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The Journal of Thoracic and... Jan 2016
Topics: Female; Humans; Male; Thymectomy; Thymoma; Thymus Neoplasms
PubMed: 26403868
DOI: 10.1016/j.jtcvs.2015.08.037 -
The Journal of Thoracic and... Aug 2020
Topics: Humans; Myasthenia Gravis; Thymectomy; Thymoma; Thymus Neoplasms
PubMed: 31761347
DOI: 10.1016/j.jtcvs.2019.10.015 -
The Journal of Thoracic and... Jul 2017Thymectomy is part of the therapeutic armamentarium for myasthenia gravis (MG). During the past 80 years, multiple observational studies have shown that thymectomy can...
Thymectomy is part of the therapeutic armamentarium for myasthenia gravis (MG). During the past 80 years, multiple observational studies have shown that thymectomy can potentially fasten stabilization of the disease, reduce the need for corticosteroids, and in some patients lead to complete remission. The benefit from thymectomy in MG is supported by propensity score analysis. A randomized control trial looking at the role of thymectomy in nonthymomatous MG patients was recently completed, but the results are not yet available. The approach and extent of thymectomy remain a topic of intense discussion, particularly with the development of minimally invasive surgery. Although the presence of extracapsular thymic tissue is frequent and well described, the accessibility of these ectopic thymic foci as well as their function and impact on outcome after surgery have been unclear, leading to divergent views between proponents of a maximal cervicomediastinal thymectomy with en bloc resection of all fatty tissue between the thyroid grand and the diaphragm and those of a less extensive approach. In the future, better definition of the type of thymectomy will be important, particularly if prospective studies and randomized trials are performed to compare different surgical approaches. One possibility would be to reserve the term "extended thymectomy" to resection of the thymus with the anterior mediastinal fat between both pleura, the pericardium and diaphragm. More extensive surgery should be specified when it encompasses sites such as the right and left pericardiophrenic angles, the aortopulmonary window, the aortocaval groove and retroinnominate space, and the perithyroid area.
Topics: Humans; Myasthenia Gravis; Thymectomy
PubMed: 26880052
DOI: 10.1016/j.jtcvs.2016.01.006 -
Interactive Cardiovascular and Thoracic... Aug 2022The aim of this study was to determine the prevalence of nontherapeutic thymectomy and define a clinical standard to reduce it.
OBJECTIVES
The aim of this study was to determine the prevalence of nontherapeutic thymectomy and define a clinical standard to reduce it.
METHODS
From 2016 to 2020, consecutive patients who underwent thymectomy were retrospectively reviewed. Univariable and multivariable analyses were used to identify the correlation factors of nontherapeutic thymectomy. A receiver operating characteristic curve was analysed to assess the cut-off threshold of factors correlated with nontherapeutic thymectomy.
RESULTS
A total of 1039 patients were included in this study. Overall, 78.4% (n = 814) of thymectomies were therapeutic and 21.6% (n = 225) were nontherapeutic. Thymoma (57.9%, n = 602) was the most common diagnosis in therapeutic thymectomy. Among those of nontherapeutic thymectomy, thymic cysts (11.9%, n = 124) were the most common lesion. Compared with therapeutic thymectomy, patients with nontherapeutic thymectomy were more likely to be younger (median age 50.1 vs 55.6 years, P < 0.001) with a smaller precontrast and postcontrast computed tomography (CT) value (P < 0.001, P < 0.001), as well as ΔCT value [10.7 vs 23.5 Hounsfield units (HU), P < 0.001]. Multivariable analysis indicated that only age and ΔCT value were significantly different between therapeutic and nontherapeutic thymectomy groups. Receiver operating characteristic curve analysis showed that cut-off values of age and ΔCT value were 44 years and 6 HU, respectively. Patients with age ≤44 years and a ΔCT value ≤6 HU had a 95% probability of nontherapeutic thymectomy.
CONCLUSIONS
Surgeons should be cautious to perform thymectomy for patients with age ≤44 years and ΔCT value ≤6 HU. This simple clinical standard is helpful to reduce the rate of nontherapeutic thymectomy.
