female patients with anti-AChR antibodies. The influence of the pro-inflammatory environment is discussed, particularly the role of TNF-α and Th17-related cytokines, which could explain the escape of thymic T cells from regulation and the chronic inflammation in the MG thymus. Together with this immune dysregulation, active angiogenic processes and the upregulation of chemokines could promote thymic follicular hyperplasia. MG is a multifactorial disease, and we review the etiological mechanisms that could lead to its onset. Recent global genetic analyses have highlighted potential susceptibility genes. In addition, miRNAs, which play a crucial role in immune function, have been implicated in MG by recent studies. We also discuss the role of sex hormones and the influence of environmental factors, such as the viral hypothesis. This hypothesis is supported by reports that type I interferon and molecules mimicking viral infection can induce thymic changes similar to those observed in MG patients with anti-AChR antibodies.
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Affiliation(s)
- Sonia Berrih-Aknin
- INSERM U974, Paris, France; CNRS UMR 7215, Paris, France; UPMC Univ Paris 6, Paris, France; AIM, Institute of myology, Paris, France.
| | - Rozen Le Panse
- INSERM U974, Paris, France; CNRS UMR 7215, Paris, France; UPMC Univ Paris 6, Paris, France; AIM, Institute of myology, Paris, France.
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16
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Berrih-Aknin S, Le Panse R. [Myasthenia gravis and autoantibodies: Pathophysiology of the different subtypes]. Rev Med Interne 2013; 35:413-20. [PMID: 24156976 DOI: 10.1016/j.revmed.2013.09.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 09/23/2013] [Indexed: 10/26/2022]
Abstract
Myasthenia gravis is characterized by muscle weakness and abnormal fatigability. It is an autoimmune disease caused by the presence of antibodies against components of the muscle membrane localized at the neuromuscular junction. In most cases, the autoantibodies are directed against the acetylcholine receptor (AChR). Recently, other targets have been described, such as muscle-specific kinase protein (MuSK) or lipoprotein related protein 4 (LRP4). The origin of the autoimmune response is not known, but thymic abnormalities and defects in immune regulation certainly play a major role in patients with anti-AChR antibodies. Genetic predisposition probably influences the occurrence of the disease. Sex hormones seem to play a role in the early form of the disease. Muscle weakness is fluctuating and worsens with exercise. Myasthenia gravis could be classified according to the location of the affected muscles (ocular versus generalized), the age of onset of symptoms, thymic abnormalities and profile of autoantibodies. These criteria are used to optimize the management and treatment of patients. In this review, we analyze the latest concepts of the pathophysiology of myasthenia gravis according to the different subgroups of the disease, including a description of the role of immunological, genetic and environmental factors. The potential viral hypothesis of this disease is discussed. Finally, we also discuss the biological assays available to validate the diagnosis.
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Affiliation(s)
- S Berrih-Aknin
- Unité mixte de recherche (UMR), CNRS UMR7215/Inserm U974/UPMC UM76/AIM, thérapie des maladies du muscle strié, groupe hospitalier Pitié-Salpêtrière, 105, boulevard de l'Hôpital, 75651 Paris cedex 13, France.
| | - R Le Panse
- Unité mixte de recherche (UMR), CNRS UMR7215/Inserm U974/UPMC UM76/AIM, thérapie des maladies du muscle strié, groupe hospitalier Pitié-Salpêtrière, 105, boulevard de l'Hôpital, 75651 Paris cedex 13, France
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17
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Weiss JM, Cufi P, Le Panse R, Berrih-Aknin S. The thymus in autoimmune Myasthenia Gravis: Paradigm for a tertiary lymphoid organ. Rev Neurol (Paris) 2013; 169:640-9. [DOI: 10.1016/j.neurol.2013.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 01/10/2013] [Accepted: 02/04/2013] [Indexed: 01/02/2023]
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18
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Marx A, Pfister F, Schalke B, Nix W, Ströbel P. Thymus pathology observed in the MGTX trial. Ann N Y Acad Sci 2013; 1275:92-100. [PMID: 23278583 DOI: 10.1111/j.1749-6632.2012.06799.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The MGTX trial is the first prospective, randomized clinical trial that aims to evaluate the impact of extended transsternal thymectomy on myasthenic symptoms, prednisone requirements, and quality of life in patients with nonthymomatous, anti-acetylcholine receptor autoantibody-positive myasthenia gravis (MG). Here, we give an overview of the rationale of thymectomy and the standardized macroscopic and histopathological work-up of thymectomy specimens as fixed in MGTX standard operating procedures, including the grading of thymic lymphofollicular hyperplasia and the morphometric strategy to assess thymic involution.
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Affiliation(s)
- Alexander Marx
- Institute of Pathology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany.
