Minimally invasive surgery in the management of resectable thymoma: a retrospective analysis from the National Cancer Database

BackgroundThymomas are relatively uncommon tumors traditionally resected via open sternotomy. Despite the appeal of minimally invasive techniques, concerns persist regarding their oncologic efficacy. We hypothesized that minimally-invasive thymectomies for resectable thymomas are oncologically safe when compared to open thymectomy.MethodsThe National Cancer Database (NCDB) was queried for patients with thymoma undergoing resection as the first mode of treatment between 2010–2015. Patient demographics, tumor characteristics and perioperative outcomes were examined for each approach (robotic, thoracoscopic, or open). The primary endpoints were rates of complete (R0) resection and need for adjuvant radiotherapy. Chi-square and Student’s t-test and logistic regression were used for analysis.ResultsA total of 2,312 patients were identified. The utilization of myocardial infarction (MI) surgery increased during the study period (robotic: 7.6% to 19.5%; thoracoscopic: 9.3% to 18.4%, both P<0.0001). Median tumor size was higher and mediastinal invasion was more common in open thymectomies. R0 resection was more common in robotic and adjuvant radiotherapy was less frequent in thoracoscopic thymectomies. In multivariate analysis absence of mediastinal invasion (P<0.0001) was the only prognostic factor for R0 resection. Positive margins, mediastinal invasion (both P<0.0001) and younger age (P<0.01) were the only predictors of the need for adjuvant radiotherapy.ConclusionsUtilization of MI approaches for resectable thymoma has increased from 2010 to 2015. After adjusting for tumor size and mediastinal invasion, minimally-invasive thymectomy was not associated with lower R0 resection rates or increased use of adjuvant radiotherapy. MI thymectomy for resectable thymoma is oncologically equivalent to open thymectomy.     

重症肌无力胸腺切除236例分析

目的　总结重症肌无力 (MG)胸腺切除的经验及治疗效果。　方法　回顾性分析我科 1978年 1月至2 0 0 2年 12月手术治疗 2 36例 MG患者术前、术后的处理 ,危象发生的有关因素及远期疗效。　结果　 2 36例术后发生危象 4 4例 (18.6 % ) ,危象的发生与术前准备、Osserm an临床分型、是否伴胸腺瘤密切相关。全组术后死亡 3例(1.3% ) ,1例死于误吸所致急性呼吸窘迫综合征 (ARDS) ,2例死于危象 ,占危象病例的 4 .5 % ,1、3、5年的有效率分别为 84 .6 %、91.0 %和 89.0 %。　结论　 MG行胸腺切除安全、有效 ,对术后发生危象高危因素的患者延期气管拔管可减少气管切开 ,部分胸骨劈开径路创伤小 ,其远期效果与文献报道其他径路无显著差别。     

电视胸腔镜与开胸手术治疗重症肌无力的疗效比较

目的通过电视胸腔镜手术(VATS)与传统经胸骨正中开胸行胸腺扩大切除术治疗重症肌无力(MG)的临床疗效比较,探讨VATS治疗重症肌无力的临床应用价值。方法将两组病人分别通过VATS和开胸方式行胸腺完整切除和前纵隔脂肪组织廓清术来治疗MG,比较2组在手术时间、术中出血量、术后胸管放置时间、术后住院时间、术后发生重症肌无力危象和疗效等方面的异同。结果VATS组手术时间(93±20.5)min、术中出血量(150±15.4)mL、术后胸管放置(2.5±1.4)d、术后住院(7.5±1.4)d等优于开胸组(122±26.3)min、(210±45.3)mL、(4.0±1.8)d、(9.5±1.7)d,各项指标差异具有统计学意义;VATS组有1例术中诊断为恶性胸腺瘤改为正中开胸手术,开胸组有1例并发重症肌无力危象,两组围术期均无临床死亡。随访6~24月,VATS组和开胸组术后缓解好转率分别为83.3%、80.0%,两组间差异无统计学意义(P>0.05)。结论VATS下行胸腺扩大切除术是安全、可行的,具有创伤小、恢复快和疗效可靠等优点,但对于恶性胸腺瘤合并重症肌无力的患者,建议开胸手术为宜。     

Appearance of systemic lupus erythematosus in patients with myasthenia gravis following thymectomy: two case reports

We report two cases of systemic lupus erythematosus (SLE) in myasthenia gravis (MG) patients who had undergone thymectomy. SLE developed in the patients 3 months or 13 yr after thymectomy, and polyarthritis was the main clinical manifestation of SLE. Both patients fulfilled at least four of the revised criteria for the classification of SLE. In this report, we describe two postthymectomy lupus patients and perform a comparative review of previous cases.     

