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J Thorac Cardiovasc Surg 2003;125:740-741
© 2003 The American Association for Thoracic Surgery

Letters to the Editor

Thymectomy in ocular myasthenia gravis

Division of Thoracic Surgery, Cardiac and Thoracic Department^a, Division of Neurology, Department of Neurosciences^b, University of Pisa, Pisa, Italy

To the Editor:

We read with interest the recent article by Roberts and associates ¹ on thymectomy in the treatment of ocular myasthenia gravis (OMG). It represents an important step in the debate concerning this issue and in the consideration of OMG as part of a broad-spectrum disease and not as a distinct disease.

What we know from the literature is that the disease will progress in about 50% of patients with initial OMG. ² On the other hand, thymectomy is considered a mainstay therapy for generalized myasthenia gravis (GMG), and the best outcome is expected in patients operated on early after the onset of the disease.

What we should simply do is predict when a pure OMG is an initial GMG and offer to such patients the best treatment, which might also include an extended thymectomy.

Apart from the presence of a thymoma, which makes the surgical procedure mandatory, no clear indication for thymectomy in OMG appears in the literature.

Only a few studies have focused on thymectomy in OMG, ^1,3-5 and when patients with OMG are merged with those with GMG, the assessment of the efficacy of thymectomy is difficult for the combined action of various medical therapies and for the lack of standardized methods for assessing patient status before and after surgical intervention and assessing the correct criteria of success.

A contribution to the discussion about this topic might be derived from our experience.

From 1993 to now, 29 patients with OMG underwent transternal extended thymectomy at our institution. In the same period, the same neurologist (R.R.) treated 343 patients with OMG, and consequently, the eligibility rate for surgical treatment of OMG was 8.5%.

Specific indications for the operation were as follows:

1. Presence of thymoma (n = 20) or suspected thymic mass (n = 3) on the thoracic computed tomographic or nuclear magnetic resonance scan
   
2. High titers of acetylcholine receptor antibody (n = 3)
   
3. Resistance to pyridostigmine therapy or relapse after steroid or immunosuppressive therapy (n = 1)
   
4. Dependance on a high dosage of corticosteroids (n = 2).
   

The neurologic results of thymectomy in our overall series of 45 patients with OMG have been recently reported. ⁶ The remission rate was significantly higher in patients with stage I myasthenia than in those in the other Osserman categories.

In the more recent series of 29 patients, the neurologic postoperative results were 22 complete remissions, 3 remissions with medication, 3 cases of improved status, and 1 case of unchanged status.

Our experience, general considerations, and results suggest that extended thymectomy might play a role in highly selected patients with OMG, and there is need for further studies to assess its efficacy.

We again congratulate the authors, who have focused and debated on what is considered a highly controversial indication for thymectomy.

References

1. Roberts PF, Venuta F, Rendina E, De Giacomo T, Coloni GF, Follette DM, et al. Thymectomy in the treatment of ocular myasthenia gravis. J Thorac Cardiovasc Surg. 2001;122:562-8.[Abstract/Free Full Text]
   
2. Evoli A, Batocchi AP, Minisci C, Di Schino C, Tonali P. Therapeutic options in ocular myasthenia gravis. Neuromuscul Disord. 2001;11:208-16.[Medline]
   
3. Schumm F, Wieltholter H, Fateh-Moghadam A, Dichgans J. Thymectomy in myasthenia with pure ocular symptoms. J Neurol Neurosurg Psychiatry. 1985;48:332-7.[Abstract/Free Full Text]
   
4. Nakamura H, Taniguchi Y, Suzuki Y, Tanaka Y, Ishiguro K, Fukud M, et al. Delayed remission after thymectomy for myasthenia gravis of the purely ocular type. J Thorac Cardiovasc Surg. 1996;112:371-5.[Abstract/Free Full Text]
   
5. Sommer N, Sigg B, Melms A, Weller M, Schepelmann K, Herzau V, et al. Ocular myasthenia gravis: response to long-term immunosuppressive treatment. J Neurol Neurosurg Psychiatry. 1997;62:156-62.[Abstract/Free Full Text]
   
6. Mussi A, Lucchi M, Murri L, Ricciardi R, Luchini L, Angeletti CA. Extended thymectomy in myasthenia gravis: a team-work of neurologist, thoracic surgeon and anaesthesist may improve the outcome. Eur J Cardiothorac Surg. 2001;19:570-5.[Abstract/Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marco Lucchi Alfredo Mussi Carlo Alberto Angeletti Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Lucchi, M. Articles by Angeletti, C. A. Search for Related Content PubMed PubMed Citation Articles by Lucchi, M. Articles by Angeletti, C. A.