胸腺瘤相关性重症肌无力：抗乙酰胆碱受体抗体在胸腺瘤复发风险中的临床特征和预测价值。Thymoma-associated myasthenia gravis: Clinical features and predictive value of antiacetylcholine receptor antibodies in the risk of recurrence of thymoma
背景：胸腺瘤相关的重症肌无力（TAMG）是重症肌无力的亚型之一，具有针对乙酰胆碱受体（AChR-Ab）的自身抗体。我们分析了胸腺切除术前后TAMG患者队列的临床特征以及AChR-Ab滴度的变化，以鉴定预测胸腺瘤复发的因素。
方法：我们回顾性评估：MG发作的年龄，根据MGFA（美国重症肌无力基金会）的MG临床状况，胸腺切除术的时代，胸腺切除术后的状况，肿瘤学特征和手术方法。在胸腺切除术之前和之后均测量了AChR-Ab剂量。应用线性回归模型来确定AChR-Ab滴度的临床决定因素，并使用Cox回归模型来估计与胸腺瘤复发风险相关的因素。
结果：该研究样本包括239名MG患者，其中27名经历了一次或多次复发（中位随访时间：4.8年）。第一次胸腺切除术后AChR-Ab滴度降低（P <0.001）；女性患者（P = 0.05），年龄较大的确诊为MG的患者（P = 0.003）以及术前MG阶段较低（P = 0.02）或Masaoka-Koga阶段较高的患者中，下降更为明显（P = 0.05） （P ＝ 0.005）。复发的风险与患者的年龄，Masaoka-Koga分期和手术方法密切相关。
结论：AChR-Ab的术前水平或术后改变与胸腺瘤复发无关。胸腺切除术后AChR-Ab滴度的降低证实了胸腺瘤在MG发病机理中的免疫作用。
要点：这项研究的重要发现：对于初发肿瘤Masaoka分期评分较高的年轻MG患者，应采用不同于胸骨切开术和VATS的方法进行胸腺切除术，以监测其高复发风险。
这项研究的补充：在大批TAMG患者中，在胸腺切除术前后，AChR-Ab滴度的变化尚无其他研究。胸腺切除术后AChR-Ab滴度的降低表明胸腺瘤在MG的发病机理中具有免疫学作用。
关键词：抗乙酰胆碱受体抗体；重症肌无力;胸腺瘤胸腺瘤复发。
图1.左图：Kaplan-Meier对所有患者的无复发生存概率（实线）进行了逐点估计，置信区间为95％（虚线）。 右图：通过Masaoka-Koga阶段（实线）对Kaplan-Meier估计的无复发生存概率。 在每个面板中，报告了处于危险中的患者数量。 Masaoka-Koga分期：（图片）I / IIa，（图片）IIb和（图片）III / IV。
Figure 1.Left panel: Kaplan‐Meier estimate of the relapse‐free survival probability for all patients (solid line) with pointwise 95% confidence intervals (dashed lines). Right panel: Kaplan‐Meier estimate of the relapse‐free survival probability by Masaoka‐Koga stage (solid lines). In each panel the numbers of patients at risk are reported. Masaoka‐Koga stage: (image) I/IIa, (image) IIb, and (image) III/IV.
Background: Thymoma-associated myasthenia gravis (TAMG) is one of the subtypes of myasthenia gravis with autoantibodies against the acetylcholine receptor (AChR-Ab). We analyzed the clinical features of our cohort of TAMG patients and the changes in AChR-Ab titer before and after thymectomy in order to identify factors predicting thymoma relapses.
Methods: We retrospectively assessed: age of MG onset, MG clinical status according to MGFA (Myasthenia Gravis Foundation of America), epoch of thymectomy, post-thymectomy status, oncological features and surgical approach. AChR-Ab dosages were measured both before and after thymectomy. Linear regression models were applied to identify clinical determinants of AChR-Ab titers and the Cox regression model was fitted to estimate the factors associated with the risk of thymoma recurrence.
Results: The study sample included 239 MG patients, 27 of whom experienced one or more recurrences (median follow-up time: 4.8 years). The AChR-Ab titers decreased after first thymectomy (P < 0.001); the decrease was more pronounced in female patients (P = 0.05), in patients diagnosed with MG at an older age (P = 0.003), and in those who had lower MG stage before surgery (P = 0.02) or higher Masaoka-Koga stage (P = 0.005). The risk of relapse was closely linked with the age of the patient, the Masaoka-Koga stage and the surgical approach.
Conclusions: Presurgery levels of AChR-Ab or their change after surgery were not associated with thymoma recurrence. The reduction of AChR-Ab titers after thymectomy confirms an immunological role of thymoma in the pathogenesis of MG.
Key points: Significant findings of the study: Young MG patients with an advanced Masaoka staging score of the primary tumor who underwent thymectomy with approaches different from sternotomy and VATS should be monitored for high risk of recurrence.
What this study adds: No other study has ever investigated the changes in AChR-Ab titers before and after thymectomy in a large cohort of TAMG patients. The reduction of AChR-Ab titers after thymectomy suggests an immunological role of thymoma in the pathogenesis of MG.
Keywords: Antiacetylcholine receptor antibody; myasthenia gravis; thymoma; thymoma recurrence.
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