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19
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Hartwich J, Tyagi S, Margaron F, Oitcica C, Teasley J, Lanning D. Robot-Assisted Thoracoscopic Thymectomy for Treating Myasthenia Gravis in Children. J Laparoendosc Adv Surg Tech A 2012; 22:925-9. [DOI: 10.1089/lap.2012.0042] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joseph Hartwich
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Sanjeev Tyagi
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Franklin Margaron
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Claudio Oitcica
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Jean Teasley
- Division of Child Neurology, Department of Neurology, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - David Lanning
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
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Kumar N, Verma AK, Mishra A, Agrawal G, Agrawal A, Misra UK, Mishra SK. Factors predicting surgical outcome of thymectomy in myasthenia gravis: A 16-year experience. Ann Indian Acad Neurol 2012; 14:267-71. [PMID: 22346015 PMCID: PMC3271465 DOI: 10.4103/0972-2327.91945] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 04/22/2011] [Accepted: 08/18/2011] [Indexed: 11/16/2022] Open
Abstract
Aim: To assess the surgical outcome of myasthenia gravis (MG) following thymectomy and to determine the outcome predictors to such therapeutic approach. Materials and Methods: This study is a retrospective review of 80 consecutive thymectomies performed for MG over a 16-year period. Results: There were 41 females and 39 males (mean age, 34.32 years) with mean disease duration of 17.45 months prior to surgery. Stagewise distribution of the patients revealed 2.5% in stage I, 48.7% in stage IIA, 33.8% in stage IIB, 8.7% in stage III, and 6.3% in stage IV. The surgical approach was either trans-sternal (n=67) or video-assisted thoracoscopic route (n=13). Follow-up was obtained in 91.2% (n=73) of patients with mean duration of 67.7 months. At their last follow-up, 26.0% were in complete remission, 35.6% were asymptomatic on decreased medications, and 17.8% had clinical improvement on decreased medications. Overall, 79.4% of patients benefited from surgery, 8.2% had unchanged disease status, and 12.3% worsened clinically. Factors influencing favorable outcome include sex, disease stage, gland weight, and preoperative medication with anti-cholinesterase (P<0.05). There was one death in the perioperative period due to septicemia. Two patients died at fourth and seventh month following thymectomy. Conclusion: Thymectomy for MG is safe and effective. Certain influencing factors may shape treatment decisions and target higher risk patients.
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Affiliation(s)
- Nilkamal Kumar
- Department of Surgery, SGRRIMS, Dehradoon, Uttarakhand, India
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21
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Díaz-Manera J, Rojas García R, Illa I. Treatment strategies for myasthenia gravis: an update. Expert Opin Pharmacother 2012; 13:1873-83. [DOI: 10.1517/14656566.2012.705831] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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22
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Renaud S, Santelmo N, Renaud M, Fleury MC, De Seze J, Tranchant C, Massard G. Robotic-assisted thymectomy with Da Vinci II versus sternotomy in the surgical treatment of non-thymomatous myasthenia gravis: early results. Rev Neurol (Paris) 2012; 169:30-6. [PMID: 22682054 DOI: 10.1016/j.neurol.2012.02.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 01/26/2012] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The role of thymectomy in myasthenia gravis remains controversial. The remission rate 5years after surgery varies from 13 to 51% in the literature. Sternotomy is the standard technique, though unacceptable by patients because of significant esthetic sequelae. Our objective was to demonstrate that the robot-assisted technique using the Da Vinci Surgical Robot II is at least as efficient and leaves fewer scars than the standard surgical technique. METHODS We retrospectively reviewed the data of 31 consecutive patients suffering from myasthenia gravis who underwent surgery in our center from January 1998 to March 2010. Ten patients with thymoma were excluded from this study. Two groups were formed: group 1 corresponding to patients treated with sternotomy, group 2 patients with robot-assisted technique. The duration of the hospital stay, the pain on D1, the degree of improvement at 1year according to Myasthenia Gravis Foundation of America (MGFA) classification, the frequency of relapses, and perioperative treatment were studied. RESULTS Our sample consisted of 14 women and seven men. The mean age was 31.3years. The mean delay before surgery was 24months. Group 1 included 15 patients and group 2 had six patients. The complete remission rate at 1year was 9.5% (n=2). Surgery decreased the frequency of relapses after surgery (P=0.08) equally in the two groups. The duration of hospital stay and the pain level on D1 in group 2 were significantly lower than those in group 1 (P=0.02 and P<0.001). The degree of postoperative improvement was not significantly different between the two groups (P=0.31). CONCLUSION The results at 1year are fully comparable for sternotomy and the robot-assisted technique. The robot provides additional benefits of minimally invasive techniques: minimal esthetic sequelae in often young patients, less parietal morbidity (including pain), shorter hospital stays. Our complete remission rate, lower than those in the literature, must be considered taking into account the early nature of these results. The surgical robot, because of its many advantages, appears to be a promising technique and should facilitate the early management of these patients.
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Affiliation(s)
- S Renaud
- Service de chirurgie thoracique, pôle de pathologie thoracique, hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France
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23
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A retrospective review of 15 patients with familial myasthenia gravis over a period of 25 years. Neurol Sci 2011; 33:771-7. [DOI: 10.1007/s10072-011-0818-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 10/06/2011] [Indexed: 10/15/2022]
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24
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Keating CP, Kong YX, Tay V, Knight SR, Clarke CP, Wright GM. VATS Thymectomy for Nonthymomatous Myasthenia Gravis Standardized Outcome Assessment Using the Myasthenia Gravis Foundation of America Clinical Classification. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011. [DOI: 10.1177/155698451100600205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Yu X. Kong
- Departments of Cardiothoracic Surgery, Melbourne, Australia
| | - Valerie Tay
- Neurology, St Vincent's Hospital, Melbourne, Australia
| | - Simon R. Knight
- Department of Thoracic Surgery, Austin Hospital, Melbourne, Australia
| | - C. Peter Clarke
- Department of Thoracic Surgery, Austin Hospital, Melbourne, Australia
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25
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VATS Thymectomy for Nonthymomatous Myasthenia Gravis Standardized Outcome Assessment Using the Myasthenia Gravis Foundation of America Clinical Classification. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011; 6:104-9. [DOI: 10.1097/imi.0b013e3182165cdb] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Objective Video-assisted thoracoscopic (VATS) thymectomy has been practiced in Australia for nearly two decades. Our aim was to assess the complete stable remission and asymptomatic disease rates after VATS thymectomy in nonthymomatous myasthenia gravis. There remains doubt that minimally invasive techniques achieve equal remission rates to open maximal operations. Therefore, we report our outcomes using the Myasthenia Gravis Foundation of America (MGFA) Clinical Classification and Kaplan-Meier analysis and compare the results to the literature. Methods A retrospective analysis of 78 consecutive patients undergoing right VATS thymectomy between April 1994 and March 2007 at two Thoracic Surgery Units in Melbourne, Australia, was undertaken. Patients with thymoma were excluded. Therefore, 57 patients were followed-up for a minimum of 12 months to apply the MGFA Clinical Classification. VATS thymectomy was performed by a three-port right side technique. Results The complete stable remission rate was 15% at 3 years and 28% at 5 years. The asymptomatic disease rate was 59% at 5 years. Median follow-up was 32 months. No prognostic factors for remission were identified. The overall morbidity rate was 14% (8/57). Conclusions Right VATS thymectomy achieves comparable remission and asymptomatic disease rates to other minimally invasive and open techniques when compared with studies using either MGFA or older criteria.
