Outcomes of Extended Thymectomy in Myasthenic and Non-Myasthenic Thymus Tumors

Öz

Aim: We retrospectively reviewed the results of patients who underwent extended thymectomy for thymic malignancy and planned to demonstrate the therapeutic effect of surgical treatment in patients with thymus tumors. Material and Method: The results of 29 patients with thymic malignancy who underwent consecutively expanded thymectomy between October 2012 and January 2018 in our clinic were examined in detail. Preoperative, postoperative and postoperative follow-up parameters of the cases were recorded. Results: 13 of the patients were male and 16 were female. The mean age was calculated as 41.4±17.7 (range 9–75 years). Nine of the cases (31%) were accompanied by myasthenia graves (MG) disease. Mean FEV1 was 2678.17±954.5 ml and mean FEV1 was calculated as 94±19.8 ml. Thymectomy was performed with sternotomy in 20 patients and thoracoscopic thymectomy was performed in 9 patients. The mean duration of operation was 137.9±31.8 minutes (133.1±45.5 minutes in thoracoscopy group, 134.1±26.5 minutes in sternotomy group), mean perioperative bleeding was 116.6±107 ml, postoperative drainage amount was 417.3±339.9 ml and duration of drainage was 2.6±0.89 days. Complication rate was found to be 13.7% while mortality was not observed. When the postoperative pain scores of the patients were evaluated, the first 24 hour visual analogue pain score (VAS) averaged 3.4, 24–48 hours 2.71 and 48–72 hours 1.9. Mean hospital stay was 4.3±2.5 days and mean follow-up was 34.7 months (1.5–124 months). Recurrence was developed only in one patient with type B2 thymoma and a myasthenic crisis was observed in one patient, on the 10th postoperative day. While no tumor metastasis was observed in any patient during the follow-up, the mean disease-free survival was 34.9 months. Conclusion: Extended thymectomy can be safely performed with low morbidity and mortality using transsternal or thoracoscopic approach in myasthenic and non-myasthenic thymus tumors.

Anahtar Kelimeler

• thymoma; thymectomy; video assisted thoracoscopic surgery; sternotomy; survival

Myastenik ve Non-Myastenik Timus Tümörlerinde Genişletilmiş Timektomi İşleminin Sonuçları

Öz

Amaç: Timik malignite nedeniyle genişletilmiş timektomi uyguladığımız hastaların sonuçlarını geriye dönük olarak inceleyerek, cerrahi tedavinin timus tümörü olan hastalarda terapotik etkilerini ortaya koymayı planladık. Materyal ve Metot: Kliniğimizde Ekim 2012-Ocak 2018 tarihleri arasında ardışık olarak genişletilmiş timektomi uyguladığımız timik maligniteli 29 hastanın sonuçları ayrıntılı olarak irdelendi. Olguların ameliyat öncesi, ameliyat sırası ve sonrasındaki takip değerleri kayıt edildi. Bulgular: Hastaların 13 tanesi erkek, 16 tanesi kadın idi. Ortalama yaş 41,4±17,7 olarak hesaplandı (9–75 yaş dağılımı). Olgularının 9 tanesine (%31) myastenia graves (MG) hastalığı eşlik etmekteydi. Ortalama FEV1 2678,17±954,5 ml ve ortalama FEV1 %94±19,8 ml olarak hesaplandı. Timektomi 20 hastada sternotomi ile uygulanırken, 9 hastada torakoskopik timektomi uygulandı. Ortalama operasyon süresi 137,9±31,8 dakika olarak hesaplanırken (Torakoskopi grubu 149,1±45,5 dakika, sternotomi grubu 134,1±26,5 dakika), ortalama peroperatif kanama 116,6±107 ml, postoperatif drenaj miktarı ortalama 417,3±339,9 ml ve dren kalış süresi 2,6±0,89 gün idi. Mortalite izlenmezken, komplikasyon oranı %13,7 olarak saptandı. Hastaların postoperatif ağrı skorları değerlendirildiğinde, ilk 24 saat görsel analog ağrı skoru (VAS) ortalaması 3,4, 24–48 saat 2,71 ve 48–72 saat arası 1,9 değerleri bulundu. Ortalama hastanede kalış süresi 4,3±2,5 gün ve ortalama takip süresi 34,7 ay olarak hesaplandı (1,5–124 ay arası). Nüks, Tip B2 timoma olan bir olguda gelişirken, bir hastada postoperatif 10. günde myastenik kriz gözlendi. Takip süresince hiçbir hastada tümör metastazı izlenmezken, hastalıksız sağkalım ortalaması 34,9 ay olarak saptandı. Sonuç: Myasteninin eşlik ettiği veya eşlik etmediği timoma olgularında genişletilmiş timektomi videotorakoskopik girişim veya transsternal girişim kullanılarak düşük morbidite ve mortalite ile güvenle uygulanabilir.

