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Altınönder İ, Kaya M, Yentür SP, Çakar A, Durmuş H, Yegen G, Özkan B, Parman Y, Sawalha AH, Saruhan-Direskeneli G. Thymic gene expression analysis reveals a potential link between HIF-1A and Th17/Treg imbalance in thymoma associated myasthenia gravis. J Neuroinflammation 2024; 21:126. [PMID: 38734662 PMCID: PMC11088784 DOI: 10.1186/s12974-024-03095-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 04/07/2024] [Indexed: 05/13/2024] Open
Abstract
Myasthenia gravis (MG) is an immune-mediated disease frequently associated with thymic changes. Increased T helper 17 (Th17) cell activity and dysfunctional regulatory T (Treg) cells have been demonstrated in subgroups of MG. On the other hand, hypoxia-inducible factor 1 (HIF-1) has been shown to regulate the Th17/Treg balance by inducing Th17 differentiation while attenuating Treg development. To identify the underlying mechanisms of different thymic pathologies in MG development, we evaluated thymic samples from thymoma-associated myasthenia gravis (TAMG), MG with hyperplasia (TFH-MG) and thymoma without MG (TOMA) patients. Differential gene expression analysis revealed that TAMG and TFH-MG cells are associated with different functional pathways. A higher RORC/FOXP3 ratio provided evidence for Th17/Treg imbalance in TAMG potentially related to increased HIF1A. The hypoxic microenvironment in thymoma may be a driver of TAMG by increasing HIF1A. These findings may lead to new therapeutic approaches targeting HIF1A in the development of TAMG.
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Affiliation(s)
- İlayda Altınönder
- Department of Physiology, Istanbul Medical Faculty, Istanbul University, Istanbul, 34093, Turkey
| | - Mustafa Kaya
- Department of Physiology, Istanbul Medical Faculty, Istanbul University, Istanbul, 34093, Turkey
| | - Sibel P Yentür
- Department of Physiology, Istanbul Medical Faculty, Istanbul University, Istanbul, 34093, Turkey
| | - Arman Çakar
- Department of Neurology, Istanbul Medical Faculty, Istanbul University, Istanbul, 34093, Turkey
| | - Hacer Durmuş
- Department of Neurology, Istanbul Medical Faculty, Istanbul University, Istanbul, 34093, Turkey
| | - Gülçin Yegen
- Department of Thoracic Surgery, Istanbul Medical Faculty, Istanbul University, Istanbul, 34093, Turkey
| | - Berker Özkan
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, Istanbul, 34093, Turkey
| | - Yeşim Parman
- Department of Neurology, Istanbul Medical Faculty, Istanbul University, Istanbul, 34093, Turkey
| | - Amr H Sawalha
- Division of Rheumatology, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
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Wang T, Wang B, Fan X, Cai Y, Li L, Fu S. Type B thymomas in patients with myasthenia gravis display a distinctive pattern of αβ TCR and IL-7 receptor α expression on CD4 +CD8 + thymocytes. Autoimmunity 2024; 57:2347379. [PMID: 38723105 DOI: 10.1080/08916934.2024.2347379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 04/21/2024] [Indexed: 06/07/2024]
Abstract
Thymoma is closely associated with myasthenia gravis (MG). However, due to the heterogeneity of thymoma and the intricate pathogenesis of MG, it remains unclear why some patients with thymoma develop MG and others do not. In this study, we conducted a comparative phenotype analysis of thymocytes in type B thymomas in patients with MG (MG (+) thymomas) and without MG (MG (-) thymomas) via fluorescence-activated cell sorting (FACS). Our results show that the developmental stages defined by the expression of CD3, CD4, and CD8 were largely maintained in both MG (+) and MG (-) thymomas, with CD4+CD8+ cells constituting the majority of thymocytes in type B thymoma, and no significant difference between this cell population was observed in MG (+) and MG (-) thymomas.We discovered that CD4+CD8+ thymocytes in MG (+) thymomas expressed low levels of αβ TCR and high levels of IL-7 receptor α (IL-7Rα), whereas in MG (-) thymomas, CD4+CD8+ thymocytes exhibited the opposite pattern of αβ TCR and IL-7Rα expression. These results suggest that the positive and negative selection processes of CD4+CD8+ thymocytes might differ between MG (+) thymomas and MG (-) thymomas. The expression of the Helios transcription factor is induced during negative selection and marks a group of T cells that have undergone negative selection and are likely to be deleted due to strong TCR binding with self-peptides/MHC ligands. We observed that the percentage of Helios-positive CD4SP T cells was greater in MG (-) than in MG (+) thymomas. Thus, the differentially regulated selection process of CD4+CD8+ thymocytes, which involves TCR and IL-7/IL-7Rα signaling, is associated with the presence of MG in type B thymomas.
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Affiliation(s)
- Tianlai Wang
- Thoracic Surgery Laboratory, Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Boyu Wang
- Thoracic Surgery Laboratory, Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaowu Fan
- Thoracic Surgery Laboratory, Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yixin Cai
- Thoracic Surgery Laboratory, Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Lequn Li
- Thoracic Surgery Laboratory, Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shengling Fu
- Thoracic Surgery Laboratory, Department of Thoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Peng Y, Yang H, Chen Q, Jin H, Xue YH, Du MQ, Liu S, Yao SY. An angel or a devil? Current view on the role of CD8 + T cells in the pathogenesis of myasthenia gravis. J Transl Med 2024; 22:183. [PMID: 38378668 PMCID: PMC10877804 DOI: 10.1186/s12967-024-04965-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/07/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND Myasthenia gravis (MG) and the experimental autoimmune MG (EAMG) animal model are characterized by T-cell-induced and B-cell-dominated autoimmune diseases that affect the neuromuscular junction. Several subtypes of CD4+ T cells, including T helper (Th) 17 cells, follicular Th cells, and regulatory T cells (Tregs), contribute to the pathogenesis of MG. However, increasing evidence suggests that CD8+ T cells also play a critical role in the pathogenesis and treatment of MG. MAIN BODY Herein, we review the literature on CD8+ T cells in MG, focusing on their potential effector and regulatory roles, as well as on relevant evidence (peripheral, in situ, cerebrospinal fluid, and under different treatments), T-cell receptor usage, cytokine and chemokine expression, cell marker expression, and Treg, Tc17, CD3+CD8+CD20+ T, and CXCR5+ CD8+ T cells. CONCLUSIONS Further studies on CD8+ T cells in MG are necessary to determine, among others, the real pattern of the Vβ gene usage of autoantigen-specific CD8+ cells in patients with MG, real images of the physiology and function of autoantigen-specific CD8+ cells from MG/EAMG, and the subset of autoantigen-specific CD8+ cells (Tc1, Tc17, and IL-17+IFN-γ+CD8+ T cells). There are many reports of CD20-expressing T (or CD20 + T) and CXCR5+ CD8 T cells on autoimmune diseases, especially on multiple sclerosis and rheumatoid arthritis. Unfortunately, up to now, there has been no report on these T cells on MG, which might be a good direction for future studies.
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Affiliation(s)
- Yong Peng
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China.
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China.
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Quan Chen
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Hong Jin
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Ya-Hui Xue
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Miao-Qiao Du
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Shu Liu
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
| | - Shun-Yu Yao
- Department of Neurology, Affiliated First Hospital of Hunan Traditional Chinese Medical College, Zhuzhou, 412000, Hunan, China
- Department of Neurology, The Third Affiliated Hospital of Hunan University of Chinese Medicine, Zhuzhou, 412000, Hunan, China
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Su M, Luo Q, Wu Z, Feng H, Zhou H. Thymoma-associated autoimmune encephalitis with myasthenia gravis: Case series and literature review. CNS Neurosci Ther 2024; 30:e14568. [PMID: 38421083 PMCID: PMC10850820 DOI: 10.1111/cns.14568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 11/20/2023] [Accepted: 12/02/2023] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVES This comprehensive review aimed to compile cases of patients with thymoma diagnosed with both autoimmune encephalitis (AE) and myasthenia gravis (MG), and describe their clinical characteristics. METHODS Clinical records of 3 AE patients in the first affiliated hospital of Sun Yat-sen University were reviewed. All of them were diagnosed with AE between 1 November 2021 and 1 March 2022, and clinical evidence about thymoma and MG was found. All published case reports were searched for comprehensive literature from January 1990 to June 2022. RESULTS A total of 18 cases diagnosed with thymoma-associated autoimmune encephalitis (TAAE) and thymoma-associated myasthenia gravis (TAMG) were included in this complication, wherein 3 cases were in the first affiliated hospital of Sun Yat-sen University and the other 15 were published case reports. 5/18 patients had alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor antibody (AMPAR-Ab) in their serum and cerebrospinal fluid (CSF). All of them had positive anti-acetylcholine receptor antibody (AChR-Ab). And 12/18 patients showed a positive response to thymectomy and immunotherapy. Besides, thymoma recurrences were detected because of AE onset. And the shortest interval between operation and AE onset was 2 years in patients with thymoma recurrence. CONCLUSIONS There was no significant difference in the clinical manifestations between these patients and others with only TAMG or TAAE. TAAE was commonly associated with AMPAR2-Ab. Significantly, AE more commonly heralded thymoma recurrences than MG onset. And the intervals of thymectomy and MG or AE onset had different meanings for thymoma recurrence and prognoses of patients.
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Affiliation(s)
- Miao Su
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Qiuyan Luo
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
- Department of NeurologyGuangzhou Women and Children's Medical CenterGuangzhouChina
| | - Zichao Wu
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Huiyu Feng
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
| | - Hongyan Zhou
- Department of NeurologyThe First Affiliated Hospital, Sun Yat‐sen UniversityGuangzhouChina
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Chen X, Qiu J, Gao Z, Liu B, Zhang C, Yu W, Yang J, Shen Y, Qi L, Yao X, Sun H, Yang X. Myasthenia gravis: Molecular mechanisms and promising therapeutic strategies. Biochem Pharmacol 2023; 218:115872. [PMID: 37865142 DOI: 10.1016/j.bcp.2023.115872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 10/23/2023]
Abstract
Myasthenia gravis (MG) is a type of autoimmune disease caused by the blockage of neuromuscular junction transmission owing to the attack of autoantibodies on transmission-related proteins. Related antibodies, such as anti-AChR, anti-MuSK and anti-LRP4 antibodies, can be detected in most patients with MG. Although traditional therapies can control most symptoms, several challenges remain to be addressed, necessitating the development of more effective and safe treatment strategies for MG. With the in-depth exploration on the mechanism and immune targets of MG, effective therapies, especially therapies using biologicals, have been reported recently. Given the important roles of immune cells, cytokines and intercellular interactions in the pathological process of MG, B-cell targeted therapy, T-cell targeted therapy, proteasome inhibitors targeting plasma cell, complement inhibitors, FcRn inhibitors have been developed for the treatment of MG. Although these novel therapies exert good therapeutic effects, they may weaken the immunity and increase the risk of infection in MG patients. This review elaborates on the pathogenesis of MG and discusses the advantages and disadvantages of the strategies of traditional treatment and biologicals. In addition, this review emphasises that combined therapy may have better therapeutic effects and reducing the risk of side effects of treatments, which has great prospects for the treatment of MG. With the deepening of research on immunotherapy targets in MG, novel opportunities and challenges in the treatment of MG will be introduced.
