[Neuroendocrine tumors of the thymus].
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Adult↗
Biomedical subjects
I Kh Ippolitov
Publications and source records attributed to I Kh Ippolitov.
[Thymomas with a myasthenic syndrome].
2560 patients with generalized myasthenia (Gm) were operated during 1960-1996. Tumors of the thymus (TT) which are the most often neoplastic masses of anterior mediastinum were revealed in 312 patients. Among them organ-specific tumors (thymomas, cancers) were detected in 252 patients (95.8%). Comparative analysis of effectiveness of a number of special methods of diagnostics of TT showed that CT and magnetic resonance tomography are the most sensitive and specific methods. Thymoma-thymectomy was carried out in 247 patients, among them in 93 (37.7%)--extended one. Postoperative lethality made up 5.1%, last years (1990-1996) there were no fatal outcomes. Among early postoperative complications wound infection was observed in 2.5% of patients, pneumonia--in 1.3%, myasthenic crisis--in 1.6%. Basing on histogenetic classification, following kinds of thymomas were singled out: in 58.9% cortical ("light cellular"), in 2.2%--medullar ("dark cellular") and in 38.9%--mixed cellular thymomas. Long-term results of thymectomy in patients with Gm in various kinds of thymomas were different: at the 5th year of follow-up they are worse in cortical cellular types and much better in medullar--cellular and mixed cellular thymomas with prevalence of medullar component.
Adult↗
[Primary hyperparathyroidism].
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Diagnosis, Differential↗
[Thirty years of experience in the surgical treatment of patients with generalized myasthenia].
The article deals with 30-year experience of the Burdenko Facultative Surgical Clinic in surgical management of generalized myasthenia. The analysis is based on 2,500 cases. This complex disease was worked out in stages, taking into account the advancements of the medical science in the given stage. It is noted that the immediate and late-term results of surgery improved after introduction of the newest methods of examination and treatment of patients with myasthenia into practice. Among these methods are CT and MRT, immunohistochemical study, and treatment with steroids and immunodepressants. The role and significance of sorption methods and splenectomy in combined treatment of serious forms of myasthenia are pointed out. The elaboration of the clinico-immuno-morphometric criteria allowed the authors to prognosticate the results of surgical treatment with high authenticity and distinguish two types of myasthenia, as a result of which the indications for surgery could be determined more precisely. The authors direct the way to further research in this field for improvement of the diagnosis and the results of treatment of generalized myasthenia.
Combined Modality Therapy↗
[Diagnosis, surgical treatment and prognosis in patients with generalized myasthenia].
The work deals with the clinical analysis of the richest experience in the surgical treatment of patients with generalized myasthenia in the country. The efficacy of various methods for the diagnosis of affection of the thymus is studied comparatively. It is shown that for more effective diagnosis of neoplastic lesions of the thymus wider use of computerized and magneto-resonance tomography is expedient and that they must replace the insufficiently informative and invasive examination methods used today (pneumonodiastinography, phlebography, scintigraphy, etc.) which still form the basis for the system of diagnostic research in patients with myasthenia. The authors determined the indications and contraindications for, the optimum terms for undertaking the surgical intervention and its volume in neoplastic and nonneoplastic diseases of the thymus in adults and children. Comparative evaluation of various means of preoperative management was conducted. It is shown that to improve the patient's condition and stabilize the myasthenic status on the possibly minimal doses of anticholesteremic agents glucocorticoid hormones should be included in the complex of preoperative management. The indications for hormonotherapy were determined. The efficacy of plasmapheresis, radiotherapy, and glomectomy with denervation of the sinocarotid zone was evaluated and their place in the complex treatment of patients was determined. From study of the late-term results of treatment of a large group of patients (children, adults with a thymus) the main causes of unsuccessful surgical treatment of generalized myasthenia were identified and the concrete means of improving the results of treatment were planned. Two types of changes in the clinico-immuno-morphological values were revealed in patients with generalized myasthenia, differing evidently in pathogenesis. New clinico-immuno-morphological correlations and prognostic factors were discovered, and a method for prognosticating the effect of thymectomy was suggested. It is shown that splenectomy has a favorable effect in the most severe category of patients in unsuccessful operative and nonoperative treatment. The tactics of management of patients accepted in the clinic led to a uncomplicated course of the postoperative period in the majority of patients in the last years.
Adult↗
[Comparative evaluation of diagnostic methods in thymus disease].
From analysis of the case records of 2,000 patients with the generalized form of myasthenia, who underwent operation at the surgical faculty clinic of the Moscow Medical Academy, the authors discuss in detail the results of using a wide spectrum of methods for examination of the thymus, including: pneumomediastinography (PMG), scintigraphy, phlebography, computed and magnetoresonance tomography (CT and MRT). Taking into account the sensitivity and specificity of each of these methods, the indications and contraindications, and the degree of invasiveness, the authors concluded that MR tomography is the method of choice for examination of the thymus. It yields the rechest information and is most simple and safe for the patient. They also noted that CT made it possible to locate the pathological process more exactly, and provided additional information on the degree of the invasion, the presence of implants, and the condition of the other mediastinal organs. The indications for phlebography of the thymus and PMG are limited because of their invasiveness, difficult techniques, high risk of complications, and relatively low informativeness. Scintigraphy of the thymus is the least informative examination method. In view of the high percentage of pseudopositive and pseudonegative results, it may be concluded that its use for detecting lesions of the thymus in patients with myasthenia is hardly expedient.
