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Kaminski HJ, Kusner LL, Cutter GR, Le Panse R, Wright CD, Perry Y, Wolfe GI. Does Surgical Removal of the Thymus Have Deleterious Consequences? Neurology 2024; 102:e209482. [PMID: 38781559 DOI: 10.1212/wnl.0000000000209482] [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: 05/25/2024] Open
Abstract
The role of immunosenescence, particularly the natural process of thymic involution during aging, is increasingly acknowledged as a factor contributing to the development of autoimmune diseases and cancer. Recently, a concern has been raised about deleterious consequences of the surgical removal of thymic tissue, including for patients who undergo thymectomy for myasthenia gravis (MG) or resection of a thymoma. This review adopts a multidisciplinary approach to scrutinize the evidence concerning the long-term risks of cancer and autoimmunity postthymectomy. We conclude that for patients with acetylcholine receptor antibody-positive MG and those diagnosed with thymoma, the removal of the thymus offers prominent benefits that well outweigh the potential risks. However, incidental removal of thymic tissue during other thoracic surgeries should be minimized whenever feasible.
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Affiliation(s)
- Henry J Kaminski
- From the Department of Neurology & Rehabilitation Medicine (H.J.K.), George Washington University, DC; Department of Pharmacology & Physiology (L.L.K.), and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; INSERM (R.L.P.), Institute of Myology, Center of Research in Myology, Sorbonne University, Paris, France; Department of Surgery (C.D.W.), Harvard Medical School, Boston, MA; and Department of Surgery (Y.P.), and Department of Neurology (G.I.W.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo/SUNY, NY
| | - Linda L Kusner
- From the Department of Neurology & Rehabilitation Medicine (H.J.K.), George Washington University, DC; Department of Pharmacology & Physiology (L.L.K.), and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; INSERM (R.L.P.), Institute of Myology, Center of Research in Myology, Sorbonne University, Paris, France; Department of Surgery (C.D.W.), Harvard Medical School, Boston, MA; and Department of Surgery (Y.P.), and Department of Neurology (G.I.W.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo/SUNY, NY
| | - Gary R Cutter
- From the Department of Neurology & Rehabilitation Medicine (H.J.K.), George Washington University, DC; Department of Pharmacology & Physiology (L.L.K.), and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; INSERM (R.L.P.), Institute of Myology, Center of Research in Myology, Sorbonne University, Paris, France; Department of Surgery (C.D.W.), Harvard Medical School, Boston, MA; and Department of Surgery (Y.P.), and Department of Neurology (G.I.W.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo/SUNY, NY
| | - Rozen Le Panse
- From the Department of Neurology & Rehabilitation Medicine (H.J.K.), George Washington University, DC; Department of Pharmacology & Physiology (L.L.K.), and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; INSERM (R.L.P.), Institute of Myology, Center of Research in Myology, Sorbonne University, Paris, France; Department of Surgery (C.D.W.), Harvard Medical School, Boston, MA; and Department of Surgery (Y.P.), and Department of Neurology (G.I.W.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo/SUNY, NY
| | - Cameron D Wright
- From the Department of Neurology & Rehabilitation Medicine (H.J.K.), George Washington University, DC; Department of Pharmacology & Physiology (L.L.K.), and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; INSERM (R.L.P.), Institute of Myology, Center of Research in Myology, Sorbonne University, Paris, France; Department of Surgery (C.D.W.), Harvard Medical School, Boston, MA; and Department of Surgery (Y.P.), and Department of Neurology (G.I.W.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo/SUNY, NY
| | - Yaron Perry
- From the Department of Neurology & Rehabilitation Medicine (H.J.K.), George Washington University, DC; Department of Pharmacology & Physiology (L.L.K.), and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; INSERM (R.L.P.), Institute of Myology, Center of Research in Myology, Sorbonne University, Paris, France; Department of Surgery (C.D.W.), Harvard Medical School, Boston, MA; and Department of Surgery (Y.P.), and Department of Neurology (G.I.W.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo/SUNY, NY
| | - Gil I Wolfe
- From the Department of Neurology & Rehabilitation Medicine (H.J.K.), George Washington University, DC; Department of Pharmacology & Physiology (L.L.K.), and Department of Biostatistics (G.R.C.), University of Alabama at Birmingham; INSERM (R.L.P.), Institute of Myology, Center of Research in Myology, Sorbonne University, Paris, France; Department of Surgery (C.D.W.), Harvard Medical School, Boston, MA; and Department of Surgery (Y.P.), and Department of Neurology (G.I.W.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo/SUNY, NY
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Evison M, Robinson SD, Sharman A, Datta S, Rammohan K, Duerden R, Montero-Fernandez MA, Gilligan D. Making an accurate diagnosis of anterior mediastinal lesions: a proposal for a new diagnostic algorithm from the BTOG Thymic Malignancies Special Interest Group. Clin Radiol 2024; 79:404-412. [PMID: 38565483 DOI: 10.1016/j.crad.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/01/2024] [Accepted: 03/12/2024] [Indexed: 04/04/2024]
Abstract
Due to the rising demand in cross-sectional thoracic imaging, anterior mediastinal lesions are being identified with increasing frequency. Following iterative and multidisciplinary discussions, the BTOG Thymic Malignancies Special Interest Group have developed an algorithm to standardise the diagnostic approach for these relatively uncommon but important conditions which span from benign (thymic remnant, thymic hyperplasia and thymic cysts) to suspected localised thymomas to suspected more aggressive malignancy (thymic carcinoma, lymphoma and germ cell tumours). For each condition, we provide a brief description, an overview of the key radiological findings and a description of the proposed algorithm including the rationale behind the recommendations. We also highlight the role of magnetic resonance (MR) imaging for the characterisation of anterior mediastinal masses in specific indications when the necessary local resources and expertise exist. In addition, we hope this provides the rationale for service development in MR of the anterior mediastinum where current resource and expertise requires development. Through this standardised pathway, we hope to drive improvements in patient care by rationalising surveillance schedules, avoiding unnecessary resections of benign entities with their associated morbidity and optimising the diagnostic work-up prior to the appropriate treatment of anterior mediastinal malignancies.
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Affiliation(s)
- M Evison
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK; Manchester Academic Health Science Centre (MAHSC), Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK.
| | - S D Robinson
- Sussex Cancer Centre, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK; Department of Biochemistry and Biomedicine, School of Life Sciences, University of Sussex, Falmer, Brighton, UK.
| | - A Sharman
- Manchester Thoracic Oncology Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - S Datta
- Department of Radiology, Royal Alexandra Hospital, NHS Glasgow and Clyde, Glasgow, UK
| | - K Rammohan
- Lung Cancer & Thoracic Surgery Directorate, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - R Duerden
- Department of Radiology, Stepping Hill Hospital, Stockport NHS Foundation Trust, Stockport, UK
| | - M A Montero-Fernandez
- Department of Histopathology, Royal Liverpool University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - D Gilligan
- Department of Oncology, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Tsai PC, Tseng YC, Ting YC, Huang CS, Hsu WH, Tang EK, Hsu HS. Long-term follow-up of non-myasthenic patients with early-stage thymoma who underwent extended thymectomy or limited resection. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108349. [PMID: 38640605 DOI: 10.1016/j.ejso.2024.108349] [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: 03/08/2024] [Revised: 04/05/2024] [Accepted: 04/14/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUD The standard resection for early-stage thymoma is total thymectomy and complete tumour excision with or without myasthenia gravis but the optimal surgery mode for patients with early-stage non-myasthenic thymoma is debatable. This study analysed the oncological outcomes for non-myasthenic patients with early-stage thymoma treated by thymectomy or limited resection in the long term. METHODS Patients who had resections of thymic neoplasms at Taipei Veteran General Hospital, Taiwan between December 1997 and March 2013 were recruited, exclusive of those combined clinical evidence of myasthenia gravis were reviewed. A total of 113 patients were retrospectively reviewed with pathologic early stage (Masaoka stage I and II) thymoma who underwent limited resection or extended thymectomy to compare their long-term oncologic and surgical outcomes. RESULTS The median observation time was 134.1 months [interquartile range (IQR) 90.7-176.1 months]. In our cohort, 52 patients underwent extended thymectomy and 61 patients underwent limited resection. Shorter duration of surgery (p < 0.001) and length of stay (p = 0.006) were demonstrated in limited resection group. Six patients experienced thymoma recurrence, two of which had combined myasthenia gravis development after recurrence. There was no significant difference (p = 0.851) in freedom-from-recurrence, with similar 10-year freedom-from-recurrence rates between the limited resection group (96.2 %) and the thymectomy group (93.2 %). Tumour-related survival was also not significantly different between groups (p = 0.726).result CONCLUSION: Patients with early-stage non-myasthenic thymoma who underwent limited resection without complete excision of the thymus achieved similar oncologic outcomes during the long-term follow-up and better peri-operative results compared to those who underwent thymectomy.
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Affiliation(s)
- Ping-Chung Tsai
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Chiang Tseng
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ying-Che Ting
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chien-Sheng Huang
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wen-Hu Hsu
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - En-Kuei Tang
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Han-Shui Hsu
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan.
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Saccà F, Salort-Campana E, Jacob S, Cortés-Vicente E, Schneider-Gold C. Refocusing generalized myasthenia gravis: Patient burden, disease profiles, and the role of evolving therapy. Eur J Neurol 2024; 31:e16180. [PMID: 38117543 DOI: 10.1111/ene.16180] [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: 02/10/2023] [Revised: 11/06/2023] [Accepted: 11/27/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND AND PURPOSE Generalized myasthenia gravis (gMG) continues to present significant challenges for clinical management due to an unpredictable disease course, frequent disease fluctuations, and varying response to therapy. The recent availability of new pharmacologic therapies presents a valuable opportunity to reevaluate how this disease is classified, assessed, and managed and identify new ways to improve the clinical care of patients with gMG. METHODS Narrative review was made of publications identified via searches of PubMed and selected congresses (January 2000-September 2022). RESULTS New consensus definitions are required to ensure consistency, to better characterize patients, and to identify patients who will benefit from specific drugs and earlier use of these agents. There is a need for more frequent, standardized patient assessment to identify the cause of motor function deficits, provide a clearer picture of the disease burden and its impact on daily living and quality of life (QoL), and better support treatment decision-making. Novel approaches that target different components of the immune system will play a role in more precise treatment of patients with gMG, alongside the development of new algorithms to guide individualized patient management. CONCLUSIONS gMG has a physical, mental, and social impact, resulting in a considerable burden of disease and substantially decreased QoL, despite standard treatments. The availability of novel, targeted treatments that influence key pathological mediators of gMG, together with new biomarkers, offers the potential to optimize patient management and ultimately enables a greater number of patients to achieve minimal manifestation status and a reduced burden of disease.
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Affiliation(s)
- Francesco Saccà
- Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University, Naples, Italy
| | - Emmanuelle Salort-Campana
- Reference Center of Neuromuscular Disorders and ALS, Timone University Hospital, Assistance Publique-Hopitaux de Marseille, Marseille, France
| | - Saiju Jacob
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Elena Cortés-Vicente
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau and Biomedical Research Institute Sant Pau, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras, Instituto de Salud Carlos III, Madrid, Spain
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Liu X, Li R, Li W, Liu W, Wang J, Jing Y. The rate of QMGS change predicts recurrence after thymectomy in myasthenia gravis. J Clin Neurosci 2024; 124:20-26. [PMID: 38640804 DOI: 10.1016/j.jocn.2024.04.011] [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: 10/26/2023] [Revised: 04/07/2024] [Accepted: 04/10/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVE To investigate the relationship between short-term changes in quantitative myasthenia gravis score (QMGS) after thymectomy and postoperative recurrence in myasthenia gravis (MG) patients without thymoma. METHODS A retrospective observational cohort study. The QMGS of 44 patients with non-thymomatous MG were evaluated before and 1 month after thymectomy, and the frequency and time of postoperative recurrence were recorded. The reduction rate of QMGS (rr-QMGS) was defined as (QMGS one week before thymectomy - QMGS one month after thymectomy)/ QMGS one week before thymectomy × 100 %, as an indicator of short-term symptom change after thymectomy. The receiver operating characteristic (ROC) curve was established to determine an appropriate cut-off value of rr-QMGS for distinguishing postoperative recurrence. Multivariate Cox regression analysis was applied to predict postoperative recurrence. RESULTS Postoperative recurrence occurred in 21 patients (30 times in total) during follow-up. The mean annual recurrence rate was 3.98 times/year preoperatively and 0.30 times/year postoperatively. ROC analysis determined the cut-off value of rr-QMGS was 36.7 % (sensitivity 90.5 %, specificity 52.2 %). Multivariate Cox regression analysis showed that rr-QMGS<36.7 % (hazard rate[HR]6.251, P = 0.014) is positive predictor of postoperative recurrence. Kaplan-Meier analysis showed that postoperative recurrence time was earlier in the low rr-QMGS group than in the high rr-QMGS group (12.62 vs. 36.60 months, p = 0.005). CONCLUSIONS Low rr-QMGS is associated with early postoperative recurrence. Rr-QMGS can be used to predict postoperative recurrence of non-thymomatous MG.
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Affiliation(s)
- Xinxin Liu
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Ran Li
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Wenwen Li
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Wei Liu
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Jiawei Wang
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Yun Jing
- Department of Neurology, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China.
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Jacob S. Treating myasthenia gravis beyond the eye clinic. Eye (Lond) 2024:10.1038/s41433-024-03133-x. [PMID: 38789789 DOI: 10.1038/s41433-024-03133-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/17/2024] [Accepted: 05/07/2024] [Indexed: 05/26/2024] Open
Abstract
Myasthenia gravis (MG) is one of the most well characterised autoimmune disorders affecting the neuromuscular junction with autoantibodies targeting the acetylcholine receptor (AChR) complex. The vast majority of patients present with ocular symptoms including double vision and ptosis, but may progress on to develop generalised fatiguable muscle weakness. Severe involvement of the bulbar muscles can lead to dysphagia, dysarthria and breathing difficulties which can progress to myasthenic crisis needing ventilatory support. Given the predominant ocular onset of the disease, it is important that ophthalmologists are aware of the differential diagnosis, investigations and management including evolving therapies. When the disease remains localised to the extraocular muscles (ocular MG) IgG1 and IgG3 antibodies against the AChR (including clustered AChR) are present in nearly 50% of patients. In generalised MG this is seen in nearly 90% patients. Other antibodies include those against muscle specific tyrosine kinase (MuSK) and lipoprotein receptor related protein 4 (LRP4). Even though decremental response on repetitive nerve stimulation is the most well recognised neurophysiological abnormality, single fibre electromyogram (SFEMG) in experienced hands is the most sensitive test which helps in the diagnosis. Initial treatment should be using cholinesterase inhibitors and then proceeding to immunosuppression using corticosteroids and steroid sparing drugs. Patients requiring bulbar muscle support may need rescue therapies including plasma exchange and intravenous immunoglobulin (IVIg). Newer therapeutic targets include those against the B lymphocytes, complement system, neonatal Fc receptors (FcRn) and various other elements of the immune system.