Topics: Adult; Humans; Mediastinal Cyst; Middle Aged; Retrospective Studies; Thymectomy; Thymoma; Thymus Neoplasms
PubMed: 35579357
DOI: 10.1093/icvts/ivac132 -
The Journal of Thoracic and... Jul 2017
Topics: Humans; Male; Myasthenia Gravis; Thymectomy
PubMed: 28365015
DOI: 10.1016/j.jtcvs.2017.02.048 -
Interactive Cardiovascular and Thoracic... Mar 2014A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was if thymectomy in non-thymomatous myasthenia gravis... (Review)
Review
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was if thymectomy in non-thymomatous myasthenia gravis was of any benefit? Overall, 137 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The outcome variables were similar in all of the papers, including complete stable remission (CSR), pharmacological remission, age at presentation, gender, duration of symptoms, preoperative classification (Oosterhius, Osserman or myasthenia gravis Foundation of America (MGFA)), thymic pathology, preoperative medications (steroids, immunosuppressants), mortality and morbidity. We conclude that evidence-based reviews have shown that relative rates of thymectomy patients compared with non-thymectomy patients attaining outcome indicate that the former group of patients is more likely to achieve medication-free remission, become asymptomatic and clinically improve (54%, P < 0.01), particularly patients with severe and generalized symptoms (P = 0.007). Patients with generalized myasthenia gravis showed 11% stronger association with favourable outcomes after thymectomy. Some studies show early remission rates (RRs), as early as 6 months post-thymectomy, of 44%. Overall, the reported remission rate for non-thymomatous myasthenia gravis is between 38 and 72% up to 10 years of follow-up. Among these patients, those with thymic hyperplasia show the best complete stable remission rates (42%, P < 0.04) in the majority of studies. Age showed variability across the studies and the cut-off was also different among them. Overall age < 45 years showed a higher probability of achieving complete stable remission during follow-up (81% benefit rate (BR), P < 0.02). Pharmacological improvement is reported between 6 and 42%. However, the certainty of these benefits has not been established due to factors such as the confounding differences between myasthenia gravis patients receiving and not receiving thymectomy, the non-randomized nature of class II studies and the lack of Class I evidence to support its use. There is currently a randomized trial ongoing looking at thymectomy by sternotomy vs controls and the results are eagerly awaited.
Topics: Adult; Benchmarking; Evidence-Based Medicine; Female; Humans; Male; Myasthenia Gravis; Patient Selection; Remission Induction; Risk Assessment; Risk Factors; Thymectomy; Time Factors; Treatment Outcome
PubMed: 24351507
DOI: 10.1093/icvts/ivt510 -
Journal of Surgical Education 2020Mediastinal mass resection and thymectomy are complex and related operations that are core components of competency for a general thoracic surgeon and an important...
OBJECTIVES
Mediastinal mass resection and thymectomy are complex and related operations that are core components of competency for a general thoracic surgeon and an important learning objective for thoracic surgery trainees. This study aimed to design a combined competency assessment instrument for mediastinal mass resection and thymectomy.
DESIGN
A comprehensive competency assessment instrument was designed by a process of logical analysis by 3 expert thoracic surgeons with an interest in mediastinal surgery. The instrument was then assessed and refined using a modified Delphi process.
SETTING
The Delphi questionnaire was distributed to all members of the Canadian Association of Thoracic Surgeons in 2018 to 2019.
PARTICIPANTS
The first round of the Delphi review was completed by 58 respondents (response rate 43.9%). Respondents represented all Canadian provinces with a wide range of clinical experience and a high rate of involvement in resident education.
RESULTS
A first draft of the competency assessment instrument included 42 steps in 6 categories. A total of 3 rounds of Delphi review were performed. Cronbach's alpha for the final round was 0.83. Ultimately, 29 items were retained from the original instrument and two modified and three new items were added. The final instrument has 34 steps in 5 categories.
CONCLUSIONS
A nationwide consensus was established on the key components of assessing competence to perform mediastinal mass resection and thymectomy. The resulting instrument could be used to guide competency based assessments of thoracic surgeons and trainees.
Topics: Canada; Clinical Competence; Delphi Technique; Humans; Surgeons; Thymectomy
PubMed: 32571689
DOI: 10.1016/j.jsurg.2020.06.004 -
Neurosciences (Riyadh, Saudi Arabia) Jan 2021To evaluate the prevalence and the factors associated with recurrence of myasthenia gravis following thymectomy.
OBJECTIVES
To evaluate the prevalence and the factors associated with recurrence of myasthenia gravis following thymectomy.
METHODS
Six electronic databases which reported on recurrence of myasthenia gravis following thymectomy and/or its risk factors from 1985 to 2018 were searched. Summary prevalence and risk values obtained based on the random effect models were reported.
RESULTS
Seventy (70) papers containing 7,287 individuals with myasthenia gravis who received thymectomy as part of their management were retrieved. The patients had a mean follow-up of 4.65 years post-thymectomy. The prevalence of myasthenia gravis recurrence post-thymectomy was 18.0% (95% CI 14.7-22.0%; 1865/7287). Evident heterogeneity was observed (I=93.6%; <0.001). Recurrence rate was insignificantly higher in male compared with female patients (31.3 vs. 23.8%; =0.104). Pooled recurrence rates for thymomatous (33.3%) was higher than the rate among non-thymomatous (20.8%) myasthenia gravis patients (Q=4.19, =0.041). Risk factors for recurrence include older age, male sex, disease severity, having thymomatous myasthenia gravis, longer duration of the myasthenia gravis before surgery, and having an ectopic thymic tissue.
