Thymectomy Research Articles

P39.05 Outcomes of Videothoracoscopic Thymectomy for Treatment Large-Sized Thymomas

Video-assisted thoracoscopy (VATS) is widely used in the treatment of mediastinal tumors. However, thymectomy (TE) performed through a median sternotomy remains the gold standard for treating large thymomas. The aim of this study is to improve the outcomes of treatment for large thymomas using VATS TE

Thymectomy in Pemphigus Foliaceous: A 30-Year Observation

Myasthenia gravis is an archetypal human autoimmune disease. Thymectomy is proven effective by controlled clinical trials, and is commonly part of the immunotherapeutic approach when myasthenia creates generalized weakness. Pemphigus foliaceus is also autoimmune but treated medically; and thymectomy is not part of therapy unless thymoma is discovered. Autoimmune mechanisms, age distribution, and response to therapy in autoimmune disorders are likely to be different with thymoma. The concurrence of generalized myasthenia with disfiguring pemphigus foliaceus in one young patient but without thymoma offered a natural experiment to assess immunologic antibody responsiveness postoperatively, and observe more than a quarter of a century of clinical remission of both following total thymectomy surgery. J Med Cases. 2021;12(2):41-44 doi: https://doi.org/10.14740/jmc3585

Evaluating the Use of Thymectomy in Myasthenia Gravis

The benefits of thymectomy for the treatment of myasthenia gravis have been controversial; many trials have compared thymectomy plus prednisone or

Síndrome de Good: associação entre timoma, hipogamaglobulinemia, aplasia pura da série vermelha e parvovírus B19 – um estudo de caso

Objetivo: Relatar o caso de um paciente acometido por Síndrome de Good, detalhando o quadro clínico inicial, evolução da doença, tratamento realizado, bem como os exames laboratoriais e de imagens responsáveis pelo seu diagnóstico. Relato do Caso: Paciente do sexo feminino, 52 anos, com timoma diagnosticado por exame de imagem após quadros infecciosos recorrentes e sucessivas transfusões de concentrados de hemácias por repetidas anemias. Tratada cirurgicamente com timectomia, apresentou ao exame histopatológico um timoma medular. Obteve resolução temporária do quadro anêmico por cerca de um ano. Desenvolveu novamente quadros de anemia e infecção, sendo aventada alguma causa de imunodeficiência subjacente, com investigação e diagnóstico laboratorial de hipogamaglobulinemia e infecção oportunista por parvovírus B19. Tratada com sucesso por meio de infusões de imunoglobulina humana. Considerações Finais: Poucos estudos debatem acerca da Síndrome de Good, dificultando a criação de medidas terapêuticas e embasamento teórico acerca do assunto.

Comparison of Thoracoscopic Versus Open Thymectomy in Treatment of Large Thymoma During Perioperative Period

Comparison of Thoracoscopic Versus Open Thymectomy in Treatment of Large Thymoma During Perioperative Period

High Frequency of Tc22 and Th22 Cells in Myasthenia Gravis Patients and Their Significant Reduction after Thymectomy

Objectives: Myasthenia gravis (MG) is an autoimmune disease accompanied by a thymic pathology and in most patients thymectomy (TE) is used as the therapeutic approach. Both B and T cells play an important role in MG pathogenesis. Methods: Twelve pre- and post-TE MG patients and 12 healthy controls (HCs) were enrolled. The mean percentages of Th22 and Tc22 cells were evaluated in MG patients (before and 6 months after TE) and HCs. Results: The mean percentage of Tc22 cells in pre-TE patients was significantly higher than in HCs (p < 0.05), and after TE Tc22 cells significantly decreased compared to pre-TE (p < 0.05). The frequency of Th22 cells in pre-TE MG patients was not significantly different from HCs, but after TE Th22 cells were significantly decreased compared to pre-TE (p < 0.05). Conclusion: Our findings suggest a possible role of Th22 and Tc22 in MG pathogenesis.