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Affiliation(s)
- Saiju Jacob
- University Hospitals Birmingham, Birmingham, UK.
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK.
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Gilhus NE, Andersen H, Andersen LK, Boldingh M, Laakso S, Leopoldsdottir MO, Madsen S, Piehl F, Popperud TH, Punga AR, Schirakow L, Vissing J. Generalized myasthenia gravis with acetylcholine receptor antibodies: A guidance for treatment. Eur J Neurol 2024; 31:e16229. [PMID: 38321574 DOI: 10.1111/ene.16229] [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: 10/10/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Generalized myasthenia gravis (MG) with antibodies against the acetylcholine receptor is a chronic disease causing muscle weakness. Access to novel treatments warrants authoritative treatment recommendations. The Nordic countries have similar, comprehensive health systems, mandatory health registers, and extensive MG research. METHODS MG experts and patient representatives from the five Nordic countries formed a working group to prepare treatment guidance for MG based on a systematic literature search and consensus meetings. RESULTS Pyridostigmine represents the first-line symptomatic treatment, while ambenonium and beta adrenergic agonists are second-line options. Early thymectomy should be undertaken if a thymoma, and in non-thymoma patients up to the age of 50-65 years if not obtaining remission on symptomatic treatment. Most patients need immunosuppressive drug treatment. Combining corticosteroids at the lowest possible dose with azathioprine is recommended, rituximab being an alternative first-line option. Mycophenolate, methotrexate, and tacrolimus represent second-line immunosuppression. Plasma exchange and intravenous immunoglobulin are used for myasthenic crises and acute exacerbations. Novel complement inhibitors and FcRn blockers are effective and fast-acting treatments with promising safety profiles. Their use depends on local availability, refunding policies, and cost-benefit analyses. Adapted physical training is recommended. Planning of pregnancies with optimal treatment, information, and awareness of neonatal MG is necessary. Social support and adaptation of work and daily life activities are recommended. CONCLUSIONS Successful treatment of MG rests on timely combination of different interventions. Due to spontaneous disease fluctuations, comorbidities, and changes in life conditions, regular long-term specialized follow-up is needed. Most patients do reasonably well but there is room for further improvement. Novel treatments are promising, though subject to restricted access due to costs.
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Affiliation(s)
- Nils Erik Gilhus
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Linda Kahr Andersen
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marion Boldingh
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Sini Laakso
- Department of Neurology, Brain Center, Helsinki University Hospital, Helsinki, Finland
- Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
| | | | - Sidsel Madsen
- The National Rehabilitation Center for Neuromuscular Diseases, Aarhus, Denmark
| | - Fredrik Piehl
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Anna Rostedt Punga
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Department of Clinical Neurophysiology, Uppsala University Hospital, Uppsala, Sweden
| | | | - John Vissing
- Copenhagen Neuromuscular Center, Department of Neurology, Copenhagen University Hospital, Copenhagen, Denmark
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Klug M, Strange CD, Truong MT, Kirshenboim Z, Ofek E, Konen E, Marom EM. Thymic Imaging Pitfalls and Strategies for Optimized Diagnosis. Radiographics 2024; 44:e230091. [PMID: 38602866 DOI: 10.1148/rg.230091] [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: 04/13/2024]
Abstract
Thymic imaging is challenging because the imaging appearance of a variety of benign and malignant thymic conditions are similar. CT is the most commonly used modality for mediastinal imaging, while MRI and fluorine 18 fluorodeoxyglucose (FDG) PET/CT are helpful when they are tailored to the correct indication. Each of these imaging modalities has limitations and technical pitfalls that may lead to an incorrect diagnosis and mismanagement. CT may not be sufficient for the characterization of cystic thymic processes and differentiation between thymic hyperplasia and thymic tumors. MRI can be used to overcome these limitations but is subject to other potential pitfalls such as an equivocal decrease in signal intensity at chemical shift imaging, size limitations, unusual signal intensity for cysts, subtraction artifacts, pseudonodularity on T2-weighted MR images, early imaging misinterpretation, flow and spatial resolution issues hampering assessment of local invasion, and the overlap of apparent diffusion coefficients between malignant and benign thymic entities. FDG PET/CT is not routinely indicated due to some overlap in FDG uptake between thymomas and benign thymic processes. However, it is useful for staging and follow-up of aggressive tumors (eg, thymic carcinoma), particularly for detection of occult metastatic disease. Pitfalls in imaging after treatment of thymic malignancies relate to technical challenges such as postthymectomy sternotomy streak metal artifacts, differentiation of postsurgical thymic bed changes from tumor recurrence, or human error with typical "blind spots" for identification of metastatic disease. Understanding these pitfalls enables appropriate selection of imaging modalities, improves diagnostic accuracy, and guides patient treatment. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Maximiliano Klug
- From the Division of Diagnostic Imaging (M.K., Z.K., E.K., E.M.M.) and Institute of Pathology (E.O.), The Chaim Sheba Medical Center, Tel Hashomer, 2 Derech Sheba St, Ramat Gan, 5265601, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (M.K., Z.K., E.O., E.K., E.M.M.); and Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex (C.D.S., M.T.T.)
| | - Chad D Strange
- From the Division of Diagnostic Imaging (M.K., Z.K., E.K., E.M.M.) and Institute of Pathology (E.O.), The Chaim Sheba Medical Center, Tel Hashomer, 2 Derech Sheba St, Ramat Gan, 5265601, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (M.K., Z.K., E.O., E.K., E.M.M.); and Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex (C.D.S., M.T.T.)
| | - Mylene T Truong
- From the Division of Diagnostic Imaging (M.K., Z.K., E.K., E.M.M.) and Institute of Pathology (E.O.), The Chaim Sheba Medical Center, Tel Hashomer, 2 Derech Sheba St, Ramat Gan, 5265601, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (M.K., Z.K., E.O., E.K., E.M.M.); and Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex (C.D.S., M.T.T.)
| | - Zehavit Kirshenboim
- From the Division of Diagnostic Imaging (M.K., Z.K., E.K., E.M.M.) and Institute of Pathology (E.O.), The Chaim Sheba Medical Center, Tel Hashomer, 2 Derech Sheba St, Ramat Gan, 5265601, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (M.K., Z.K., E.O., E.K., E.M.M.); and Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex (C.D.S., M.T.T.)
| | - Efrat Ofek
- From the Division of Diagnostic Imaging (M.K., Z.K., E.K., E.M.M.) and Institute of Pathology (E.O.), The Chaim Sheba Medical Center, Tel Hashomer, 2 Derech Sheba St, Ramat Gan, 5265601, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (M.K., Z.K., E.O., E.K., E.M.M.); and Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex (C.D.S., M.T.T.)
| | - Eli Konen
- From the Division of Diagnostic Imaging (M.K., Z.K., E.K., E.M.M.) and Institute of Pathology (E.O.), The Chaim Sheba Medical Center, Tel Hashomer, 2 Derech Sheba St, Ramat Gan, 5265601, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (M.K., Z.K., E.O., E.K., E.M.M.); and Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex (C.D.S., M.T.T.)
| | - Edith Michelle Marom
- From the Division of Diagnostic Imaging (M.K., Z.K., E.K., E.M.M.) and Institute of Pathology (E.O.), The Chaim Sheba Medical Center, Tel Hashomer, 2 Derech Sheba St, Ramat Gan, 5265601, Israel; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (M.K., Z.K., E.O., E.K., E.M.M.); and Department of Thoracic Imaging, University of Texas MD Anderson Cancer Center, Houston, Tex (C.D.S., M.T.T.)
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Dodd KC, Ahmed R, Ambrose P, Holt JK, Jacob S, Leite MI, Miller JA, San PP, Spillane J, Viegas S, Sussman J. Mycophenolate and methotrexate are better tolerated than azathioprine in myasthenia gravis. Neuromuscul Disord 2024; 38:51-57. [PMID: 38626662 DOI: 10.1016/j.nmd.2024.03.010] [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: 12/19/2023] [Revised: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/18/2024]
Abstract
Azathioprine is recommended as the first-line steroid-sparing immunosuppressive agent for myasthenia gravis. Mycophenolate and methotrexate are often considered as second-line choices despite widespread consensus on their efficacy. We aimed to gather real-world data comparing the tolerability and reasons for discontinuation for these agents, by performing a national United Kingdom survey of side effects and reasons for discontinuation of immunosuppressants in myasthenia gravis. Of 235 patients, 166 had taken azathioprine, 102 mycophenolate, and 40 methotrexate. The most common side effects for each agent were liver dysfunction for azathioprine (23 %), diarrhoea for mycophenolate (14 %), and fatigue for methotrexate (18 %). Women were generally more likely to experience side effects of immunosuppressants. Azathioprine was significantly more likely to be discontinued than mycophenolate and methotrexate due to side effects. There was no significant difference in treatment cessation due to lack of efficacy. This study highlights the significant side-effect burden of treatment for myasthenia gravis. Mechanisms to reduce azathioprine toxicity should be utilised, however mycophenolate and methotrexate appear to be good treatment choices if teratogenicity is not a concern. Women are disadvantaged due to higher frequency of side effects and considerations around pregnancy and breastfeeding. Treatments with improved tolerability are needed.
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Affiliation(s)
- Katherine C Dodd
- Manchester Centre for Clinical Neuroscience, Northern Care Alliance NHS Foundation Trust, Salford Royal, Stott Lane, Salford, M6 8HD, UK; The University of Manchester, Manchester Academic Health Science Centre, Core Technology Facility, Manchester, M13 9WU, UK.
| | - Rohan Ahmed
- The Walton Centre NHS Foundation Trust, Lower Lane, Liverpool, L9 7LJ, UK
| | - Philip Ambrose
- Nottingham University Hospitals NHS Foundation Trust, Queen's Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
| | - James Kl Holt
- The Walton Centre NHS Foundation Trust, Lower Lane, Liverpool, L9 7LJ, UK
| | - Saiju Jacob
- University Hospitals Birmingham, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, B15 2WB, UK; Institute of Immunology and Immunotherapy, University of Birmingham, B15 2TT, UK
| | - M Isabel Leite
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - James Al Miller
- Department of Neurology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, NE1 4LP, UK
| | - Pyae Phyo San
- University Hospitals Birmingham, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, B15 2WB, UK; Institute of Immunology and Immunotherapy, University of Birmingham, B15 2TT, UK
| | - Jennifer Spillane
- University College London Hospitals NHS Foundation Trust, National Hospital for Neurology and Neurosurgery, 12 Queen Square, London, WC1N 3BG, UK
| | - Stuart Viegas
- Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, M6 8RF, UK
| | - Jon Sussman
- Manchester Centre for Clinical Neuroscience, Northern Care Alliance NHS Foundation Trust, Salford Royal, Stott Lane, Salford, M6 8HD, UK; The University of Manchester, Manchester Academic Health Science Centre, Core Technology Facility, Manchester, M13 9WU, UK
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10
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De Bleecker JL, Remiche G, Alonso-Jiménez A, Van Parys V, Bissay V, Delstanche S, Claeys KG. Recommendations for the management of myasthenia gravis in Belgium. Acta Neurol Belg 2024:10.1007/s13760-024-02552-7. [PMID: 38649556 DOI: 10.1007/s13760-024-02552-7] [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: 02/07/2024] [Accepted: 03/31/2024] [Indexed: 04/25/2024]
Abstract
International guidelines on the treatment of myasthenia gravis (MG) have been published but are not tailored to the Belgian situation. This publication presents recommendations from a group of Belgian MG experts for the practical management of MG in Belgium. It includes recommendations for treatment of adult patients with generalized myasthenia gravis (gMG) or ocular myasthenia gravis (oMG). Depending on the MG-related antibody a treatment sequence is suggested with therapies that can be added on if the treatment goal is not achieved. Selection of treatments was based on the level of evidence of efficacy, registration and reimbursement status in Belgium, common daily practice and the personal views and experiences of the authors. The paper reflects the situation in February 2024. In addition to the treatment considerations, other relevant aspects in the management of MG are addressed, including comorbidities, drugs aggravating disease symptoms, pregnancy, and vaccination. As many new treatments might potentially come to market, a realistic future perspective on the impact of these treatments on clinical practice is given. In conclusion, these recommendations intend to be a guide for neurologists treating patients with MG in Belgium.
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Affiliation(s)
- Jan L De Bleecker
- Department of Neurology, University Hospital Ghent and AZ Sint-Lucas, Ghent, Belgium.
| | - Gauthier Remiche
- Centre de Référence Neuromusculaire, Department of Neurology, Hôpital Universitaire de Bruxelles (HUB)-Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Alicia Alonso-Jiménez
- Department of Neurology, Faculty of Medicine and Health Sciences, Antwerp University Hospital, Translational Neurosciences, UAntwerpen, Antwerp, Belgium
| | - Vinciane Van Parys
- Department of Neurology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Véronique Bissay
- Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel, NEUR Research Group and Department of Neurology, Brussels, Belgium
| | | | - Kristl G Claeys
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Laboratory for Muscle Diseases and Neuropathies, Department of Neurosciences, KULeuven, and Leuven Brain Institute (LBI), Leuven, Belgium
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11
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Manyak GA, Bassiri A, Alvarado CE, Sarnaik KS, Sinopoli J, Tapias L, Linden PA, Towe CW. Is Minimally Invasive Resection of Large Thymoma Appropriate? Am Surg 2024:31348241246180. [PMID: 38584508 DOI: 10.1177/00031348241246180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
BACKGROUND Current practice patterns suggest open rather than minimally invasive (MIS) approaches for thymomas >4 cm. We hypothesized there would be similar perioperative outcomes and overall survival between open and MIS approaches for large (>4 cm) thymoma resection. METHODS The National Cancer Database was queried for patients who underwent thymectomy from 2010 to 2020. Surgical approach was characterized as either open or MIS. The primary outcome was overall survival and secondary outcomes were margin status, and length of stay (LOS). Differences between approach cohorts were compared after a 1:1 propensity match. RESULTS Among 4121 thymectomies, 2474 (60%) were open and 1647 (40%) were MIS. Patients undergoing MIS were older, had fewer comorbidities, and had smaller tumors (median; 4.6 vs 6 cm, P < .001). In the unmatched cohort, MIS and open had similar 90-day mortality (1.1% vs 1.8%, P = .158) and rate of positive margin (25.1% vs 27.9%, P = .109). MIS thymectomy was associated with shorter LOS (2 (1-4) vs 4 (3-6) days, P < .001). Propensity matching reduced the bias between the groups. In this cohort, overall survival was similar between the groups by log-rank test (P = .462) and multivariate cox hazard analysis (HR .882, P = .472). Multivariable regression showed shorter LOS with MIS approach (Coef -1.139, P < .001), and similar odds of positive margin (OR 1.130, P = .150). DISCUSSION MIS has equivalent oncologic benefit to open resection for large thymomas, but is associated with shorter LOS. When clinically appropriate, MIS thymectomy may be considered a safe alternative to open resection for large thymomas.
