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Ao Y, Deng J, Jiang J, Yao M, Gao J, Wang S, Jin C, Liu Q, Zhai Y, Du F, Zhang Y, Zhang J, Zheng Y, Ren J, Yu Z, Shen Y, Ke A, Cao Y, Wang H, Ding J. Detecting ectopic thymus in thymoma-associated myasthenia gravis through flow cytometry analysis of CD3 mediumTCRvβ mediumCD4 +CD8 + T cells and its clinical significance. Ann Med Surg (Lond) 2025; 87:515-526. [PMID: 40110256 PMCID: PMC11918567 DOI: 10.1097/ms9.0000000000002921] [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: 11/01/2024] [Accepted: 12/20/2024] [Indexed: 03/22/2025] Open
Abstract
Background Traditional histological methods for identifying ectopic thymus (ET) have significant limitations including high risk of false negatives. This study aims to evaluate the effectiveness of flow cytometry in detecting ETs in patients undergoing total thymectomy. Methods We analyzed 864 samples from 103 patients using flow cytometry and hematoxylin and eosin (H&E) staining. ETs were identified by the presence of CD3mediumTCRvβmediumCD4+CD8+ T cells in flow cytometry or Hassall's corpuscles in H&E staining. Results In the discovery set, flow cytometry detected ETs in 69.2% of samples, compared to 23.6% by histological methods. The validation set showed a higher incidence of ETs in myasthenia gravis (MG) patients than in non-MG patients (73.5% vs. 58.0%, P < 0.0001) and in those with thymic epithelial tumors versus normal thymus (68.1% vs. 58.1%, P = 0.0088). MG patients exhibited a higher prevalence of active ETs, characterized by a high proportion of CD4+CD8+ T cells, indicating robust thymopoiesis, compared to those without MG (P = 0.0001). Specific regions, such as the left cervical root, areas along the right and left phrenic nerves, and the left innominate vein, showed significantly higher activity (P < 0.05). Additionally, ETs were more frequently found in the cervical region than in the mediastinum (75.0% vs. 60.8%, P = 0.0012), and in patients aged 40 years or younger compared to those older than 40 years (73.0% vs. 60.6%, P = 0.0027). Conclusions Flow cytometry is a viable alternative for ET detection, providing a novel distribution map that enhances surgical decision-making in MG treatment.
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Affiliation(s)
- Yongqiang Ao
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie Deng
- CAS Key Laboratory of Molecular Virology and Immunology, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
- Institute of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiahao Jiang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Min Yao
- CAS Key Laboratory of Molecular Virology and Immunology, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Jian Gao
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuai Wang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chun Jin
- Department of Thoracic Surgery, Changhai Hospital, Second Military Medical University (Naval Medical University), Shanghai, China
| | - Qiuyue Liu
- State Key Laboratory of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yunze Zhai
- State Key Laboratory of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fengxue Du
- State Key Laboratory of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yu Zhang
- CAS Key Laboratory of Molecular Virology and Immunology, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Juan Zhang
- CAS Key Laboratory of Molecular Virology and Immunology, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
| | - Yuejuan Zheng
- The Research Center for Traditional Chinese Medicine, Shanghai Institute of Infectious Diseases and Biosecurity, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Jiazi Ren
- State Key Laboratory of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zuoren Yu
- State Key Laboratory of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yunli Shen
- Department of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Aiwu Ke
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongbing Cao
- Institute of Vascular Disease, Shanghai TCM-Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Haikun Wang
- CAS Key Laboratory of Molecular Virology and Immunology, Shanghai Institute of Immunity and Infection, Chinese Academy of Sciences, University of Chinese Academy of Sciences, Shanghai, China
- State Key Laboratory of Cardiology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jianyong Ding
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
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Leng X, Chen M, Zhang Y, Gao J, You Z, Hu Z. Choosing the proper path: outcomes of subxiphoid vs. lateral intercostal approaches in the resection of anterior mediastinal masses. Front Surg 2024; 11:1463881. [PMID: 39691683 PMCID: PMC11649629 DOI: 10.3389/fsurg.2024.1463881] [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: 07/12/2024] [Accepted: 11/19/2024] [Indexed: 12/19/2024] Open
Abstract
Background While the subxiphoid approach (SA) in thoracoscopic thymectomy offers benefits in terms of fat removal and pain reduction, it remains unclear which patients with anterior mediastinal masses benefit most from the subxiphoid vs. the lateral intercostal approach (LA). Methods This retrospective study analyzed patients treated for anterior mediastinal masses at our center from January 2019 to December 2023. Patients were categorized into two groups based on the surgical approach: SA (35 cases) and LA (56 cases). Demographic data, clinical characteristics, perioperative metrics, and short-term outcomes were compared. Results Ninety-one patients were included, with diagnoses including thymic cysts (43), thymomas types A, AB, and B1 (24), B2 thymomas (18), thymic carcinoma (6).No significant differences were found between the groups in terms of gender, age, tumor size, body mass index, conversion to sternotomy, or blood loss. The LA group, however, experienced shorter surgical durations (P < 0.001), less drainage (P = 0.021), shorter hospital stays (P < 0.001), and lower hospitalization costs (P = 0.024). Pain scores on the visual analogue scale were similar between groups on the day of surgery and the first postoperative day. Conclusion The findings suggest that the lateral intercostal approach is preferable for patients with thymic cysts and Masaoka stage I-II thymomas without myasthenia gravis due to its efficiency and cost-effectiveness.