Effects of different anesthetic methods on postoperative acute pain in patients with myasthenia gravis undergoing video-assisted thoracoscopic thymectomy

Objective To evaluate the effects of different anesthetic methods on postoperative acute pain in patients with myasthenia gravis undergoing video-assisted thoracoscopic thymectomy. Methods Fifty-four patients of both sexes, aged 18-64 yr, with body mass index of 20-28 kg/m2, of American Society of Anesthesiologists physical statusⅠor Ⅱ, scheduled for elective video-assisted thoracoscopic thymectomy, were allocated into 2 groups (n=27 each) using a random number table method: sevoflurane-based anesthesia group (group S) and propofol-based anesthesia group (group P). After routine anesthesia induction in two groups, anesthesia was maintained by inhaling sevoflurane and target-controlled infusion of remifentanil in group S and by target-controlled infusion of propofol and remifentanil in group P. Heart rate and mean arterial pressure were recorded before operation and at 5 and 10 min after extubation (T1, 2). The intensity of pain at T2 and visual analog scale (VAS) score and consumption of morphine at 1, 2, 4, 24 and 48 h after operation (T3-7) were recorded.The pressing times of analgesia pump, requirement for rescue analgesia and development of nausea and vomiting were recorded at T7. Results There were no significant differences in heart rate or mean arterial pressure at each time point between two groups (P>0.05). Compared with group S, the intensity of pain was significantly alleviated at T2, and VAS scores and morphine consumption were decreased at T3, 4 in group P (P 0.05). Conclusion Propofol-based anesthesia provides better efficacy in alleviating postoperative acute pain in patients with myasthenia gravis undergoing video-assisted thoracoscopic thymectomy. Key words: Propofol; Anesthetics, inhalation; Pain postoperative; Myasthenia gravis; Thoracoscopy; Thymectomy

Clinical differences between early-and late-onset myasthenia

Objective To explore the clinical differences between patients with early-onset myasthenia gravis(EOMG)and those with late-onset myasthenia gravis(LOMG). Methods This was a retrospective study enrolling 157 MG patients.Based on the age of onset, patients were divided into the EOMG group(n=85)and the LOMG group(n=72). The groups were compared on clinical characteristics, including clinical manifestations, MG classification, electrophysiological findings on repetitive nerve stimulation(RNS), single fiber electromyography(SFEMG), levels of antibody against acetylcholine receptors(Ach-R Ab), antibody to muscle-specific kinase(MuSK Ab), titin antibody(Titin Ab), ryanodine receptor antibody(RyR Ab), thyroid function, thymectomy, thymus pathology and responses to treatment. Results The mean ages of onset were markedly different〔(40.9±9.7)years vs.(62.0±12.2)years, P 0.05). Moreover, patients in the EOMG group were more likely to have abnormal thyroid function and higher percentages of receiving steroids, tacrolimus, plasma exchange therapy, and thymectomy(P<0.05). Conclusions The clinical profiles of LOMG are different from those of EOMG in clinical manifestations, thyroid function, thymectomy frequency, striational antibody levels and disease-modifying drug options. Key words: Myasthenia gravis; Recepors, cholinergic

Correlation of blood concentration with efficacy and safety of tacrolimus in treatment of myasthenia gravis patients

Objective To investigate the relationship of blood concentration of tacrolimus with efficacy and safety in treatment of patients with myasthenia gravis. Methods The clinical data of 74 patients with myasthenia gravis admitted in our hospital from January 2013 to December 2015 were analyzed retrospectively. The blood concentrations of tacrolimus were determined by chemiluminescence microparticle immunoassay. Treatment effects were evaluated with clinical relative scoring in China. Results There were 41 men and 33 women in 74 patients with the mean age of (56.7±15.8) years. According to the Osserman classification, there were 7 cases of type Ⅰ, 18 cases of type Ⅱb, 27 cases of type Ⅱa, 5 cases of type Ⅲ and 17 cases of type Ⅳ. Forty seven patients underwent thymectomy, including 9 cases of thymoma and 38 cases of hyperplasia. Patients were followed up for (28.1±14.5)days, and the effective rate was 74 %(55/74). There was no significant correlation between tacrolimus blood concentration and clinical efficacy. The incidence of adverse reaction of tacrolimus was 22%(16/74), and the incidence of adverse reactions increased with the increase of blood concentration. Conclusion Tacrolimus is effective in treatment of myasthenia gravis. The correlation of blood concentration of tacrolimus with the clinical efficacy needs to be further studied, but certainly, the monitoring of blood concentration can reduce the incidence of adverse reactions. Key words: Myasthenia gravis; Tacrolimus; Drug monitoring; Adverse drug reaction