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Affiliation(s)
- Grigory A Manyak
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
- Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Aria Bassiri
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Kunaal S Sarnaik
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
- Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Jilian Sinopoli
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Leonidas Tapias
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, University Hospitals Cleveland Medical Center and Case Western Reserve School of Medicine, Cleveland, OH, USA
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12
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Hoffmann S, Verlohren S, Herdick M. [Myasthenia gravis-Gender aspects and family planning]. DER NERVENARZT 2024; 95:316-328. [PMID: 38499774 DOI: 10.1007/s00115-024-01640-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/23/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND There is evidence that gender-specific differences can influence the diagnostics, treatment and long-term disease course of myasthenia gravis (MG). In women the diagnosis is often made during childbearing age. OBJECTIVE Gender-specific differences in MG and relevant aspects in routine clinical practice are presented. In addition, current studies on family planning, pregnancy and childbirth in MG are highlighted and treatment recommendations are derived. MATERIAL AND METHODS Narrative literature review. RESULTS In addition to sociodemographic data, gender-specific differences encompass clinical as well as paraclinical factors, such as disease severity and antibody status. With few exceptions pregnancy is possible with good maternal and neonatal outcome. During pregnancy and peripartum, children of MG patients should be closely monitored for early detection and treatment of potential syndromes caused by diaplacental transfer of maternal antibodies. CONCLUSION Gender-specific factors can influence the course of MG. Adequate medical counselling and multidisciplinary collaboration are essential for MG patients who wish to have children.
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Affiliation(s)
- Sarah Hoffmann
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Stefan Verlohren
- Department of Obstetrics, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Deutschland
| | - Meret Herdick
- Department of Neurology, Neuroscience Clinical Research Center (NCRC) and Integrated Myasthenia Gravis Center, Charité - Universitätsmedizin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Deutschland
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13
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Lala S, Jha NK. SECRETS: Subject-efficient clinical randomized controlled trials using synthetic intervention. Contemp Clin Trials Commun 2024; 38:101265. [PMID: 38352896 PMCID: PMC10862504 DOI: 10.1016/j.conctc.2024.101265] [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: 09/16/2023] [Revised: 12/15/2023] [Accepted: 01/28/2024] [Indexed: 02/16/2024] Open
Abstract
Background The parallel-group randomized controlled trial (RCT) is commonly used in Phase-3 clinical trials to establish treatment effectiveness but requires hundreds-to-thousands of subjects, making it difficult to implement, which leads to high Phase-3 trial failure rates. One approach to increasing power of a trial is to augment data collected from an RCT with external data from prospective studies or prior RCTs. However, this requires that external data be comparable to data from the study of interest, a condition that does not hold for new interventions or populations being studied. Another approach is to lower sample size requirements by using the cross-over design, which measures individual treatment effects (ITEs) to remove inter-subject variability; however, this design is only suitable for chronic conditions and interventions with effects that wash out rapidly. Method We propose a novel and practical framework called SECRETS (Subject-Efficient Clinical Randomized Controlled Trials using Synthetic Intervention) to increase power of any parallel-group RCT by simulating the cross-over design using only data collected from the study. SECRETS first estimates ITEs across all subjects recruited to the RCT by using a state-of-the-art counterfactual estimation algorithm called synthetic intervention (SI). Since SI induces dependencies among the ITEs, we introduce a novel hypothesis testing strategy to test for treatment effectiveness. Results We show that SECRETS can increase the power of an RCT while maintaining comparable significance levels; in particular, on three real-world clinical RCTs (Phase-3 trials), SECRETS increases power over the baseline method by 6 - 54 % (average: 21.5%, standard deviation: 15.8%), thereby reducing the number of subjects needed to obtain a typically desired statistical operating point of 80% power and 5% significance level by 25 - 76 % (10-3,957 fewer subjects per arm). Our analyses show that SECRETS increases power by consistently reducing the variance of the average treatment effect, thereby mimicking the effects of a cross-over design. Conclusion SECRETS increases subject efficiency of an RCT by simulating the cross-over design using only data collected from the RCT; therefore, it is a feasible solution for increasing the trial's power, especially under settings where satisfying sample size requirements is difficult.
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Affiliation(s)
- Sayeri Lala
- Department of Electrical and Computer Engineering, Princeton University, Princeton, 08544, NJ, USA
| | - Niraj K. Jha
- Department of Electrical and Computer Engineering, Princeton University, Princeton, 08544, NJ, USA
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14
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Hawkes MA, Wijdicks EFM. Improving Outcome in Severe Myasthenia Gravis and Guillain-Barré Syndrome. Semin Neurol 2024. [PMID: 38560985 DOI: 10.1055/s-0044-1785509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
When progressive and severe, myasthenia gravis and Guillain-Barré syndrome may have the potential for fatal and unfavorable clinical outcomes. Regardless of important differences in their clinical course, the development of weakness of oropharyngeal muscles and respiratory failure with requirement of mechanical ventilation is the main driver of poor prognosis in both conditions. The need for prolonged mechanical ventilation is particularly relevant because it immobilizes the patient and care becomes extraordinarily complex due to daily risks of systemic complications. Additionally, patients with myasthenia gravis often require long-term immunosuppressive treatments with associated toxicity and infectious risks. Unlike myasthenia gravis, the recovery period is prolonged in Guillain-Barré syndrome, but often favorable, even in the more severely affected patients. Outcome, for a large part, is determined by expert neurocritical care.
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Affiliation(s)
- Maximiliano A Hawkes
- Department of Neurology, Neurocritical Care Services, Mayo Clinic, Rochester, Minnesota
| | - Eelco F M Wijdicks
- Department of Neurology, Neurocritical Care Services, Mayo Clinic, Rochester, Minnesota
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15
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Gutschmidt K, Schoser B. [Myasthenia Gravis - Update]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2024; 92:139-156. [PMID: 38636491 DOI: 10.1055/a-2238-7784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
Myasthenia gravis - still a challenge for sufferers and doctors in 2023. But which therapy is best suited? Our clinically experienced experts have summarized the current guidelines for diagnosis and treatment in order to provide optimal support for those affected. Find out how you can carry out a quick and targeted diagnosis and which treatment options are available to alleviate the course of the disease.
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16
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Suzuki T, Hishida T, Suzuki S, Okubo Y, Masai K, Kaseda K, Asakura K, Emoto K, Asamura H. Clinicopathological predictors of postoperative long-term myasthenic status in resected thymoma with myasthenia gravis. Surg Today 2024:10.1007/s00595-024-02806-0. [PMID: 38416144 DOI: 10.1007/s00595-024-02806-0] [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: 08/24/2023] [Accepted: 11/22/2023] [Indexed: 02/29/2024]
Abstract
PURPOSE Surgical patients with thymoma and myasthenia gravis (MG) must have their MG status and oncological outcomes critically monitored. We aimed to identify clinicopathological predictors of the postoperative MG status. METHODS We conducted a retrospective review of 40 consecutive surgical patients with MG-related thymomas between 2002 and 2020. The quantitative myasthenia gravis score (QMGS) and Myasthenia Gravis Foundation of America post-intervention status (MGFA-PIS) were used to evaluate postoperative MG status. RESULTS All patients underwent extended total thymectomy. The most common WHO type was type B2 (32%), while 65% of patients had type B1-B3 and 35% had type A-AB thymomas. Eleven patients (28%) achieved controlled MG status in MGFA-PIS 6 months after surgery. This controlled status was observed more frequently in type A-AB than in B1-B3 (57% vs. 12%, p = 0.007). In a multivariate analysis, WHO type (A-AB or B1-B3) was an independent predictor of worsening episodes of MG based on the QMGS (Type B1-B3, hazard ratio: 3.23, 95% confidence interval: 1.12-9.25). At the last follow-up, 23 patients (58%) achieved controlled MG status. The 5-year overall survival rate of all patients was 93.7%. CONCLUSION The WHO type of thymoma is an informative predictor of postoperative MG status in patients with MG-related thymoma.
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Affiliation(s)
- Takahiro Suzuki
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Tomoyuki Hishida
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan.
| | - Shigeaki Suzuki
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Yu Okubo
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Kyohei Masai
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Kaoru Kaseda
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Keisuke Asakura
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
| | - Katsura Emoto
- Division of Diagnostic Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Hisao Asamura
- Division of Thoracic Surgery, Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-Ku, Tokyo, 160-8582, Japan
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17
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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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18
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Huang L, Zuo Y, Yang H, He X, Zhang L. Identification of key genes as potential diagnostic and therapeutic targets for comorbidity of myasthenia gravis and COVID-19. Front Neurol 2024; 14:1334131. [PMID: 38384322 PMCID: PMC10879883 DOI: 10.3389/fneur.2023.1334131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/28/2023] [Indexed: 02/23/2024] Open
Abstract
Introduction Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disorder. Coronavirus disease 2019 (COVID-19) has a significant impact on the health and quality of life of MG patients and may even trigger the onset of MG in some cases. With the worldwide development of the COVID-19 vaccination, several new-onset MG cases and exacerbations following the COVID-19 vaccines have been acknowledged. The potential link between myasthenia gravis (MG) and COVID-19 has prompted the need for further investigation into the underlying molecular mechanism. Methods and results The differential expression analysis identified six differentially expressed genes (DEGs) shared by myasthenia gravis (MG) and COVID-19, namely SAMD9, PLEK, GZMB, JUNB, NR4A1, and NR1D1. The relationship between the six common genes and immune cells was investigated in the COVID-19 dataset. The predictive value of the shared genes was assessed and a nomogram was constructed using machine learning algorithms. The regulatory miRNAs, transcription factors and small molecular drugs were predicted, and the molecular docking was carried out by AutoDock. Discussion We have identified six common DEGs of MG and COVID-19 and explored their immunological effects and regulatory mechanisms. The result may provide new insights for further mechanism research.
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Affiliation(s)
- Liyan Huang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yao Zuo
- Shandong University, Jinan, Shandong, China
- China Rehabilitation Research Center, Beijing Bo’ai Hospital, Beijing, China
| | - Hui Yang
- Department of Neurology, The Second Affiliated Hospital of Guizhou University of Chinese Medicine, Guiyang, China
| | - Xiaofang He
- Department of Pediatric Intensive Care Unit, Guizhou Provincial People's Hospital, Guiyang, China
| | - Lin Zhang
- Department of Neurology, The Second Affiliated Hospital of Guizhou University of Chinese Medicine, Guiyang, China
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Trujillo Reyes JC, Martinez Tellez E, Belda Sanchis J, Planas Canovas G, Libreros Niño A, Guarino M, Hernández Ferrandez J, Moral Duarte A. Are the minimally invasive techniques the new gold standard in thymus surgery for myasthenia gravis? Experience of a reference single-site in VATS thymectomy. Front Neurol 2024; 15:1309173. [PMID: 38361645 PMCID: PMC10867208 DOI: 10.3389/fneur.2024.1309173] [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: 10/07/2023] [Accepted: 01/04/2024] [Indexed: 02/17/2024] Open
Abstract
The thymus is the primary lymphoid organ responsible for the maturation and proliferation of T lymphocytes. During the first years of our lives, the activation and inactivation of T lymphocytes occur within the thymus, facilitating the correct maturation of central immunity. Alterations in the positive and negative selection of T lymphocytes have been studied as the possible origins of autoimmune diseases, with Myasthenia Gravis (MG) being the most representative example. Structural alterations in the thymus appear to be involved in the initial autoimmune response observed in MG, leading to the consideration of thymectomy as part of the treatment for the disease. However, the role of thymectomy in MG has been a subject of controversy for many years. Several publications raised doubts about the lack of evidence justifying thymectomy's role in MG until 2016 when a randomized study comparing thymectomy via sternotomy plus prednisone versus prednisone alone was published in the New England Journal of Medicine (NEJM). The results clearly favored the group of patients who underwent surgery, showing improvements in symptoms, reduced corticosteroid requirements, and fewer recurrences over 3 years of follow-up. In recent years, the emergence of less invasive surgical techniques has made video-assisted or robotic-assisted thoracoscopic (VATS/RATS) thymectomy more common, replacing the traditional sternotomy approach. Despite the increasing use of VATS, it has not been validated as a technique with lower morbidity compared to sternotomy in the treatment of MG. The results of the 2016 trial highlighted the benefits of thymectomy, but all the patients underwent surgery via sternotomy. Our hypothesis is that VATS thymectomy is a technique with lower morbidity, reduced postoperative pain, and shorter postoperative hospital stays than sternotomy. Additionally, VATS offers better clinical improvement in patients with MG. The primary objective of this study is to validate the VATS technique as the preferred approach for thymectomy. Furthermore, we aim to analyze the impact of VATS thymectomy on symptoms and corticosteroid dosage in patients with MG, identifying factors that may predict a better response to surgery.