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26
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Chieza J, Fleming I, Parry N, Skelton V. Maternal myasthenia gravis complicated by fetal arthrogryposis multiplex congenita. Int J Obstet Anesth 2011; 20:79-82. [DOI: 10.1016/j.ijoa.2010.08.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 05/31/2010] [Accepted: 08/31/2010] [Indexed: 11/28/2022]
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27
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28
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Liu GT, Volpe NJ, Galetta SL. Eyelid and facial nerve disorders. Neuroophthalmology 2010. [DOI: 10.1016/b978-1-4160-2311-1.00014-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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29
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Meacci E, Cesario A, Margaritora S, Porziella V, Tessitore A, Cusumano G, Evoli A, Granone P. Thymectomy in myasthenia gravis via original video-assisted infra-mammary cosmetic incision and median sternotomy: long-term results in 180 patients. Eur J Cardiothorac Surg 2009; 35:1063-9; discussion 1069. [DOI: 10.1016/j.ejcts.2009.01.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 01/22/2009] [Accepted: 01/24/2009] [Indexed: 10/21/2022] Open
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30
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Díaz-Manera J, Rojas-García R, Illa I. Treatment strategies for myasthenia gravis. Expert Opin Pharmacother 2009; 10:1329-42. [DOI: 10.1517/14656560902950619] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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31
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Ponseti JM, Gamez J, Vilallonga R, Ruiz C, Azem J, López-Cano M, Armengol M. Influence of ectopic thymic tissue on clinical outcome following extended thymectomy in generalized seropositive nonthymomatous myasthenia gravis. Eur J Cardiothorac Surg 2008; 34:1062-7. [DOI: 10.1016/j.ejcts.2008.07.049] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Revised: 07/18/2008] [Accepted: 07/21/2008] [Indexed: 10/21/2022] Open
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32
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Sommer N, Tackenberg B, Hohlfeld R. The immunopathogenesis of myasthenia gravis. HANDBOOK OF CLINICAL NEUROLOGY 2008; 91:169-212. [PMID: 18631843 DOI: 10.1016/s0072-9752(07)01505-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Norbert Sommer
- Clinical Neuroimmunology Group, Philipps-University, Marburg, Germany
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Kim HK, Park MS, Choi YS, Kim K, Shim YM, Han J, Kim BJ, Kim J. Neurologic outcomes of thymectomy in myasthenia gravis: Comparative analysis of the effect of thymoma. J Thorac Cardiovasc Surg 2007; 134:601-7. [PMID: 17723805 DOI: 10.1016/j.jtcvs.2007.05.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Revised: 05/01/2007] [Accepted: 05/11/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The objectives of this study were to compare the clinical features and the outcomes after thymectomy between patients with and without thymoma and to evaluate the influence of thymectomy on the subsequent clinical course of myasthenia gravis. METHODS Between 1995 and 2003, 64 consecutive patients underwent thymectomy, and of these, 60 patients were followed up for at least 12 months postoperatively. The study population was divided into 2 groups based on the presence of thymoma. We performed a retrospective analysis to compare the neurologic outcomes of thymectomy between patients with thymomatous myasthenia gravis and those with nonthymomatous myasthenia gravis. RESULTS Twenty-four patients had a thymoma. No significant differences were observed between the 2 groups regarding the preoperative severity of myasthenia gravis. There was no significant difference in the follow-up duration between the 2 groups. There was no significant difference in the overall remission rate between the 2 groups (P = .064). The mean time required to reach a remission was 10.6 months and 23.5 months in the thymoma and nonthymoma groups, respectively. The mean duration of remission was 43.1 months and 30.8 months in the thymoma and nonthymoma groups, respectively. In the early phase of follow-up, more patients reached remission in the thymoma group than those in the nonthymoma group (P = .040). CONCLUSIONS Neurologic outcomes of the thymoma group were no worse than those of the nonthymoma group. It is expected that earlier thymectomy is likely to result in a better prognosis by shortening the disease period, even for patients with nonthymomatous myasthenia gravis.
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Affiliation(s)
- Hong Kwan Kim
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Barbaud A, Carlander B, Pagès M. Formes tardives de myasthénie. Étude comparative avec la myasthénie du sujet jeune. Rev Neurol (Paris) 2006; 162:990-6. [PMID: 17028567 DOI: 10.1016/s0035-3787(06)75109-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The incidence of myasthenia gravis appears to be increasing in elderly but few studies have been devoted to late onset myasthenia gravis. PATIENTS AND METHODS We retrospectively compared myasthenic patients with an age at onset above or below 35 years which were observed in two departments of Neurology from 1980 to 2002. RESULTS 81 cases were included, 28 of which were late onset myasthenia gravis. The two populations were similar in terms of sex-ratio, clinical symptoms, course of the disease and therapeutic response. There was a trend for older patients to present more frequently at onset with dysphagia and axial or proximal involvement, and to have extra-ocular symptoms more quickly. Antibodies against acetylcholine receptor and striated muscle were statistically more frequent in elder patients. CONCLUSIONS A late onset is not a factor of poor prognosis in myasthenia gravis and older patients must be treated in the same way than younger ones.