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Affiliation(s)
- Xin Chen
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Jiayi Qiu
- Department of Clinical Medicine, Medical College, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Zihui Gao
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Boya Liu
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Chen Zhang
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Weiran Yu
- Department of Clinical Medicine, Medical College, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Jiawen Yang
- Department of Clinical Medicine, Medical College, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Yuntian Shen
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Lei Qi
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, Jiangsu Province 226001, PR China
| | - Xinlei Yao
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China.
| | - Hualin Sun
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China.
| | - Xiaoming Yang
- Key Laboratory of Neuroregeneration of Jiangsu and Ministry of Education, Co-Innovation Center of Neuroregeneration, Department of Neurology, Affiliated Hospital of Nantong University, Nantong University, Nantong, Jiangsu Province 226001, PR China.
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Liu L, Zhang J, Guo C, Chen Y, Liu H, Li S, Huang C. Combined effect of thymectomy on myasthenia gravis in patients with concomitant auto-immune diseases: a 22-year single-center experience. Updates Surg 2023; 75:2321-2326. [PMID: 37368230 PMCID: PMC10710378 DOI: 10.1007/s13304-023-01568-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
Myasthenia gravis (MG) is an autoimmune disease (AD), and patients with MG often have other types of ADs. We analyzed the prognosis of patients with MG complicated by AD after thymectomy. A retrospective analysis was performed for patients with MG complicated by ADs treated surgically in our center over the past 22 years, and their general condition and follow-up data were collected and analyzed. 33 patients were included totally. 28 patients displayed improvement or even complete recovery of MG, and 23 of 36 ADs revealed improvement or even complete recovery. The prognosis of MG is significantly correlated with the duration of postoperative follow-up time (p = 0.028), and in patients with thymoma, the larger the tumor diameter, the better the prognosis of MG (p = 0.026). Thymic hyperplasia patients were predominantly female (p = 0.049) and young (p < 0.001). The most common concomitant AD in this study was a thyroid-associated AD, which was associated with thymic hyperplasia (p < 0.001), Osserman type I MG (p < 0.001), and young age (p < 0.001). Thymectomy had a good therapeutic effect on MG complicated by AD, and there was a close correlation between surgery, thymus, MG, and ADs.
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Affiliation(s)
- Lei Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking, No.1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Jiaqi Zhang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking, No.1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Chao Guo
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking, No.1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Yeye Chen
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking, No.1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Hongsheng Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking, No.1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking, No.1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Cheng Huang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking, No.1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing, 100730, People's Republic of China.
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Saito Y, Yazawa T, Nagashima T, Ohtaki Y, Kawatani N, Narusawa E, Yoshikawa R, Matsumura N, Maehara T, Shirabe K. Autoimmune alopecia areata due to thymoma without myasthenia gravis: a case report. Surg Case Rep 2023; 9:68. [PMID: 37133711 PMCID: PMC10156902 DOI: 10.1186/s40792-023-01655-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 04/27/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Thymoma is associated with autoimmune diseases. Myasthenia gravis is frequently associated with thymoma, but cases of thymoma complicated by alopecia areata are very rare. In this report, we present a case of thymoma associated with alopecia areata, but without Myasthenia gravis. CASE PRESENTATION A 60-year-old woman had a complaint of rapid progression of alopecia areata. A hair follicular biopsy was performed, which showed the infiltration of CD8-positive lymphocytes. She was prescribed topical steroids for 2 months prior to surgery, but her hair loss was not improved. Screening computed tomography showed a mass in the anterior mediastinum, which was suspected to be a thymoma. Myasthenia gravis was ruled out because she had no relevant symptoms or physical findings, and no anti-acetylcholine receptor antibodies were detected in serum. We performed a transsternal extended thymectomy based on a diagnosis of thymoma Masaoka stage I, without myasthenia gravis. Pathological examination showed Type AB thymoma, Masaoka stage II. The chest drainage tube was removed on postoperative day 1, and the patient was discharged on postoperative day 6. The patient has continued topical steroids and showed improvement 2 months postoperatively. CONCLUSIONS Although alopecia areata is a rare complication in thymoma cases without myasthenia gravis, thoracic surgeons need to keep this condition in mind because alopecia reduces the patient's quality of life.
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Affiliation(s)
- Yukino Saito
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15, Showa-Machi, 371-8511, Maebashi, Gunma, Japan
| | - Tomohiro Yazawa
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15, Showa-Machi, 371-8511, Maebashi, Gunma, Japan.
| | - Toshiteru Nagashima
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15, Showa-Machi, 371-8511, Maebashi, Gunma, Japan
| | - Yoichi Ohtaki
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15, Showa-Machi, 371-8511, Maebashi, Gunma, Japan
| | - Natsuko Kawatani
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15, Showa-Machi, 371-8511, Maebashi, Gunma, Japan
| | - Eiji Narusawa
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15, Showa-Machi, 371-8511, Maebashi, Gunma, Japan
| | - Ryohei Yoshikawa
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15, Showa-Machi, 371-8511, Maebashi, Gunma, Japan
| | - Nozomi Matsumura
- Department of Pathology, Gunma University Hospital, Gunma, Japan
| | - Tatsuro Maehara
- Department of Pathology, Gunma University Hospital, Gunma, Japan
| | - Ken Shirabe
- Division of General Thoracic Surgery, Integrative Center of General Surgery, Gunma University Hospital, 3-39-15, Showa-Machi, 371-8511, Maebashi, Gunma, Japan
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Song W, Li K, Li J, Liu X, Wu X, Xu X, Xiong K, Chen X, Zhang Y. Thymoma-associated autoimmune encephalitis: Analysis of factors determining prognosis. CNS Neurosci Ther 2023; 29:1213-1221. [PMID: 36914970 PMCID: PMC10068466 DOI: 10.1111/cns.14166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION Autoimmune encephalitis (AE) is a heterogeneous group of inflammatory central nervous system disorders caused by a misdirected immune response against self-antigens expressed in the central nervous system. The thymus is a central organ in the immune system and thymic tumors are thought to be possible initiators of many neurological disorders. Recently, there is growing evidence that thymomas are associated with autoimmune encephalitis. AIMS Our study initially explored the characteristics of patients with autoimmune encephalitis combined with thymoma. METHODS We used patient data from January 1, 2011 to October 1, 2021 from the PubMed, Web of Science, Ovid, and CNKI platforms to analyze overall demographics, frequency of symptoms and associations, and treatment prognosis outcomes. RESULTS A total of 68 patients were included. There were 39 female cases (57.4%). The mean age was 50 years (IQR 40-66 years). All had acute and subacute onset. The clinical manifestations were mostly cognitive changes (70.6%), mental disorders (57.4%), and epilepsy (50.0%). The most common neuronal antibody was alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA). Magnetic resonance imaging (MRI) abnormalities were present in 81.0% of patients, mostly in the hippocampus, temporal lobe, and some in cortical and subcortical areas. Abnormalities in the electroencephalogram (EEG) in 69.8% of patients. Treatment involved immunotherapy and thymoma treatment, with 79.7% of patients improving after treatment. While 20.3% of patients had a poor prognosis. Further, 14.8% of patients relapsed. Mental disorders, autonomic dysfunction, sleep disturbances, anti-Ma2, and thymoma untreated were more frequent in patients with poor prognosis. CONCLUSION Thymoma-associated autoimmune encephalitis is a unique disease entity. Long-term follow-up of chest CT findings is recommended for patients with autoimmune encephalitis.
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Affiliation(s)
- Wenli Song
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Keru Li
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiao Li
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoni Liu
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Fudan University, Shanghai, China
| | - Xiaoke Wu
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaodong Xu
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Kangping Xiong
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiangjun Chen
- Department of Neurology, Huashan Hospital and Institute of Neurology, Fudan University, Shanghai, China.,National Center for Neurological Disorders, Fudan University, Shanghai, China.,Human Phenome Institute, Fudan University, Shanghai, China
| | - Yanlin Zhang
- Department of Neurology and Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
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Tang M, Shao Y, Dong J, Gao X, Wei S, Ma J, Hong Y, Li Z, Bi T, Yin Y, Zhang W, Liu W. Risk factors for postoperative myasthenia gravis in patients with thymoma without myasthenia gravis: A systematic review and meta-analysis. Front Oncol 2023; 13:1061264. [PMID: 36845745 PMCID: PMC9944936 DOI: 10.3389/fonc.2023.1061264] [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: 10/04/2022] [Accepted: 01/19/2023] [Indexed: 02/11/2023] Open
Abstract
Introduction According to the principle, thymomas combined with myasthenia gravis (MG) require surgical treatment. However, patients with non-MG thymoma rarely develop MG and early- or late-onset MG after surgery is called postoperative MG (PMG). Our study used a meta-analysis to examine the incidence of PMG and risk factors. Methods Relevant studies were searched for in the PubMed, EMBASE, Web of Science, CNKI,and Wanfang databases. Investigations that directly or indirectly analyzed the risk factors for PMG development in patients with non-MG thymoma were included in this study. Furthermore, risk ratios (RR) with 95% confidence intervals (CI) were pooled using meta-analysis, and fixed-effects or random-effects models were used depending on the heterogeneity of the included studies. Results Thirteen cohorts containing 2,448 patients that met the inclusion criteria were included. Metaanalysis revealed that the incidence of PMG in preoperative patients with non-MG thymoma was 8%. Preoperative seropositive acetylcholine receptor antibody (AChR-Ab) (RR = 5.53, 95% CI 2.36 - 12.96, P<0.001), open thymectomy (RR =1.84, 95% CI 1.39 - 2.43, P<0.001), non-R0 resection (RR = 1.87, 95% CI 1.36 - 2.54, P<0.001), world health organization (WHO) type B (RR =1.80, 95% CI 1.07 - 3.04, P= 0.028), and postoperative inflammation (RR = 1.63, 95% CI 1.26 - 2.12, P<0.001) were the risk factors for PMG in patients with thymoma. Masaoka stage (P = 0.151) and sex (P = 0.777) were not significantly associated with PMG. Discussion Patients with thymoma but without MG had a high probability of developing PMG. Although the incidence of PMG was very low, thymectomy could not completely prevent the occurrence of MG. Preoperative seropositive AChR-Ab level, open thymectomy, non-R0 resection, WHO type B, and postoperative inflammation were risk factors for PMG. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022360002.
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Affiliation(s)
- Mingbo Tang
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yifeng Shao
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Junxue Dong
- Laboratory of Infection Oncology, Institute of Clinical Molecular Biology, Universitätsklinikum Schleswig-Holstein (UKSH), Christian Albrechts University of Kiel, Kiel, Germany
| | - Xinliang Gao
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Shixiong Wei
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jianzun Ma
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yang Hong
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Zhiqin Li
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Taiyu Bi
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Yipeng Yin
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Wenyu Zhang
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Wei Liu
- Department of Thoracic Surgery, The First Hospital of Jilin University, Changchun, Jilin, China,*Correspondence: Wei Liu,
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10
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Rio P, Cavallaro C, Diomedi-Camassei F, Cianci R, Gambassi G. Thymus-kidneys: a dangerous liaison. Intern Emerg Med 2022; 17:2057-2061. [PMID: 35751742 DOI: 10.1007/s11739-022-03021-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/28/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Pierluigi Rio
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Chiara Cavallaro
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
| | - Francesca Diomedi-Camassei
- Department of Laboratories-Pathology Unit, Bambino Gesù Children's Hospital, IRCCS, p.zza S. Onofrio 4, 00165, Rome, Italy
| | - Rossella Cianci
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy.
| | - Giovanni Gambassi
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Largo A. Gemelli, 8, 00168, Rome, Italy
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11
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Chen K, Li Y, Yang H. Poor responses and adverse outcomes of myasthenia gravis after thymectomy: Predicting factors and immunological implications. J Autoimmun 2022; 132:102895. [PMID: 36041292 DOI: 10.1016/j.jaut.2022.102895] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 10/15/2022]
Abstract
Myasthenia gravis (MG) has been recognized as a series of heterogeneous but treatable autoimmune conditions. As one of the indispensable therapies, thymectomy can achieve favorable prognosis especially in early-onset generalized MG patients with seropositive acetylcholine receptor antibody. However, poor outcomes, including worsening or relapse of MG, postoperative myasthenic crisis and even post-thymectomy MG, are also observed in certain scenarios. The responses to thymectomy may be associated with the general characteristics of patients, disease conditions of MG, autoantibody profiles, native or ectopic thymic pathologies, surgical-related factors, pharmacotherapy and other adjuvant modalities, and the presence of comorbidities and complications. However, in addition to these variations among individuals, pathological remnants and the abnormal immunological milieu and responses potentially represent major mechanisms that underlie the detrimental neurological outcomes after thymectomy. We underscore these plausible risk factors and discuss the immunological implications therein, which may be conducive to better managing the indications for thymectomy, to avoiding modifiable risk factors of poor responses and adverse outcomes, and to developing post-thymectomy preventive and therapeutic strategies for MG.
