BackgroundThe co-existence of myasthenia gravis (MG) and thymoma makes the surgical treatment more complicated and adjuvant radiation more controversial. The aim of this study was to investigate adjuvant radiotherapy for thymoma with MG after extended thymectomy.

MethodsA total of 181 patients with both MG and thymoma were recruited between 2003 and 2014 at Tongren Hospital, China. Among all the patients, 157 patients received radiation therapy after surgery (Group A); whereas the other 24 patients did not receive radiation therapy (Group B). According to the time that patients started mediastinal radiation therapy, we subdivided the 157 patients in Group A into subgroups (1-month subgroup, n = 98; 2-month subgroup, n = 7; and 3-month subgroup, n = 52). We then compared the effect of the mediastinal radiation therapy across these different groups using the survival rate, the rate of postoperative myasthenic crisis, and the complete stable remission (CSR) rate as the primary endpoints.

ResultsThere was a significant difference in the occurrence of postoperative myasthenic crisis between 1-month subgroup and Group B (χ = 4.631, P = 0.031). The rates of reaching CSR were 32.6% in 1-month subgroup, 25% in 3-month subgroup, and 22.7% in Group B, respectively. The overall survival rates of 1-month subgroup, 3-month subgroup, and Group B were 88.8%, 83.3%, and 77.3%, respectively. Analysis on the Kaplan-Meier survival curves demonstrated that within 8 years after surgery, there was no significant difference in aspects of overall survival and disease-free survival between 1-month subgroup and Group B, and between 3-month subgroup and Group B; over 8 years after surgery, the disease-free survival rates in 1-month subgroup, 3-month subgroup and Group B were 79.4%, 70.6%, and 55.3%, respectively.

ConclusionsAdjuvant radiation within 1 month after extended thymectomy may be helpful in controlling postoperative MG, such as decreasing the possibility of postoperative myasthenic crisis, and raising cumulative probabilities of reaching CSR.

Adult ; Aged ; Aged, 80 and over ; Female ; Humans ; Kaplan-Meier Estimate ; Male ; Middle Aged ; Myasthenia Gravis ; surgery ; therapy ; Postoperative Period ; Radiotherapy, Adjuvant ; methods ; Thymectomy ; methods ; Thymoma ; surgery ; therapy ; Thymus Neoplasms ; surgery ; therapy ; Treatment Outcome

The da Vinci S surgical system (Intuitive Surgical) was approved as a medical device in 2009 by the Japanese Ministry of Health, Labour and Welfare. Robotic surgery has since been used in gastrointestinal, thoracic, gynecological, and urological surgeries. In April 2012, robotic-assisted laparoscopic radical prostatectomy (RALP) was first approved for insurance coverage. Since then, RALP has been increasingly used, with more than 3,000 RALP procedures performed by March 2013. By July 2014, 183 institutions in Japan had installed the da Vinci surgical system. Other types of robotic surgeries are not widespread because they are not covered by public health insurance. Clinical trials using robotic partial nephrectomy and robotic gastrectomy for renal and gastric cancers, respectively, have recently begun as advanced medical treatments to evaluate health insurance coverage. These procedures must be evaluated for efficacy and safety before being covered by public health insurance. Other types of robotic surgery are being evaluated in clinical studies. There are several challenges in robotic surgery, including accreditation, training, efficacy, and cost. The largest issue is the cost-benefit balance. In this review, the current situation and a prospective view of robotic surgery in Japan are discussed.
Cost-Benefit Analysis ; Esophageal Neoplasms/surgery ; Gastrectomy/*methods ; Gynecologic Surgical Procedures/methods ; Humans ; Japan ; Laparoscopy/*methods ; Nephrectomy/*methods ; Otolaryngology/methods ; Prospective Studies ; Prostatectomy/*methods ; Rectal Neoplasms/surgery ; Robotic Surgical Procedures/education/*trends ; Stomach Neoplasms/surgery ; Thymectomy/methods ; Thyroid Diseases/surgery

BACKGROUNDThymectomy is an established treatment for myasthenia gravis (MG), and video-assisted thoracoscopic surgery (VATS) thymectomy has become an acceptable surgical procedure. This study aimed to compare the results of VATS thymectomy and open thymectomy and to identify the prognostic factors after thymectomy.

METHODSThe clinical data of 187 consecutive thymectomies performed between July 2000 and December 2009 were retrospectively reviewed; 75 open thymectomies and 112 VATS thymectomies. Clinical efficacy and variables influencing outcome were assessed by Kaplan-Meier survival curves and Cox proportional hazards regression analysis.