Increased Proportion of Tc17 and Th17 Cells and Their Significant Reduction after Thymectomy May Be Related to Disease Progression in Myasthenia Gravis

Objective: Myasthenia gravis (MG) is an autoimmune disease mediated by autoantibodies against the neuromuscular junction. The thymus has an important role in the pathogenesis of MG because most patients have thymic pathology, and thymectomy (TE) can reduce the severity of the disease. Methods: In this study, the frequency of Th17 and Tc17 cells was studied in 12 MG patients (pre-TE and 6 months post-TE) and in 12 healthy controls (HC). Results: The frequency of Tc17 cells in the pre-TE patients was significantly higher than in the HC (p < 0.05), and after TE, these cells had significantly decreased compared to before TE (p < 0.05). The frequency of Th17 cells in pre-TE patients was significantly higher than in the HC (p < 0.05), and after TE, these cells had significantly decreased compared to before TE (p < 0.05). Conclusion: Our findings indicated a possible role of Tc17 and Th17 in MG pathogenesis.

Primary renal angiosarcoma: case report and review of world literature.

This article focuses on a rare case of primary renal angiosarcoma in a 56-year-old man with a previous clinical history of stage III Hodgkin's lymphoma treated with supra- and subdiaphragmatic radiotherapy, splenectomy in association with vincristine-based chemotherapy and thermochemotherapy, and subsequent thymectomy. The patient was referred to the department of urology from the department of cardiology, where he had been seen for right coronary stenosis after the incidental finding on an abdominal scan of a large left renal mass. There was no family history of renal cancer. Diagnosis was high-grade angiosarcoma, extensively necrotic and hemorrhagic, involving the renal parenchyma and perirenal soft tissue. Taking into account tumor histology, grade, size and site as well as patient's age and general condition, a therapeutic program was planned comprising surgery followed by chemotherapy (epirubicin 60 mg/m² and ifosfamide 3000 mg/m²). Adjuvant radiotherapy, normally delivered to the site of surgery, was not considered necessary. Unfortunately the patient died 4 months after surgery, before chemotherapy was started. Our paper highlights the extreme rarity and aggressiveness of renal sarcoma, its poor prognosis, and the fact that there is no one, accepted approach to its treatment.

A Simple Clinical Predictive Score for Postoperative Myasthenic Crisis

A recent study has shown that thymectomy improves outcomes over a 3-year period in patients with nonthymomatous myasthenia gravis (MG). However,

Myastenia gravis s protilátkami proti MuSK

Myastenia gravis je autoimunitni onemocněni s tvorbou protilatek proti postsynapticke casti nervosvalove plotenky. Při průkazu protilatek proti acetylcholinovým receptorům se jedna o seropozitivni myastenia gravis a pokud tyto protilatky nejsou přitomny, pak je to seronegativni myastenia gravis. U 35 % (0–49 %) seronegativnich forem byla prokazana protilatka proti svalove specificke tyrozin-kinaze (MuSK). Tyto anti-MuSK myasthenia gravis se vyznacuji převahou postiženi žen, casnějsich vznikem, charakteristickým klinickým nalezem, horsi a nekonstantni reakci na lecbu inhibitory cholinesterazy. Z neurofyziologických vysetřeni je důležite vysetřit repetitivni stimulaci i proximalni svaly (m. trapezius, m. deltoides) a mimicke svaly (m. nasalis, m. orbicularis oculi). Při vysetřeni SF EMG (single-fiber EMG) je podstatně vyssi pozitivita při vysetřeni m. frontalis ci m. orbicularis oculi. Neni indikovana thymektomie. Ucinna je imunoterapie – podani imunoglobulinů, plazmafereza, kortikoidy v kombinaci s dalsimi imunosupresivy. Myastenia gravis s anti-MuSK protilatkami se vyznacuje nestabilnim průběhem, větsi frekvenci myastenických krizi a větsi terapeutickou narocnosti.