Humans↗
[Clinico-immunological features of generalized myasthenia in patients with hyperplasia and atrophy of the thymus gland].
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Adolescent↗
[Clinical value of fine-needle aspiration biopsy of the thyroid gland].
The work compares the results of fine-needle aspiration biopsy (FAB) of the thyroid gland in nodular and diffuse-nodular euthyroid goiter (63 patients) with the findings of pathomorphological study of the operative material (51 patients). The authors' original device for puncture of the thyroid node is described. The suggested method makes it possible to raise the efficacy of obtaining an adequate amount of aspired material to 92%. On the basis of the results of FAB and ultrasonic examination (USE) unfounded surgical intervention was avoided in 12 of the 63 cases. The results of the study bear evidence of the high diagnostic efficacy of FAB as to obtaining the cytologic material and revealing malignant degeneration (96% specificity). The authors believe that FAB in combination with USE should be an obligatory component of complex clinico-instrumental examination of patients with various diseases of the thyroid, nodular forms of affection in particular.
Adolescent↗
[Diagnosis and surgical treatment of myasthenia gravis in childhood].
Thirty-year experience in surgical treatment of myasthenia in children and adolescents (175 patients) is generalized. It provides evidence of delayed recognition of this disease in many patients and of prolonged, often ineffective nonoperative treatment. Operation for thymectomy should be one of the main methods for the management of myasthenia in children. Operative treatment is indicated in a disease of moderate severity or in a severe course of myasthenia, particularly in patients with the first type of immunomorphological changes. It is important to amend the myasthenic disorders before the operation by means of maximally possible doses of anticholinesterases with addition of corticosteroids, whenever necessary. Whatever the method of treatment chosen, the patients must be kept under skilled dynamic control. Excellent and good late-term results were produced in 84.6% of cases.
Adolescent↗
[Cortical-cell thymomas with predominance of so-called nurse-cells in patients with myasthenia].
30 thymomas in patients with generalized myasthenia studied histologically and immunohistochemically are classified as cortico-cell thymomas (n-15), medullary-cell (n-1), mixed-cell (n-10) and cortical-cell thymomas consisting mainly of thymic "nurse"-cells. Pronounced histological features of thymomas with the predominance of "nurse"-cells allow one to consider them as a special variant of thymic tumours. Production of thymic hormones by tumour cells in combination with the loss of HLA-DR antigen expression may be of importance in the pathogenesis of autoimmunization in patients with myasthenia.
Cell Count↗
[The morphological and clinico-immunological characteristics of 2 types of myasthenia].
The thymus is studied morphologically in 139 cases of myasthenia (with no thymic neoplasia). Hyperplasia of true thymic parenchyma (without its intralobular perivascular spaces) was observed in 28%, no change in 40% and atrophy in 32% of cases. Two types of the disease were distinguished on the basis of morphological and clinico-immunological parameters: the 1st type with a hyperplastic or normal thymic parenchyma and the 2nd type with its atrophy. These types probably differ in their pathogenesis. The outcome of the thymectomy in patients with the 1st type of myasthenia is most favourable, while in patients with the 2nd type the outcome in 42% of patients is either satisfactory or unfavourable.
Adolescent↗
[Tactical and technical errors in surgical treatment of patients with generalized myasthenia gravis].
From experience in surgical treatment of 1,800 patients with generalized myasthenia as well as from literature data, the authors analyse the main tactical and technical errors in the treatment of this category of patients. A complex approach and a program of improving the results of treatment of patients with myasthenia were elaborated. Compulsory examination of the mediastinum for revealing possible affection of the thymus is indicated in myasthenia. Median sternotomy with ++extra-fascial removal of the whole thymus is considered the optimal approach in thymectomy. Thymomthymectomy with extensive removal of the areolar tissue of the anterior mediastinum is believed to be the operation of ++choice in tumors of the thymus. Thymus tissue which is not removed during the operation is one of the causes of recurrent myasthenia, while unjustified extension of the volume of the operation in nonneoplastic affection of the thymus is also inadvisable. Preoperative radiotherapy is not recommended. The principles elaborated in the clinic enabled the authors to reduce the frequency of assisted ventilation sevenfold and the incidence of infectious complications, pneumonia among others, to 0.6%.
Adult↗
[Residual thymus gland in patients operated on for myasthenia].