RESULTSThe operative blood loss in the VATS group was significantly less than that in the open group ((62.14 ± 55.43) ml vs. (137.87 ± 165.25) ml, P < 0.05). The postoperative crisis rate increased with the severity of preoperative MG and the prescription dose of anticholinesterase. Complete follow-up information of patients more than 12 months after the thymectomy was obtained on 151 cases, 89 cases from the VATS group and 62 cases from the open group, with a mean follow-up period of 59.3 months, range from 12 to 117 months. Complete stable remission (CSR) was the end point for evaluation of the treatment results. The overall five-year CSR rate was 57.5%. Two good prognostic factors were identified; preoperative prescription of anticholinesterase alone (P = 0.035) and non-thymomatous MG (P = 0.003). The five-year CSR rate of the ocular type of MG reached a high level of 67.4%.

CONCLUSIONSThymectomy can achieve good long-term CSR in MG, and VATS is an ideal alternative method. High-dose prescription of anticholinesterase and the advanced stage by Myasthenia Gravis Foundation of America (MGFA) classification have higher risks of postoperative crisis. Preoperative prescription of anticholinesterase alone and non-thymomatous MG are good prognostic factors. Thymectomy should also be considered for the ocular type of MG.

Adolescent ; Adult ; Aged ; Child ; Female ; Humans ; Male ; Middle Aged ; Myasthenia Gravis ; surgery ; Proportional Hazards Models ; Thoracic Surgery, Video-Assisted ; methods ; Thymectomy ; adverse effects ; methods ; Time Factors ; Treatment Outcome

OBJECTIVESTo evaluate the feasibility and safety of video-assisted thoracoscopic surgery (VATS), and to compare surgical results of VATS with standard median sternotomy (MS) and other minimal invasive approaches through various small incisions (SI).

METHODSTotally 111 patients underwent surgery for thymic disorders (maximun diameter ≤ 5 cm, clinical stage I-II for thymic tumors) during March 2010 to June 2012 was retrospectively reviewed. There were 46 male and 65 female patients with a mean age of (51 ± 15) years.Resection via VATS was carried out in 47 patients, via SI in 26 patients, and via MS in 38 patients. Demographic characteristics, operation time, number and cause of conversion, blood loss during operation, duration and amount of chest tube drainage, transfusion, morbidity, and length of hospital stay (LHS) were compared between the three groups.

RESULTSOf the 111 patients, 79 patients had thymic epithelia tumors (stage I 32 patients, stage II 39 patients, stage III 8 patients), 31 patients had benign cysts and 1 patient had tuberculosis.In the VATS group, there were 3 conversions among 38 patients through right-side approach, and 4 conversions among 9 patients through left-side approach. The causes for conversion included dense pleura adhesion, invasion of tumor into adjacent structures (pericardium, lung, or great vessels), and injury of the left inominate vein. There was no significant difference in operative time, blood loss or transfusion during operation, duration or amount of postoperative chest tube drainage among the 3 groups (P > 0.05). Average LHS was significantly shorter in the VATS group (5.7 ± 1.7) days than in the SI group (7.5 ± 2.2) days and the MS group (8.2 ± 1.9) days (F = 3.759, P = 0.002). Total thymectomy was performed in 74 patients, 25 patients (53.2%, 25/47) in VATS group, 11 patients (42.3%, 11/26) in SI group, and 38 patients (100%, 38/38) in MS group. The reset of the patients received tumor resection and partial thymectomy. Among all the subgroups, LHS was the shortest in VATS total thymectomy patients (5.0 ± 1.4) days (F = 5.844, P = 0.001). There was no perioperative mortality. The only major morbidity was a postoperative bleeding necessitating reintervention in SI group.

CONCLUSIONSVATS for benign thymic lesions and early-stage thymic tumors is safe and feasible.It is associated with shorter hospital stay compared with other minimal invasive approaches or standard sternotomy.

Adult ; Aged ; Female ; Humans ; Male ; Middle Aged ; Retrospective Studies ; Thymectomy ; methods ; Thymoma ; surgery ; Thymus Neoplasms ; surgery

OBJECTIVETo explore if folic acid/polyamide-amine (FA/PAMAM) enhances the therapeutic effect of miR-7gene therapy for glioma in vivo.

METHODSThe miR-7 gene was transfected into U251 glioma cells by FA/PAMAM. The efficiency of gene transfection was assessed by fluorescence microscopy. The miR-7 level was detect by quantitative RT-PCR. Intracranial glioma models were established in thymectomized mice, and FA/PAMAM nanoparticles were transplanted into the tumors in situ 3 days later. The animal survival was recorded and the gross tumor volume and degree of edema were observed by MRI. Apoptosis in the glioma cells and expression of proliferating cell nuclear antigen (PCNA), matrix metalloproteinases 2 and 9 (MMP-2 and MMP-9) were assessed by immunohistochemistry, and EGFR and AKT-2 protein expression was detected by Western blot assay.