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Affiliation(s)
- A Barbaud
- Service de Neurologie A et Maladies Neurovasculaires, CHU Gui de Chauliac, Montpellier, France
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Ponseti JM, Azem J, Fort JM, López-Cano M, Vilallonga R, Gamez J, Armengol M. Experience with starting tacrolimus postoperatively after transsternal extended thymectomy in patients with myasthenia gravis. Curr Med Res Opin 2006; 22:885-95. [PMID: 16709310 DOI: 10.1185/030079906x104650] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Thymectomy is a standard treatment of myasthenia gravis (MG). Immunomodulating agents are frequently given during the post-thymectomy latency period until complete remission is fully consolidated, but serious side effects is a relevant clinical problem for patients on long-term immunomodulating treatment. OBJECTIVE To assess the effectiveness of starting tacrolimus in the immediate postoperative period in MG patients undergoing transsternal extended thymectomy, with complete stable remission (CSR) as the primary outcome of the study. METHODS Forty-eight MG patients received tacrolimus, 0.1 mg/kg per day b.i.d. (started 24 h after thymectomy) and prednisone 1.5 mg/kg/day. Histologically, 34 patients had hyperplasia, 20 thymic involution, and 14 thymoma. Of the 48 patients, 40 completed 1 year of tacrolimus therapy, 38 completed 2 years, 27 completed 3 years, 21 completed 4 years, and 9 more than 5 years. Mean dose of tacrolimus was 4.9 mg/day (range 2-8 mg/day) with a mean plasma drug concentration of 7.6 ng/mL (range 7-9 ng/mL). Prednisone could be withdrawn after the first year in 93.7% of patients and at 2 years in 100%. RESULTS The mean follow-up was 24.4 months, SD 17.3 (range 6-60 months). Improvement of muscular strength and decrease of anti-AChR antibodies were statistically significant (p < 0.001) shortly after operation. CSR was obtained in 33.4% of patients, pharmacological remission in 62.6%; 4% of patients had minimal symptoms. None of the patients with thymoma achieved CSR. The estimated median follow-up to obtain a CSR was 37.9 months (95% confidence interval [CI] 26.4-49.5 months). The overall crude CSR rate was 33.4%, with 47% for non-thymoma patients. The probability to achieve CSR at 3 years was 67% for the non-thymomatous group. CONCLUSIONS Long-term immune-directed treatment with tacrolimus to improve the effectiveness of thymectomy in MG is feasible and was associated with a high rate of CSR in patients without thymoma.
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Affiliation(s)
- José M Ponseti
- Unit of Myasthenia Gravis, Department of Surgery, Hospital General Universitari Vall d'Hebrón, Autonomous University of Barcelona, Spain.
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Huang CS, Hsu HS, Huang BS, Lee HC, Kao KP, Hsu WH, Huang MH. Factors influencing the outcome of transsternal thymectomy for myasthenia gravis. Acta Neurol Scand 2005; 112:108-14. [PMID: 16008537 DOI: 10.1111/j.1600-0404.2005.00424.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Thymectomy is one of the current treatment strategies for patients with myasthenia gravis (MG); however, the selection criteria for surgery remain controversial. METHODS The demographic data and the surgical results of 168 patients with MG who underwent transsternal thymectomy from June 1986 to December 2000 were retrospectively reviewed. Follow-up information was obtained by review of the hospital records or telephone contact. The postoperative status of MG was assessed at the interval of 1, 3 and 6 months and then annually. The complete remission rate (CRR) between groups was compared. RESULTS A total of 168 patients, including 69 male patients and 99 female patients, with a mean age of 38.3 years (range 13-80 years), were analyzed. The symptom duration before operations was from 1 to 312 months with a mean of 33.8 months. Complete follow-up information was obtained on 154 patients (91.6%) with a mean follow-up duration of 98.9 months. Complete remission was achieved in 89 of 154 patients (57.8%) and marked clinical improvement in 47 patients (30.5%). Total improvement rate was 88.3%. Seventeen of 24 patients (70.8%) with ocular MG and 18 of 35 patients (51.4%) with thymoma had reached complete remission during the follow-up period. The CRR increased with each consecutive year and reached the plateau in the fourth postoperative year. There was no surgical mortality. The complication rate was 16.6%. Univariate analysis demonstrated that age <35 years old (P = 0.0001), symptom duration before operation <24 months (P = 0.01) and absence of preoperative steroid treatment (P = 0.04) were favorable prognostic factors. Multivariate Cox regression analysis revealed age <35 years old (odds ratio = 3.645, P = 0.001), symptom duration before operation <24 months (2.311, P = 0.041) were favorable prognostic factors for patients having transsternal thymectomy. CONCLUSIONS Transsternal thymectomy is feasible in the management of patients with MG at all stages with high improvement rate and low surgical morbidity. Those patients aged 35 years or less at operation, with symptoms developed <24 months before operation, may benefit more from thymectomy. MG patients with thymoma did as well as patients without thymoma, and 18 of 35 patients with thymoma had reached complete remission during the follow-up period. Thymectomy seems to be beneficial also for ocular MG.
