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Ann Thorac Surg 2000;69:313-314
© 2000 The Society of Thoracic Surgeons

Correspondence

Thymectomy for elderly myasthenia gravis patients

Paul A. Kirschner, MDa

a Department of Cardiothoracic Surgery, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1028, New York, NY 10029, USA

To the Editor

The back-to-back articles by Tsuchida and associates [1] and Nieto and associates [2] fail to emphasize the heterogeneous nature of myasthenia gravis as related to pathologic, demographic, and immunobiological findings, although some references to this are deeply embedded in the two papers.

I believe it is essential to differentiate thymomatous myasthenia gravis from the nonthymomatous variety for the following reasons: (1) Osserman classification: This is a clinical classification but thymomas are mentioned to have the highest incidence in groups III and IV, the most severe cases [4]. (2) Demographics: A preponderance of thymomas is noted in older males, while most nonthymomatous myasthenia occurs in younger females [3]. (3) Immunology: Different HLA antigen and other immunological patterns occur in thymomas vs nonthymomas [3]. (4) Emergence of myasthenia gravis after thymectomy: This, to my knowledge, only occurs in thymoma patients [5]. A subheading of this is exacerbation of myasthenia after thymomectomy [6]. There is no comparable phenomenon in nonthymomatous myasthenia. Parenthetically, Somnier [7] has shown that the titer of acetylcholine receptor antibodies rises after thymomectomy as compared with a fall with nonthymomatous thymectomy. (5) Extent of resection: "Extended" or "maximal" thymectomy in nonthymomatous myasthenia refers to wide excision of extrathymic fatty tissue, which may contain islands of ectopic thymus [8], while in thymomas, it usually refers to en bloc or otherwise wide excision of invasive thymomas [9]. (6) Pathology of the thymus: The term "thymoma" is not further defined, except in the paper by Nieto and associates [2], in which they list an astounding 9.8% incidence of thymolipoma. In practically all other reports, thymolipoma is rarely if ever associated with myasthenia. It deserves further comment. Also, no mention is made in either paper of the new classifications of thymomas including the cortical, medullary, and well-differentiated thymic carcinoma.

Stricter adherence to these distinctions would further our knowledge of this vexing group of diseases, the myasthenias.

References

  1. Tsuchida M., Yamato Y., Souma T., et al. Efficacy and safety of extended thymectomy for elderly patients with myasthenia gravis. Ann Thorac Surg 1999;67:1563-1567.[Abstract/Free Full Text]
  2. Nieto I.P., Robledo J.P.P., Pajuelo M.C., et al. Prognostic factors for myasthenia gravis treated by thymectomy. Ann Thorac Surg 1999;67:1568-1571.[Abstract/Free Full Text]
  3. Compston D.A.S., Vincent A., Newsom-Davis J., et al. Clinical, pathological, HLA antigen and immunological evidence for disease heterogeneity in myasthenia gravis. Brain 1980;103:579-601.[Free Full Text]
  4. Osserman K.E., Genkins G. Studies in myasthenia gravis. Mt Sinai J Med 1971;38:497-537.[Medline]
  5. Namba T., Brunner N.G., Grob D. Myasthenia gravis in patients with thymoma with particular reference to onset after thymectomy. Medicine 1978;57:411-433.[Medline]
  6. Kuroda Y., Oda K., Neshige R., et al. Exacerbation of myasthenia gravis after removal of a thymoma having a membrane phenotype of suppressor T-cells. Ann Neurol 1984;15:400-402.[Medline]
  7. Somnier F.E. Exacerbation of myasthenia gravis after removal of thymomas. Acta Neurol Scand 1994;90:56-66.[Medline]
  8. Jaretzki A., III, Penn A.S., Younger D.S., et al. "Maximal" thymectomy for myasthenia gravis results. J Thorac Cardiovasc Surg 1988;95:747-757.[Abstract]
  9. Kirschner P.A. Reoperation for thymoma. Ann Thorac Surg 1990;49:550-555.[Abstract]




This Article
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