RESULTSCompared with the liposomes, the FA/PAMAM nanoparticles were more efficient to transfer miR-7 gene into U251 glioma cells, MRI showed that the tumor growth was much slower in the FA/PAMAM/miR-7 group, and the animal survival time was longer. The apoptosis rate was (5.3 ± 0.9)% in the control group, (11.4 ± 2.4)% in the liposome/miR-7 group, and (17.7 ± 3.7)% in the FA/PAMAM/miR-7 group. The immunohistochemical assay showed that the levels of PCNA, MMP-2 and MMP-9 protein in the FA/PAMAM/miR-7 group were (34.6 ± 5.4)%, (24.5 ± 4.1)%, (25.4 ± 5.1)%, respectively, significantly lower than those in the liposome/miR-7 group (49.3 ± 5.9)%, (31.7 ± 7.1)% and (39.4 ± 6.4)%, respectively, and those in the control group (57.3 ± 7.4)%, (45.4 ± 6.9)% and (55.1 ± 7.3)%, respectively (all P < 0.05). The expressions of EGFR and AKT-2 proteins were 1.09 ± 0.12 and 0.62 ± 0.10 in the control group, 0.63 ± 0.11 and 0.43 ± 0.07 in the liposome/miR-7 group, and significantly deceased (0.47 ± 0.09 and 0.31 ± 0.04, respectively) in the FA/PAMAM/miR-7 group (all P < 0.05).

CONCLUSIONCompared with the liposomes, FA/PAMAM can transfect miR-7 into glioma cells with a higher efficiency in vivo, makes a longer time of the drug action, and shows a certain inhibitory effect on the growth of glioma, therefore, might become a new drug targeting agent in gene therapy forglioma.

Animals ; Apoptosis ; Brain Neoplasms ; genetics ; metabolism ; pathology ; Cell Line, Tumor ; Dendrimers ; chemistry ; Folic Acid ; chemistry ; Genetic Therapy ; methods ; Glioma ; genetics ; metabolism ; pathology ; Humans ; Male ; Matrix Metalloproteinase 2 ; metabolism ; Matrix Metalloproteinase 9 ; metabolism ; Mice ; Mice, Nude ; MicroRNAs ; genetics ; metabolism ; Nanoparticles ; Neoplasm Transplantation ; Proliferating Cell Nuclear Antigen ; metabolism ; Proto-Oncogene Proteins c-akt ; metabolism ; Receptor, Epidermal Growth Factor ; metabolism ; Thymectomy ; Transfection

Antineoplastic Combined Chemotherapy Protocols ; therapeutic use ; Humans ; Lung Neoplasms ; drug therapy ; radiotherapy ; secondary ; surgery ; Molecular Targeted Therapy ; Neoplasm Recurrence, Local ; Neoplasm Staging ; Radiotherapy, Adjuvant ; Survival Rate ; Thymectomy ; methods ; Thymoma ; drug therapy ; radiotherapy ; surgery ; Thymus Neoplasms ; drug therapy ; radiotherapy ; surgery

BACKGROUNDThymokidney has been reported as an approach for a vascularized thymus for transplantation to induce donor specific tolerance. A completely thymectomized model which ensures that the obtained thymus is not injured has not been developed yet and it would be useful for evaluating autologous thymokidney function in rats.

METHODSAdult Sprague-Dawley male rats weighing 150 - 300 g (n = 30) underwent non-invasive intubation with the assistance of an improved self-made wedge-shaped cannula made from a 2-ml plastic syringe and transillumination from the anterior tracheal area by an operation spotlight. The rats then received a thoracotomy while their breathing was supported by a small animal ventilator, and both lobes of the thymus were entirely extirpated under a 10× microscope. The postoperative survival rate of the rats was recorded, and changes in the T-cell reservoir from 9 of 30 rats within 21 days after surgery were monitored using flow cytometry. The complete thymectomy rate was confirmed by autopsy and histological examination on 21 days post-operation.

RESULTSThe postoperative survival rate of rats was 100%. The exsected thymus was free of injury and the rate of complete thymectomy was 100%.

CONCLUSIONSThis model has a stable survival rate and complete thymectomy is able to be achieved. The obtained thymus tissue is free of injury and can be used for transplantation.