Is thymomectomy sufficient for non-myasthenic early stage thymoma patients? A retrospective, single center experience.

BackgroundThymic complete resection is considered the standard treatment for all thymic tumors; however, the ideal resection for non‐myasthenic early stage thymic tumors has not yet been determined. We conducted a retrospective study to examine this unique scenario.MethodsWe retrospectively analyzed the data of 118 early stage thymoma patients who underwent thymectomy (TM) or thymomectomy (TMM) with curative intent between January 2003 and December 2013 at our institution. Patients with myasthenia, thymic carcinomas, tumors with undetermined histology, and more advanced stage thymoma patients were excluded. We compared overall survival (OS) and disease‐free survival (DFS) according to the extent of thymic resection, tumor staging, and size.ResultsOne hundred and eighteen patients were staged as early thymoma. TM was performed in 43 (35.6%) patients and TMM in 75 (64.4%). Forty‐nine (65.3%) patients with a tumor ≤ 3 cm underwent TMM, and 9 (20.9%) TM. Twenty‐six (34.7%) patients with a tumor > 3 cm underwent TMM, and 34 (79.1%) TM. Seventy‐four patients were categorized as stage I: 57 (76%) underwent TMM and 17 (39.5%) TM. Forty‐four patients were categorized as stage II: 18 (24%) underwent TMM and 26 (60.5%) TM. There was no statistically significant difference in recurrence between the groups (P = 0.250).ConclusionNo difference in the rate of recurrence was observed in early stage non‐myasthenic patients following thymic resection and Masaoka–Koga staging. However, TM is considered a better option for early stage thymoma patients with tumors > 3 cm.

Effects of high-flow nasal catheter and noninvasive mechanical ventilation on respiratory failure after thymectomy in patients with myasthenia gravis

Objective To observe the reintubation rate of acute respiratory failure after thymectomy in patients with myasthenia gravis (MG) by two kinds of oxygen therapy (HFNC) and noninvasive mechanical ventilation. Methods Sixty-seven patients were treated with HFNC (observation group), and 80 patients were treated with noninvasive mechanical ventilation(control group). The baseline of the two groups was comparable. Results The rate of re-intubation and ICU stay time was 18.42% (14/76), (5.35±1.95) din control group and 7.50% (6/80), (3.42±1.61) d in observation group. The difference was statistically significant (χ2=4.159, P=0.041; t=5.135, P=0.025).The respiratory rate、SpO2, PaO2, PaCO2 was (28.27±4.32)beats/min, 0.9107±0.0130, (86.43±5.66)mmHg, (57.44±5.73) mmHg in observation group and (24.84±2.48) beats/min, 0.8867±0.0309, (81.31±2.85) mmHg, (65.38±10.00) mmHg in control group. The difference was statistically significant (t=5.189-58.502, all P<0.01 or<0.05). Conclusion HFNC can improve the respiratory function of patients with myasthenia gravis after thymectomy, reduce the incidence of respiratory failure and re-intubation rate. Key words: Myasthenia gravis; High-flow nasal catheter oxygen inhalation; Noninvasive mechanical ventilation; Reintubation rate; Myasthenia gravis

Comparison between single-port video-assisted thoracoscopic surgery and second intercostal trans-sternal incision in thymectomy for myasthenia gravis

Comparison between single-port video-assisted thoracoscopic surgery and second intercostal trans-sternal incision in thymectomy for myasthenia gravis

Comparison of the effects of thoracotomy and laparoscopic thymectomy on immune function and inflammatory factors in patients with myasthenia gravis