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Affiliation(s)
- Juan Carlos Trujillo Reyes
- Department of Thoracic Surgery, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
- Department of Surgery, Faculty of Medicine, Autonomous University of Barcelona, Bellaterra, Spain
| | - Elisabeth Martinez Tellez
- Department of Thoracic Surgery, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
- Department of Surgery, Faculty of Medicine, Autonomous University of Barcelona, Bellaterra, Spain
| | - Josep Belda Sanchis
- Department of Thoracic Surgery, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
- Department of Surgery, Faculty of Medicine, Autonomous University of Barcelona, Bellaterra, Spain
| | | | | | - Mauro Guarino
- Department of Thoracic Surgery, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | | | - Antonio Moral Duarte
- Department of Surgery, Faculty of Medicine, Autonomous University of Barcelona, Bellaterra, Spain
- Department of General Surgery, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
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20
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Zhang P, Liu Y, Chen S, Zhang X, Wang Y, Zhang H, Li J, Yang Z, Xiong K, Duan S, Zhang Z, Wang Y, Wang P. Distribution of multi-level B cell subsets in thymoma and thymoma-associated myasthenia gravis. Sci Rep 2024; 14:2674. [PMID: 38302676 PMCID: PMC10834956 DOI: 10.1038/s41598-024-53250-6] [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: 06/06/2023] [Accepted: 01/30/2024] [Indexed: 02/03/2024] Open
Abstract
B-cell subsets in peripheral blood (PB) and tumor microenvironment (TME) were evaluated to determine myasthenia gravis (MG) severity in patients with thymoma-associated MG (TMG) and the distribution of B cells in type B TMG. The distribution of mature B cells, including Bm1-Bm5, CD19+ and CD20+ B cells and non-switched (NSMBCs) and switched (SMBCs) memory B cells, were determined in 79 patients with thymoma or TMG. Quantitative relationships between the T and TMG groups and the TMG-low and TMG-high subgroups were determined. NSMBCs and SMBCs were compared in TME and PB. Type B thymoma was more likely to develop into MG, with types B2 and B3 being especially associated with MG worsening. The percentage of CD19+ B cells in PB gradually increased, whereas the percentage of CD20+ B cells and the CD19/CD20 ratio were not altered. The (Bm2 + Bm2')/(eBm5 + Bm5) index was significantly higher in the TMG-high than in thymoma group. The difference between SMBC/CD19+ and NSMBC/CD19+ B cell ratios was significantly lower in the thymoma than TMG group. NSMBCs assembled around tertiary lymphoid tissue in thymomas of patients with TMG. Few NSMBCs were observed in patients with thymoma alone, with these cells being diffusely distributed. MG severity in patients with TMG can be determined by measuring CD19+ B cells and Bm1-Bm5 in PB. The CD19/CD20 ratio is a marker of disease severity in TMG patients. Differences between NSMBCs and SMBCs in PB and TME of thymomas can synergistically determine MG severity in patients with TMG.
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Affiliation(s)
- Peng Zhang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China.
| | - Yuxin Liu
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Si Chen
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Xinyu Zhang
- School of Medicine, University of Dundee, Dundee, UK
| | - Yuanguo Wang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Hui Zhang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Jian Li
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Zhaoyu Yang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Kai Xiong
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Shuning Duan
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Zeyang Zhang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Yan Wang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Anshan Road No. 154, Heping District, Tianjin, 300052, China
| | - Ping Wang
- Tianjin Ruichuang Biological Technology Co. Ltd, Tianjin, China
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21
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Iorio R. Myasthenia gravis: the changing treatment landscape in the era of molecular therapies. Nat Rev Neurol 2024; 20:84-98. [PMID: 38191918 DOI: 10.1038/s41582-023-00916-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2023] [Indexed: 01/10/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder that affects the neuromuscular junction, leading to muscle weakness and fatigue. MG is caused by antibodies against the acetylcholine receptor (AChR), the muscle-specific kinase (MuSK) or other AChR-related proteins that are expressed in the postsynaptic muscle membrane. The standard therapeutic approach for MG has relied on acetylcholinesterase inhibitors, corticosteroids and immunosuppressants, which have shown good efficacy in improving MG-related symptoms in most people with the disease; however, these therapies can carry a considerable burden of long-term adverse effects. Moreover, up to 15% of individuals with MG exhibit limited or no response to these standard therapies. The emergence of molecular therapies, including monoclonal antibodies, B cell-depleting agents and chimeric antigen receptor T cell-based therapies, has the potential to revolutionize the MG treatment landscape. This Review provides a comprehensive overview of the progress achieved in molecular therapies for MG associated with AChR antibodies and MuSK antibodies, elucidating both the challenges and the opportunities these therapies present to the field. The latest developments in MG treatment are described, exploring the potential for personalized medicine approaches.
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Affiliation(s)
- Raffaele Iorio
- Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy.
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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22
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Wang S, Wang Q, Jin L, Dong J, Ding J. Efgartigimod is a new option for the treatment of thymoma associated myasthenia gravis: A case report. Int J Surg Case Rep 2024; 115:109241. [PMID: 38219512 PMCID: PMC10826335 DOI: 10.1016/j.ijscr.2024.109241] [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: 11/17/2023] [Revised: 01/04/2024] [Accepted: 01/05/2024] [Indexed: 01/16/2024] Open
Abstract
INTRODUCTION The perioperative efficacy and safety of efgartigimod in patients with thymoma associated myasthenia gravis have not been reported. CASE PRESENTATION We described the case of a 47-year-old woman who presented thymoma associated myasthenia gravis. Primarily, the patient was treated with acetylcholinesterase inhibitors, immunosuppressive medications, and intravenous immunoglobulin. Unfortunately, the control of symptoms was unsatisfactory. The patient was treated with recommended dosage of efgartigimod (10 mg/kg administered as a 1 h intravenous infusion once weekly for 2 weeks) combined with immunosuppressive therapy. Consequently, improved outcomes and rapid clinical remission were observed. Then, modified subxiphoid thoracoscopic thymectomy was performed smoothly and the patient was discharged from hospital after recovery in short time. DISCUSSION Administration of efgartigimod could control symptoms significantly and rapidly. Efgartigimod provides the opportunity of thymectomy in short time. Importantly, there was no any perioperative complication or any adverse event related to efgartigimod. CONCLUSION The improved outcomes of the patient with thymoma associated myasthenia gravis highlight the importance of efgartigimod. Large-scale clinical trials are needed to validate the safety and efficacy of efgartigimod during the perioperative period of thymectomy.
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Affiliation(s)
- Shuai Wang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan university, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan university, Shanghai 200032, China
| | - Qin Wang
- Cancer Center, Zhongshan Hospital, Fudan university, Shanghai 200032, China; Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Lirong Jin
- Cancer Center, Zhongshan Hospital, Fudan university, Shanghai 200032, China; Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jihong Dong
- Cancer Center, Zhongshan Hospital, Fudan university, Shanghai 200032, China; Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Jianyong Ding
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan university, Shanghai 200032, China; Cancer Center, Zhongshan Hospital, Fudan university, Shanghai 200032, China.
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Liu Y, Chen S, Wang Y, Zhang Z, Zhang H, Wang Z, Tao Z, Wang J, Zhang P. Dexamethasone improves thymoma-associated myasthenia gravis via the AKT-mTOR pathway. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024; 397:817-828. [PMID: 37498332 PMCID: PMC10791733 DOI: 10.1007/s00210-023-02641-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 07/19/2023] [Indexed: 07/28/2023]
Abstract
Clinically, thymoma patients are often complicated with myasthenia gravis (MG). Dexamethasone, a glucocorticoid with anti-inflammatory effects, could be used as an immunosuppressant for thymoma-associated MG, but the mechanism of action remains to be explored. In this study, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis, weighted gene co-expression network analysis (WGCNA) of potential targets was performed by screening the intersection targets of dexamethasone and thymoma-associated MG from the database. Furthermore, the key targets and core active components were identified by topological analysis of the protein-protein interaction (PPI) network. Molecular docking technology was applied to screen the complexes with stable binding of dexamethasone and core targets. Patients with thymoma were divided into two groups according to whether they received dexamethasone before operation, and immunohistochemistry and western blot were used to verify the selected target of dexamethasone in treating thymoma-associated MG. The results showed that the action pathway of dexamethasone on the disease was closely enriched to phosphatidylinositol 3-kinase (PI3K)-protein kinase B (PKB/AKT), mammalian target of rapamycin (mTOR) signaling pathways. The expressions of AKT1 and its downstream molecule mTOR in the thymoma microenvironment of thymoma-associated MG patients who did not receive dexamethasone before operation were higher than those in the group receiving dexamethasone before operation. This study demonstrates that dexamethasone can promote apoptosis through the AKT-mTOR pathway for the treatment of thymoma-associated MG, as validated by network pharmacology predictions and clinical specimen experiments, and can be verified by large-scale clinical trials in the future. This study also provides theoretical support and new research perspectives for this disease.
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Affiliation(s)
- Yuxin Liu
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Si Chen
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Yan Wang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zeyang Zhang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hui Zhang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Ziyi Wang
- School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Ziyou Tao
- Department of Thoracic Surgery, The First Affiliated Hospital of Zhengzhou University, No.1 Jianshe East Road, Zhengzhou, China
| | - Jianyao Wang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Peng Zhang
- Department of Cardiovascular Thoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China.
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24
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Shibuya M, Shichiji M, Ikeda M, Kodama K, Miyabayashi T, Sato R, Okubo Y, Endo W, Inui T, Togashi N, Nagao M, Sato K, Sato T, Kanzaki M, Segawa O, Masui K, Ishigaki K, Haginoya K. The Clinical Course and Treatment of a Case of Refractory Systemic Juvenile Myasthenia Gravis Successfully Treated with Thymectomy. TOHOKU J EXP MED 2024; 262:29-31. [PMID: 37967941 DOI: 10.1620/tjem.2023.j094] [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] [Indexed: 11/17/2023]
Abstract
Juvenile myasthenia gravis (JMG) exhibits a more favorable response to glucocorticoids and has a better prognosis than adult myasthenia gravis. However, no established treatment exists for refractory JMG. Although thymectomy has been performed in several patients with refractory systemic JMG, there are few detailed clinical descriptions of patients who underwent thymectomy. Here, we present the case of a 10-year-old boy with refractory systemic JMG who was successfully treated with thymectomy. The patient developed symptoms, including dysphagia, malaise, diurnal ptosis, and weakness in the trunk muscles, and he was diagnosed with generalized JMG. Despite undergoing various treatments, including steroids, tacrolimus, steroid pulse therapy, intravenous immunoglobulin, azathioprine (AZT), and rituximab, his symptoms did not improve. Therefore, he underwent a thoracoscopic thymectomy 24 months after disease onset. Thymectomy led to remission, as demonstrated by a significant reduction in the quantitative myasthenia gravis score and anti-acetylcholine receptor antibody levels, which persisted for 43 months after surgery. Our case demonstrates the effectiveness of thymectomy in systemic JMG patients with positive anti-acetylcholine receptor antibodies, despite therapeutic failure with AZT and rituximab, within 2 years of disease onset.
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Affiliation(s)
- Moriei Shibuya
- Department of Pediatric Neurology, Miyagi Children's Hospital
| | - Minobu Shichiji
- Department of Pediatrics, Tokyo Women's Medical University School of Medicine
| | - Miki Ikeda
- Department of Pediatric Neurology, Miyagi Children's Hospital
| | - Kaori Kodama
- Department of Pediatric Neurology, Miyagi Children's Hospital
| | | | - Ryo Sato
- Department of Pediatric Neurology, Miyagi Children's Hospital
| | - Yukimune Okubo
- Department of Pediatric Neurology, Miyagi Children's Hospital
| | - Wakaba Endo
- Department of Pediatric Neurology, Miyagi Children's Hospital
| | - Takehiko Inui
- Department of Pediatric Neurology, Miyagi Children's Hospital
| | - Noriko Togashi
- Department of Pediatric Neurology, Miyagi Children's Hospital
| | - Mika Nagao
- Department of Pediatrics, Ohta Nishinouchi Hospital
| | - Kaname Sato
- Department of Pediatrics, Ohta Nishinouchi Hospital
| | - Takatoshi Sato
- Department of Pediatrics, Tokyo Women's Medical University School of Medicine
| | - Masato Kanzaki
- Department of Thoracic Surgery, Tokyo Women's Medical University
| | - Osamu Segawa
- Department of Pediatric Surgery, Tokyo Women's Medical University
| | - Kenta Masui
- Department of Surgical Pathology, Tokyo Women's Medical University
| | - Keiko Ishigaki
- Department of Pediatrics, Tokyo Women's Medical University School of Medicine
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25
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Sicolo E, Zirafa CC, Romano G, Brandolini J, De Palma A, Bongiolatti S, Gallina FT, Ricciardi S, Maestri M, Guida M, Morganti R, Carleo G, Mugnaini G, Tajè R, Calabró F, Lenzini A, Davini F, Cardillo G, Facciolo F, Voltolini L, Marulli G, Solli P, Melfi F. National Multicenter Study on the Comparison of Robotic and Open Thymectomy for Thymic Neoplasms in Myasthenic Patients: Surgical, Neurological and Oncological Outcomes. Cancers (Basel) 2024; 16:406. [PMID: 38254894 PMCID: PMC10814766 DOI: 10.3390/cancers16020406] [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: 12/29/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
Thymectomy is the gold standard in the treatment of thymic neoplasm and plays a key role in the therapeutic path of myasthenia gravis. For years, sternotomy has been the traditional approach for removing anterior mediastinal lesions, although the robotic thymectomy is now widely performed. The literature is still lacking in papers comparing the two approaches and evaluating long-term oncological and neurological outcomes. This study aims to analyze the postoperative results of open and robotic thymectomy for thymic neoplasms in myasthenic patients. Surgical, oncological and neurological data of myasthenic patients affected by thymic neoplasms and surgically treated with extended thymectomy, both with the open and the robotic approach, in six Italian Thoracic Centers between 2011 and 2021 were evaluated. A total of 213 patients were enrolled in the study: 110 (51.6%) were treated with the open approach, and 103 (48.4%) were treated with robotic surgery. The open surgery, compared with the robotic, presented a shorter operating time (p < 0.001), a higher number of postoperative complications (p = 0.038) and longer postoperative hospitalization (p = 0.006). No other differences were observed in terms of surgical, oncological or neurological outcomes. The robotic approach can be considered safe and feasible, comparable to the open technique, in terms of surgical, oncological and neurological outcomes.