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Affiliation(s)
- Xuechun Leng
- Department of Thoracic Surgery, The Affiliated Huaian No.1 People’s Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - Mengzou Chen
- Department of Thoracic Surgery, The Affiliated Huaian No.1 People’s Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - Yang Zhang
- Department of Anesthesiology, The Affiliated Huaian No.1 People’s Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - Jian Gao
- Clinical Statistics Center, The Affiliated Huaian No.1 People’s Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - Zhenbing You
- Department of Thoracic Surgery, The Affiliated Huaian No.1 People’s Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - Zhongwu Hu
- Department of Thoracic Surgery, The Affiliated Huaian No.1 People’s Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
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Mayer A, Voller J, Varga I. Enigmatic thymus: Variations in anatomical localisation of thymic tissue as an easily misdiagnosed congenital anomaly in surgical practice. World J Clin Cases 2024; 12:5646-5652. [PMID: 39247750 PMCID: PMC11263050 DOI: 10.12998/wjcc.v12.i25.5646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/24/2024] [Accepted: 05/27/2024] [Indexed: 07/12/2024] Open
Abstract
We point out the issue of differential diagnosis regarding the finding of ectopically localised thymic tissue (a thymic cyst) in the neck. Thymic tissue can be found anywhere along its developmental tract of descent, from the angle of the mandible to the upper mediastinum. Disruption of the thymic descent can result in ectopically/abnormally localised islets of accessory thymic tissue, which may undergo cystic changes, as described in a case report by Sun et al. This anatomical variation of the thymus may be clinically misinterpreted as a neoplasm or other congenital anomalies as a branchial cyst, lymphatic malformation or cystic hygroma. The present editorial focuses on the challenge of establishing a diagnosis of ectopically localised tissue of thymus often presented as a lateral cervical mass, especially in the case of cystic variation/degeneration of this thymic tissue. We summarise hypotheses on the origin of such congenital cervical thymic cysts from the point of view of evolutionary history and embryology. We also discuss lesser-known facts about the anatomy, histopathology and developmental biology of the thymus as one of the most enigmatic organs in the human body.
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Affiliation(s)
- Alexander Mayer
- Fourth Department of Surgery, Faculty of Medicine, Comenius University and University Hospital Bratislava, Bratislava 81372, Slovakia
| | - Jaroslav Voller
- Faculty of Health Care Studies, University of Western Bohemia, Pilsen 30100, Czech Republic
| | - Ivan Varga
- Institute of Histology and Embryology, Faculty of Medicine, Comenius University in Bratislava, Bratislava 81372, Slovakia
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Zhu A, Kemp U. Is a subxiphoid approach equivalent to midline sternotomy for extended thymectomy for achieving disease remission in patients with myasthenia gravis? INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad202. [PMID: 38085242 PMCID: PMC10733717 DOI: 10.1093/icvts/ivad202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 11/20/2023] [Accepted: 12/11/2023] [Indexed: 12/22/2023]
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients with myasthenia gravis undergoing extended thymectomy, is a subxiphoid approach equivalent to midline sternotomy for achieving disease remission?' Altogether 106 papers were found using the reported search, of which 5 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. Five studies of a total of 803 patients with myasthenia gravis (MG) reported their experience with thymectomy by subxiphoid approach versus thymectomy by midline sternotomy. These studies demonstrated shorter operation duration, reduced intraoperative blood loss, reduced hospital length of stay and lower postoperative pain scores in the subxiphoid group. There was no significant difference in rates of postoperative MG crisis between the 2 groups, and similar rates of improvement in quantitative myasthenia gravis scores. We conclude that while further high-quality research is required, thymectomy by subxiphoid approach for MG may be considered in preference to midline sternotomy due to improved short-term postoperative outcomes and similar disease remission rates.