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Affiliation(s)
- Kangzhi Chen
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Yi Li
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Huan Yang
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China.
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12
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Malfitano AM, D’Esposito V, De Placido P, Tortora M, Ottaviano M, Pietroluongo E, Morra R, Mucci B, Napolitano F, Montella L, Giuliano M, De Placido S, Terracciano D, Palmieri G, Formisano P. Immunological signature of patients with thymic epithelial tumors and Good syndrome. Front Immunol 2022; 13:908453. [PMID: 36059463 PMCID: PMC9434000 DOI: 10.3389/fimmu.2022.908453] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/27/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundThymic epithelial tumors (TETs) are frequently accompanied by Good Syndrome (GS), a rare immunodeficiency, characterized by hypogammaglobulinemia and peripheral B cell lymphopenia. TETs can be also associated to other immunological disorders, both immunodeficiency and autoimmunity.MethodsIn this study, we enrolled TET patients with GS to address differences between patients with or without associated autoimmune diseases (AD). We analyzed the immunophenotype from peripheral blood of these patients focusing on selected immune cell subsets (CD4+T cells, CD8+T cells, T regulatory cells, NK cells, B-cells, monocytes, eosinophils, basophils, neutrophils) and serum levels of cytokines, chemokines and growth factors.ResultsWe observed higher number of leucocytes, in particular lymphocytes, B lymphopenia and lower number of T regulatory cells in TET patients with associated AD compared to TET patients without AD. In the group of TET patients with AD, we also observed increased serum levels of IL-15, VEGF, IP-10, GM-CSF, IL-6, and MIP-1α. Thus, we identified considerable differences in the lymphocyte profiles of TET patients with and without ADs, in particular a reduction in the numbers of B lymphocytes and T-regulatory cells in the former, as well as differences in the serum levels of various immune modulators.ConclusionsAlthough the pathogenic mechanisms are still unclear, our results add new knowledge to better understand the disease, suggesting the need of surveilling the immunophenotype of TET patients to ameliorate their clinical management.
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Affiliation(s)
- Anna Maria Malfitano
- Department of Translational Medical Sciences, University “Federico II”, Naples, Italy
- *Correspondence: Pietro Formisano, ; Anna Maria Malfitano,
| | - Vittoria D’Esposito
- Research Unit (URT) Genomics of Diabetes, Institute of Experimental Endocrinology and Oncology, National Research Council, Naples, Italy
| | - Pietro De Placido
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - Marianna Tortora
- Department of Translational Medical Sciences, University “Federico II”, Naples, Italy
- Rare Tumors Coordinating Center of Campania Region (CRCTR), Naples, Italy
| | - Margaret Ottaviano
- Rare Tumors Coordinating Center of Campania Region (CRCTR), Naples, Italy
- Oncology Unit, Ospedale del Mare, Napoli, Italy
| | - Erica Pietroluongo
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - Rocco Morra
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - Brigitta Mucci
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
| | - Fabiana Napolitano
- Department of Translational Medical Sciences, University “Federico II”, Naples, Italy
| | - Liliana Montella
- ASL NA2 NORD, Oncology Operative Unit, “Santa Maria delle Grazie” Hospital, Pozzuoli, Italy
| | - Mario Giuliano
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
- Rare Tumors Coordinating Center of Campania Region (CRCTR), Naples, Italy
| | - Sabino De Placido
- Department of Clinical Medicine and Surgery, University Federico II, Naples, Italy
- Rare Tumors Coordinating Center of Campania Region (CRCTR), Naples, Italy
| | - Daniela Terracciano
- Department of Translational Medical Sciences, University “Federico II”, Naples, Italy
| | | | - Pietro Formisano
- Department of Translational Medical Sciences, University “Federico II”, Naples, Italy
- Research Unit (URT) Genomics of Diabetes, Institute of Experimental Endocrinology and Oncology, National Research Council, Naples, Italy
- *Correspondence: Pietro Formisano, ; Anna Maria Malfitano,
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13
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Zhou RQ, Li LJ, Wu QC. Refractory post-thymectomy myasthenia gravis with onset at MGFA stage V: a case report. J Cardiothorac Surg 2022; 17:115. [PMID: 35551621 PMCID: PMC9097348 DOI: 10.1186/s13019-022-01872-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 04/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-thymectomy myasthenia gravis (PTMG) is defined as thymoma patients without signs of myasthenia gravis (MG) pre-operation, but develop MG after radical surgical resection. PTMG might be misdiagnosed not only because of its rare incidence, but also the uncertain interval between the removal of thymoma and the new onset MG. Additionally, some surgeons and anesthesiologists pay less attention to those asymptomatic thymoma patients in perioperative management, leading to the neglect of new onset PTMG, and miss the best time to treat it. CASE PRESENTATION Majority of cases of PTMG with onset at stage I-II on the basis of Myasthenia Gravis Foundation of America (MGFA) classification have been reported, but rarely at stage V, which requiring intubation or non-invasive ventilation to avoid intubation. Herein, we presented a 70-year-old male with PTMG onset at MGFA stage V, meanwhile, he had severe pulmonary infection interfering with the diagnosis of PTMG, and eventually progressed to refractory PTMG, which requiring much more expensive treatments and longer hospital stays. CONCLUSION In the perioperative management of asymptomatic thymoma patients, careful preoperative evaluation including physical examination, electrophysiological test and acetylcholine receptor antibodies (AChR-Ab) level should be done to identify subclinical MG. Complete resection should be performed during thymectomy, if not, additional postoperative adjuvant therapy is neccessary to avoid recurrence. It's important to identify PTMG at a early stage, especially when being interfered with by postoperative complications, such as lung infection, so that treatments could be initiated as soon as possible to avoid developing to refractory PTMG.
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Affiliation(s)
- Rui-Qin Zhou
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Lin-Jun Li
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Qing-Chen Wu
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Ao YQ, Jiang JH, Gao J, Wang HK, Ding JY. Recent thymic emigrants as the bridge between thymoma and autoimmune diseases. Biochim Biophys Acta Rev Cancer 2022; 1877:188730. [DOI: 10.1016/j.bbcan.2022.188730] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 11/27/2022]
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15
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Singhal S, Hellyer J, Ouseph MM, Wakelee HA, Padda SK. Autoimmune Disease in Patients with Advanced Thymic Epithelial Tumors. JTO Clin Res Rep 2022; 3:100323. [PMID: 35601925 PMCID: PMC9121321 DOI: 10.1016/j.jtocrr.2022.100323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/31/2022] [Accepted: 04/02/2022] [Indexed: 11/01/2022] Open
Abstract
Introduction Methods Results Conclusions
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16
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Cho YR, Kim JH, Kim KH. Surgical Removal of a Thymoma without Myasthenia Gravis Can Have a Therapeutic Effect on Concurrent Alopecia Areata: A Case Report. Ann Dermatol 2022; 34:287-290. [PMID: 35948331 PMCID: PMC9365659 DOI: 10.5021/ad.20.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/30/2020] [Accepted: 08/04/2020] [Indexed: 11/24/2022] Open
Abstract
Alopecia areata is a chronic organ-specific autoimmune disease and it could be associated with other autoimmune diseases. We, herein, report a case of alopecia areata in a patient with a thymoma without myasthenia gravis. Multiple hairless patches rapidly developed 6 weeks before the first visit on the patient who had been newly diagnosed with thymoma 2 weeks before the hairless patches occurred, and thymectomy was done 2 weeks before visiting dermatologic department. She had no symptoms associated with myasthenia gravis, and there were no abnormal findings on neurologic exams and acetylcholine receptor autoantibody was not detected in serum. Scalp biopsy showed numerous lymphocytic inflammations around hair follicles and in immunohistochemical staining, the aggregation of CD4+ and CD8+ T cells was observed around hair follicles and FoxP3+ T lymphocytes were rarely observed around hair follicles. The patient refused any treatment and her hairless patches were completely recovered 3 months after thymectomy, without being recurred 3 years after thymectomy. On the basis of both clinical manifestations and histologic findings, we concluded that alopecia areata in the patient had developed in association with thymoma and was recovered rapidly after thymectomy.
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Affiliation(s)
- Yu-Ri Cho
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Korea
| | - Jung-Hwan Kim
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Korea
| | - Ki-Ho Kim
- Department of Dermatology, College of Medicine, Dong-A University, Busan, Korea
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17
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Xian S, Dosset M, Almanza G, Searles S, Sahani P, Waller TC, Jepsen K, Carter H, Zanetti M. The unfolded protein response links tumor aneuploidy to local immune dysregulation. EMBO Rep 2021; 22:e52509. [PMID: 34698427 PMCID: PMC8647024 DOI: 10.15252/embr.202152509] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 09/14/2021] [Accepted: 09/22/2021] [Indexed: 12/19/2022] Open
Abstract
Aneuploidy is a chromosomal abnormality associated with poor prognosis in many cancer types. Here, we tested the hypothesis that the unfolded protein response (UPR) mechanistically links aneuploidy and local immune dysregulation. Using a single somatic copy number alteration (SCNA) score inclusive of whole‐chromosome, chromosome arm, and focal alterations in a pan‐cancer analysis of 9,375 samples in The Cancer Genome Atlas (TCGA) database, we found an inverse correlation with a cytotoxicity (CYT) score across disease stages. Co‐expression patterns of UPR genes changed substantially between SCNAlow and SCNAhigh groups. Pathway activity scores showed increased activity of multiple branches of the UPR in response to aneuploidy. The PERK branch showed the strongest association with a reduced CYT score. The conditioned medium of aneuploid cells transmitted XBP1 splicing and caused IL‐6 and arginase 1 transcription in receiver bone marrow‐derived macrophages and markedly diminished the production of IFN‐γ and granzyme B in activated human T cells. We propose the UPR as a mechanistic link between aneuploidy and immune dysregulation in the tumor microenvironment.