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Affiliation(s)
- Elisa Sicolo
- Minimally Invasive and Robotic Thoracic Surgery—Surgical, Medical, Molecular and Critical Care Pathology Department, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (G.R.); (F.C.); (A.L.); (F.D.); (F.M.)
| | - Carmelina Cristina Zirafa
- Minimally Invasive and Robotic Thoracic Surgery—Surgical, Medical, Molecular and Critical Care Pathology Department, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (G.R.); (F.C.); (A.L.); (F.D.); (F.M.)
| | - Gaetano Romano
- Minimally Invasive and Robotic Thoracic Surgery—Surgical, Medical, Molecular and Critical Care Pathology Department, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (G.R.); (F.C.); (A.L.); (F.D.); (F.M.)
| | - Jury Brandolini
- Department of Thoracic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (J.B.); (P.S.)
| | - Angela De Palma
- Unit of Thoracic Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, 70121 Bari, Italy; (A.D.P.); (G.C.); (G.M.)
| | - Stefano Bongiolatti
- Thoracic Surgery Unit, Department of Experimental and Clinical Medicine, Careggi University Hospital, 50134 Florence, Italy; (S.B.); (G.M.); (L.V.)
| | - Filippo Tommaso Gallina
- Thoracic Surgery Unit IRCCS Regina Elena National Cancer Center, 00144 Rome, Italy; (F.T.G.); (R.T.); (F.F.)
| | - Sara Ricciardi
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy; (S.R.); (G.C.)
| | - Michelangelo Maestri
- Neurology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, 56124 Pisa, Italy; (M.M.)
| | - Melania Guida
- Neurology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, 56124 Pisa, Italy; (M.M.)
| | - Riccardo Morganti
- Section of Statistics, University Hospital of Pisa, 56124 Pisa, Italy;
| | - Graziana Carleo
- Unit of Thoracic Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, 70121 Bari, Italy; (A.D.P.); (G.C.); (G.M.)
| | - Giovanni Mugnaini
- Thoracic Surgery Unit, Department of Experimental and Clinical Medicine, Careggi University Hospital, 50134 Florence, Italy; (S.B.); (G.M.); (L.V.)
| | - Riccardo Tajè
- Thoracic Surgery Unit IRCCS Regina Elena National Cancer Center, 00144 Rome, Italy; (F.T.G.); (R.T.); (F.F.)
| | - Fabrizia Calabró
- Minimally Invasive and Robotic Thoracic Surgery—Surgical, Medical, Molecular and Critical Care Pathology Department, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (G.R.); (F.C.); (A.L.); (F.D.); (F.M.)
| | - Alessandra Lenzini
- Minimally Invasive and Robotic Thoracic Surgery—Surgical, Medical, Molecular and Critical Care Pathology Department, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (G.R.); (F.C.); (A.L.); (F.D.); (F.M.)
| | - Federico Davini
- Minimally Invasive and Robotic Thoracic Surgery—Surgical, Medical, Molecular and Critical Care Pathology Department, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (G.R.); (F.C.); (A.L.); (F.D.); (F.M.)
| | - Giuseppe Cardillo
- Unit of Thoracic Surgery, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy; (S.R.); (G.C.)
| | - Francesco Facciolo
- Thoracic Surgery Unit IRCCS Regina Elena National Cancer Center, 00144 Rome, Italy; (F.T.G.); (R.T.); (F.F.)
| | - Luca Voltolini
- Thoracic Surgery Unit, Department of Experimental and Clinical Medicine, Careggi University Hospital, 50134 Florence, Italy; (S.B.); (G.M.); (L.V.)
| | - Giuseppe Marulli
- Unit of Thoracic Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari “Aldo Moro”, 70121 Bari, Italy; (A.D.P.); (G.C.); (G.M.)
| | - Piergiorgio Solli
- Department of Thoracic Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (J.B.); (P.S.)
| | - Franca Melfi
- Minimally Invasive and Robotic Thoracic Surgery—Surgical, Medical, Molecular and Critical Care Pathology Department, University Hospital of Pisa, 56124 Pisa, Italy; (C.C.Z.); (G.R.); (F.C.); (A.L.); (F.D.); (F.M.)
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26
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Tannemaat MR, Huijbers MG, Verschuuren JJGM. Myasthenia gravis-Pathophysiology, diagnosis, and treatment. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:283-305. [PMID: 38494283 DOI: 10.1016/b978-0-12-823912-4.00026-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by dysfunction of the neuromuscular junction resulting in skeletal muscle weakness. It is equally prevalent in males and females, but debuts at a younger age in females and at an older age in males. Ptosis, diplopia, facial bulbar weakness, and limb weakness are the most common symptoms. MG can be classified based on the presence of serum autoantibodies. Acetylcholine receptor (AChR) antibodies are found in 80%-85% of patients, muscle-specific kinase (MuSK) antibodies in 5%-8%, and <1% may have low-density lipoprotein receptor-related protein 4 (Lrp4) antibodies. Approximately 10% of patients are seronegative for antibodies binding the known disease-related antigens. In patients with AChR MG, 10%-20% have a thymoma, which is usually detected at the onset of the disease. Important differences between clinical presentation, treatment responsiveness, and disease mechanisms have been observed between these different serologic MG classes. Besides the typical clinical features and serologic testing, the diagnosis can be established with additional tests, including repetitive nerve stimulation, single fiber EMG, and the ice pack test. Treatment options for MG consist of symptomatic treatment (such as pyridostigmine), immunosuppressive treatment, or thymectomy. Despite the treatment with symptomatic drugs, steroid-sparing immunosuppressants, intravenous immunoglobulins, plasmapheresis, and thymectomy, a large proportion of patients remain chronically dependent on corticosteroids (CS). In the past decade, the number of treatment options for MG has considerably increased. Advances in the understanding of the pathophysiology have led to new treatment options targeting B or T cells, the complement cascade, the neonatal Fc receptor or cytokines. In the future, these new treatments are likely to reduce the chronic use of CS, diminish side effects, and decrease the number of patients with refractory disease.
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Affiliation(s)
- Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje G Huijbers
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
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27
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Keehn CC, Yazdian A, Hunt PJ, Davila-Siliezar P, Laylani NA, Lee AG. Monoclonal antibodies in neuro-ophthalmology. Saudi J Ophthalmol 2024; 38:13-24. [PMID: 38628411 PMCID: PMC11017005 DOI: 10.4103/sjopt.sjopt_256_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 11/12/2023] [Accepted: 11/14/2023] [Indexed: 04/19/2024] Open
Abstract
Neuro-ophthalmologic diseases include a broad range of disorders affecting the afferent and efferent visual pathways. Recently, monoclonal antibody (mAb) therapies have emerged as a promising targeted approach in the management of several of these complex conditions. Here, we describe the mechanism-specific applications and advancements in neuro-ophthalmologic mAb therapies. The application of mAbs in neuro-ophthalmologic diseases highlights our increasing understanding of disease-specific mechanisms in autoimmune conditions such as neuromyelitis optica, thyroid eye disease, and myasthenia gravis. Due to the specificity of mAb therapies, applications in neuro-ophthalmologic diseases have yielded exceptional clinical outcomes, including both reduced rate of relapse and progression to disability, visual function preservation, and quality of life improvement. These advancements have not only expanded the range of treatable neuro-ophthalmologic diseases but also reduced adverse events and increased the response rate to treatment. Further research into neuro-ophthalmologic disease mechanisms will provide accurate and specific targeting of important disease mediators through applications of future mAbs. As our understanding of these diseases and the relevant therapeutic targets evolve, we will continue to build on our understanding of how mAbs interfere with disease pathogenesis, and how these changes improve clinical outcomes and quality of life for patients.
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Affiliation(s)
- Caroline C. Keehn
- Department of Ophthalmology, Baylor College of Medicine, Houston, USA
| | - Arman Yazdian
- Department of Ophthalmology, Baylor College of Medicine, Houston, USA
| | - Patrick J. Hunt
- Department of Ophthalmology, Baylor College of Medicine, Houston, USA
| | - Pamela Davila-Siliezar
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, USA
| | - Noor A. Laylani
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, USA
| | - Andrew G. Lee
- Department of Ophthalmology, Baylor College of Medicine, Houston, USA
- Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, USA
- Department of Ophthalmology, The University of Texas MD Anderson Cancer Center, Houston, USA
- Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, USA
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, USA
- Department of Ophthalmology, Texas A and M College of Medicine, Bryan, Texas, USA
- Department of Ophthalmology, University of Buffalo, Buffalo, NY, USA
- Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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28
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Tian Y, Shen Q, Peng S, Meng L, Fang R, Xiong A, Li S, Yang Y, Chang W, Ni J, Zhu W. Mapping current trends and hotspots in myasthenia gravis from 2003 to 2022: a bibliometric analysis. Front Neurol 2023; 14:1320344. [PMID: 38213833 PMCID: PMC10782526 DOI: 10.3389/fneur.2023.1320344] [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: 10/12/2023] [Accepted: 12/15/2023] [Indexed: 01/13/2024] Open
Abstract
Introduction Research on myasthenia gravis (MG) has undergone rapid development in recent years. This article aimed to elucidate the characteristics of MG publications over the past 20 years and analyze emerging trends using bibliometric methods. Methods Information on MG articles was obtained from the Web of Science Core Collection and stored in Excel for quantitative analyses. Bibliometric analyses were performed using CiteSpace and VOSviewer to visualize publications according to countries/regions, institutions, journals, and authors. Results A total of 3,610 publications were included in the analysis. The USA had the highest number of publications (NP) and H-index. Among the institutions, the University of Oxford had the highest NP, followed by the University of Toronto and Duke University. Close cooperation was observed among countries and institutions. The most productive author was Renato Mantegazza, followed by Jan J. Verschuuren, and Amelia Evoli. Muscle & Nerve published the most articles on MG, followed by the Journal of Neuroimmunology and Neuromuscular Disorders. The keyword with the highest strength is "neuromuscular transmission," followed by "safety" and "rituximab." Co-citation analysis includes 103 publications cited at least 65 times, categorized into four clusters. Additionally, 123 keywords cited more than 40 times were analyzed and divided into five clusters. Conclusion This bibliometric analysis shows the framework of research over the past 20 years by mapping the scholarly contributions of various countries or regions, institutions, journals, and authors in MG. The analysis also explores future trends and prospective directions, emphasizing individualized treatment based on subtypes, novel immunotherapeutic approaches, and thymectomy.
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Affiliation(s)
- Yukun Tian
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Qiqi Shen
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Siyang Peng
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Linghao Meng
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Ruiying Fang
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Anni Xiong
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Shaohong Li
- Treatment Center of Traditional Chinese Medicine Bo’ai Hospital, China Rehabilitation Research Center, Beijing, China
| | - Yajing Yang
- Department of Traditional Chinese Medicine, Yuyuantan Community Health Center, Beijing, China
| | - Weiqian Chang
- Department of Acupuncture, Guang’anmen Hospital, Chinese Academy of Traditional Chinese Medicine Ji’nan Hospital (Ji’nan Hospital of Traditional Chinese Medicine), Jinan, Shandong, China
| | - Jinxia Ni
- Department of Acupuncture, Dongzhimen Hospital of Beijing University of Traditional Chinese Medicine, Beijing, China
| | - Wenzeng Zhu
- Department of Acupuncture, Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Wiendl H, Abicht A, Chan A, Della Marina A, Hagenacker T, Hekmat K, Hoffmann S, Hoffmann HS, Jander S, Keller C, Marx A, Melms A, Melzer N, Müller-Felber W, Pawlitzki M, Rückert JC, Schneider-Gold C, Schoser B, Schreiner B, Schroeter M, Schubert B, Sieb JP, Zimprich F, Meisel A. Guideline for the management of myasthenic syndromes. Ther Adv Neurol Disord 2023; 16:17562864231213240. [PMID: 38152089 PMCID: PMC10752078 DOI: 10.1177/17562864231213240] [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: 05/26/2023] [Accepted: 10/23/2023] [Indexed: 12/29/2023] Open
Abstract
Myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS), and congenital myasthenic syndromes (CMS) represent an etiologically heterogeneous group of (very) rare chronic diseases. MG and LEMS have an autoimmune-mediated etiology, while CMS are genetic disorders. A (strain dependent) muscle weakness due to neuromuscular transmission disorder is a common feature. Generalized MG requires increasingly differentiated therapeutic strategies that consider the enormous therapeutic developments of recent years. To include the newest therapy recommendations, a comprehensive update of the available German-language guideline 'Diagnostics and therapy of myasthenic syndromes' has been published by the German Neurological society with the aid of an interdisciplinary expert panel. This paper is an adapted translation of the updated and partly newly developed treatment guideline. It defines the rapid achievement of complete disease control in myasthenic patients as a central treatment goal. The use of standard therapies, as well as modern immunotherapeutics, is subject to a staged regimen that takes into account autoantibody status and disease activity. With the advent of modern, fast-acting immunomodulators, disease activity assessment has become pivotal and requires evaluation of the clinical course, including severity and required therapies. Applying MG-specific scores and classifications such as Myasthenia Gravis Activities of Daily Living, Quantitative Myasthenia Gravis, and Myasthenia Gravis Foundation of America allows differentiation between mild/moderate and (highly) active (including refractory) disease. Therapy decisions must consider age, thymic pathology, antibody status, and disease activity. Glucocorticosteroids and the classical immunosuppressants (primarily azathioprine) are the basic immunotherapeutics to treat mild/moderate to (highly) active generalized MG/young MG and ocular MG. Thymectomy is indicated as a treatment for thymoma-associated MG and generalized MG with acetylcholine receptor antibody (AChR-Ab)-positive status. In (highly) active generalized MG, complement inhibitors (currently eculizumab and ravulizumab) or neonatal Fc receptor modulators (currently efgartigimod) are recommended for AChR-Ab-positive status and rituximab for muscle-specific receptor tyrosine kinase (MuSK)-Ab-positive status. Specific treatment for myasthenic crises requires plasmapheresis, immunoadsorption, or IVIG. Specific aspects of ocular, juvenile, and congenital myasthenia are highlighted. The guideline will be further developed based on new study results for other immunomodulators and biomarkers that aid the accurate measurement of disease activity.
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Affiliation(s)
- Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building A1, Münster 48149, Germany
| | - Angela Abicht
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Andrew Chan
- Universitätsklinik für Neurologie, Inselspital Bern, Bern, Switzerland
| | - Adela Della Marina
- Klinik für Kinderheilkunde I, Universitätsklinikum Essen, Essen, Germany
| | - Tim Hagenacker
- Klinik für Neurologie, Universitätsklinikum Essen, Essen, Germany
| | | | - Sarah Hoffmann
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
| | | | - Sebastian Jander
- Klinik für Neurologie, Marien Hospital Düsseldorf, Düsseldorf, Germany
| | - Christian Keller
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Alexander Marx
- Pathologisches Institut, Universitätsklinikum Mannheim, Mannheim, Germany
| | - Arthur Melms
- Facharztpraxis für Neurologie und Psychiatrie, Stuttgart, Germany
| | - Nico Melzer
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | - Wolfgang Müller-Felber
- Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, LMU Munich, Munich, Germany
| | - Marc Pawlitzki
- Klinik für Neurologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany
| | | | | | - Benedikt Schoser
- Friedrich-Baur-Institut an der Neurologischen Klinik und Poliklinik, LMU Munich, Munich, Germany
| | - Bettina Schreiner
- Klinik für Neurologie, Universitätsspital Zürich, Zürich, Switzerland
| | - Michael Schroeter
- Klinik und Poliklinik für Neurologie, Uniklinik Cologne, Cologne, Germany
| | | | | | - Fritz Zimprich
- Universitätsklinik für Neurologie, AKH-Wien, Wien, Austria
| | - Andreas Meisel
- Charité – Universitätsmedizin Berlin, Klinik für Neurologie mit Experimenteller Neurologie, Berlin, Germany
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Sansoni J, Menon N, Viali L, White S, Vucic S. Clinical features, treatments, their impact, and quality of life for Myasthenia Gravis patients in Australia. J Clin Neurosci 2023; 118:16-22. [PMID: 37844489 DOI: 10.1016/j.jocn.2023.09.023] [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: 04/08/2023] [Revised: 07/07/2023] [Accepted: 09/28/2023] [Indexed: 10/18/2023]
Abstract
This survey provides an update on the experience of Myasthenia Gravis (MG) patients in Australia. Items were drawn from the 2011 Australian Survey and a 2019 US survey allowing for comparative discussion of survey findings. Patients were recruited through the Myasthenia Alliance Australia. Following consent, patients completed an online survey using REDCap software. Questions included demographics, clinical features, treatment side-effects and quality of life (QOL) scales. Samples for completion of survey sections ranged from N = 242-280 representing a power level of over 80%. Female and seronegative patients reported a significantly greater symptom load, earlier disease onset, longer time to diagnosis, more MG exacerbations, treatment side-effects, and poorer QOL. For exacerbation management there was a higher rate of oral corticosteroid use (66%), a lower use of Intravenous Immunoglobulin (IVIg, 47%) and particularly, Therapeutic Plasma Exchange (TPE, 4.5%) within this sample. Although steroid induced side-effects were rarer (9-34%), a comparatively high use of corticosteroids was reported for current and overall treatments including those for MG crises (52-83%). Common treatment side-effects reported by 57-85% of patients, included fatigue, weight gain, a decrease in the ability to fight infections, gastrointestinal symptoms, and muscle weakness. The impact of MG on daily activities and QOL was considerable, but those who had a thymectomy reported better QOL. The survey identified areas for potential practice improvement in MG treatments (corticosteroids, IVIg, TPE), particularly for exacerbation management, and review is recommended. Further research on gender and antibody status differentials regarding clinical features is required.