Objective To compare the effect of laparoscopic thymectomy on immune function and inflammatory factors in patients with myasthenia gravis. Methods 80 patients with myasthenia gravis treated by thymectomy were selected, and they were divided into observation group and control group according to the random number method, each group in 40cases. The observation group was treated with video assisted thoracoscopic surgery, the control group was treated by thoracotomy. All the patients were followed up for outpatient visits in 3 months. The incidences of myasthenia gravis crisis in the two groups were compared and the ratio postoperative humoral immunoglobulin levels and inflammation related factor changes were observed. Results The operation time of the observation group [(118.6±11.3)min] was shorter than (138.5±13.8)min of the control group (t=7.056, P<0.05). The amount of bleeding of the observation group [(96.6±3.8)mL] was less than (125.5±5.6)mL of the control group (t=27.008, P<0.05). The hospitalization time of the observation group [(7.2±0.3)d] was shorter than (10.8±1.1)d of the control group (t=19.969, P<0.05). The incidence rate of myasthenia gravis crisis in the observation group was significantly lower than that in the control group (1 patient vs 9 cases, χ2=5.600, P=0.018). The levels of IgM, IgG and IgA in the observation group were (1.65±0.03)mg/L, (9.55±0.12)mg/L, (3.99±0.20)mg/L respectively, which were higher than (1.31±0.02)mg/L, (8.82±0.10)mg/L, (1.81±0.13)mg/L in the control group(t=59.640, 29.557, 57.800, all P<0.05). The IL-6, TNF-α, IL-1, hs-CRP levels in the observation group were (34.5±6.1)ng/mL, (12±0.2)ng/mL, (0.60±0.1)g/mL, (10.3±1.0)mg/L respectively, which were lower than (153±14.1)ng/mL, (18.1±0.5)ng/mL, (0.92±0.2)g/mL, (31.3±2.0)mg/L in the control group (t=48.784, 71.641, 9.051, 59.397, all P<0.05). Conclusion Laparoscopic thymectomy for myasthenia gravis has short operative time and less bleeding. It has little effect on the humoral immune function of the patients and can significantly reduce the inflammatory response and promote the recovery of the patients. Key words: Thoracoscopy; Thymectomy; Myasthenia gravis; Immune function; Inflammatory factors

Relationship between neuromuscular block induced by cisatracurium for tracheal intubation during anesthesia induction and types of myasthenia gravis

Objective To determine the relationship between neuromuscular block induced by cisatracurium for tracheal intubation during anesthesia induction and types of myasthenia gravis(MG). Methods Sixty-five patients of both sexes with MG, aged 20-75 yr, weighing 53-92 kg, with body height of 155-185 cm, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, undergoing elective video-assisted thoracoscopic thymectomy, were enrolled in the study.Among the 65 patients, there were 8 patients with ocular MG(typeⅠ), 19 patients with mild generalized MG(typeⅡa), 33 patients with subacute generalized MG(typeⅡb), 2 patients with acute MG(type Ⅲ) and 3 patients with late severe MG(type Ⅳ). Neuromuscular monitoring was initiated when the patients lost consciousness after induction of anesthesia.Cisatracurium was administrated with the initial dose of 0.05 mg/kg, and if T1 depression was less than 95% within 6 min, cisatracurium 0.015 mg/kg was intravenously injected until T1 depression was more than 95%.The patients were then tracheally intubated.The amount of cisatracurium consumed for intubation, onset time(from the beginning of cisatracurium injection to T1 depression >95%) and recovery time(recovery of T4/T1 to 25% of control height) of neuromuscular block were recorded.T1 depression > 95% within 6 min after administration of 1-fold ED95 cistracurium was defined as sensitivity to muscle relaxants.The requirement for cistracurium > 1-fold ED95 when T1 depression > 95% was defined as insensitivity to muscle relaxants.The proportion of sensitivity/insensitivity was calculated. Results There was no significant difference in the amount of cisatracurium consumed for intubation and onset time and recovery time of neuromuscular block between patients with typeⅠ and those with typeⅡa(P>0.05). Compared with patients with typeⅠ and type Ⅱa, the amount of cisatracurium consumed for intubation was significantly decreased, the proportion of sensitivity/insensitivity was increased, the onset time was shortened, and the recovery time was prolonged in patients with typeⅡb(P<0.05). Conclusion With the severity of MG, the consumption of cisatracurium is gradually decreased when used for tracheal intubation during anesthesia induction, and the sensitivity is gradually increased in the patients with MG. Key words: Androstanes; Myasthenia gravis; Intubation, intratracheal; Dose-response relationship, drug