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Affiliation(s)
- Su Xian
- Division of Medical Genetics Biostatistics, Department of Medicine, Bioinformatics and System Biology Program, University of California, San Diego, La Jolla, CA, USA
| | - Magalie Dosset
- The Laboratory of Immunology, Department of Medicine and Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | - Gonzalo Almanza
- The Laboratory of Immunology, Department of Medicine and Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | - Stephen Searles
- The Laboratory of Immunology, Department of Medicine and Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | - Paras Sahani
- The Laboratory of Immunology, Department of Medicine and Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | - T Cameron Waller
- Division of Medical Genetics Biostatistics, Department of Medicine, Bioinformatics and System Biology Program, University of California, San Diego, La Jolla, CA, USA
| | - Kristen Jepsen
- IGM Genomics Center, University of California, San Diego, La Jolla, CA, USA
| | - Hannah Carter
- Division of Medical Genetics Biostatistics, Department of Medicine, Bioinformatics and System Biology Program, University of California, San Diego, La Jolla, CA, USA
| | - Maurizio Zanetti
- The Laboratory of Immunology, Department of Medicine and Moores Cancer Center, University of California, San Diego, La Jolla, CA, USA
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18
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Gurowich L, Yiin G, Maxwell A, Rice A. Post-thymectomy myasthenia gravis: a case report and systematic review of literature. BMJ Case Rep 2021; 14:e246005. [PMID: 34857591 PMCID: PMC8640658 DOI: 10.1136/bcr-2021-246005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2021] [Indexed: 11/04/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune condition affecting the neuromuscular junction characterised by weakness and fatiguability, carrying a high morbidity if treatment is delayed. A clear association with thymoma has led to management with thymectomy as a common practice, but MG presenting post-thymectomy has rarely been reported. We present a case of an 82- year-old woman developing fatigue, ptosis and dysarthria 3 months after thymectomy. After a clinical diagnosis of MG was made, she responded well to prompt treatment with prednisolone and pyridostigmine. Her anti-acetylcholine receptor antibody (anti-AChR) subsequently came back positive. Our systematic review reveals that post-thymectomy MG can be categorised as early-onset or late-onset form with differing aetiology, and demonstrated correlation between preoperative anti-AChR titres and post-thymectomy MG. The postulated mechanisms for post-thymectomy MG centre around long-lasting peripheral autoantibodies. Clinicians should actively look for MG symptoms in thymoma patients and measure anti-AChR preoperatively to aid prognostication.
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Affiliation(s)
- Louise Gurowich
- General Surgery, Taunton and Somerset NHS Foundation Trust, Taunton, UK
- Neurology, Swindon and Marlborough NHS Trust, Swindon, UK
| | - Gabriel Yiin
- Neurology, Swindon and Marlborough NHS Trust, Swindon, UK
| | - Adam Maxwell
- Neurology, Swindon and Marlborough NHS Trust, Swindon, UK
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Zhou Y, Bing Z, Qin Y, Ma D, Liu H. Type B thymoma in a patient with HIV infection: A case report with a review of HIV and thymoma coexistence. Thorac Cancer 2021; 12:2618-2621. [PMID: 34486210 PMCID: PMC8487817 DOI: 10.1111/1759-7714.14135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 08/18/2021] [Indexed: 12/01/2022] Open
Abstract
HIV infection predisposes people to cancer, including AIDS‐defining cancers, such as Kaposi sarcoma, and a broad range of non‐AIDS‐defining cancers. Here we report a case with rare coexistence of HIV and thymoma, and summarize all the comorbid cases that currently exist. We found that in all the cases reported, thymoma occurred when CD4+ counts were within a normal range, but the immune response in peripheral T‐cell repertoire remains unknown. In our case, an overview of the immune system under this complicated situation is given for the first time by showing the lymphocyte subpopulations in the blood and the immune cell distribution of the thymoma. This case expands the scope of non‐AIDS‐defining cancers, and provides insight into the influence of the immune system under two immunocompromising conditions, HIV infection and thymoma.
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Affiliation(s)
- Yaxuan Zhou
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China.,Peking Union Medical College MD Program, Beijing, China
| | - Zhongxing Bing
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yingzhi Qin
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Dongjie Ma
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hongsheng Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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20
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Takebayashi S, Yoshikawa Y, Morita M, Nagashima R, Nakazono Y, Miyamoto S. Myasthenic crisis appearing after resection of intracardiac ectopic thymoma with superior vena cava syndrome. Surg Case Rep 2021; 7:144. [PMID: 34131826 PMCID: PMC8206305 DOI: 10.1186/s40792-021-01233-4] [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] [Received: 03/02/2021] [Accepted: 06/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background We describe herein an extremely rare case of intracardiac ectopic thymoma—only two pure cases have been reported to date—associated with myasthenia gravis, an infrequent complication of ectopic thymoma. Case presentation A 71-year-old woman with superior vena cava syndrome was found to have a large mass mainly located in the right atrium. Tumor resection under cardiopulmonary bypass was performed. The pathological diagnosis was type AB ectopic thymoma. The postoperative course was complicated by progressive respiratory failure, and she was diagnosed with myasthenic crisis based on clinical signs and the edrophonium test. The patient recovered and was weaned from prolonged mechanical ventilation after receiving intravenous immunoglobulin, and was subsequently discharged uneventfully. Conclusions This is the first report of myasthenic crisis due to intracardiac ectopic thymoma. Residual thymoma is a risk factor for the development of post-thymectomy myasthenia gravis, and long-term follow-up is required.
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Affiliation(s)
- Satoshi Takebayashi
- The Department of Cardiovascular Surgery, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu, Oita, 874-0011, Japan.
| | - Yasuji Yoshikawa
- The Department of Pathology, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu, Oita, 874-0011, Japan
| | - Masato Morita
- The Department of Cardiovascular Surgery, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu, Oita, 874-0011, Japan
| | - Ryotaro Nagashima
- The Department of Cardiovascular Surgery, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu, Oita, 874-0011, Japan
| | - Yuichi Nakazono
- The Department of Pathology, National Hospital Organization Beppu Medical Center, 1473 Uchikamado, Beppu, Oita, 874-0011, Japan
| | - Shinji Miyamoto
- The Department of Cardiovascular Surgery, Oita University Hospital, 1-1 Idaigaoka, Hasama-machi, Yufu, Oita, 879-5593, Japan
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21
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Rotondo Dottore G, Leo M, Ricciardi R, Maestri M, Bucci I, Lucchi M, Melfi F, Guida M, De Rosa A, Petrucci L, Ionni I, Lanzolla G, Nicolì F, Mantuano M, Ricci D, Latrofa F, Mariotti S, Marcocci C, Marinò M. Disappearance of Anti-Thyroid Autoantibodies following Thymectomy in Patients with Myasthenia Gravis. Eur Thyroid J 2021; 10:237-247. [PMID: 34178710 PMCID: PMC8216016 DOI: 10.1159/000510701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/04/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES The thymus plays a central role in immune tolerance, which prevents autoimmunity. Myasthenia gravis (MG) is commonly associated with thymoma or thymus hyperplasia, and it can coexist with autoimmune thyroid diseases. However, the role of the thymus in thyroid autoimmunity remains to be clarified, which we investigated here. STUDY DESIGN The study design entailed the inclusion of consecutive MG patients and the measurement of anti-thyroid autoantibodies at baseline and, limited to autoantibody-positive patients, also at 24 and 48 weeks. One hundred and seven MG patients were studied. The main outcome measure was the behaviour of anti-thyroglobulin autoantibodies (TgAbs) and anti-thyroperoxidase autoantibodies (TPOAbs) over time in relation to thymectomy. RESULTS Serum TgAbs and/or TPOAbs were detected in ∼20% of patients in the absence of thyroid dysfunction. The prevalence of positive serum TgAbs and/or TPOAbs decreased significantly (p = 0.002) over the follow-up period in patients who underwent thymectomy, but not in patients who were not thymectomized. When the analysis was restricted to TgAbs or TPOAbs, findings were similar. On the same line, there was a general trend towards a reduction in the serum concentrations of anti-thyroid autoantibodies in patients who underwent thymectomy, which was significant for TPOAbs (p = 0.009). CONCLUSIONS Our findings suggest a role of the thymus in the maintenance of humoral thyroid autoimmunity.
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Affiliation(s)
- Giovanna Rotondo Dottore
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Marenza Leo
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Roberta Ricciardi
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa and University Hospital of Pisa, Pisa, Italy
- Department of Surgical, Medical and Molecular Pathology, Division of Thoracic Surgery, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Michelangelo Maestri
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Ilaria Bucci
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Marco Lucchi
- Department of Surgical, Medical and Molecular Pathology, Division of Thoracic Surgery, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Franca Melfi
- Department of Surgical, Medical and Molecular Pathology, Division of Thoracic Surgery, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Melania Guida
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Anna De Rosa
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Loredana Petrucci
- Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Ilaria Ionni
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Giulia Lanzolla
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Francesca Nicolì
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Michele Mantuano
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Debora Ricci
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Francesco Latrofa
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Stefano Mariotti
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Michele Marinò
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
- *Michele Marinò, Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Via Paradisa 2, IT–56124 Pisa (Italy),
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Renal Diseases Associated with Hematologic Malignancies and Thymoma in the Absence of Renal Monoclonal Immunoglobulin Deposits. Diagnostics (Basel) 2021; 11:diagnostics11040710. [PMID: 33921123 PMCID: PMC8071536 DOI: 10.3390/diagnostics11040710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/02/2021] [Accepted: 04/13/2021] [Indexed: 12/05/2022] Open
Abstract
In addition to kidney diseases characterized by the precipitation and deposition of overproduced monoclonal immunoglobulin and kidney damage due to chemotherapy agents, a broad spectrum of renal lesions may be found in patients with hematologic malignancies. Glomerular diseases, in the form of paraneoplastic glomerulopathies and acute kidney injury with various degrees of proteinuria due to specific lymphomatous interstitial and/or glomerular infiltration, are two major renal complications observed in the lymphoid disorder setting. However, other hematologic neoplasms, including chronic lymphocytic leukemia, thymoma, myeloproliferative disorders, Castleman disease and hemophagocytic syndrome, have also been associated with the development of kidney lesions. These renal disorders require prompt recognition by the clinician, due to the need to implement specific treatment, depending on the chemotherapy regimen, to decrease the risk of subsequent chronic kidney disease. In the context of renal disease related to hematologic malignancies, renal biopsy remains crucial for accurate pathological diagnosis, with the aim of optimizing medical care for these patients. In this review, we provide an update on the epidemiology, clinical presentation, pathophysiological processes and diagnostic strategy for kidney diseases associated with hematologic malignancies outside the spectrum of monoclonal gammopathy of renal significance.
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Gurnari C, Maciejewski JP. How I manage acquired pure red cell aplasia in adults. Blood 2021; 137:2001-2009. [PMID: 33657207 PMCID: PMC8057257 DOI: 10.1182/blood.2021010898] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/18/2021] [Indexed: 12/19/2022] Open
Abstract
Pure red cell aplasia (PRCA) is a rare hematological disorder with multiple etiologies. The multifaceted nature of this disease is emphasized by the variety of concomitant clinical features. Classic idiopathic presentation aside, prompt recognition of pathogenetic clues is important because of their diagnostic and therapeutic implications. As a consequence, treatment of PRCA is diverse and strictly dependent on the presented clinical scenario. Here, we propose a series of clinical vignettes that showcase instructive representative situations derived from our routine clinical practice. Using these illustrative clinical cases, we review the diagnostic workup needed for a precise diagnosis and the currently available therapeutic options, discussing their applications in regard to the various PRCA-associated conditions and individual patients' characteristics. Finally, we propose a treatment algorithm that may offer guidance for personalized therapeutic recommendations.