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Affiliation(s)
- Janet Sansoni
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia; Health Outcomes Collaboration, 2 Bramston St, Fadden, ACT 2904, Australia.
| | - Nidhi Menon
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia
| | - Lachlan Viali
- Biological Data Science Institute, Australian National University, Acton, ACT 2601, Australia
| | - Susan White
- Myasthenia Alliance Australia, 17 Aldridge Ave, Corrimal East, NSW 2518, Australia; Myasthenia Gravis Association of Queensland Inc., PO Box16, Mt Gravatt, Queensland 4122, Australia
| | - Steve Vucic
- Brain and Nerve Research Centre, University of Sydney Concord Clinical School, Concord, NSW 2139, Australia
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31
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Saccà F, Pane C, Espinosa PE, Sormani MP, Signori A. Efficacy of innovative therapies in myasthenia gravis: A systematic review, meta-analysis and network meta-analysis. Eur J Neurol 2023; 30:3854-3867. [PMID: 37204031 DOI: 10.1111/ene.15872] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/17/2023] [Accepted: 05/15/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND AND PURPOSE Therapy for myasthenia gravis (MG) is undergoing a profound change, with new treatments being tested. These include complement inhibitors and neonatal Fc receptor (FcRn) blockers. The aim of this study was to perform a meta-analysis and network meta-analysis of randomized and placebo-controlled trials of innovative therapies in MG with available efficacy data. METHODS We assessed statistical heterogeneity across trials based on the Cochrane Q test and I2 values, and mean differences were pooled using the random-effects model. Treatment efficacy was assessed after 26 weeks of eculizumab and ravulizumab, 28 days of efgartigimod, 43 days of rozanolixizumab, 12 weeks of zilucoplan, and 16, 24 or 52 weeks of rituximab treatment. RESULTS We observed an overall mean Myasthenia Gravis-Activities of Daily Living scale (MG-ADL) score change of -2.17 points (95% confidence interval [CI] -2.67, -1.67; p < 0.001) as compared to placebo. No significant difference emerged between complement inhibitors and anti-FcRn treatment (p = 0.16). The change in Quantitative Myasthenia Gravis scale (QMG) score was -3.46 (95% CI -4.53, -2.39; p < 0.001), with a higher reduction with FcRns (-4.78 vs. -2.60; p < 0.001). Rituximab did not significantly improve the MG-ADL (-0.92 [95% CI -2.24, 0.39]; p = 0.17) or QMG scores (-1.9 [95% CI -3.97, 0.18]; p = 0.07). In the network meta-analysis, efgartigimod had the highest probability of being the best treatment, followed by rozanolixizumab. CONCLUSION Anti-complement and FcRn treatments both proved to be effective in MG patients, whereas rituximab did not show a significant benefit for patients. Within the limitations of this meta-analysis, including efficacy time points, FcRn treatments showed a greater effect on QMG score in the short term. Real-life studies with long-term measurements are needed to confirm our results.
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Affiliation(s)
- Francesco Saccà
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, University "Federico II", Naples, Italy
| | - Chiara Pane
- Department of Neurosciences and Reproductive and Odontostomatological Sciences, University "Federico II", Naples, Italy
| | | | | | - Alessio Signori
- Department of Health Sciences, University of Genoa, Genoa, Italy
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Weidmayer SL, Gallagher G. Refractory generalized myasthenia gravis with myasthenic incomplete ophthalmoplegia successfully treated with eculizumab. Am J Ophthalmol Case Rep 2023; 32:101925. [PMID: 37711751 PMCID: PMC10498161 DOI: 10.1016/j.ajoc.2023.101925] [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: 03/21/2023] [Revised: 08/07/2023] [Accepted: 08/24/2023] [Indexed: 09/16/2023] Open
Abstract
Purpose This is a case of myasthenic incomplete ophthalmoplegia mimicking a partial cranial nerve 3 palsy both subjectively and objectively improving after treatment with eculizumab. Observations We chronicle a case of severe generalized myasthenia gravis including myasthenia masquerading as a partial cranial nerve 3 palsy, refractory to pyridostigmine, mycophenolate, prednisone, intravenous immunoglobulin and plasma exchange but responsive to eculizumab. Conclusions and importance This case demonstrates ocular and generalized myasthenia gravis refractory to several other therapies but amenable to eculizumab infusions, suggesting this medication may be of significant value in these difficult cases, and should be further explored for refractory ocular myasthenia gravis.
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Affiliation(s)
- Sara L. Weidmayer
- LTC Charles S. Kettles VA Medical Center, VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI, United States
- WK Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, 1000 Wall Street, Ann Arbor, MI, United States
| | - Gary Gallagher
- Department of Neurology, University of Michigan, 1500 E. Medical Center Dr #1914, Ann Arbor, MI, United States
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Sun J, Chen J, Xie Q, Sun M, Zhang W, Wang H, Liu N, Wang Q, Wang M. Sodium butyrate alleviates R97-116 peptide-induced myasthenia gravis in mice by improving the gut microbiota and modulating immune response. J Inflamm (Lond) 2023; 20:37. [PMID: 37924056 PMCID: PMC10625296 DOI: 10.1186/s12950-023-00363-w] [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: 05/09/2023] [Accepted: 10/17/2023] [Indexed: 11/06/2023] Open
Abstract
Fermented butyrate exhibits an anti-inflammatory response to maintain immune homeostasis within the gut. However, the effect and underlying mechanism of butyrate on myasthenia gravis (MG) remain unclear. The changes in the gut microbiota and fecal contents of SCFAs in MG patients were examined. R97-116 peptide was used to induce the experimental autoimmune myasthenia gravis (EAMG) mice and sodium butyrate (NaB) was gavaged to the EAMG mice. Gut microbiota, the frequency of Th1, Th17, Treg, Tfh, and B cells, the levels of IFN-γ, IL-17 A, IL-10, IL-21, and anti-R97-116 IgG, RNA-seq of total B cells in the spleen were explored by metagenomics, flow cytometry, ELISA, and transcriptomics. A significant reduction in SCFA-producing bacteria including Butyricimonas synergistica and functional modules including butyrate synthesis/production II was observed in MG patients and fecal SCFAs detection confirmed the increase. The EAMG mice were successfully constructed and NaB supplementation has changed the composition and function of the gut microbiota. The numbers of Th1, Th17, Tfh, and B cells were significantly increased while that of Treg cells was obviously decreased in EAMG mice compared with controls. Interestingly, NaB treatment has reduced the amounts of Th17, Tfh, and B cells but increased that of Treg cells. Accordingly, the levels of IL-17 A, IL-21, and IgG were increased while IL-10 was decreased in EAMG mice. However, NaB treatment reduced IL-17 A and IL-21 but increased that of IL-10. RNA-seq of B cells has revealed 4577 deferentially expressed genes (DEGs), in which 1218 DEGs were up-regulated while 3359 DEGs were down-regulated in NaB-treated EAMG mice. GO enrichment and KEGG pathway analysis unveiled that the function of these DEGs was mainly focused on immunoglobulin production, mitochondrial respiratory chain complex, ribosome, oxidative phosphorylation, and CNS diseases including amyotrophic lateral sclerosis. We have found that butyrate was significantly reduced in MG patients and NaB gavage could evidently improve MG symptoms in EAMG mice by changing the gut microbiota, regulating the immune response, and altering the gene expression and function of B cells, suggesting NaB might be a potential immunomodulatory supplement for MG drugs.
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Affiliation(s)
- Jing Sun
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Juanjuan Chen
- Cuiying Biomedical Research Center, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China
| | - Qinfang Xie
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Mengjiao Sun
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Wenjing Zhang
- Department of Neurology, Qinghai Provincial People's Hospital, Xining, 810007, China
| | - Hongxia Wang
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Ning Liu
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, 730030, China
| | - Qi Wang
- Cuiying Biomedical Research Center, Lanzhou University Second Hospital, Lanzhou, 730030, Gansu, China.
| | - Manxia Wang
- Department of Neurology, Lanzhou University Second Hospital, Lanzhou, 730030, China.
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De Boer C, Zeineddin S, Ott K, Hu A, Linton S, George M, Rao VK, Abdullah F, Chin A, Goldstein SD. Measuring the Efficacy of Thymectomy for Pediatric Myasthenia Gravis Across Tertiary Children's Hospitals. Pediatr Neurol 2023; 148:17-22. [PMID: 37651972 DOI: 10.1016/j.pediatrneurol.2023.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/23/2023] [Accepted: 07/31/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Thymectomy is a treatment for pediatric myasthenia gravis, but the efficacy over time is unknown. Multi-institutional data are also lacking. Therefore, the objective of this study was to determine the efficacy of thymectomy for pediatric myasthenia gravis using medication burden and health care utilization as proxies for disease severity. METHODS This was a cross-sectional study of the Pediatric Health Information System database among children who underwent thymectomy at one of 49 children's hospitals from 2004 to 2022. Differences in annual median number of doses of myasthenia-related medications, admissions, and health care costs in the year before thymectomy to three years after were compared. A comparison cohort that did not undergo thymectomy was utilized. Medians were compared using the Wilcoxon signed-rank test. Generalized linear regression estimated the effect of surgical approach on outcomes. RESULTS A total of451 patients (238 patients who underwent thymectomy and 213 nonthymectomy patients) were identified. Following thymectomy, the decrease in annual median total number of myasthenia-related doses was 12.0 (interquartile range: 6 to 31) (P < 0.001). The decrease in number of annual admissions was 2.0 (1 to 4) (P < 0.001), which represented a cost difference of $5292 ($3533 to $8681) (P < 0.001). No differences were observed in the control cohort. In a generalized linear regression model, surgical approach was not associated with the efficacy of thymectomy (P = 0.55). CONCLUSIONS Thymectomy is an effective treatment for pediatric myasthenia gravis, evidenced by the decreased medication burden and health care utilization after surgery. Surgical approach did not influence the success of surgery. Thymectomy should be considered earlier in the treatment algorithm.
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Affiliation(s)
- Christopher De Boer
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Katherine Ott
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michael George
- Division of Rheumatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vamshi K Rao
- Division of Neurology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Anthony Chin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Antozzi C, Mantegazza R. Impact of Ravulizumab on Patient Outcomes and Quality of Life in Generalized Myasthenia Gravis. Patient Relat Outcome Meas 2023; 14:305-312. [PMID: 37876920 PMCID: PMC10590807 DOI: 10.2147/prom.s408175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/21/2023] [Indexed: 10/26/2023] Open
Abstract
Myasthenia gravis (MG) is an autoimmune ion channel disorder in which antibodies to different end-plate antigens impair neuromuscular transmission, ultimately leading to muscle weakness and fatigability. In about 85% of patients with MG, autoantibodies against the acetylcholine receptor (AChR) activate the complement cascade, causing damage to the neuromuscular junction. MG is a chronic disorder for which standard therapies with corticosteroids, immunosuppressive drugs, and immunomodulation with plasma exchange or intravenous immunoglobulins modify the course of the disease, but the residual burden of physical, psychological, and social disability highlights several unmet needs, among these the need for specific, targeted, and well tolerated therapies able to improve the patients' quality of life. Complement inhibition paved the way to precision medicine in MG since, for the first time, a specific therapy targeting a crucial pathogenetic step has been designed, tested, and proven to be effective in a controlled fashion. Ravulizumab represents the first long-acting complement inhibitor approved for treatment of patients with generalized MG, able to provide rapid, complete, and sustained complement inhibition. Ravulizumab improved the MG Activity of Daily Living scale and other clinical parameters up to 26 weeks as shown by the CHAMPION MG trial, and by its open label extension, with the added value of being administered every 8 weeks. The schedule of administration is likely to improve patients' adherence and hence their quality of life. The introduction of complement inhibition will considerably change the traditional therapeutic strategy for MG.
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Affiliation(s)
- Carlo Antozzi
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
- Immunotherapy and Apheresis Departmental Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Renato Mantegazza
- Neuroimmunology and Neuromuscular Diseases Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
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Wilcke H, Glaubitz S, Kück F, Anten C, Liebetanz D, Schmidt J, Zschüntzsch J. Female sex and overweight are associated with a lower quality of life in patients with myasthenia gravis: a single center cohort study. BMC Neurol 2023; 23:366. [PMID: 37817097 PMCID: PMC10563278 DOI: 10.1186/s12883-023-03406-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 09/27/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Myasthenia gravis (MG) affects individuals as a chronic autoimmune disease for many years. Commonly, chronic diseases significantly reduce the patients' quality of life. Aiming to improve the future quality of life in MG, this study assessed the factors impacting quality of life. As gender-specific medicine is becoming increasingly important, this study also focused on understanding gender differences in the outcome of MG. METHODS The study is a combined monocentric, retrospective and prospective database analysis of patient records based on 2,370 presentations of 165 patients with clinically, serologically and/or electrophysiologically confirmed MG over an observation period of up to 47 years. The data collection included the following parameters: antibody status, disease severity, age, medication use, gender, and disease duration. In addition, a prospective survey was conducted on the quality of life using the Myasthenia gravis-specific 15-item Quality of Life scale (MG-QoL15) and on the activities of daily living using the MG-specific Activities of Daily Living scale (MG-ADL). RESULTS Of the 165 patients, 85 were male (51.5%) and 80 were female (48.5%). The remaining baseline characteristics (e.g. age and antibody status) were consistent with other myasthenia gravis cohorts. A high body mass index (BMI) (p = 0.005) and a high disease severity (p < 0.001) were significantly associated with lower disease-specific quality of life. Additionally, the quality of life in women with MG was significantly reduced compared to male patients (19.7 vs. 13.0 points in the MG-QoL15, p = 0.024). Gender differences were also observable in terms of the period between initial manifestation and initial diagnosis and women were significantly more impaired in their activities of daily living (MG-ADL) than men (4.8 vs. 3.0 points, p = 0.032). CONCLUSION Women with MG had significantly poorer disease specific quality of life compared to men as well as patients with a higher BMI. In order to improve the quality of life, gender-specific medicine and further investigation regarding a modification of the quality of life by lowering the BMI are essential and necessary. TRIAL REGISTRATION Study approval by the Ethics Committee of the University Medical Center Göttingen was granted (number 6/5/18).