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Affiliation(s)
- C-S Huang
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital and National Yang-Ming University School of Medicine, Taipei, Taiwan
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Nagayasu T, Yamayoshi T, Matsumoto K, Ide N, Hashizume S, Nomura M, Muraoka M, Tagawa T, Akamine S, Oka T. Beneficial effects of plasmapheresis before thymectomy on the outcome in myasthenia gravis. ACTA ACUST UNITED AC 2005; 53:2-7. [PMID: 15724495 DOI: 10.1007/s11748-005-1001-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Since 1980, we have performed plasmapheresis before thymectomy for patients with generalized symptoms in order to protect against myasthenic crisis and to improve patient outcomes after thymectomy. The aim of this study was to evaluate an immediate and a long-term results of plasmapheresis before thymectomy for myasthenia gravis, retrospectively. METHODS Between January 1980 and December 1997, 51 patients with Osserman class IIA or IIB symptoms were treated with transsternal thymectomy. Nineteen patients (group 1) were treated with plasmapheresis before thymectomy and 32 patients (group 2) were treated with thymectomy alone. RESULTS In group 1, the time of plasmapheresis prior to thymectomy was 3.2 +/- 1.5. Nine (28.1%) patients in group 2 had crisis within 1 year after thymectomy as compared with only one (5.3%) patient in group 1 had crisis (p = 0.049). There was no evidence of crisis within 30 days after thymectomy in group 1 and 5 (15.6%) patients in group 2 (p = 0.0724). There was no postoperative death among patients in group 1. Responses to thymectomy in group 1 improved significantly, the improvement and pharmacologic remission rate had increased up to 100% and 79% at 5-7 years after operation, while the improvement and pharmacologic remission rate of group 2 had increased to 81.3% (p = 0.0466 vs. group 1) and 50.0% at that time (p = 0.0427 vs. group 1). CONCLUSIONS The present study demonstrated that preoperative plasmapheresis may facilitate improved outcomes of patients with myasthenia gravis after thymectomy.
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Affiliation(s)
- Takeshi Nagayasu
- Division of Surgical Oncology, Department of Translational Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Soleimani A, Moayyeri A, Akhondzadeh S, Sadatsafavi M, Shalmani HT, Soltanzadeh A. Frequency of myasthenic crisis in relation to thymectomy in generalized myasthenia gravis: a 17-year experience. BMC Neurol 2004; 4:12. [PMID: 15361260 PMCID: PMC518967 DOI: 10.1186/1471-2377-4-12] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2003] [Accepted: 09/11/2004] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myasthenic crisis is the most serious life-threatening event in generalized myasthenia gravis (MG) patients. The objective of this study was to assess the long-term impact of thymectomy on rate and severity of these attacks in Iranian patients. METHODS We reviewed the clinical records from 272 myasthenic patients diagnosed and treated in our neurology clinic during 1985 to 2002. Fifty-three patients were excluded because of unconfirmed diagnosis, ocular form of MG, contraindication to surgery, concomitant diseases and loss to follow-up. The Osserman classification was used to assess the initial severity of the disease. Frequency and severity of the attacks were compared between two groups with appropriate statistical tests according to the nature of variables. Multivariate logistic regression analysis was used to assess the predictors of myasthenic crisis in the group of patients without thymoma. RESULTS 110 patients were in thymectomy group and the other 109 patients were on medical therapy. These two groups had no significant differences with respect to age at onset, gender, Osserman score in baseline and follow up period. 62 patients (28.3% of all 219 patients) had reported 89 attacks of myasthenic crisis. 20 patients of 62 (32%) were in thymectomy group and 42 (68%) were in the other group. There was significant difference between the two groups in number of patients with crisis (P = 0.001; odds ratio = 2.8 with 95% CI of 1.5 to 5.2). In addition, these attacks were more severe in group of non-thymectomized patients as the duration of ICU admission was longer and they needed more ventilatory support during their attacks. Regression model showed thymectomy and lower age at onset as two predictors of decrement in myasthenic crisis rate in non-thymomatous MG patients. CONCLUSIONS It is suggested that frequency and severity of myasthenic attacks as important endpoints in evaluation of MG patients. Thymectomy seems to have a preventive role on rate and severity of these attacks.
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Affiliation(s)
- Ali Soleimani
- Division of neurology, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Moayyeri
- Research Development Center, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahin Akhondzadeh
- Psychiatric Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Sadatsafavi
- Research Development Center, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Akbar Soltanzadeh
- Division of neurology, Shariati hospital, Tehran University of Medical Sciences, Tehran, Iran
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Bramis J, Diamantis T, Tsigris C, Pikoulis E, Papaconstantinou I, Nikolaou A, Leonardou P, Bastounis E. Video-assisted transcervical thymectomy. Surg Endosc 2004; 18:1535-8. [PMID: 15791384 DOI: 10.1007/s00464-003-9203-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2003] [Accepted: 02/17/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND The optimal surgical approach for complete removal of the thymus gland has long been debated. In this report, the excision of the entire gland through a transcervical incision using video-assisted techniques is described. METHODS Ten patients, including one with thymoma and myasthenia gravis, underwent surgery via the transcervical approach. After standard dissection up to the level of the innominate vein and ligation of the thymic vessels, a laparoscope was inserted into the mediastinum. In the patient with thymoma, the operation was completed by a small incision in the third intercostal space. RESULTS No perioperative mortality or long-term morbitity was observed. The mean hospital stay was 69.6 h. After a mean follow-up period of 63.8 months, eight patients displayed complete remission, whereas one continued to receive minimal medication. The patient with thymoma showed considerable improvement, but remained on same medical regimen No complications were seen throughout the study. CONCLUSION Video-assisted thymectomy improves effectiveness of the transcervical approach for thymectomy with a minimum of trauma and excellent results.