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Affiliation(s)
- Alison Zhu
- Department of Cardiothoracic Surgery, Westmead Hospital, Sydney, Australia
| | - Ursula Kemp
- Department of Cardiothoracic Surgery, Westmead Hospital, Sydney, Australia
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Rath J, Moser B, Zimprich F. Thymectomy in myasthenia gravis. Curr Opin Neurol 2023; 36:416-423. [PMID: 37639450 DOI: 10.1097/wco.0000000000001189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Thymectomy has long been used in the treatment of patients with myasthenia gravis and antibodies against the acetylcholine receptor. However, its effectiveness has only been proven a few years ago in a randomized controlled trial in patients under the age of 65. Here, we review the current literature focusing on patient subgroups, potential biomarkers for outcome prediction and the choice of surgical approach. RECENT FINDINGS Long-term follow-up studies after thymectomy confirmed that the benefits regarding clinical outcome parameters and a reduced need for immunosuppressive treatment persist. Nevertheless, a substantial proportion of patients in real-world cohorts do not reach complete stable remission after thymectomy indicating that the underlying autoimmune process is sustained in the periphery. Our understanding of the responsible mechanisms has improved with recent studies. Presently, outcome data after thymectomy in several patient subgroups, such as those aged over 50 years, those with juvenile onset or those with purely ocular symptoms are limited and have been the focus of recent research activities. Similarly, biomarkers guiding an appropriate patient selection for thymectomy are under investigation. A number of cohort studies demonstrated that minimal invasive surgical techniques such as extended robotic thymectomy lead to similar positive outcomes as a transsternal approach with potentially fewer short-term adverse effects. SUMMARY Thymectomy is an effective treatment option in adult patients with early onset acetylcholine-receptor positive myasthenia gravis but uncertainty remains with regard to certain patient subgroups.
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Affiliation(s)
| | - Bernhard Moser
- Department of Thoracic Surgery, Medical University Vienna, Vienna, Austria
- ESTS Thymic Working Group
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Zhu X, Jin K, Wu X, Yu G. Clinical Application of Thoracoscopic Resection of Anterior Mediastinal Tumors under the Xiphoid Process. BIOMED RESEARCH INTERNATIONAL 2022; 2022:2012457. [PMID: 36051485 PMCID: PMC9427266 DOI: 10.1155/2022/2012457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/18/2022] [Accepted: 08/02/2022] [Indexed: 11/29/2022]
Abstract
Objective To explore the feasibility and advantages of thoracoscopic resection of anterior mediastinal tumors through subxiphoid and lateral thoracic approaches. Method 74 patients with anterior mediastinal tumors hospitalized in our hospital from January 2019 to January 2022 were retrospectively analyzed. They were divided into the lateral chest group (31 cases) and the infraxiphoid group (43 cases) according to different operation methods. The tumor size, operation time, intraoperative bleeding, postoperative pain score, postoperative complications, postoperative drainage tube removal time, and hospital stay were compared between the two groups. Result The intraoperative bleeding and postoperative pain scores in the subxiphoid group were better than those in the lateral chest group. There was no significant difference in operation time and postoperative complications between the two groups. Conclusion Compared with the lateral thoracic approach, the thoracoscopic subxiphoid approach can be more safe and effective in resectioning anterior mediastinal tumors.
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Affiliation(s)
- Xingfeng Zhu
- Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Kuanzhe Jin
- Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Xiaobo Wu
- Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi, Jiangsu 214023, China
| | - Guiping Yu
- Department of Cardiothoracic Surgery, Jiangyin Clinical College of Xuzhou Medical University, Wuxi, Jiangsu 214400, China
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