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Affiliation(s)
- Hannah Wilcke
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Stefanie Glaubitz
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Fabian Kück
- Department of Medical Statistics, University Medical Center, Göttingen, Germany
| | - Christoph Anten
- Department of Medical Statistics, University Medical Center, Göttingen, Germany
| | - David Liebetanz
- Department of Neurology, University Medical Center, Göttingen, Germany
| | - Jens Schmidt
- Department of Neurology, University Medical Center, Göttingen, Germany
- Department of Neurology and Pain Treatment, Immanuel Clinic Rüdersdorf, University Hospital of the Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
| | - Jana Zschüntzsch
- Department of Neurology, University Medical Center, Göttingen, Germany.
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Sikorski P, Li Y, Cheema M, Wolfe GI, Kusner LL, Aban I, Kaminski HJ. Serum metabolomics of treatment response in myasthenia gravis. PLoS One 2023; 18:e0287654. [PMID: 37816000 PMCID: PMC10564178 DOI: 10.1371/journal.pone.0287654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/09/2023] [Indexed: 10/12/2023] Open
Abstract
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.
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Affiliation(s)
- Patricia Sikorski
- Department of Neurology & Rehabilitation Medicine, George Washington University, Washington, DC, United States of America
- Department of Pharmacology & Physiology, George Washington University, Washington, DC, United States of America
| | - Yaoxiang Li
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, United States of America
| | - Mehar Cheema
- Department of Neurology & Rehabilitation Medicine, George Washington University, Washington, DC, United States of America
| | - Gil I. Wolfe
- Department of Neurology, University at Buffalo/SUNY, Buffalo, New York, United States of America
| | - Linda L. Kusner
- Department of Pharmacology & Physiology, George Washington University, Washington, DC, United States of America
| | - Inmaculada Aban
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Henry J. Kaminski
- Department of Neurology & Rehabilitation Medicine, George Washington University, Washington, DC, United States of America
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Almodovar JL, Mehrabyan A. Disease-Based Prognostication: Myasthenia Gravis. Semin Neurol 2023; 43:799-806. [PMID: 37751854 DOI: 10.1055/s-0043-1775791] [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: 09/28/2023]
Abstract
Myasthenia gravis (MG) is an acquired autoimmune neuromuscular junction transmission disorder that clinically presents as fluctuating or persistent weakness in various skeletal muscle groups. Neuroprognostication in MG begins with some basic observations on the natural history of the disease and known treatment outcomes. Our objective is to provide a framework that can assist a clinician who encounters the MG patient for the first time and attempts to prognosticate probable outcomes in individual patients. In this review article, we explore clinical type, age of onset, antibody status, severity of disease, thymus pathology, autoimmune, and other comorbidities as prognostic factors in MG.
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Affiliation(s)
- Jorge L Almodovar
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Anahit Mehrabyan
- Department of Neurology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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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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Al Shammari A, Saad A, Saif LT, Othman SA, Ghosheh MJ, Khdeir GM, Alashgar O, Abu-Rayya MA, Ahmed MH, AlKattan K, Saleh W. Clinicodemographic characteristics and prognostic role of myasthenia gravis in thymoma: Experience from a Saudi population. Ann Thorac Med 2023; 18:211-216. [PMID: 38058787 PMCID: PMC10697300 DOI: 10.4103/atm.atm_61_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 06/10/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES The objectives of the study were to determine the clinicodemographic characteristics and the prognostic role of myasthenia gravis (MG) in thymoma. METHODS The records of patients who underwent surgical resection of thymoma at King Faisal Specialist Hospital and Research Center in the past 23 years were reviewed. Seventy thymoma patients were finally included and were then categorized based on MG status into the MG group (39 patients) and the non-MG group (31 patients). Collected data included patients' demographic characteristics, tumor characteristics, and postoperative clinical outcomes. All analyses were conducted using SPSS. The comparison between both groups was tested using the Student t-test and Chi-square test for continuous and categorical variables, respectively. A P = 0.05 or less indicated statistical significance. RESULTS Patients' age ranged from 11 to 76 years, and female predominance was observed (55.7%). Compared to the non-MG group, no difference in patients' gender was observed (P = 0.058); however, MG patients had a younger age (39.30 vs. 48.77, P = 0.0095). No difference was noted between both groups based on the World Health Organization classification (P = 0.398), but MG patients tended to present with less-advanced tumors based on the TNM classification (P = 0.039) and lower stage based on the MASAOKA staging system (P = 0.017). No significant change in tumor size (P = 0.077), resectability (P = 0.507), and adjuvant therapy (P = 0.075) were observed. MG was not significantly associated with postoperative complications, morbidity, or mortality. However, it exhibited a prognostic protective role in terms of lower recurrence (2.56% vs. 35.48%, P = 0.0001) and longer survival duration (18.62 vs. 10.21 years, P < 0.001) as compared to non-MG patients. CONCLUSIONS MG occurrence in thymoma patients is more likely to occur at a younger age, higher TNM classification, and advanced MASAOKA stage. Although no significant association was noted between MG and complications and mortality, MG exhibited a protective role in thymoma by providing a lower recurrence rate and longer survival duration.
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Affiliation(s)
- Abdullah Al Shammari
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Department of Thoracic Surgery, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Aida Saad
- Department of Thoracic Surgery, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Lama Tareq Saif
- Department of Thoracic Surgery, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Safy A. Othman
- Department of Thoracic Surgery, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Mohammad J. Ghosheh
- Department of Thoracic Surgery, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Ghadir M. Khdeir
- Department of Thoracic Surgery, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Omniyah Alashgar
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | | | - Khaled AlKattan
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Department of Thoracic Surgery, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Waleed Saleh
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Guan S, Long W, Liu Y, Cai B, Luo J. Prognosis of Concurrent Versus Sequential Chemo-Radiotherapy Induction Followed by Surgical Resection in Patients with Advanced Thymic Epithelial Tumors: A Retrospective Study. Ann Surg Oncol 2023; 30:6739-6747. [PMID: 37454019 DOI: 10.1245/s10434-023-13954-x] [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: 10/04/2022] [Accepted: 06/19/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND This study aimed to evaluate the prognosis of concurrent chemo-radiotherapy (CCRT) versus sequential chemo-radiotherapy (SCRT) induction followed by surgical resection in patients with advanced thymic epithelial tumors (TETs). METHODS This retrospective study included patients with advanced TETs who underwent CCRT or SCRT induction followed by surgical resection at the Second General Hospital of Guangdong Province between January 2008 and December 2019. The primary outcomes were induction response rate and surgical complete resection rate. The secondary outcomes were surgery combined resection, post-induction T staging, postoperative TNM staging, postoperative pathological tumor regression grade, progression-free survival (PFS) and overall survival (OS), and adverse events (AEs). RESULTS A total of 31 patients were included, 15 of whom received CCRT and the other 16 SCRT. The induction response rates were 80.0 and 62.5%, respectively, the post-induction step-down rates were 46.7 and 31.3%, respectively, and the post-induction R0 resection rates were 80.0 and 68.8%, respectively, without significant differences between CCRT and SCRT groups (all P > 0.05). The 5-year OS rate was 64.2 and 51.6%, respectively, and PFS was 42.3 and 21.4%, respectively, without significant differences between CCRT and SCRT groups (both P > 0.05). AEs in the hematologic system were significantly higher with CCRT compared with SCRT (P = 0.009). CONCLUSIONS Patients with advanced TETs might have a good prognosis with both CCRT and SCRT induction therapy, while SCRT induction may result in a lower probability of AEs in the hematologic system.
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Affiliation(s)
- Shubin Guan
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China.
| | - Weiguang Long
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Yang Liu
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Bin Cai
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Juan Luo
- Department of Chest Wall Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
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Li J, Zhang Z, Chen Y, Wang Y, Liu Y, Zhang P. Downregulation of HMGB1 in thymoma cells affects T cell differentiation. Cent Eur J Immunol 2023; 48:237-244. [PMID: 37901862 PMCID: PMC10604641 DOI: 10.5114/ceji.2023.132198] [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: 12/08/2022] [Accepted: 08/03/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction Thymoma is the most common anterior mediastinal tumor and is closely associated with myasthenia gravis (MG). Our previous study showed that the expression of Th17 cells increased and the expression of Treg decreased in MG-associated thymoma tissues and peripheral blood. High mobility group box 1 (HMGB1) is an inflammatory mediator and participates in the pathogenesis of various autoimmune diseases. However, its function in thymoma is still unclear. Material and methods: We first analyzed immune indices in peripheral blood of patients with MG-associated thymoma and patients with thymoma alone. Next, we explored the expression of HMGB1 in MG-associated thymoma and thymoma alone tissues. Furthermore, we transfected si-HMGB1 in thymoma cell line Thy0517 and co-cultured Thy0517 with peripheral blood mononuclear cells (PBMC). Results In this study, the levels of IgG, C3, C4, CRP and globulins in peripheral blood of patients with MG-associated thymoma were different from those of patients with thymoma alone (p < 0.05). The expression of HMGB1 in MG-associated thymoma tissues was higher than thymoma alone. Co-culture of Thy0517 and PBMC showed that the percentage of Th17 cells in PBMC was lower than that in the control group, and the percentage of Treg cells was higher than that in the control group. Conclusions These findings demonstrate that HMGB1 is involved in the mechanism of abnormal Th17/Treg cell differentiation in thymoma and affects the occurrence of immune abnormalities in MG-associated thymoma.
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Affiliation(s)
- Jian Li
- Tianjin Medical University General Hospital, China
| | - Zeyang Zhang
- Tianjin Medical University General Hospital, China
| | - Yuan Chen
- Tianjin Medical University General Hospital, China
| | - Yuanguo Wang
- Tianjin Medical University General Hospital, China
| | - Yuxin Liu
- Tianjin Medical University General Hospital, China
| | - Peng Zhang
- Tianjin Medical University General Hospital, China
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Guptill JT, Benatar M, Granit V, Habib AA, Howard JF, Barnett-Tapia C, Nowak RJ, Lee I, Ruzhansky K, Dimachkie MM, Cutter GR, Kaminski HJ. Addressing Outcome Measure Variability in Myasthenia Gravis Clinical Trials. Neurology 2023; 101:442-451. [PMID: 37076302 PMCID: PMC10491448 DOI: 10.1212/wnl.0000000000207278] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 02/23/2023] [Indexed: 04/21/2023] Open
Abstract
An increasing number of clinical trials are enrolling patients with myasthenia gravis (MG). A lack of standardization in the performance of outcome measures leads to confusion among site research teams and is a source of variability in clinical trial data. MGNet, the NIH-supported Rare Disease Clinical Research Network for MG, views standardization of MG outcome measures as a critical need. To address this issue, a group of experts summarized key outcome measures used in MG clinical trials and a symposium was convened to address issues contributing to outcome measure variability. Consensus recommendations resulted in changes to outcome measure instructions and, in some cases, modifications to specific instruments. Recommended changes were posted for public commentary before finalization. Changes to the MG-Activities of Daily Living, MG-Quality of Life-15r, and MG-Impairment Index were limited to adding details to the administration instructions. Recommendations for proper positioning of participants and how to score items that could not be performed because of non-MG reasons were provided for the MG Composite. The Quantitative MG (QMG) score required the most attention, and changes were made both to the instructions and the performance of certain items resulting in the QMG-Revised. The Postintervention Status was believed to have a limited role in clinical trials, except for the concept of minimal manifestation status. As a next step, training materials and revised source documents, which will be freely available to study teams, will be created and posted on the MGNet website. Further studies are needed to validate changes made to the QMG-Revised.
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Affiliation(s)
- Jeffrey T Guptill
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC.
| | - Michael Benatar
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Volkan Granit
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Ali A Habib
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - James F Howard
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Carolina Barnett-Tapia
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Richard J Nowak
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Ikjae Lee
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Katherine Ruzhansky
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Mazen M Dimachkie
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Gary R Cutter
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
| | - Henry J Kaminski
- From the Duke University School of Medicine (J.T.G.), Durham, NC; argenx US (J.T.G.), Boston, MA; University of Miami School of Medicine (M.B., V.G.), FL; Biohaven Pharmaceuticals (V.G.), New Haven, CT; University of California, Irvine (A.A.H.); The University of North Carolina School of Medicine (J.F.H.), Chapel Hill; Division of Neurology (C.B.-T.), Department of Medicine, University of Toronto, Ontario, Canada; Yale University School of Medicine (R.J.N.), New Haven, CT; Columbia University (I.L.), New York, NY; Medical University of South Carolina (K.R.), Charleston; Kansas University Medical Center (M.M.D.), Kansas City; School of Public Health (G.R.C.), University of Alabama at Birmingham; and George Washington University School of Medicine & Health Sciences (H.J.K.), DC
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Cebi M, Cakar A, Erdogdu E, Durmus-Tekce H, Yegen G, Ozkan B, Parman Y, Saruhan-Direskeneli G. Thymoma patients with or without myasthenia gravis have increased Th17 cells, IL-17 production and ICOS expression. J Neuroimmunol 2023; 381:578129. [PMID: 37329662 DOI: 10.1016/j.jneuroim.2023.578129] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/08/2023] [Accepted: 06/11/2023] [Indexed: 06/19/2023]
Abstract
Thymoma associated myasthenia gravis (TAMG) is a small disease subgroup with autoantibodies against the acetylcholine receptor. The aim of this study was to assess the role of T helper (Th) cells in TAMG compared to thymoma patients without MG (TOMA) and healthy controls (HC). Peripheral blood cells were used for intracellular cytokine measurements and phenotyping of CD4+ Th cells. IL-21 and IL-4 productions and peripheral Th cells were higher in TAMG compared to TOMA patients and HC. Increases of ICOS and Th17 population were detected both in TAMG and TOMA groups. Higher IL-10 and Th1 population have been observed related to thymectomy. ICOS expression and Th17 induced by thymoma may contribute to the development of TAMG.
