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Wiendl H, Abicht A, Chan A, Della Marina A, Hagenacker T, Hekmat K, Hoffmann S, Hoffmann HS, Jander S, Keller C, Marx A, Melms A, Melzer N, Müller-Felber W, Pawlitzki M, Rückert JC, Schneider-Gold C, Schoser B, Schreiner B, Schroeter M, Schubert B, Sieb JP, Zimprich F, Meisel A. Guideline for the management of myasthenic syndromes. Ther Adv Neurol Disord 2023; 16:17562864231213240. [PMID: 38152089 PMCID: PMC10752078 DOI: 10.1177/17562864231213240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/23/2023] [Indexed: 12/29/2023] Open
Abstract
Myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS), and congenital myasthenic syndromes (CMS) represent an etiologically heterogeneous group of (very) rare chronic diseases. MG and LEMS have an autoimmune-mediated etiology, while CMS are genetic disorders. A (strain dependent) muscle weakness due to neuromuscular transmission disorder is a common feature. Generalized MG requires increasingly differentiated therapeutic strategies that consider the enormous therapeutic developments of recent years. To include the newest therapy recommendations, a comprehensive update of the available German-language guideline 'Diagnostics and therapy of myasthenic syndromes' has been published by the German Neurological society with the aid of an interdisciplinary expert panel. This paper is an adapted translation of the updated and partly newly developed treatment guideline. It defines the rapid achievement of complete disease control in myasthenic patients as a central treatment goal. The use of standard therapies, as well as modern immunotherapeutics, is subject to a staged regimen that takes into account autoantibody status and disease activity. With the advent of modern, fast-acting immunomodulators, disease activity assessment has become pivotal and requires evaluation of the clinical course, including severity and required therapies. Applying MG-specific scores and classifications such as Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, and Myasthenia Gravis Foundation of America allows differentiation between mild/moderate and (highly) active (including refractory) disease. Therapy decisions must consider age, thymic pathology, antibody status, and disease activity. Glucocorticosteroids and the classical immunosuppressants (primarily azathioprine) are the basic immunotherapeutics to treat mild/moderate to (highly) active generalized MG/young MG and ocular MG. Thymectomy is indicated as a treatment for thymoma-associated MG and generalized MG with acetylcholine receptor antibody (AChR-Ab)-positive status. In (highly) active generalized MG, complement inhibitors (currently eculizumab and ravulizumab) or neonatal Fc receptor modulators (currently efgartigimod) are recommended for AChR-Ab-positive status and rituximab for muscle-specific receptor tyrosine kinase (MuSK)-Ab-positive status. Specific treatment for myasthenic crises requires plasmapheresis, immunoadsorption, or IVIG. Specific aspects of ocular, juvenile, and congenital myasthenia are highlighted. The guideline will be further developed based on new study results for other immunomodulators and biomarkers that aid the accurate measurement of disease activity.
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Affiliation(s)
- Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, Münster 48149, Germany
| | - Angela Abicht
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Andrew Chan
- Universitätsklinik für Neurologie, Inselspital Bern, Bern, Switzerland
| | - Adela Della Marina
- Klinik für Kinderheilkunde I, Universitätsklinikum Essen, Essen, Germany
| | - Tim Hagenacker
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | | | - Sarah Hoffmann
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
| | | | - Sebastian Jander
- Klinik für Neurologie, Marien Hospital Düsseldorf, Düsseldorf, Germany
| | - Christian Keller
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Alexander Marx
- Pathologisches Institut, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Arthur Melms
- Facharztpraxis für Neurologie und Psychiatrie, Stuttgart, Germany
| | - Nico Melzer
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Wolfgang Müller-Felber
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU Munich, Munich, Germany
| | - Marc Pawlitzki
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | | | - Benedikt Schoser
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Bettina Schreiner
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Switzerland
| | - Michael Schroeter
- Klinik und Poliklinik für Neurologie, Uniklinik Cologne, Cologne, Germany
| | | | | | - Fritz Zimprich
- Universitätsklinik für Neurologie, AKH-Wien, Wien, Austria
| | - Andreas Meisel
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
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[Mediastinal tumors : Diagnosis and treatment of the most common tumor entities]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:277-288. [PMID: 35876853 DOI: 10.1007/s00104-022-01685-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/04/2022] [Indexed: 10/16/2022]
Abstract
The mediastinum is defined as the space formed ventrally by the sternum, dorsally by the spine, and laterally by the mediastinal pleura. A mediastinal mass is frequently an incidental finding. The wide spectrum of underlying diseases and the anatomic proximity to central structures makes diagnosis and treatment challenging. In many cases, the combination of anamnesis, physical examination, imaging and laboratory tests already provides valuable information about the tumor entity. In addition to diagnostic procedures for histological examination of an unclear mediastinal tumor, radical resection is very important for the prognosis of the patients, especially in the case of tumors of the thymus. Multimodal treatment of advanced tumors that involve adjacent structures is best performed in designated centers.
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