CONCLUSION
A fifth of individuals with myasthenia gravis experience recurrence after thymectomy. Closer monitoring should be given to at-risk patients and further studies are needed to understand interventions to address these risks.
Topics: Databases, Factual; Humans; Myasthenia Gravis; Prevalence; Recurrence; Risk Factors; Thymectomy; Time Factors; Treatment Outcome
PubMed: 33530037
DOI: 10.17712/nsj.2021.1.20190041 -
PloS One 2023High-dose prednisone use, lasting several months or longer, is the primary initial therapy for myasthenia gravis (MG). Upwards of a third of patients do not respond to... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
High-dose prednisone use, lasting several months or longer, is the primary initial therapy for myasthenia gravis (MG). Upwards of a third of patients do not respond to treatment. Currently no biomarkers can predict clinical responsiveness to corticosteroid treatment. We conducted a discovery-based study to identify treatment responsive biomarkers in MG using sera obtained at study entry to the thymectomy clinical trial (MGTX), an NIH-sponsored randomized, controlled study of thymectomy plus prednisone versus prednisone alone.
METHODS
We applied ultra-performance liquid chromatography coupled with electro-spray quadrupole time of flight mass spectrometry to obtain comparative serum metabolomic and lipidomic profiles at study entry to correlate with treatment response at 6 months. Treatment response was assessed using validated outcome measures of minimal manifestation status (MMS), MG-Activities of Daily Living (MG-ADL), Quantitative MG (QMG) score, or a strictly defined composite measure of response.
RESULTS
Increased serum levels of phospholipids were associated with treatment response as assessed by QMG, MMS, and the Responders classification, but all measures showed limited overlap in metabolomic profiles, in particular the MG-ADL. A panel including histidine, free fatty acid (13:0), γ-cholestenol and guanosine was highly predictive of the strictly defined treatment response measure. The AUC in Responders' prediction for these markers was 0.90 irrespective of gender, age, thymectomy or baseline prednisone use. Pathway analysis suggests that xenobiotic metabolism could play a major role in treatment resistance. There was no association with outcome and gender, age, thymectomy or baseline prednisone use.
INTERPRETATION
We have defined a metabolomic and lipidomic profile that can now undergo validation as a treatment predictive marker for MG patients undergoing corticosteroid therapy. Metabolomic profiles of outcome measures had limited overlap consistent with their assessing distinct aspects of treatment response and supporting unique biological underpinning for each outcome measure. Interindividual variation in prednisone metabolism may be a determinate of how well patients respond to treatment.
Topics: Humans; Prednisone; Activities of Daily Living; Glucocorticoids; Myasthenia Gravis; Combined Modality Therapy; Thymectomy; Treatment Outcome
PubMed: 37816000
DOI: 10.1371/journal.pone.0287654 -
Neurology India 2022Thymectomy, combined with corticosteroids, immunosuppressive agents, and cholinesterase inhibitors, has been accepted as the standard treatment for myasthenia gravis...
BACKGROUND
Thymectomy, combined with corticosteroids, immunosuppressive agents, and cholinesterase inhibitors, has been accepted as the standard treatment for myasthenia gravis (MG) patients. Data on the effect of thymectomy on occurrence of myasthenic crisis are few.
OBJECTIVES
To assess the long-term impact of thymectomy in patients with generalized Myasthenia gravis (GMG) in terms of occurrence of myasthenia crisis and quality of life.
METHODS
A retrospective analysis of 274 clinical records of patients diagnosed with myasthenia gravis (MG) in Nizam's institute of medical sciences (NIMS), a tertiary level teaching hospital between January 2000 and December 2015 was done. Severity of the disease was assessed using Myasthenia Gravis Foundation of America (MGFA) classification and quantitative myasthenia gravis (QMG) score. Myasthenia crisis was diagnosed in our patients when they required ventilator assistance due to respiratory failure caused by muscle weakness (MGFA class V). Quality of life (QoL) was assessed.
RESULTS
Of 230 cases included in the final analysis, 108 (46.9%) underwent thymectomy. Posttreatment crisis occurred in 53.3% of the nonthymectomy subjects, and 25.9% of thymectomy group (P < 0.001). In multivariate logistic regression analysis, after controlling for the effect of gender, age at diagnosis and grade of the disease, the odds ratio of myasthenic crisis in people with thymectomy was 0.186.(95% CI 0.087 to 0.387, P = 0.001). No statistically significant differences were observed in quality of life scores between thymectomy and nonthymectomy groups, either before (P = 0.86) or after surgery (P = 0.939).
CONCLUSIONS
The odds of myasthenia crisis was lesser in people, who underwent thymectomy even after controlling for MGFA grade and other potential confounders but no significant differences in quality of life were found with thymectomy.
Topics: Humans; Quality of Life; Retrospective Studies; Treatment Outcome; Thymectomy; Incidence; Myasthenia Gravis
PubMed: 36537428
DOI: 10.4103/0028-3886.364067