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Affiliation(s)
- Merve Cebi
- Department of Physiology, Istanbul Medical Faculty, Istanbul University, 34093 Istanbul, Turkey; Department of Immunology, Institute of Health Sciences, Istanbul University, Turkey
| | - Arman Cakar
- Department of Neurology, Istanbul Medical Faculty, Istanbul University, 34093 Istanbul, Turkey
| | - Eren Erdogdu
- Department of Thoracic Surgery, Istanbul Medical Faculty, Istanbul University, 34093 Istanbul, Turkey
| | - Hacer Durmus-Tekce
- Department of Neurology, Istanbul Medical Faculty, Istanbul University, 34093 Istanbul, Turkey
| | - Gulcin Yegen
- Department of Pathology, Istanbul Medical Faculty, Istanbul University, 34093 Istanbul, Turkey
| | - Berker Ozkan
- Department of Thoracic Surgery, Istanbul Medical Faculty, Istanbul University, 34093 Istanbul, Turkey
| | - Yesim Parman
- Department of Neurology, Istanbul Medical Faculty, Istanbul University, 34093 Istanbul, Turkey
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Dhamne MC. Clinical Outcomes in AchR Antibody-Positive Myasthenia Gravis: Where Does Rituximab Stand in the Current Times? Ann Indian Acad Neurol 2023; 26:313-314. [PMID: 37970317 PMCID: PMC10645217 DOI: 10.4103/aian.aian_516_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 06/23/2023] [Indexed: 11/17/2023] Open
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Hiew FL. ACHR-Positive Generalized Myasthenia Gravis: The Old is Gold and the New Is for us to Explore. Ann Indian Acad Neurol 2023; 26:366-367. [PMID: 37970281 PMCID: PMC10645266 DOI: 10.4103/aian.aian_430_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/16/2023] [Indexed: 11/17/2023] Open
Affiliation(s)
- Fu Liong Hiew
- Neurology Division, Department of Medical, Sunway Medical Centre, Bandar Sunway, Selangor, Malaysia
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Ojha PT, Gaikwad AM, Singh R, Jagiasi K, Nagendra S. The Clinical Outcome in AChR-Positive Generalized Myasthenia Gravis: A Retrospective Observational Study. Ann Indian Acad Neurol 2023; 26:395-400. [PMID: 37970279 PMCID: PMC10645268 DOI: 10.4103/aian.aian_186_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/23/2023] [Accepted: 06/13/2023] [Indexed: 11/17/2023] Open
Abstract
Background Myasthenia gravis (MG) is an autoimmune disease affecting the neuromuscular junction, and in over 80% of cases, antibodies are identified against the nicotinic type of acetylcholine receptor (AChR) on the muscle endplate. Despite the availability of various treatment options, patients with MG experience relapses and remission during the course of the disease. Aims and Objective: To understand the clinical profile, predictors of outcomes in acetyl choline receptor (AChR) antibody positive generalized MG. Methods This is a retrospective, single-centre, observational study of 108 patients with AChR positive generalized MG. We collected data on clinical and demographical profiles, treatments received, and treatment responses from those who fulfilled inclusion criteria over a mean follow up period of 33.75 ±7.30 months. Clinical outcomes were studied in terms of the type of remission and crisis or disease exacerbations patients had, considering different variables and treatment received. Results We found the commonest initial symptoms were ocular or oculo-bulbar, which progressed to generalized MG in the first year of disease onset. 36 (33.3%) patients experienced a crisis requiring mechanical ventilation within a mean period of 9.4 ±4.77 months from the disease onset. Multivariate regression analysis showed late-onset MG (age of onset between 50-70 years) and treatment with rituximab were better correlated with remission, (odd ratio of 4.7; 95 % CI ,1.12 -12.6; P value < 0.05 and odd ratio of 4.56; 95 % CI ,1.2 -10.04; P value < 0.05) respectively. While treatment with Mycofenolate Mofetile (MMF) was associated with a higher number of relapses (odd ratio of 1.8; 95 % CI ,0.08 -0.96; P value < 0.05). Treatment with Rituximab showed a higher rate of remission as compared to treatment refractory (TR) on conventional immunosuppressant therapy (IST). Out of 35(32 %) thymoma patients, 21 patients underwent thymectomy and these patients showed significantly greater rate of remission as compared both thymoma patients who denied thymectomy as a treatment option (N = 10 ;55.60 % vs N = 4; 23.50%). Conclusion In this study of AChR antibody positive generalized MG patients, we found that nearly one-third of them experienced myasthenic crisis despite receiving the best medical care. Rituximab appeared to be effective in the treatment of refractory MG and those who failed thymectomy. Thymectomy was associated with better outcomes in patients, both with or without a thymoma.
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Affiliation(s)
- Pawan T. Ojha
- Department of Neurology, Grant Government Medical College and Sir J. J. Hospital, Mumbai, Maharashtra, India
| | - Abhijeet M. Gaikwad
- Department of Neurology, Grant Government Medical College and Sir J. J. Hospital, Mumbai, Maharashtra, India
| | - Rakesh Singh
- Department of Neurology, Grant Government Medical College and Sir J. J. Hospital, Mumbai, Maharashtra, India
| | - Kamlesh Jagiasi
- Department of Neurology, Grant Government Medical College and Sir J. J. Hospital, Mumbai, Maharashtra, India
| | - Shashank Nagendra
- Department of Neurology, Grant Government Medical College and Sir J. J. Hospital, Mumbai, Maharashtra, India
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Yang J, Wu J, Han T, Lu H, Li F, Li L, Su S, Jiang P, Hou Z. Global research hotspots and frontiers of myasthenia gravis from 2002 to 2021: A bibliometric study. Medicine (Baltimore) 2023; 102:e34002. [PMID: 37327308 PMCID: PMC10270528 DOI: 10.1097/md.0000000000034002] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 05/24/2023] [Indexed: 06/18/2023] Open
Abstract
The objective of this study is to utilize bibliometric and visual analysis techniques to identify hotspots and frontiers of research in myasthenia gravis (MG) and provide valuable references for future research. The Web of Science Core Collection (WoSCC) database was used to retrieve literature data related to MG research, which was then analyzed using VOSviewer 1.6.18, CiteSpace 6.1.R3, and the Online Platform for Bibliometric Analysis. The analysis revealed 6734 publications distributed across 1612 journals and contributed by as many as 24,024 authors affiliated with 4708 institutions across 107 countries/regions. The number of annual publications and citations for MG research has steadily increased over the past 2 decades, with the last 2 years alone witnessing a remarkable increase in annual publications and citations to over 600 and 17,000, respectively. In terms of productivity, the United States emerged as the top producing country, while the University of Oxford ranked first in terms of research institutions. Vincent A was identified as the top contributor in terms of publications and citations. Muscle & Nerve and Neurology ranked first in publications and citations respectively, with clinical neurology and neurosciences among the main subject categories explored. The study also identified pathogenesis, eculizumab, thymic epithelial cells, immune checkpoint inhibitors, thymectomy, MuSK antibodies, risk, diagnosis, and management as the current hot research topics in MG, while burst keywords like quality of life, immune-related adverse events (irAEs), rituximab, safety, nivolumab, cancer, and classification indicated the frontiers of MG research. This study effectively identifies the hotspots and frontiers of MG research, and offers valuable references for researchers interested in this area.
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Affiliation(s)
- Jiali Yang
- Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
| | - Jiaojiao Wu
- Xiangyu Pharmaceutical Co., Ltd., Linyi, China
| | - Tingliang Han
- Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
| | - Hua Lu
- Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
| | - Fangcun Li
- Guilin Municipal Hospital of Traditional Chinese Medicine, Guilin, China
| | - Leilei Li
- Guangxi University of Chinese Medicine, Nanning, China
| | - Shaoting Su
- Guangxi University of Chinese Medicine, Nanning, China
| | - Ping Jiang
- Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Zhaomeng Hou
- Yancheng TCM Hospital Affiliated to Nanjing University of Chinese Medicine, Yancheng, China
- Guangxi University of Chinese Medicine, Nanning, China
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Menghesha H, Schroeter M, Nelke C, Ruck T, Schlachtenberger G, Welskop C, Camo A, Heldwein M, Bennink G, Wahlers T, Bölükbas S, Doerr F, Hekmat K. The impact of thymectomy in subgroups of Myasthenia gravis patients: a single center longitudinal observation. Neurol Res Pract 2023; 5:24. [PMID: 37316910 DOI: 10.1186/s42466-023-00252-w] [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: 01/04/2023] [Accepted: 05/24/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is a rare neuromuscular disorder. Symptoms can range from ptosis only to life threatening myasthenic crisis. Thymectomy is recommended for anti-acetylcholine receptor-antibody positive patients with early-onset MG. Here, we investigated prognostic factors shaping therapeutic outcomes of thymectomy to improve patient stratification. METHODS We retrospectively collected single-center data from a specialized center for MG from all consecutive adult patients that underwent thymectomy from 01/2012 to 12/2020. We selected patients with thymoma-associated and non-thymomatous MG for further investigations. We analyzed the patient collective regarding perioperative parameters in relation to the surgical approach. Furthermore, we investigated the dynamics of the anti-acetylcholine receptor-antibody titers and concurrent immunosuppressive therapies, as well as the therapeutic outcomes in dependence of clinical classifications. RESULTS Of 137 patients 94 were included for further analysis. We used a minimally invasive approach in 73 patients, whereas 21 patients underwent sternotomy. A total of 45 patients were classified as early-onset MG (EOMG), 28 as late-onset MG (LOMG) and 21 as thymoma-associated MG (TAMG). The groups differed in terms of age at diagnosis (EOMG: 31.1 ± 12.2 years; LOMG: 59.8 ± 13.7 years; TAMG: 58.6 ± 16.7 years; p < 0.001). Patients with EOMG and TAMG were more often female than patients in the LOMG group (EOMG: 75.6%; LOMG: 42.9%; TAMG: 61.9%; p = 0.018). There were no significant differences in outcome scores (quantitative MG; MG activities of daily living; MG Quality of Live) with a median follow-up of 46 months. However, Complete Stable Remission was achieved significantly more frequently in the EOMG group than in the other two groups (p = 0.031). At the same time, symptoms seem to improve similarly in all three groups (p = 0.25). CONCLUSION Our study confirms the benefit of thymectomy in the therapy of MG. Both, the concentration of acetylcholine receptor antibodies and the necessary dosage of cortisone therapy show a continuous regression after thymectomy in the overall cohort. Beyond EOMG, groups of LOMG and thymomatous MG responded to thymectomy as well, but therapy success was less pronounced and delayed compared to the EOMG subgroup. Thymectomy is a mainstay of MG therapy to be considered in all subgroups of MG patients investigated.
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Affiliation(s)
- Hruy Menghesha
- Department of Thoracic Surgery, University Medical Center Essen - Ruhrlandclinic, Tüschener Weg 40, 45239, Essen, Germany.
| | - Michael Schroeter
- Faculty of Medicine, Department of Neurology, University of Cologne, University Hospital Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Christopher Nelke
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Tobias Ruck
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Dusseldorf, Germany
| | - Georg Schlachtenberger
- Faculty of Medicine, Department of Cardiothoracic Surgery, University of Cologne, University Hospital Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Clara Welskop
- Faculty of Medicine, University of Cologne, Joseph-Stelzmann-Strasse 20, 50931, Cologne, Germany
| | - Amina Camo
- Faculty of Medicine, University of Cologne, Joseph-Stelzmann-Strasse 20, 50931, Cologne, Germany
| | - Matthias Heldwein
- Faculty of Medicine, Department of Cardiothoracic Surgery, University of Cologne, University Hospital Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Gerardus Bennink
- Faculty of Medicine, Department of Cardiothoracic Surgery, University of Cologne, University Hospital Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Thorsten Wahlers
- Faculty of Medicine, Department of Cardiothoracic Surgery, University of Cologne, University Hospital Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Servet Bölükbas
- Department of Thoracic Surgery, University Medical Center Essen - Ruhrlandclinic, Tüschener Weg 40, 45239, Essen, Germany
| | - Fabian Doerr
- Department of Thoracic Surgery, University Medical Center Essen - Ruhrlandclinic, Tüschener Weg 40, 45239, Essen, Germany
| | - Khosro Hekmat
- Faculty of Medicine, Department of Cardiothoracic Surgery, University of Cologne, University Hospital Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
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Hamedani AG, McPherson TO, Aban I, Lee I, Kupersmith MJ, Wolfe GI, Kaminski HJ. Attitudes and Beliefs Toward Thymectomy in the Myasthenia Gravis Patient Registry. J Clin Neuromuscul Dis 2023; 24:222-228. [PMID: 37219866 DOI: 10.1097/cnd.0000000000000449] [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: 05/24/2023]
Abstract
OBJECTIVES To evaluate patient attitudes and beliefs toward thymectomy for myasthenia gravis (MG). METHODS The Myasthenia Gravis Foundation of America administered a questionnaire to the MG Patient Registry, an ongoing longitudinal survey of adult MG patients. Questions assessed reasons for or against thymectomy and how hypothetical scenarios would have affected their decision. RESULTS Of 621 respondents, 190 (31%) reported a history of thymectomy. Of those who underwent thymectomy for nonthymomatous MG, 97 (51.6%) ranked symptom improvement as most important and 100 (53.2%) ranked reducing medication as least important. Among 431 nonthymectomy patients, the most frequent reason for not undergoing thymectomy was that their doctor did not discuss it (152 of 431 = 35.2%) and 235 (56.8%) said that they would have considered it more strongly if their doctor spent more time discussing it. CONCLUSIONS Thymectomies are motivated more by symptoms than by medication, and a lack of neurologist discussion is the most common barrier to thymectomy.
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Affiliation(s)
- Ali G Hamedani
- Departments of Neurology and Ophthalmology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Tarrant O McPherson
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham AL
| | - Inmaculada Aban
- Department of Biostatistics, The University of Alabama at Birmingham, Birmingham AL
| | - Ikjae Lee
- Department of Neurology, Columbia University, New York, NY
| | - Mark J Kupersmith
- Departments of Neurology, Icahn School of Medicine at Mount Sinai and New York Eye and Ear Infirmary, New York, NY
| | - Gil I Wolfe
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY; and
| | - Henry J Kaminski
- Department of Neurology, George Washington University, Washington, DC
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