胸腺瘤型重症肌无力扩大胸腺切除术的神经学转归：剑突下与胸骨正中入路对比

Neurological outcomes of extended thymectomy for thymomatous myasthenia gravis: Subxiphoid vs. trans-sternal approaches.

作者信息

Zhu Haoshuai, Liu Zhihao, Yao Xiaojing, Zou Jianyong, Zeng Bo, Zhang Xin, Chen Zhenguang, Su Chunhua

机构信息

The Thoracic Surgery Department of The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.

出版信息

Front Surg. 2022 Sep 6;9:973954. doi: 10.3389/fsurg.2022.973954. eCollection 2022.

DOI:10.3389/fsurg.2022.973954

PMID:36147693

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC9485494/

Abstract

BACKGROUND

The subxiphoid approach has been widely used recently. However, there is little data focusing on neurological outcomes in patients with thymomatous myasthenia gravis (MG) who underwent subxiphoid thoracoscopic thymectomy. The purpose of this study was to compare the neurological outcomes of patients with thymomatous MG who underwent extended thymectomy with a subxiphoid or transthoracic approach 1 year postoperatively.

METHODS

The records of patients with Masaoka stage I and II thymomas who underwent extended thymectomy from January 2019 to December 2020 with tumor size less than 5 cm and thymomatous MG were retrospectively reviewed and evaluated. Neurological outcomes were measured by a quantitative myasthenia gravis score (QMGS), with a 2.3-point reduction in QMGS associated with improvement in clinical MG status. The clinical efficacy and variables affecting the outcomes were assessed using the Kaplan-Meier method and Cox proportional hazard regression analysis.

RESULTS

A total of 89 patients were included in the analysis, of which 44 had a subxiphoid approach and 45 had a trans-sternal approach. Mean QMGS decreased from 12 at initial diagnosis to 8.7 preoperatively and 5.6 at 12 months postoperatively in the subxiphoid group and from 12.1 to 8.9 to 6.0 in the transthoracic group. Thirteen patients (28.9%) who underwent the trans-sternal approach and 10 (22.7%) who underwent the subxiphoid approach did not have an improved clinical status compared with their preoperative status. The median time to clinical improvement was 3 months (95% CI, 2.15-3.85) for the subxiphoid approach and 6 months (95% CI, 5.54-6.46) for the trans-sternal approach. Univariate results showed that the subxiphoid approach was associated with a faster improvement in clinical status (HR = 1.701, 95% CI, 1.044-2.773, < 0.05), and age ≦48 was associated with a faster improvement in clinical status (HR = 1.709, 95% CI, 1.044-2.799, < 0.05). The multivariate model including age ≦48 (HR = 1.837, 95% CI, 1.093-3.086, = 0.022) and the subxiphoid approach (HR = 1.892, 95% CI, 1.127-3.177, = 0.016) was significantly associated with a faster improvement in clinical status.

CONCLUSIONS

In patients with Masaoka stage I and II thymoma who underwent thymectomy, with tumor size less than 5 cm and thymomatous MG, age ≦48 years and the subxiphoid approach were associated with a rapid improvement in clinical status.

摘要

背景

剑突下入路近来已被广泛应用。然而，关于接受剑突下胸腔镜胸腺切除术的胸腺瘤型重症肌无力（MG）患者神经功能转归的数据较少。本研究的目的是比较接受扩大胸腺切除术的胸腺瘤型MG患者在术后1年采用剑突下入路或经胸入路的神经功能转归。

方法

回顾性分析2019年1月至2020年12月期间接受扩大胸腺切除术、肿瘤大小小于5 cm的Masaoka I期和II期胸腺瘤且患有胸腺瘤型MG患者的记录并进行评估。通过定量重症肌无力评分（QMGS）来衡量神经功能转归，QMGS降低2.3分与临床MG状态改善相关。采用Kaplan-Meier法和Cox比例风险回归分析评估临床疗效及影响转归的变量。

结果

共有89例患者纳入分析，其中44例采用剑突下入路，45例采用经胸骨入路。剑突下组的平均QMGS从初始诊断时的12分降至术前的8.7分和术后12个月时的5.6分，经胸组从12.1分降至8.9分再降至6.0分。与术前状态相比，13例（28.9%）接受经胸骨入路的患者和10例（22.7%）接受剑突下入路的患者临床状态未改善。剑突下入路临床改善的中位时间为3个月（95%CI，2.15 - 3.85），经胸骨入路为6个月（95%CI，5.54 - 6.46）。单因素结果显示，剑突下入路与临床状态更快改善相关（HR = 1.701，95%CI，1.044 - 2.773，<0.05），年龄≤48岁与临床状态更快改善相关（HR = 1.709，95%CI，1.044 - 2.799，<0.05）。包含年龄≤48岁（HR = 1.837，95%CI，1.093 - 3.086，=0.022）和剑突下入路（HR = 1.892，95%CI，1.127 - 3.177，=0.016）的多因素模型与临床状态更快改善显著相关。