An update on thymectomy in myasthenia gravis

ABSTRACT

Introduction: Myasthenia gravis (MG) is one of the best treatable autoimmune diseases. However, in most patients, treatment is necessarily long-term and related side effects are a serious burden. Thymectomy has a special place in the disease management as a non-pharmacological disease-modifying therapy. For several decades, its role has only been supported by observational studies. Despite the recently achieved class I evidence, many questions remain unaddressed.

Areas covered: This review discusses the pathogenic role of the thymus and evidence and controversies concerning therapeutic thymectomy. It also describes minimally invasive techniques that have largely replaced open surgery and the available evidence in MG patients.

Expert opinion: Thymectomy plays a primary role in MG management, though its use is still controversial in some disease subtypes. Patient selection for surgery and adequate pre-operative MG control are critical. Thymectomy must ensure the exeresis of the whole thymus together with peri-thymic fat tissue. Minimally invasive techniques have many advantages over open approaches, provided they are as extensive as trans-sternal thymectomy. The investigation of thymectomy-related biomarkers will contribute to enhance the knowledge of its impact on the specific immune response.

KEYWORDS:

• Myasthenia gravis
• thymectomy
• thymoma
• video-assisted thymectomy
• robotic-assisted thymectomy

Article Highlights

• MG clinical and pathogenic heterogeneity must be taken into account when planning treatment.

• Thymectomy should be performed early in the course of the disease. However, even in patients with thymoma, it should never be an emergency treatment. Stable MG control should be achieved pre-operatively, particularly in patients with bulbar muscle involvement.

• In some patient subgroups, there is no agreement on therapeutic thymectomy. Surgery should be considered on an individual basis evaluating possible advantages and associated risks.

• In the hands of skilled and expert surgeons, minimally invasive thymectomy appears to be a valid alternative to open surgery.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This paper was not funded