The clinical study of non-drainage tube after single-port video-assisted thoracoscopic thymectomy

Objective To assess the feasibility of non-drainage tube after single-port video-assisted thoracoscopic thymectomy in patients with myasthenia gravis (MG). Methods According to whether the thoracic drainage tube was placed after thymectomy, the patients with MG were divided into control group (38 cases) and experimental group (25 cases). The thoracic drainage tube was inserted between the ribs in the control group, and not placed in the experimental group. The clinical data including duration and score of post-operative chest pain and post-operative hospital stay were recorded and analyzed by independent samples t test. Results There was statistically significant difference between the two groups in the duration of post-operative chest pain [(32.7±10.2) h vs. (14.2±2.9) h, P=0.000], the score of post-operative chest pain [(2-6) 3.8 scores vs. (1-5) 2.4 scores, P=0.000], duration of post-operative hospital stay [(5.6±1.0) days vs. (4.9±0.7) days, P=0.016], post-operative chest drainage time [(23.6±8.7) h vs. (0) d, P=0.000] and post-operative thoracic drainage volume [(60.8±9.5) ml vs. (0) ml, P=0.000]. At 3rd day after operation, the results of the chest CT examination showed 38 cases in the control group had a small amount of pleural effusion (<50 ml) and no pneumothorax, and 25 cases in the experimental group had a small amount of pleural effusion (<150 ml) and 2 cases had a small amount of pneumothorax (<10%). At first month after operation, the results of the chest CT examination showed that there were no significant pleural effusion (<30 ml) and no pneumothorax in the two groups. Thoracentesis was not needed in the two groups after operation. Conclusion It is safe and feasible that thoracic drainage tube is not placed after single-port video-assisted thoracoscopic thymectomy in patients with MG. Key words: Myasthenia gravis; Video-assisted thoracoscopic surgery; Thymectomy; Draining tube

Correlation of features of chest computed tomographic scans with histologic subtypes of thymoma according to the World Health Organisation classification in asymptomatic patients

Objective To assess the computed tomographic (CT) features of various subtypes of thymic epithelial neoplasms on the basis of the World Health Organization (WHO) classification especially in asymptomatic patients, and provide reference for the clinical treatment strategy of asymptomatic patients with thymoma. Methods We reviewed preoperative CT imaging and postoperative pathological results for 61 thymoma patients who had undergone thymectomy, and assessed the differences in CT features between the low-risk thymoma (type A, B) and the high-risk thymoma (type B1, B2, B3 and C). Results There were no significant differences between low-risk thymoma and high-risk thymoma in the gender (P=0.884), age (P=0.579), maximum diameter (P=0.851), mean diameter(P=0.904) or shape of tumor(P=0.437). However, there were significant differences between the two groups of thymoma in the average CT value on contrast-enhanced images (P=0.001), boundary (P=0.000), homogeneity (P=0.029), calcification (P=0.019), cystic degeneration or necrosis (P=0.000) and involvement of adjacent tissues (P=0.000). The receiver operating characteristic (ROC) curve analysis revealed an average CT value of 68.31 HU on contrast-enhanced images could produce 73.5% sensitivity and 77.8% specificity in determining low risk subtypes, and the area under the curve was 0.76 when the CT value reached this best cutoff point. Conclusion Some features of CT have a certain value in distinguishing low-risk thymoma and high-risk thymoma. A combined prediction using these variables will provide a reference for appropriate therapeutic strategies of TETs patients, especially the asymptomatic ones. Key words: Thymoma; CT imaging feature; World Health Organisation classification