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Affiliation(s)
- Carmelo Gurnari
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH; and
- Department of Biomedicine and Prevention, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, Rome, Italy
| | - Jaroslaw P Maciejewski
- Translational Hematology and Oncology Research Department, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH; and
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24
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Marruecos L, Manils J, Moreta C, Gómez D, Filgaira I, Serafin A, Cañas X, Espinosa L, Soler C. Single loss of a Trp53 allele triggers an increased oxidative, DNA damage and cytokine inflammatory responses through deregulation of IκBα expression. Cell Death Dis 2021; 12:359. [PMID: 33824284 PMCID: PMC8024389 DOI: 10.1038/s41419-021-03638-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 12/15/2022]
Abstract
Dose of Trp53, the main keeper of genome stability, influences tumorigenesis; however, the causes underlying and driving tumorigenesis over time by the loss of a single p53 allele are still poorly characterized. Here, we found that single p53 allele loss specifically impacted the oxidative, DNA damage and inflammatory status of hematopoietic lineages. In particular, single Trp53 allele loss in mice triggered oxidative stress in peripheral blood granulocytes and spleenocytes, whereas lack of two Trp53 alleles produced enhanced oxidative stress in thymus cells, resulting in a higher incidence of lymphomas in the Trp53 knockout (KO) mice compared with hemizygous (HEM). In addition, single or complete loss of Trp53 alleles, as well as p53 downregulation, led to a differential increase in basal, LPS- and UVB-induced expression of a plethora of pro-inflammatory cytokine, such as interleukin-12 (Il-12a), TNFα (Tnfa) and interleukin (Il-23a) in bone marrow-derived macrophage cells (BMDMs) compared to WT cells. Interestingly, p53-dependent increased inflammatory gene expression correlated with deregulated expression of the NF-κB pathway inhibitor IκBα. Chromatin immunoprecipitation data revealed decreased p65 binding to Nfkbia in the absence of p53 and p53 binding to Nfkbia promoter, uncovering a novel crosstalk mechanism between p53 and NF-κB transcription factors. Overall, our data suggest that single Trp53 allele loss can drive a sustained inflammatory, DNA damage and oxidative stress response that, over time, facilitate and support carcinogenesis.
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Affiliation(s)
- Laura Marruecos
- Cancer Research Program, CIBERONC Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Joan Manils
- Unitat d'Immunologia, Departament de Patologia i Terapèutica Experimental, Facultat de Medicina i Ciències de la Salut, Institut de Neurociències, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain.,Department of Immunology & Inflammation, Imperial College London, London, United Kingdom
| | - Cristina Moreta
- Unitat d'Immunologia, Departament de Patologia i Terapèutica Experimental, Facultat de Medicina i Ciències de la Salut, Institut de Neurociències, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Diana Gómez
- Unitat d'Immunologia, Departament de Patologia i Terapèutica Experimental, Facultat de Medicina i Ciències de la Salut, Institut de Neurociències, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Ingrid Filgaira
- Unitat d'Immunologia, Departament de Patologia i Terapèutica Experimental, Facultat de Medicina i Ciències de la Salut, Institut de Neurociències, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anna Serafin
- PCB Animal Facility, Parc Científic de Barcelona, Barcelona, Spain
| | - Xavier Cañas
- Vall d'Hebron Institute of Research, Barcelona, Spain
| | - Lluís Espinosa
- Cancer Research Program, CIBERONC Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain
| | - Concepció Soler
- Unitat d'Immunologia, Departament de Patologia i Terapèutica Experimental, Facultat de Medicina i Ciències de la Salut, Institut de Neurociències, Universitat de Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain. .,Neuropharmacology & Pain Group, Neuroscience Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain.
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25
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Marx A, Yamada Y, Simon-Keller K, Schalke B, Willcox N, Ströbel P, Weis CA. Thymus and autoimmunity. Semin Immunopathol 2021; 43:45-64. [PMID: 33537838 PMCID: PMC7925479 DOI: 10.1007/s00281-021-00842-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/12/2021] [Indexed: 12/19/2022]
Abstract
The thymus prevents autoimmune diseases through mechanisms that operate in the cortex and medulla, comprising positive and negative selection and the generation of regulatory T-cells (Tregs). Egress from the thymus through the perivascular space (PVS) to the blood is another possible checkpoint, as shown by some autoimmune/immunodeficiency syndromes. In polygenic autoimmune diseases, subtle thymic dysfunctions may compound genetic, hormonal and environmental cues. Here, we cover (a) tolerance-inducing cell types, whether thymic epithelial or tuft cells, or dendritic, B- or thymic myoid cells; (b) tolerance-inducing mechanisms and their failure in relation to thymic anatomic compartments, and with special emphasis on human monogenic and polygenic autoimmune diseases and the related thymic pathologies, if known; (c) polymorphisms and mutations of tolerance-related genes with an impact on positive selection (e.g. the gene encoding the thymoproteasome-specific subunit, PSMB11), promiscuous gene expression (e.g. AIRE, PRKDC, FEZF2, CHD4), Treg development (e.g. SATB1, FOXP3), T-cell migration (e.g. TAGAP) and egress from the thymus (e.g. MTS1, CORO1A); (d) myasthenia gravis as the prototypic outcome of an inflamed or disordered neoplastic ‘sick thymus’.
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Affiliation(s)
- Alexander Marx
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Yosuke Yamada
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, 606-8507, Japan
| | - Katja Simon-Keller
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Berthold Schalke
- Department of Neurology, Bezirkskrankenhaus, University of Regensburg, 93042, Regensburg, Germany
| | - Nick Willcox
- Neurosciences Group, Nuffield Department of Clinical Neurology, Weatherall Institute of Molecular Medicine, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Philipp Ströbel
- Institute of Pathology, University Medical Center Göttingen, University of Göttigen, 37075, Göttingen, Germany
| | - Cleo-Aron Weis
- Institute of Pathology, University Medical Centre Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Chemotherapy-induced myasthenic crisis in thymoma treated with primary chemotherapy with curative intent on mechanical ventilation: a case report and review of the literature. J Med Case Rep 2021; 15:32. [PMID: 33526108 PMCID: PMC7852190 DOI: 10.1186/s13256-020-02601-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 11/26/2020] [Indexed: 11/23/2022] Open
Abstract
Background Thymoma is an uncommon cancer often associated with myasthenia gravis, an autoimmune disorder of the neuromuscular junction characterized by muscular fatigability. In patients with advanced nonmetastatic thymoma, primary chemotherapy may be required to induce tumor shrinkage and to achieve radical resection. Cancer chemotherapy has been anecdotally reported as a trigger factor for worsening of myasthenia gravis in thymic epithelial cancers. The study of uncommon cases of chemotherapy-related myasthenic crisis is warranted to gain knowledge of clinical situations requiring intensive care support in the case of life-threatening respiratory failure. Case presentation We report a case of an 18-year-old Caucasian woman with advanced Masaoka-Koga stage III type B2 thymoma and myasthenia gravis on treatment with pyridostigmine, steroids and intravenous immunoglobulins, who developed a myasthenic crisis 2 hours after initiation of cyclophosphamide/doxorubicin/cisplatin primary chemotherapy. Because of severe acute respiratory failure, emergency tracheal intubation, mechanical ventilation, and temporary (2 hours) discontinuation of chemotherapy were needed. Considering the curative intent of the multimodal therapeutic program, we elected to resume primary chemotherapy administration while the patient remained on mechanical ventilation. After 24 hours, the recovery of adequate respiratory function allowed successful weaning from respiratory support, and no further adverse events occurred. After 3 weeks, upon plasma exchange initiation with amelioration of myasthenic symptoms, a second course of chemotherapy was given, and in week 6, having documented partial tumor remission, the patient underwent radical surgery (R0) and then consolidation radiation therapy with 50.4 Gy in 28 fractions in weeks 15–20. Conclusions This case report, together with the only four available in a review of the literature, highlights that chemotherapy may carry the risk of myasthenic crisis in patients affected by thymoma and myasthenia gravis. To our knowledge, this is the first reported case of chemotherapy continuation on mechanical ventilation in a patient with chemotherapy-induced myasthenic crisis requiring tracheal intubation. The lesson learned from the present case is that, in selected cases of advanced thymoma, the paradoxical worsening of myasthenia gravis during chemotherapy should not be considered an absolute contraindication for the continuation of primary chemotherapy with curative intent.
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Guevara-Hoyer K, Fuentes-Antrás J, Calatayud Gastardi J, Sánchez-Ramón S. Immunodeficiency and thymoma in Good syndrome: Two sides of the same coin. Immunol Lett 2021; 231:11-17. [PMID: 33418010 DOI: 10.1016/j.imlet.2020.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/20/2020] [Accepted: 12/24/2020] [Indexed: 02/03/2023]
Abstract
Good Syndrome is a rare clinical entity first described as the conjunction of thymoma and hypogammaglobulinemia, and more recently depicted as a complex disease integrating a medical history of thymoma with humoral immunodeficiency (more accurately stated: hypogammaglobulinemia) with or without cellular immunodeficiency, recurrent infections, autoimmunity, paraneoplastic syndromes and diverse aberrations in the immunological profile. This condition has an ominous prognosis with a high mortality rate secondary to recalcitrant infectious diseases. Understanding the possible discordances in clinical presentation and the temporal relationship between manifestations and immunological alterations is key to prevent misdiagnosis and complications. To this end, here we provide two illustrative patients with Good Syndrome that share common clinical manifestations and yet show unique and opposed immunological profiles, thereby highlighting the pivotal interest of a comprehensive immunological profiling in these patients. We conducted a thorough review of existing literature on the elusive molecular mechanisms underlying the syndrome and provide a clinical assessment algorithm to facilitate the management of these challenging patients.
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Affiliation(s)
- Kissy Guevara-Hoyer
- Department of Clinical Immunology, IML and IdSSC, Hospital Clínico San Carlos, Madrid, Spain.
| | | | | | - Silvia Sánchez-Ramón
- Department of Clinical Immunology, IML and IdSSC, Hospital Clínico San Carlos, Madrid, Spain
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Tateo V, Manuzzi L, De Giglio A, Parisi C, Lamberti G, Campana D, Pantaleo MA. Immunobiology of Thymic Epithelial Tumors: Implications for Immunotherapy with Immune Checkpoint Inhibitors. Int J Mol Sci 2020; 21:E9056. [PMID: 33260538 PMCID: PMC7730788 DOI: 10.3390/ijms21239056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/23/2020] [Accepted: 11/26/2020] [Indexed: 02/08/2023] Open
Abstract
Thymic epithelial tumors (TETs) are a group of rare thoracic malignancies, including thymic carcinomas (TC) and thymomas (Tm). Autoimmune paraneoplastic diseases are often observed in TETs, especially Tms. To date, chemotherapy is still the standard treatment for advanced disease. Unfortunately, few therapeutic options are available for relapsed/refractory TETs. In the last few years, the deepening of knowledge on thymus' immunobiology and involved altered genetic pathways have laid the foundation for new treatment options in these rare neoplasms. Recently, the immunotherapy revolution has landed in TETs, showing both a dark and light side. Indeed, despite the survival benefit, the occurrence of severe autoimmune treatment-related adverse events has risen crescent uncertainty about the feasibility of immunotherapy in these patients, prone to autoimmunity for their cancer biology. In this review, after summarizing immunobiology and immunopathology of TETs, we discuss available data on immune-checkpoint inhibitors and future perspectives of this therapeutic strategy.