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Affiliation(s)
- J Bramis
- First Surgical Department, Athens University, Medical School, Laikon Hospital, Athens, Greece
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Ruiz Jr RL, Reibscheid SM, Cataneo AJM, Rezende LADL. Resultado da timectomia ampliada no tratamento de pacientes com Miastenia gravis. J Bras Pneumol 2004. [DOI: 10.1590/s1806-37132004000200007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUÇÃO: Diversas variações da timectomia podem ser realizadas, dentre elas a transesternal ampliada. A literatura sugere que, quanto mais extenso o procedimento para ressecção da glândula e tecidos do mediastino anterior, melhores os resultados e prognóstico. OBJETIVO: Avaliar retrospectivamente a resposta à timectomia ampliada em portadores de Miastenia gravis. MÉTODO: Foram avaliados 46 portadores de Miastenia gravis, submetidos à plasmaferese pré-operatória e à timectomia ampliada, entre agosto de 1992 e janeiro de 2003, divididos em três grupos, segundo o tempo decorrido desde o início dos sintomas: menor que 12 meses, 13 a 24 meses e maior que 25 meses. RESULTADOS: Trinta e um pacientes eram do sexo feminino e 15 do masculino. A média de idade foi de 30 anos. O tempo médio de evolução da doença foi de 26,3 meses. O acompanhamento ambulatorial pós-operatório foi em média de 26,6 meses. Quanto ao grau de resposta à timectomia, 89% dos pacientes tiveram boa resposta, sendo que 50% apresentaram remissão completa. Ocorreu um óbito nesta série. O exame anatomopatológico demonstrou que a hiperplasia tímica foi o achado mais freqüente. Apenas 3 pacientes (6,5%) apresentaram timomas benignos. Em 5 pacientes (10,8%) encontramos tecido tímico extraglandular: na gordura peritímica em 2 deles, na gordura pericárdica em 1, junto ao nervo frênico esquerdo em outro e na janela aorto-pulmonar em outro. CONCLUSÃO: A timectomia ampliada para tratamento da Miastenia gravis mostrou-se segura, eficiente, e apresentou alta porcentagem de remissão completa. Houve a detecção de tecido tímico extraglandular em alguns pacientes. Tão logo seja feito o diagnóstico, está indicada como terapêutica associada à plasmaferese pré-operatória e à medicamentosa, independentemente da idade, patologia tímica, e início dos sintomas.
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Ashton RC, McGinnis KM, Connery CP, Swistel DG, Ewing DR, DeRose JJ. Totally endoscopic robotic thymectomy for myasthenia gravis. Ann Thorac Surg 2003; 75:569-71. [PMID: 12607676 DOI: 10.1016/s0003-4975(02)04296-0] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The current recommendations for treating myasthenia gravis include surgical thymectomy for patients between puberty and 60 years of age. This is a report of a new method for surgical thymectomy using the robotic da Vinci surgical system for a totally endoscopic approach. This new procedure combines the potential advantages of minimally invasive methods with the efficacy of open procedures.
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Affiliation(s)
- Robert C Ashton
- St. Luke's Roosevelt Hospital Center, College of Physicians and Surgeons, Columbia University, New York, New York 10019, USA.
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Remes-Troche JM, Téllez-Zenteno JF, Estañol B, Garduño-Espinoza J, García-Ramos G. Thymectomy in myasthenia gravis: response, complications, and associated conditions. Arch Med Res 2002; 33:545-51. [PMID: 12505100 DOI: 10.1016/s0188-4409(02)00405-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thymectomy is considered the most effective treatment for achieving sustained improvement as well as remission in patients with myasthenia gravis (MG), and most neurologists favor the use of this procedure. The main focus of many current studies is to determine response-predicting factors. METHODS Clinical records of 152 patients with an established diagnosis of MG who underwent thymectomy at our institution were reviewed. The purpose was to evaluate outcome of surgical management for MG and prognostic factors that influence that outcome. RESULTS The majority of patients were women (119 of 152); mean age was 32.10 +/- 14.42 years, while time elapsed from diagnosis to surgery was 20.67 +/- 19.7 months. Transsternal thymectomy was performed on 113 patients and transcervical on 39. Forty percent of patients achieved remission and 28% showed improvement; with this, a good response to thymectomy was seen in 68% of patients (n = 103). The most important variables associated with remission were <60 years of age, <2 years of preoperative symptoms, and use of pyridostigmine at low doses. Factors related with poor response were >60 years of age, preoperative Osserman stage other than II, use of high doses of pyridostigmine, use of corticosteroids, and presence of thymic atrophy or thymoma in histopathologic analyses. There was no mortality, although 20 patients (13%) presented complications. CONCLUSIONS Mexican patients with MG undergoing thymectomies show improvement and remission rates similar to those reported by other studies. Age, length of symptoms, thymic pathology, and medications appear to be predictors of response to thymectomy for MG.