Animals ; Intubation, Intratracheal ; methods ; Male ; Rats ; Rats, Sprague-Dawley ; Thoracotomy ; methods ; Thymectomy ; methods ; Thymus Gland ; surgery

OBJECTIVETo investigate different characteristics of the video-assisted thoracoscopic (VATS) versus transsternal thymectomy for myasthenia gravis (MG).

METHODSThe clinical data of 106 patients who underwent VATS thymectomy for MG between February 2002 and May 2007, and 108 patients who underwent transsternal thymectomy between March 1998 and August 2003 were analyzed retrospectively. In VATS group, there were 64 male and 42 female patients, and the mean age was 38-years-old. In the transsternal group, 68 patients were male and 40 were female, and the mean age was 36-years-old. Analysis of conditions related to the surgical procedure between two groups was made, such as length of surgery, operative bleeding, postoperative drainage, hospital stay, hospitalization expenses and complications. The mean time of follow-up was 38.5 months (ranging from 10 to 67 months). All patients were classified according to the MGFA clinical classification.

RESULTSIntraoperative bleeding in VATS group was (34 +/- 5) ml, significantly less than (150 +/- 23) ml in the transsternal group. Postoperative drainage in VATS group was (42 +/- 18) ml, significantly less than (168 +/- 31) ml in the transsternal group. Complications and hospital stay in VATS group were also significantly lower than those in the transsternal group. There was no significantly different in the long-term outcome between two groups.

CONCLUSIONAlthough both thoracoscopic and transsternal approaches to thymectomy in patients with MG are effective after the long-term follow-up, VATS thymectomy has its specific advantages of minimal invasion, less complications, and rapid recovery.

Adolescent ; Adult ; Aged ; Child ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Myasthenia Gravis ; surgery ; Retrospective Studies ; Thoracic Surgery, Video-Assisted ; Thymectomy ; methods ; Treatment Outcome ; Young Adult

OBJECTIVETo compare the therapeutic effects of video-assisted thoracoscopic extended thymectomy (VATET) and transsternal extended thymectomy (TET) for myasthenia gravis (MG).

METHODThis study included 21 patients undergoing VATET through the "three holes" approach on the right chest and 32 undergoing TET with sternum dissection. The thymus was excised and the anterior mediastinum adipose tissue removed in both groups.

RESULTSVATET was associated with reduced intraoperative blood loss and longer operative time without the use of postoperative analgesics; very few patients were admitted into the intensive care unit (ICU), showing significant differences from the TET group (P<0.05). No significant difference was found between the two groups in tracheal tube removal time, length of stay in ICU, closed thoracic drainage removal time, and postoperative hospital stay, total hospital stay, postoperative complications, total hospitalization costs, or the rate of remission and improvement (P>0.05).

CONCLUSIONSCompared with TET, VATET requires only a small incision without leaving metal foreign body in the body, and the patients experience less postoperative pain and rapid recovery, with similar mid- and long-term clinical outcomes.

Adolescent ; Adult ; Case-Control Studies ; Child ; Child, Preschool ; Humans ; Intraoperative Period ; Male ; Myasthenia Gravis ; surgery ; Postoperative Complications ; Thoracic Surgery, Video-Assisted ; adverse effects ; methods ; Thymectomy ; adverse effects ; methods ; Young Adult

OBJECTIVETo investigate the outcome of video-assisted thoracoscopic extended thymectomy (VATET) for myasthenia gravis.

METHODSFrom January 2005 to February 2006, VATET had been performed for 41 patients of myasthenia gravis. Among them, 23 patients were female and 18 were male. The age ranged from 18 to 67 years old, and the disease duration ranged from 1 month to 3 years. In order to achieve maximal benefit, a transverse cervical incision was given access to the peri-thyroid space to remove fat in the neck which may contain ectopic thymus after all thymic tissue, including far-reaching ectopic sites. Peri-thymic adipose tissue in the anterior mediastinum was completely removed.

RESULTSIn the 41 patients, mean operative time was 162 min. Sever patients sustained myasthenic crises that required reintubation and mechanical ventilation for a few days. Of all patients, 35 had lymphadenectasis, and 4 had ectopic thymus in the peri-thyroid space. After the 2 years' follow-up, the rate of complete stable remission was 41.4%, and the effective rate was 85.4%.

CONCLUSIONSVideo-assisted thoracoscopic thymectomy represents a safe and valid approach for patients with myasthenia gravis. VATET may be a complement to completely remove all thymus including ectopic tissues.

Adolescent ; Adult ; Aged ; Feasibility Studies ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Myasthenia Gravis ; surgery ; Thoracoscopy ; Thymectomy ; methods ; Treatment Outcome