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Affiliation(s)
- Valentina Tateo
- Department of Experimental, Diagnostic and Specialty Medicine, Policlinico di Sant’Orsola University Hospital, Via P. Albertoni 15, 40138 Bologna, Italy; (V.T.); (L.M.); (A.D.G.); (C.P.)
| | - Lisa Manuzzi
- Department of Experimental, Diagnostic and Specialty Medicine, Policlinico di Sant’Orsola University Hospital, Via P. Albertoni 15, 40138 Bologna, Italy; (V.T.); (L.M.); (A.D.G.); (C.P.)
| | - Andrea De Giglio
- Department of Experimental, Diagnostic and Specialty Medicine, Policlinico di Sant’Orsola University Hospital, Via P. Albertoni 15, 40138 Bologna, Italy; (V.T.); (L.M.); (A.D.G.); (C.P.)
| | - Claudia Parisi
- Department of Experimental, Diagnostic and Specialty Medicine, Policlinico di Sant’Orsola University Hospital, Via P. Albertoni 15, 40138 Bologna, Italy; (V.T.); (L.M.); (A.D.G.); (C.P.)
| | - Giuseppe Lamberti
- Department of Experimental, Diagnostic and Specialty Medicine, Policlinico di Sant’Orsola University Hospital, Via P. Albertoni 15, 40138 Bologna, Italy; (V.T.); (L.M.); (A.D.G.); (C.P.)
- Oncologia Medica, Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (D.C.); (M.A.P.)
| | - Davide Campana
- Oncologia Medica, Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (D.C.); (M.A.P.)
| | - Maria Abbondanza Pantaleo
- Oncologia Medica, Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138 Bologna, Italy; (D.C.); (M.A.P.)
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Mishra S, Padhi S, Adhya AK, DasMajumdar SK, Pattnaik A, Chhabra G. Peripheral blood T lymphocytosis in thymoma: an insight into immunobiology. J Cancer Res Clin Oncol 2020; 147:295-301. [PMID: 33164149 DOI: 10.1007/s00432-020-03440-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/27/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Peripheral blood T lymphocytosis (PBTL) is a rare, yet poorly understood manifestations of thymoma, which is postulated to be linked with autoimmune/paraneoplastic manifestations such as myasthenia gravis (MG), pure red cell aplasia (PRCA), etc.; more commonly encountered in this neoplasm. METHOD We aim to describe the flowcytometric immunophenotypic data of PBTL in a 43-year-old male; 6 months after successful completion of chemoradiotherapy (CT/RT) for a large, invasive, and metastatic type B1 thymoma; and present a comprehensive review of all such cases reported over last 42 years (N = 21) (1977-2019). RESULT A larger size of the tumors (≥ 10 cm), presence of local invasion and/or distant metastasis, and type B (cortical or lymphocyte rich) histology were more likely to be associated with PBTL. Tumors associated with MG/PRCA (N = 9/21) tend to have lower PBTL compared to those without such manifestations; and PBTL subsided following thymectomy with or without CT/RT. Immunophenotypic analysis of PB revealed a CD8 + > CD4 + mature (naïve) polyclonal T cells resembling late cortical thymocytes. CONCLUSION Thymic intratumoral microenvironment might influence occurrence PBTL that may have a pathophysiologic link to development of autoimmune manifestations. Immunophenotypic characteristics of peripheral blood lymphoid cells should be the clue for accurate characterization and to avoid a misdiagnosis of a lymphoproliferative neoplasm.
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Affiliation(s)
- Shruti Mishra
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Somanath Padhi
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India.
| | - Amit Kumar Adhya
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Saroj Kumar DasMajumdar
- Department of Radiotherapy, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Ashutosh Pattnaik
- Department of Radiotherapy, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
| | - Gaurav Chhabra
- Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, 751019, India
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Liu L, Zhang J, Wang G, Guo C, Chen Y, Huang C, Li S. Surgical treatment is effective in treating thymoma accompanied with non-myasthenia gravis autoimmune diseases: a single-center clinical experience. Scand J Surg 2020; 110:420-426. [PMID: 33045936 DOI: 10.1177/1457496920964337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND AIMS Although thymoma is inextricably linked to autoimmune disease, its best treatment method remains unclear. In this study, we sought to evaluate therapeutic effect of surgical resection of thymoma on non-myasthenia gravis autoimmune diseases. MATERIALS AND METHODS This was a retrospective study covering 32 patients with thymoma accompanied with non-myasthenia gravis autoimmune disease. The relationships between surgical treatment, thymoma pathological type, and prognosis of autoimmune diseases were analyzed from postoperative follow-up data. RESULTS In total, 32 patients in this study underwent surgical treatment. The mean age of the patients was 51.7 years. By the last follow-up, 2 patients had died, while the other 30 patients showed no sign of tumor recurrence and metastasis. According to the postoperative follow-up data, 22 patients (68.75%) showed improvement or even complete recovery of autoimmune disease symptoms, 9 patients (28.13%) showed no significant change, and only 1 patient's (3.12%) postoperative symptom was aggravated. Female patients and patients aged 50 and older were more likely to combine with non-organ-specific autoimmune diseases (p = 0.036, p = 0.017). CONCLUSIONS In conclusion, this study presents that surgical treatment achieves a satisfactory prognosis for thymoma combined with non-myasthenia gravis autoimmune disease.
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Affiliation(s)
- Lei Liu
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiaqi Zhang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Guige Wang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao Guo
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yeye Chen
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cheng Huang
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shanqing Li
- Department of Thoracic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Dongcheng District, Beijing 100730, P.R. China
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Yuen CA, Rezania K, Park DM, Reder AT. Asymptomatic brainstem lesions and pachymeningeal enhancement after anti-PD-1 therapy. Immunotherapy 2020; 13:11-17. [PMID: 33023359 DOI: 10.2217/imt-2020-0186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Neurological immune-related adverse events (irAEs) are rare toxicities that occur following immune checkpoint inhibitor therapy. We propose that patients with thymic malignancies and graft-versus-host disease (GVHD) are predisposed to irAEs. We present two asymptomatic patients, one with thymoma and another with GVHD, who developed abnormal brain MRIs after treatment with programmed cell death protein 1 inhibitors. The first patient, with thymic cancer and thymoma, developed pontine enhancing MRI lesions following treatment with pembrolizumab. The second patient, with prior GVHD, developed pachymeningeal enhancement following treatment with nivolumab. IrAEs with abnormal MRI studies, despite asymptomatology, have significant impact on the treatment strategy for these patients.
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Affiliation(s)
- Carlen A Yuen
- Department of Neurology, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Kourosh Rezania
- Department of Neurology, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Deric M Park
- Department of Neurology, University of Chicago Medical Center, Chicago, IL 60637, USA
| | - Anthony T Reder
- Department of Neurology, University of Chicago Medical Center, Chicago, IL 60637, USA
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Interleukin-8 as a candidate for thymoma identification and recurrence surveillance. Nat Commun 2020; 11:4881. [PMID: 32985506 PMCID: PMC7522267 DOI: 10.1038/s41467-020-18697-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 09/04/2020] [Indexed: 01/09/2023] Open
Abstract
Thymoma is the most common tumor of the anterior mediastinum. Routine imaging methods such as computed tomography or magnetic resonance imaging often lead to misdiagnosis between thymoma and other thymic abnormalities. Therefore, urgently needed is to develop a new diagnostic strategy. Here we identify interleukin-8 (IL-8) as a biomarker for auxiliary diagnosis of thymoma. We find that IL-8 levels in naïve T cells are markedly elevated in patients with thymoma compared to those with other thymic tumors. IL-8 levels in naive T cells are significantly decreased after surgical resection in thymoma patients, and rise again when thymoma recurs. A receiver operating characteristic curve analysis shows that IL-8 evaluation performs well in thymoma identification, with high specificities and sensitivities. We also observe significant clinical relevance between IL-8 levels in naïve T cells and clinicopathological features. In conclusion, our study suggests that IL-8 is a biomarker for thymoma identification and recurrence surveillance. Imaging methods, such as CT or MRI, cannot provide accurate diagnosis between malignant thymomas and other thymic abnormalities. Here the authors show that the levels of IL-8 in circulating naive T cells are elevated in patients with thymoma compared with other thymic masses, proposing IL-8 as a candidate biomarker for thymoma diagnosis and recurrence surveillance.
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33
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Conforti F, Pala L, Giaccone G, De Pas T. Thymic epithelial tumors: From biology to treatment. Cancer Treat Rev 2020; 86:102014. [PMID: 32272379 DOI: 10.1016/j.ctrv.2020.102014] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 02/29/2020] [Accepted: 03/19/2020] [Indexed: 11/30/2022]
Abstract
In the last few years, meaningful advances have been made in the knowledge of the biology of Thymic Epithelial Tumors (TETs). Data available suggest that in most cases, the different histological subtypes could be distinct biological entities, characterized by specific molecular aberrations, rather than representing a histological continuum of diseases. Recurrent gene mutations in Thymomas and Thymic Carcinoma have been identified, but we still do not know the exact role played by these mutations in TETs pathogenesis. Relevant new data are now available on the pathogenetic mechanisms underlying the association between TETs and autoimmune diseases that warrant further investigations for the potential therapeutic implications. The progress in knowledge of the molecular pathways involved in TETs pathogenesis, allowed to identify and to test target therapies potentially active in such diseases. Platinum-based chemotherapy remains the standard first line treatment for patients with advanced or metastatic TETs. However, some promising data have been reported on the activity of new target therapies, including anti-angiogenic drugs, Cycline Dependent Kinases and PI3K/mTOR inhibitors, as well as of Immune-checkpoint inhibitors. A number of new drugs and combinations are currently under evaluation. The efficacy of new drugs should be balanced with their toxicity profiles, in such complex patients that seem to be more susceptible to develop drug-related toxicities, in particular with immunotherapies.
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Affiliation(s)
- Fabio Conforti
- Division of Medical Oncology for Melanoma, Sarcoma, and Rare Tumors, IEO, European Institute of Oncology IRCCS, Milan, Italy.
| | - Laura Pala
- Division of Medical Oncology for Melanoma, Sarcoma, and Rare Tumors, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Tommaso De Pas
- Division of Medical Oncology for Melanoma, Sarcoma, and Rare Tumors, IEO, European Institute of Oncology IRCCS, Milan, Italy
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Ruffini E, Lyberis P, Guerrera F, Filosso PL. Commentary: Dangerous liaisons-Paraneoplastic syndromes and thymoma. J Thorac Cardiovasc Surg 2020; 160:318-319. [PMID: 32067787 DOI: 10.1016/j.jtcvs.2020.01.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 01/02/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Enrico Ruffini
- Thoracic Surgery Unit, University of Torino, Torino, Italy.
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35
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Wang W, Chen LY, Zhao W, Ren Y, Wang L, Li X, Jiang Y, Gao H. Coexistence of Pure Red Cell Aplasia and Autoimmune Haemolytic Anaemia Associated with Thymoma. Acta Haematol 2020; 143:491-495. [PMID: 31962320 DOI: 10.1159/000503376] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 09/02/2019] [Indexed: 11/19/2022]
Abstract
Thymoma is an uncommon neoplasia derived from the epithelial cells of the thymus, which leads to immune dysregulation and is associated with a series of autoimmune diseases. However, the concurrence of these disease entities is rare, and the exact mechanisms of these diseases are still unclear. We have admitted several cases who were diagnosed with thymoma, autoimmune haemolytic anaemia, and pure red cell aplasia. These cases were the first to report the concurrence of these three disorders. After thymectomy, anaemia improved, haemolytic cells decreased, and haemoglobin was normalized.