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Affiliation(s)
- José María Remes-Troche
- Departamento de Medicina Interna, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, INCMNSZ, Mexico City, Mexico
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Katzberg HD, Aziz T, Oger J. In myasthenia gravis, clinical and immunological improvement post-thymectomy segregate with results of in vitro antibody secretion by immunocytes. J Neurol Sci 2002; 202:77-83. [PMID: 12220697 DOI: 10.1016/s0022-510x(02)00226-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
In myasthenia gravis (MG), presence of pathogenic acetylcholine receptor antibodies (AchRAb) and thymic pathology are related. Our study assesses the long-term clinical outcome of thymectomy as a function of thymic pathologies, AchRAb levels in blood and the ability of immunocytes to secrete AchRAb ex vivo. We found that those patients who have thymocytes that secrete AchRAb in vitro have a greater decrease in their need for Mestinon over the 60 months of follow-up than the non-secretors (p = 0.04). Those patients whose cultured peripheral blood mononuclear cells (PBMC) secreted AchRAb also had a greater decrease in Mestinon requirements over the 60 months of follow-up than the non-secretors (p = 0.05), however, differences between the two groups at each individual assessment were not statistically significant. Serial post-op AchRAb measurements in sera of thymocyte and PBMC non-secretors showed no change from pre-op levels (< 10 nmol/l), while secretors had a reduction of more than 80% from pre-op levels, starting 6 months post-op. We also found that results of PBMC culture at time of thymectomy is a better predictor of response to thymectomy than serum AchRAb levels but inferior to results of thymocytes cultures. Patients with thymoma had the highest proportion of individuals secreting AchRAb from thymocytes in culture (78%), the shortest duration of disease (9 months) and showed the greatest trend toward improvement in clinical signs and symptoms post-op. We have thus demonstrated the long held suspicion that removal of actively secreting cells from the thymus at an early time in the disease confers the greatest benefit.
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Affiliation(s)
- Hans D Katzberg
- Brain Research Centre and Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, Canada
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De Feo LG, Schottlender J, Martelli NA, Molfino NA. Use of intravenous pulsed cyclophosphamide in severe, generalized myasthenia gravis. Muscle Nerve 2002; 26:31-6. [PMID: 12115946 DOI: 10.1002/mus.10133] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Twenty-three myasthenia gravis (MG) subjects, mean (SD) age 41.6 years (14), showing poor disease control or steroid-related side effects, received treatment for 12 months with intravenous cyclophosphamide (CP; n = 12) or placebo (PL; n = 11) in a randomized, double-blind trial. Pulses were given monthly at an initial dose of 500 mg/m(2) of body surface, and titrated according to changes of peripheral muscle strength or side effects. Changes of muscle strength, steroid and pyridostigmine requirements, and development of ventilatory failure or swallowing impairment were evaluated at 0, 3, 6, and 12 months. No differences were observed between groups at baseline. Statistically significant reductions of methylprednisone doses were noted in both groups but were more pronounced in subjects receiving CP than PL at 6 months (P < 0.05) and at 12 months (P < 0.03). At 12 months, five subjects on CP had tapered off their steroids whereas no subject on PL achieved further reductions (P < 0.03). Four CP subjects were not receiving steroids 36 months after completing the study and three other CP subjects had stopped pyridostigmine. CP improved muscle strength at 3 and 6 months, and this reached statistical significance compared to PL at 12 months mainly in the bulbar and masticatory (P < 0.009) and extraocular muscles (P < 0.03). Ventilatory failure was noted in one subject on CP (due to bronchopneumonia) and two on PL (due to muscle weakness). No significant increases of CP-related side effects were observed. Thus, this study suggests that intravenous pulses of CP allow reductions of systemic steroids usage without muscle strength deterioration or CP-related side effects.
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Pêgo-Fernandes PM, de Campos JRM, Jatene FB, Marchiori P, Suso FV, de Oliveira SA. Thymectomy by partial sternotomy for the treatment of myasthenia gravis. Ann Thorac Surg 2002; 74:204-8. [PMID: 12118759 DOI: 10.1016/s0003-4975(02)03640-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Myasthenia gravis is an autoimmune disease characterized by weakness and fatigue of voluntary muscles. Surgical treatment of choice for myasthenia gravis has been thymectomy. However, thymectomy indications and surgical approach are still controversial. The purpose of this study is to evaluate the efficacy of partial median sternotomy approach to the thymus. METHODS From 1973 to 1999, 478 patients with myasthenia gravis underwent thymectomy through a partial median sternotomy. RESULTS Sixty-one patients (12.7%) had complete remission of symptoms, 299 (62.5%) had a significant improvement, and 83 (17.4%), a mild improvement; whereas 35 patients (7.4%) had no improvement of clinical symptoms. CONCLUSIONS Partial median sternotomy has shown to be a useful surgical approach to the thymus, as demonstrated by the good functional and aesthetic results, associated with low morbidity and no mortality.
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Abstract
BACKGROUND In myasthenia gravis (MG), the prototypic autoimmune disease, antibodies against acetylcholine receptors impair neuromuscular transmission and produce weakness. Although recognized for several hundred years, it has only been over the last three decades that effective treatments have become available for MG. REVIEW SUMMARY This review summarizes the principles of normal neuromuscular transmission, the clinical features of MG, and the tests available for its diagnosis. The current treatments for MG are discussed, including possible mechanisms of action and a discussion of potential adverse effects. When available, evidence-based justification for individual treatment options is given, and areas of controversy identified. CONCLUSIONS Significant improvements in the diagnosis and management of MG have been made over the last several decades. The available treatments either improve neuromuscular transmission directly, or suppress or modulate the pathogenic immune response in MG. Treatment is highly individualized and must take into account the severity of disease, the presence of other diseases, and the kinetics of response for the available treatments. This requires detailed knowledge of the mechanisms of action and possible adverse effects for each treatment. However, despite an optimistic outlook with modern treatment, the management of MG continues to be plagued by lack of efficacy in some, and significant adverse effects in most MG patients.
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Affiliation(s)
- Michael W Nicolle
- Department of Clinical Neurological Sciences, London Health Sciences Center, The University of Western Ontario, London, Ontario, Canada.