Dysphagische Störungen bei den Myastheniekranken und ihre Dynamik unter dem Einfluß der chirurgischen Behandlung (Thymektomie)

Zusammenfassung Mittels der Methode der Ballon-Kymographie sind von uns die Pharynx- und Oesophagusfunktionen bei 42 Myastheniekranken vor und in verschiedenen Zeitabschnitten nach der operativen Behandlung (Thymektomie) gründlich studiert worden. Die erhaltenen Angaben zeugen davon, daß bei Myasthenie nicht nur die Funktion der glatten Muskulatur gestört wird, sondern auch die der Oesophagusmuskulatur! Auch die der Muskulatur der distalen Oesophagushälfte, deren Wandmuskulatur aus glatten Muskelfasern besteht.

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Dysphagic disturbances in patients with myasthenia gravis and their dynamics as affected by surgical treatment

Summary We have thoroughly studied the pharyngeal and esophageal functions in 42 patients with myasthenia gravis by means of balloon kymography before and at different intervals after surgical treatment (thymectomy). The data obtained indicate that in myasthenia gravis it is not only the function of the smooth muscles that is impaired, but also that of the esophageal muscles and of the muscles of the distal half of the esophagus made up by smooth muscle fibers.

     

Evaluation of results of thymectomy in myasthenia gravis

Summary The results of thymectomy carried out in 150 cases of myasthenia gravis are discussed. In a group of 123 cases followed for 1 to 5 years after the operation, full remission was observed in 24.4% of cases, significant improvement in 36.6%, slight improvement in 24.4% and no improvement in 8.1%, while deterioration occurred in 1.6% of patients. No correlation was found between the result of the operation and the age and sex of patients, but better results were achieved in those treated surgically rather soon after the onset of symptoms. This correlation was particularly evident in the group with full remissions. The results obtained in the cases without thymic tumors were better than in the cases with tumors. No correlation was noted between the results of the operation and the histological characteristics of the thymus in the group with thymic hyperplasia and in the group with thymic atrophy. The surgically treated group (150 cases), compared with the conservatively treated group (75 cases), showed the superiority of the surgical method (lower rate of death and deterioration, higher rate of improvement and remission).In discussing the indications for surgical treatment the authors emphasize that advances in anaesthesiology in recent years have reduced the risk of operation. It is suggested that the indications for surgical treatment should be expanded and operations should be performed as early as possible after the onset of clinical manifestations without regard to the age and sex of the patient. Operation should not be considered in cases belonging to group 1, 2a (sometimes 2b) only, with duration of the disease over 8–10 years and with little or no progression of the process, if the presence of a thymic tumor has been excluded.This work was supported by NIH., N.I.N.D.S.—Bethesda (agreement 05-002-1).     

Thymic carcinoma with myasthenia gravis: Two case reports

IntroductionMyasthenia gravis (MG) has been reported to correlate with earlier-stage thymoma, and theoretically does not accompany thymic carcinoma. However, we encountered two cases of thymic carcinoma with MG.Presentation of casesCase 1 involved a 54-year-old man who had been diagnosed with MG based on symptoms and detection of anti-acetylcholine receptor antibody (ARAB). Computed tomography (CT) revealed an anterior mediastinal tumor 30 mm in diameter. Prednisolone (PSL) and tacrolimus were administered without surgery at that time. Six years after diagnosis of MG, he was admitted to our hospital and underwent extended thymectomy. Pathological examination revealed type B2-B3 thymoma according to World Health Organization criteria, comprising 80% of the tumor with small cell carcinoma as 20%. Case 2 involved a 51-year-old woman. She had been diagnosed with MG based on eyelid ptosis and detection of ARAB. Ten years after diagnosis of MG, diaphragm elevation was detected on chest X-ray. CT revealed an anterior mediastinal tumor, 47 mm in diameter. We suspected tumor invasion to the right phrenic nerve, right atrium, and superior vena cava. We therefore performed extended thymectomy after preoperative radiotherapy (40 Gy). Pathological examination revealed squamous cell carcinoma.DiscussionMost cases of thymic carcinomas appear to arise de novo, but appearance in thymomas has been described. In both our cases, MG was treated with pharmacotherapy alone without extended thymectomy, and thymic carcinoma was considered to have developed from the thymoma during long-term follow-up.ConclusionThymic carcinoma can accompany MG.     