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Affiliation(s)
- Wei Wang
- Department of Haematology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China,
| | - Li-Yan Chen
- Department of Haematology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Weiwei Zhao
- Department of Haematology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yuyue Ren
- Department of Haematology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lianjie Wang
- Department of Haematology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xiaoyun Li
- Department of Haematology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yongfang Jiang
- Department of Haematology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Haiyan Gao
- Department of Haematology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
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36
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Geng Y, Zhang H, Wang Y. Risk factors of myasthenia crisis after thymectomy among myasthenia gravis patients: A meta-analysis. Medicine (Baltimore) 2020; 99:e18622. [PMID: 31895819 PMCID: PMC6946543 DOI: 10.1097/md.0000000000018622] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 11/28/2019] [Accepted: 12/06/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The purpose of the study was to determine the risk factors of post-surgery myasthenia crisis (PMC) among myasthenia gravis (MG) patients. METHODS A meta-analysis to synthesize all eligible literatures was conducted to analyze PMC predictors among MG patients. RESULTS A total of 15 trials with 2626 patients were included for the meta-analysis. As a result, patients with history of MC (RR = 3.36, 95%CI: 2.46-4.59, P < .001), generalized MG (RR = 0.39, 95%CI: 0.26-0.59, P < .001), bulbar symptom (RR = 3.59,95%CI:2.53-5.09, P < .001), thymoma (RR = 2.10, 95%CI:1.37-3.21, P = .001), post-surgery morbidity presence(RR = 2.59, 95%CI:1.90-3.54, P < .001), high-dose pyridostigmine usage (SMD = 0.480, 95%CI: 0.35-0.61 P < .001) tended to develop PMC. Large dose of steroid may reduce the incidence of PMC (RR = 0.41 95%CI: 0.18-0.94, P = .036). Regular steroid use (P = .066), immunosuppressive therapy (P = .179), gender (P = .774), and age at thymectomy (P = .212) had no impact upon PMC development. CONCLUSION History of PMC, thymoma, generalized MG, bulbar symptom, and concomitant complication are the risk factors of PMC.
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Abstract
Thymic malignancies are rare mediastinal cancers, classified according to the World Health Organization's histopathologic classification which distinguishes thymomas from thymic carcinomas. One key consideration when discussing immunotherapy for thymic epithelial tumors is that one-third of patients diagnosed with thymomas present at the time of diagnosis with autoimmune disorders, the most common being myasthenia gravis. The first step in the understanding of autoimmunity in thymic epithelial tumors is to distinguish true autoimmune disorders from paraneoplastic syndromes; besides pathophysiology, clinical correlates, impact on oncological management and survival may differ strongly. Autoimmune disorders are related to a deregulation in the physiological role of the thymus (i.e. to induce central tolerance to tissue self-antigens) through control of differentiation and subsequent positive and negative selection of immature T cells; from a clinical standpoint, in thymomas, once autoimmune disorders are present, they may not regress significantly after thymectomy. PD-L1 expression, while observed in more than 90% of epithelial cells of the normal thymus with a medullar tropism respecting Hassall's corpuscles, has also been identified in thymomas and thymic carcinomas using various immunohistochemistry protocols. Immune checkpoint inhibitors of the PD-1/PD-L1 axis have been assessed in advanced and metastatic thymic epithelial tumors, mainly thymic carcinomas. Several case reports have been published, and four trials have assessed the efficacy and safety of these inhibitors. Immunotherapy is not standard given the frequent occurrence of severe autoimmune disorders, and clinical trials are ongoing. Thymic malignancies are rare tumors. Advanced, metastatic and refractory thymic tumors may be treated with chemotherapy. Autoimmune disorders, such as myasthenia gravis, are observed in 30% of cases. PD-L1 expression is a hallmark of thymic epithelial cells. Immunotherapy is not standard, given the occurrence of autoimmune disorders.
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Affiliation(s)
- Nicolas Girard
- Correspondence to: Nicolas Girard, Institut Curie, 26 rue d’Ulm, 75248 Paris Cedex 05, France.
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38
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Kawamura T, Naito T, Kobayashi H, Nakashima K, Omori S, Wakuda K, Ono A, Kenmotsu H, Murakami H, Endo M, Takahashi T. Acquired immunodeficiency associated with thymoma: a case report. BMC Cancer 2019; 19:762. [PMID: 31375083 PMCID: PMC6679538 DOI: 10.1186/s12885-019-5980-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 07/25/2019] [Indexed: 12/02/2022] Open
Abstract
Background Acquired immunodeficiency associated with thymoma is a rare disorder. Here we reported a case of acquired immunodeficiency with thymoma, with an unusual pattern of low CD4+ count with normal gammaglobulin levels. Case presentation A 70-year-old man presented to the emergency room of our hospital with a high-grade fever, headache, and nausea. He had a five-year history of unresectable thymoma treatment, including several cytotoxic regimens. He had received thoracic palliative radiotherapy 2 months prior to the emergent visit. During the previous month, he had experienced multiple febrile episodes, dry cough, fatigue, weight loss, and watery diarrhea. Upon admission, he had a high-grade fever, nausea, and immobility. Physical examination revealed indistinct consciousness, neck stiffness, and oropharyngeal candidiasis. Both cerebrospinal fluid and blood cultures yielded multiple short chains of Gram-positive rods later identified as Listeria monocytogenes, so he was diagnosed with Listeria meningitis. Intravenous administration of antibiotics was initiated, and the patient fully recovered and was discharged. Additional examination found normal immunoglobulin levels. Peripheral-blood cell counts revealed low CD4+ cell count (108 CD4+ cells/μl). His CD4+ cell count remained low after discharge. Conclusions Our findings suggest that physicians need to be aware of severe infections due to immunodeficiency with thymoma.
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Affiliation(s)
- Takahisa Kawamura
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Tateaki Naito
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Haruki Kobayashi
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kazuhisa Nakashima
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Shota Omori
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kazushige Wakuda
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Akira Ono
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Hirotsugu Kenmotsu
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Haruyasu Murakami
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Masahiro Endo
- Division of Diagnostic Radiology, Shizuoka Cancer Center Hospital, Shizuoka, Japan
| | - Toshiaki Takahashi
- Division of Thoracic Oncology, Shizuoka Cancer Center Hospital, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
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39
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JC virus identified in a patient with persistent and severe West Nile virus disease. J Neurovirol 2019; 25:608-611. [DOI: 10.1007/s13365-019-00744-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/26/2019] [Accepted: 03/27/2019] [Indexed: 11/26/2022]
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40
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Geng Y, Dong J, Zhou Q. Rapid improvement of muscle weakness post-thymectomy indicates good long-term neurological outcome in patients with ocular myasthenia gravis. Eur J Neurol 2019; 26:1421-1423. [PMID: 31299129 DOI: 10.1111/ene.14036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 07/08/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND PURPOSE This study was conducted to evaluate whether post-thymectomy rapid remission of ocular myasthenia gravis (oMG) is a prognostic indicator of good long-term neurological outcome. METHODS Eighty-four oMG patients who underwent thymectomy at our institute were enrolled. The incidence of 5-year complete stable remission (CSR) was compared between patients with rapid remission of MG status (<1 month after surgery) and those with non-rapid remission. RESULTS Kaplan-Meier survival analysis indicated that the incidence of CSR was higher in oMG patients with rapid remission than in those without rapid remission (P < 0.001). Multivariate analysis showed that rapid remission (odds ratio 16.34, 95% confidence interval 3.58-74.60, P < 0.001) is an independent prognostic factor for CSR. CONCLUSION Postoperative rapid remission of MG status predicts a higher likelihood of complete remission in patients with oMG.
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Affiliation(s)
- Y Geng
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China.,Department of Lung Cancer Center, West China Hospital of Sichuan University, Chengdu, China
| | - J Dong
- Department of Lung Cancer Center, West China Hospital of Sichuan University, Chengdu, China
| | - Q Zhou
- Department of Thoracic Surgery, West China Hospital of Sichuan University, Chengdu, China.,Department of Lung Cancer Center, West China Hospital of Sichuan University, Chengdu, China
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41
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Myasthenia Gravis: Pathogenic Effects of Autoantibodies on Neuromuscular Architecture. Cells 2019; 8:cells8070671. [PMID: 31269763 PMCID: PMC6678492 DOI: 10.3390/cells8070671] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 06/26/2019] [Accepted: 06/28/2019] [Indexed: 12/13/2022] Open
Abstract
Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction (NMJ). Autoantibodies target key molecules at the NMJ, such as the nicotinic acetylcholine receptor (AChR), muscle-specific kinase (MuSK), and low-density lipoprotein receptor-related protein 4 (Lrp4), that lead by a range of different pathogenic mechanisms to altered tissue architecture and reduced densities or functionality of AChRs, reduced neuromuscular transmission, and therefore a severe fatigable skeletal muscle weakness. In this review, we give an overview of the history and clinical aspects of MG, with a focus on the structure and function of myasthenic autoantigens at the NMJ and how they are affected by the autoantibodies' pathogenic mechanisms. Furthermore, we give a short overview of the cells that are implicated in the production of the autoantibodies and briefly discuss diagnostic challenges and treatment strategies.