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Higuchi T, Taki J, Kinuya S, Yamada M, Kawasuji M, Matsui O, Nonomura A, Bunko H, Tonami N. Thymic lesions in patients with myasthenia gravis: characterization with thallium 201 scintigraphy. Radiology 2001; 221:201-6. [PMID: 11568341 DOI: 10.1148/radiol.2211001047] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess thallium 201 ((201)Tl) single photon emission computed tomography (SPECT) for evaluation of thymic lesions associated with myasthenia gravis (MG), including lymphoid follicular hyperplasia (LFH) and thymoma. MATERIALS AND METHODS (201)Tl SPECT and computed tomography (CT) were performed preoperatively in 46 patients with MG who had undergone thymectomy. SPECT was conducted 15 (early image) and 180 (delayed image) minutes after (201)Tl injection. Results were visually assessed, and (201)Tl uptake ratios (thymic lesion count density/lung count density) were measured for quantitative analysis. Uptake was analyzed among the normal thymus, LFH, and thymoma patient groups. RESULTS Histopathologic results indicated a normal thymus, LFH, and thymoma in 19, 16, and 11 patients, respectively. Mean uptake ratios in the normal thymus, LFH, and thymoma were 0.96 (95% CI: 0.90, 1.03), 1.14 (95% CI: 1.04, 1.25), and 1.87 (95% CI: 1.56, 2.25), respectively, on early images and 1.09 (95% CI: 1.00, 1.18), 1.65 (95% CI: 1.48, 1.85), and 2.03 (95% CI: 1.65, 2.50), respectively, on delayed images. Thymoma showed more intense (201)Tl accumulation than did the normal thymus (P <.001) and LFH (P <.001) on early images. Both thymoma (P <.001) and LFH (P <.001) displayed more intense uptake than did the normal thymus on delayed images. CONCLUSION (201)Tl SPECT can enable differentiation between normal thymus, LFH, and thymoma in patients with MG.
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Affiliation(s)
- T Higuchi
- Department of Nuclear Medicine, Kanazawa University School of Medicine, Takaramachi 13-1, Kanazawa, Ishikawa, Japan.
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Abstract
BACKGROUND Factors determining predictability of response to thymectomy for myasthenia gravis (MG) vary in the literature. METHODS A 25-year retrospective review (1974 to 1999) of all thymectomies performed at a single institution was undertaken. RESULTS In 113 consecutive thymectomies for MG, women comprised 79% (89 of 113 patients), and mean age was 40+/-15 years. Complications occurred in 14% of patients (16 of 113). In-hospital mortality was 0, but 90-day hospital mortality was 0.88% (1 of 113 patients). Follow-up was obtained in 81% (92 of 113 patients) at a mean of 51+/-59 months postoperatively. Complete remission was achieved in 21% of patients (19 of 92), and marked improvement of MG in 54% (50 of 92), for a total benefit rate of 75%. Fourteen percent (13 of 92) were unchanged, and 11% (10 of 92) were worse. Using univariate analysis, sex, age, and pathology correlated significantly with outcome (p < 0.05): 80% of women (57 of 70) benefited from the procedure, versus 57% of men (12 of 21). Eighty percent (57 of 70) of patients less than 51 years of age were improved or in remission, versus 57% (12 of 22) older than 50. Twenty-three percent (5 of 22) of patients with thymoma deteriorated, versus 7.1% (5 of 70) without thymoma. Sex did not significantly correlate in the multivariate model. CONCLUSIONS Sex, age, and thymic pathology are potential predictors of outcome in thymectomy for MG, and may shape treatment decisions and target higher-risk patients.
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Affiliation(s)
- J M Budde
- Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, Georgia 30322, USA
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Vázquez-Pelillo J, Gil Alonso J, Díaz-Agero P, García Sánchez-Girón J, Roca Serrano R, Díez Tejedor E, Casillas Pajuelo M. [Prognostic factors and outcome of thymectomy in 80 cases of myasthenia gravis]. Arch Bronconeumol 2001; 37:166-70. [PMID: 11412500 DOI: 10.1016/s0300-2896(01)75045-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To analyze the results of thymectomy in our series of patients with myasthenia gravis (MG) and to study the influence of the most common prognostic factors. MATERIAL AND METHODS Eighty MG patients over a period of 23 years underwent thymectomy consecutively in our hospital. Preoperative assessment included clinical evaluation of muscle weakness, edrophonium testing, electromyography, lung function testing, chest X-rays and CAT scans. Symptoms were assessed by the Osserman scale. The surgical approach was amplified transsternal thymectomy. The prognostic factors studied were sex, age, clinical stage, duration of disease before surgery and histology of the thymus. Clinical outcome was assessed using Millichap and Dodge's criteria. Follow-up was by the chest surgery and neurology departments. RESULTS Complete remission was observed in 29 cases (36.2%) and significant improvement in 42 (52.5%). Complications developed in 9 patients (11.2%). Most patients were women (53/27) and outcomes for men and women were not statistically different. Mean age was 36 years (range 11-79), with no significant difference in outcome for patients who were older or younger than 60 years of age. Nor were differences evident related to presurgical clinical stage or levels of severity (I + IIa/IIb + III). Differences in outcome were highly significantly related to duration of disease (< 24 / > 24 months) (p = 0.0022), such that outcome was more satisfactory when the pre-surgical course of disease was shorter, provided that no thymoma was present. CONCLUSIONS Amplified transsternal thymectomy was safe and effective for those patients with MG. When disease had been present for less than two years, the prognosis was better.
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Affiliation(s)
- J Vázquez-Pelillo
- Servicios de Cirugía Torácica. Hospital Universitario La Paz. Madrid
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