Immunohistochemical and electron microscopic changes in the endocrine pancreas after thymectomy

Summary This study showed that six months after adult thymectomy blood glucose level in rats was significantly lower compared to that of control animals. The low glucose level found in thymectomized rats was accompanied by structural changes in the pancreatic islets. Electron microscopy and paraldehyde fuchsin (PAF) stained paraffin sections revealed partial degranulation of B-cells.     

Outcome of children with acetylcholine receptor (AChR) antibody positive juvenile myasthenia gravis following thymectomy

Most evidence supporting the benefit of thymectomy in juvenile myasthenia gravis (JMG) is extrapolated from adult studies, with only little data concerning paediatric populations. Here we evaluate the outcome of children with generalized JMG who underwent thymectomy between 1996 and 2010 at 2 tertiary paediatric neurology referral centres in the United Kingdom. Twenty patients (15 female, 5 male), aged 13 months to 15.5 years (median 10.4 years) at disease onset, were identified. Prior to thymectomy, disease severity was graded as IIb in 3, III in 11, and IV in 6 patients according to the Osserman classification. All demonstrated positive anti-acetylcholine receptor (AChR) antibody titres. All patients received pyridostigmine and 14 received additional steroid therapy. Transternal thymectomy was performed at the age of 2.7–16.6 years (median 11.1 years). At the last follow-up (10 months to 10.9 years, median 2.7 years, after thymectomy), the majority of children demonstrated substantial improvement, although some had required additional immune-modulatory therapies. About one third achieved complete remission. The postoperative morbidity was low. No benefit was observed in one patient with thymoma. We conclude that thymectomy should be considered as a treatment option early in the course of generalised AChR antibody-positive JMG.     

经剑突下入路胸腔镜胸腺切除的解剖基础与临床分析

目的 探讨经剑突下入路胸腔镜胸腺切除的解剖基础与临床效果分析。方法 回顾性分析2018年6月-2019年12月蚌埠医学院第一附属医院胸外科收治的33例经剑突下入路胸腔镜胸腺切除患者的临床资料。其中,男15例、女18例,年龄(53.94±13.37)岁。患者术前均诊断为胸腺肿物。术后病理诊断:胸腺瘤12例、胸腺癌1例、畸胎瘤3例、胸腺增生1例、胸腺囊肿16例。观察手术路径的安全性及术野显露情况;记录术后引流量及引流管放置时间、术后住院时间,术后24 h进行疼痛视觉模拟评分(VAS),观察术后并发症发生情况。结果 本组患者均顺利完成胸腔镜胸腺完整切除术,无中转开放手术。其中合并有肺楔形切除2例,合并心包部分切除2例。剑突下入路手术路径安全,暴露良好,术中胸腺周围的解剖结构显示清晰,能完整显示左右两侧心包膈神经、上腔静脉、前方胸骨、后方心包及左侧无名静脉、上方甲状腺下极等胸腺毗邻结构。术后引流量(429.24±308.34)mL;引流时间(3.61±1.56)d;住院时间(5.88±3.43)d;术后24 h疼痛VAS 评分为(1.82±0.68)分。围术期无死亡病例,1例重症肌无力患者术后症状加重,经机械通气、药物等治疗后痊愈;1例患者术后出现低钠血症,补钠后痊愈。结论 经剑突下入路胸腔镜胸腺切除的解剖路径暴露良好,具有较好的手术安全性和临床效果,更好地体现了微创理念。