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42
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Paraneoplastic and Therapy-Related Immune Complications in Thymic Malignancies. Curr Treat Options Oncol 2019; 20:62. [DOI: 10.1007/s11864-019-0661-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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43
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Yoon JK, Jang HR, Park JH, Kim KH, Roh EY, Byun JM. A case of immune thrombocytopenia associated with invasive thymoma successfully treated with eltrombopag. Blood Res 2019; 54:74-79. [PMID: 30956967 PMCID: PMC6439297 DOI: 10.5045/br.2019.54.1.74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/30/2018] [Accepted: 10/12/2018] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jung-Ki Yoon
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hee Ryeong Jang
- Department of Internal Medicine, Kangwon National University Hospital, Chuncheon, Korea
| | - Jin Hyun Park
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ki Hwan Kim
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Eu Youn Roh
- Department of Laboratory Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
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44
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Pan H, Song L, Sun LR. Nephrotic syndrome: first presentation of lymphoepithelioma-like thymic carcinoma. Br J Hosp Med (Lond) 2019; 80:52-53. [PMID: 30592665 DOI: 10.12968/hmed.2019.80.1.52] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hua Pan
- Academic Foundation Year 8 Doctor, Department of Emergency Paediatrics, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Liang Song
- Academic Foundation Year 10 Doctor, Department of Pediatric Intensive Care Unit, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Li-rong Sun
- Professor of Clinical Hematology, Department of Pediatric Hematology, Affiliated Hospital of Qingdao University, Qingdao, Shandong 266003, China
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45
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Christopoulos P, Chung I, Bozorgmehr F, Muley T, Meister M, Kobinger S, Marx A, Thomas M, Winter H, Herpel E, Rieker RJ, Fisch P, Grosch H. Deficient CD247 expression is a typical histopathological characteristic of thymomas with cortical features. Histopathology 2018; 73:1040-1043. [PMID: 30079467 DOI: 10.1111/his.13724] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Petros Christopoulos
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), Heidelberg, Germany
| | - Inn Chung
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Farastuk Bozorgmehr
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), Heidelberg, Germany
| | - Thomas Muley
- Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), Heidelberg, Germany.,Translational Research Unit, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Meister
- Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), Heidelberg, Germany.,Translational Research Unit, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Sonja Kobinger
- Department of Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Alexander Marx
- Institute of Pathology, Mannheim University Hospital, Mannheim, Germany
| | - Michael Thomas
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany.,Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), Heidelberg, Germany
| | - Hauke Winter
- Translational Lung Research Center Heidelberg, German Center for Lung Research (DZL), Heidelberg, Germany.,Department of Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | - Esther Herpel
- Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany.,Tissue Bank of the National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Ralf J Rieker
- Institute of Pathology, University Hospital, Friedrich Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Paul Fisch
- Department of Pathology, Freiburg University Hospital, Freiburg, Germany
| | - Heidrun Grosch
- Department of Thoracic Oncology, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
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46
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Tabata R, Tabata C, Yamamoto N, Shibuya S, Yasumizu R, Kojima M. Progressive peripheral CD8+ T lymphocytosis complicated by pure red cell aplasia following immunosuppressive therapy for thymoma-associated myasthenia gravis. Int Immunopharmacol 2018; 63:14-18. [DOI: 10.1016/j.intimp.2018.07.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 07/12/2018] [Accepted: 07/25/2018] [Indexed: 10/28/2022]
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47
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Janik S, Raunegger T, Hacker P, Ghanim B, Einwallner E, Müllauer L, Schiefer AI, Moser J, Klepetko W, Ankersmit HJ, Moser B. Prognostic and diagnostic impact of fibrinogen, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio on thymic epithelial tumors outcome. Oncotarget 2018; 9:21861-21875. [PMID: 29774108 PMCID: PMC5955144 DOI: 10.18632/oncotarget.25076] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 03/22/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Peripheral blood-derived inflammation-based markers, such as Neutrophil-to-Lymphocyte Ratio (NLR), Platelet-to-Lymphocyte Ratio (PLR), and Fibrinogen have been identified as prognostic markers in various solid malignancies. Here we aimed to investigate the prognostic and diagnostic impact of NLR, PLR, and Fibrinogen in patients with thymic epithelial tumors (TETs). RESULTS Pretreatment Fibrinogen serum concentrations, NLRs and PLRs were highest in patients with TCs and advanced tumor stages. High pretreatment Fibrinogen serum concentration (≥452.5 mg/dL) was significantly associated with worse cause specific survival (CSS; p = 0.001) and freedom from recurrence (FFR; p = 0.043), high NLR (≥4.0) with worse FFR (p = 0.008), and high PLR (≥136.5) with worse CSS (p = 0.032). Longitudinal analysis revealed that compared to patients without tumor recurrence, patients with tumor recurrence had significantly higher NLR (11.8 ± 4.0 vs. 4.70 ± 0.5; p = 0.001) and PLR (410.8 ± 149.1 vs. 228.3 ± 23.7; p = 0.031). CONCLUSION Overall, Fibrinogen serum concentrations, NLRs, and PLRs were associated with higher tumor stage, more aggressive tumor behavior, recurrence, and worse outcome. Prospective multicenter studies of the diagnostic and prognostic potential of Fibrinogen, NLR, and PLR are warranted. METHODS This retrospective analysis included 122 patients with TETs who underwent surgical resection between 1999-2015. Fibrinogen serum concentrations, NLRs, and PLRs were measured in patients preoperatively, postoperatively, and later during follow-up. These markers were analyzed for association with several clinical variables, including tumor stage, tumor subtype, FFR, and CSS and to evaluate their prognostic and diagnostic impact for detecting tumor recurrence.
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Affiliation(s)
- Stefan Janik
- Department of Thoracic Surgery, Division of Surgery, Medical University Vienna, Vienna, Austria
- Christian Doppler Laboratory for Diagnosis and Regeneration of Cardiac and Thoracic Diseases, Medical University Vienna, Vienna, Austria
| | - Thomas Raunegger
- Department of Thoracic Surgery, Division of Surgery, Medical University Vienna, Vienna, Austria
- Christian Doppler Laboratory for Diagnosis and Regeneration of Cardiac and Thoracic Diseases, Medical University Vienna, Vienna, Austria
| | - Philipp Hacker
- Department of Thoracic Surgery, Division of Surgery, Medical University Vienna, Vienna, Austria
- Christian Doppler Laboratory for Diagnosis and Regeneration of Cardiac and Thoracic Diseases, Medical University Vienna, Vienna, Austria
| | - Bahil Ghanim
- Department of Thoracic Surgery, Division of Surgery, Medical University Vienna, Vienna, Austria
| | - Elisa Einwallner
- Department of Laboratory Medicine, Medical University Vienna, Vienna, Austria
| | - Leonhard Müllauer
- Clinical Institute of Pathology, Medical University Vienna, Vienna, Austria
| | - Ana-Iris Schiefer
- Clinical Institute of Pathology, Medical University Vienna, Vienna, Austria
| | - Julia Moser
- Departments of Dermatology and Venereology and Karl Landsteiner Institute of Dermatological Research, Karl Landsteiner University of Health Sciences, St. Pölten, Austria
| | - Walter Klepetko
- Department of Thoracic Surgery, Division of Surgery, Medical University Vienna, Vienna, Austria
| | - Hendrik Jan Ankersmit
- Department of Thoracic Surgery, Division of Surgery, Medical University Vienna, Vienna, Austria
- Christian Doppler Laboratory for Diagnosis and Regeneration of Cardiac and Thoracic Diseases, Medical University Vienna, Vienna, Austria
- Head FFG Project “APOSEC“, FOLAB Surgery, Medical University Vienna, Vienna, Austria
| | - Bernhard Moser
- Department of Thoracic Surgery, Division of Surgery, Medical University Vienna, Vienna, Austria
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48
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Mineo TC, Tamburrini A, Schillaci O, Ambrogi V. Onset and Evolution of Clinically Apparent Myasthenia Gravis After Resection of Non-myasthenic Thymomas. Semin Thorac Cardiovasc Surg 2018. [PMID: 29522809 DOI: 10.1053/j.semtcvs.2018.02.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Patients with thymoma and without clinical or electromyographical myasthenic signs may occasionally develop myasthenia several years after thymectomy. Hereby, we investigated the predictors and the evolution of this peculiar disease. We performed a retrospective analysis in 104 consecutive patients who underwent thymectomy between 1987 and 2013 for thymoma without clinical or electromyographic signs of myasthenia gravis. Predictors of post-thymectomy onset of myasthenia gravis were investigated with univariate time-to-disease analysis. Evolution of myasthenia was analyzed with time-to-regression analysis. Eight patients developed late myasthenia gravis after a median period of 33 months from thymectomy. No significant correlation was found for age, gender, Masaoka's stage, and World Health Organization histology. Only high preoperative serum acetylcholine-receptor antibodies titer (>0.3 nmol/L) was significantly associated with post-thymectomy myasthenia gravis at univariate time-to-disease (P = 0.003) analysis. Positron emission tomography was always performed in high-titer patients, and increased metabolic activity was detected in 4 of these patients. Surgical treatment through redo-sternotomy or video-assisted thoracoscopy was performed in these last cases with a remission in all patients after 12, 24, 32 and 48 months, respectively. No patient under medical treatment has yet developed a complete remission. In our study the presence of preoperative high-level serum acetylcholine receptor antibodies was the only factor significantly associated with the development of post-thymectomy myasthenia gravis. The persistence of residual islet of ectopic thymic tissue was one of the causes of the onset of myasthenia and its surgical removal was successful.
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Affiliation(s)
- Tommaso Claudio Mineo
- Department of Surgery and Experimental Medicine, Multidisciplinary Myasthenia Gravis Unit, Policlinico Tor Vergata University, Rome, Italy.
| | | | - Orazio Schillaci
- Department of Biomedicine and Prevention, Nuclear Medicine Unit, Tor Vergata University, Rome, Italy; IRCCS Neuromed, Pozzilli, Italy
| | - Vincenzo Ambrogi
- Department of Surgery and Experimental Medicine, Multidisciplinary Myasthenia Gravis Unit, Policlinico Tor Vergata University, Rome, Italy
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49
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Padda SK, Yao X, Antonicelli A, Riess JW, Shang Y, Shrager JB, Korst R, Detterbeck F, Huang J, Burt BM, Wakelee HA, Badve SS. Paraneoplastic Syndromes and Thymic Malignancies: An Examination of the International Thymic Malignancy Interest Group Retrospective Database. J Thorac Oncol 2018; 13:436-446. [PMID: 29191778 PMCID: PMC5983900 DOI: 10.1016/j.jtho.2017.11.118] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/08/2017] [Accepted: 11/12/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Thymic epithelial tumors (TETs) are associated with paraneoplastic/autoimmune (PN/AI) syndromes. Myasthenia gravis is the most common PN/AI syndrome associated with TETs. METHODS The International Thymic Malignancy Interest Group retrospective database was examined to determine (1) baseline and treatment characteristics associated with PN/AI syndromes and (2) the prognostic role of PN/AI syndromes for patients with TETs. The competing risks model was used to estimate cumulative incidence of recurrence (CIR) and the Kaplan-Meier method was used to calculate overall survival (OS). A Cox proportional hazards model was used for multivariate analysis. RESULTS A total of 6670 patients with known PN/AI syndrome status from 1951 to 2012 were identified. PN/AI syndromes were associated with younger age, female sex, thymoma histologic type, earlier stage, and an increased rate of total thymectomy and complete resection status. There was a statistically significant lower CIR in the group with a PN/AI syndrome than in the group without a PN/AI syndrome (10-year CIR 17.3% versus 21.2%, respectively [p = 0.0003]). The OS was improved in the group with a PN/AI syndrome compared to the group without a PN/AI syndrome (median OS 21.6 years versus 17.0 years, respectively [hazard ratio = 0.63, 95% confidence interval: 0.54-0.74, p < 0.0001]). However, in the multivariate model for recurrence-free survival and OS, PN/AI syndrome was not an independent prognostic factor. DISCUSSION Previously, there have been mixed data regarding the prognostic role of PN/AI syndromes for patients with TETs. Here, using the largest data set in the world for TETs, PN/AI syndromes were associated with favorable features (i.e., earlier stage and complete resection status) but were not an independent prognostic factor for patients with TETs.
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Affiliation(s)
- Sukhmani K Padda
- Department of Medicine, Division of Oncology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California.
| | - Xiaopan Yao
- Department of Surgery, Division of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Alberto Antonicelli
- Department of Surgery, Division of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan W Riess
- Department of Medicine, Division of Oncology, University of California Davis Cancer Center, Sacramento, California
| | - Yue Shang
- The MathWorks, Natick, Massachusetts
| | - Joseph B Shrager
- Department of Cardiothoracic Surgery, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California
| | - Robert Korst
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai Health System, New York, New York; Valley/Mount Sinai Comprehensive Cancer Care, Paramus, New Jersey
| | - Frank Detterbeck
- Department of Surgery, Division of Thoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - James Huang
- Department of Surgery, Thoracic Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bryan M Burt
- Department of Surgery, Division of Thoracic Surgery, Baylor College of Medicine, Houston, Texas
| | - Heather A Wakelee
- Department of Medicine, Division of Oncology, Stanford Cancer Institute/Stanford University School of Medicine, Stanford, California
| | - Sunil S Badve
- Department of Pathology, Indiana University, Indianapolis, Indiana
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50
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Girard N. Thymic Tumors: Revisiting Autoimmunity to Give a Chance to Immunotherapy. J Thorac Oncol 2018; 13:295-297. [PMID: 29472052 DOI: 10.1016/j.jtho.2018.01.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 01/17/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Nicolas Girard
- University of Lyon, University Claude Bernard Lyon 1, Lyon, France; Thorax Institute Curie-Montsouris, Institut Curie, Paris, France.
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