Anahtar Kelimeler

• timoma; timektomi; video yardımlı torakoskopik cerrahi; sternotomi; sağkalım

Kaynakça

1. 1. Levine GD, Rosai J. Thymic hyperplasia and neoplasia: a review of current concepts. Hum Pathol 1978;9:495–515. 2. Qu YJ, Liu GB, Shi HS, et al. Preoperative CT findings of thymoma are correlated with postoperative Masaoka clinical stage. Acad Radiol 2013;20:66–72. 3. Yim AP. Video-assisted thoracoscopic resection of anterior mediastinal masses. Int Surg 1996;81, 350–53. 4. Cheng YJ, Kao EL, Chou SH. Videothoracoscopic resection of stage II thymoma: prospective comparison of the results between thoracoscopy and open methods. Chest 2005;128:3010–12. 5. Qian L, Chen X, Huang J, Lin H, Mao F, Zhao X, et al. A comparison of three approaches for the treatment of earlystage thymomas: robot-assisted thoracic surgery, videoassisted thoracic surgery, and median sternotomy. J Thorac Dis 2017;9:1997. 6. Masaoka A, Monden Y, Nakahara K, et al. Follow-up study of thymomas with special reference to their clinical stages. Cancer 1981;48:2485–92. 7. Kirchner T, Muller-Hermelink HK. New approaches to the diagnosis of thymic epithelial tumors. Prog Surg Pathol 1989;10:167–89. 8. Rosai J. Histological typing of tumours of the thymus. In: WHO International histological classification of tumours, 2nd Ed. New York: Springer-Verlag, 1999:5–15. 9. Detterbeck F, Youssef S, Ruffini E, Okumura M. A review of prognostic factors in thymic malignancies. J Thorac Oncol 2011;6:1698–704. 10. Detterbeck F, Parsons A. Thymic tumors: a review of current diagnosis, classification, and treatment, in: J. Patterson, J. D. Lerut, T. W. Luketich, F. G. Rice (Eds.), Thoracic and Esophageal Surgery, 3rd ed., Elsevier, Philadelphia, 2008;1589–614. 11. Detterbeck FC, Zeeshan A. Thymoma: current diagnosis and treatment, Chin Med J (Engl)2013;126:2186–91. 12. Di Crescenzo V, Laperuta P, Garzi A, Napolitano F, Cascone A, Vatrella A. Small cell lung cancer associated with solitary fibrous tumors of the pleura: a case study and literature review. Int J Surg 2014;12(1):19–21. 13. Friedant AJ, Handorf EA, Su S, Scott WJ. Minimally invasive versus open thymectomy for thymic malignancies: systematic review and meta-analysis. J Thorac Oncol 2016;11:30–38. 14. Fiorelli A, Mazzella A, Cascone R, Caronia FP, Arrigo E, Santini M. Bilateral thoracoscopic extended thymectomy versus sternotomy. Asian Cardiovasc Thorac Ann 2016;24:555–61. 15. Durmuş B, Kaya FN, Gören S, Acay G, Özden S, Şentürk S. Miyastenia Gravisli Olgularda Timektomi Uygulamasında Peroperatif Anestezi Yönetiminin Retrospektif Değerlendirilmesi. GKDA Derg 2014;20:154–61. 16. Kalita J, Kohat AK, Misra UK. Predictors of outcome of myasthenic crisis. Neurol Sci 2014;35:1109–14. 17. Xue L, Wang L, Dong J, Yuan Y, Fan H, Zhang Y, et al. Risk factors of myasthenic crisis after thymectomy for thymoma patients with myasthenia gravis. Eur J Cardio-Thoracic Surg 2017;52:692–7. 18. Toker A, Özkan B. Video Yardımlı Torakoskopik Timektomi. Türkiye Klinikleri özel sayısı 2009;2:78–83. 19. Manoly I, Whistance RN, Sreekumar R, Khawaja S, Horton JM, Khan AZ, et al. Early and mid-term outcomes of transsternal and video-assisted thoracoscopic surgery for thymoma. Eur J Cardio-Thoracic Surg 2014;45:187–93. 20. Liman T, Taştepe İ, Demircan S, Topçu S, Çetin, G, Kuzucu A. Timomalarda tedavi ve prognoz. Türk Göğüs Kalp Damar 2000;10:793–96. 21. Odaka, M, Tsukamoto Y, Shibasaki T, Mori S, Asano H, Yamashita M, et al. Surgical and oncological outcomes of thoracoscopic thymectomy for thymoma. J Visualised Surg 2017;3:54. 22. Kirmani BH, Mazhar K, Saleh HZ, Ward AN, Shaw M, Fabri BM, et al. External validity of the Society of Thoracic Surgeons risk stratification tool for deep sternal wound infection after cardiac surgery in a UK population. Interact Cardiovasc Thorac Surg 2013;17:479–84. 23. Toker A, Sonett J, Zielinski M, Rea F, Tomulescu V, Detterbeck FC. Standard terms, definitions, and policies for minimally invasive resection of thymoma. J Thorac Oncol 2011;6:1739–42.