The authors studied the causes of ineffective surgical treatment of myasthenia and found residual thymus to be one of them. From analysis of 21 cases in which part of the thymus was not removed (in 19 cases the diagnosis was verified histologically), they drew the conclusion that the causes of residual thymus may be technical errors due to inadequate choice of the surgical approach of the surgeons' insufficient experience, in removal of a thymoma failure to excise part of the thymus not involved in the tumor, incomplete knowledge of the role of the thymus in the pathogenesis of myasthenia and its incomplete removal in thymectomy in patients with generalized myasthenia. Uneventful postoperative course was noted in 11 patients, crises with respiratory disorders in 6 (prolonged artificial lung ventilation had to be resorted to in 4 of them), suppuration of the wound in 2, and pneumonia in 1 patient who was under artificial lung ventilation. The late--term results were studied in follow--up periods of 12 months to 15 years. The myasthenic status improved in all patients, the results were excellent and good in 15. In view of the difficulty in establishing the diagnosis and management, this grave category of patients must be treated at specialized centers.
Adolescent↗
[Plasmapheresis in combined treatment of severe generalized myasthenia].
Experience in the application of plasmapheresis in various stages of treatment is analysed. It was conducted in 52 patients with severe forms of generalized myasthenia; 12 of them were males and 40 were females. It is noted that plasmapheresis is very effective in the preoperative period for the preparation of patients for operation and is ineffective in medicamentous therapy. In the late-term periods after thymectomy plasmapheresis is mainly recommended for arresting crises and precritical conditions because of the rapid and short effect of the method. In patients who underwent thymectomy and splenectomy the effect of plasmapheresis in the late-term period after the operation was of a longer duration. Research must be continued and clinical experience accumulated to identify exactly the mechanism of the effect of plasmapheresis on the myasthenic status and the immune and neuroendocrine systems and to determine the place of the method in the complex of therapeutic measures.
Adult↗
[Splenectomy in the treatment of severe forms of myasthenia gravis].
The authors describe the results of clinical and electromyography examinations of 20 patients with grave generalized myasthenia, carried out within the short-term (up to 2 weeks) and long-term period (up to 1 year) after splenectomy. In these patients, the preceding therapy (thymectomy, gamma-therapy of the thymic area, the treatment with prednisolone, azathioprine, plasmapheresis, etc) had not produced any beneficial effect. The efficacy of splenectomy was assessed according to the Keens classification (A-E). In the short-term period after splenectomy the C effect was recorded in 13 out of the 20 patients. Out of 9 patients examined in the long-term period, the B effect was revealed in 3 patients, the C effect persisted in 3 patients, and 3 patients manifested the return to the initial status, namely to the E effect. Therefore in the group of patients with grave generalized myasthenia, the efficacy of splenectomy amounted to 65%. In view of this fact the inclusion of the given treatment method into the multimodality treatment of myasthenic patients is regarded advisable.
Adult↗
[Splenectomy in the treatment of severe generalized myasthenia gravis (first experience)].
The authors discuss the results of splenectomy carried out on 20 patients with generalized myasthenia in whom previous complex treatment including thymectomy, corticosteroid and azathioprine therapy, repeated courses of plasmapheresis during medication with anticholinesterase agents, did not cause any essential improvement. Different values of homeostasis and immunological status were studied before and in different periods after splenectomy. The condition improved in 65% of patients, which was confirmed by the results of myography; the doses of corticosteroids and anticholinesterase agents were reduced. Bearing in mind the severe condition of patients selected for splenectomy, it is recommended to treat them only in medical centers possessing sufficient experience in treatment of myasthenia. The indications and contraindications for splenectomy in complex treatment of myasthenia must be specified further.
Adrenal Cortex Hormones↗
[Thymus gland pathology in myasthenia gravis: cause or consequence?].
Analysis of the literature data and of the findings of histologic and immunohistochemical studies of operation biopsy specimens of the thymus obtained from 92 patients with myasthenia has demonstrated that abnormalities of the thymus are characteristic of myasthenia patients. In nontumor involvement of the thymus (84.7 percent of the examinees) these abnormalities present as thymic parenchyma involution of varying gravity, combined (in 54.3 percent of patients) with hyperplasia of intralobular perivascular cavities, this simulating the so-called thymic hyperplasia with lymphoid follicles. Furthermore, impaired expression of certain epitheliocytic antigens is detectable and changed counts of these cells subpopulations; thymic hormones hyperproduction occurs in young patients. In thymomas (15.3 percent of the examined myasthenia patients) the tumor epithelial cell subcortical and/or cortical antigens are intact, thymic hormones production is not always excessive, and disorders in some antigens expression are similar to those observed in nontumor involvement of the thymus. Thymic dysfunction appears to play the key role in the pathogenesis of autoimmune disturbances in myasthenia, and disordered activity of the epithelial cells and lymphoepithelial interactions may be the major factors here.
Adolescent↗
[Surgical interventions in concurrent and concomitant diseases in patients with myasthenia gravis].
The authors analyse the recent 15 years' results of treatment of 51 patients with generalized myasthenia who underwent operation in the clinic for various surgical diseases. Forty-three of them had a history of operation on the thymus. The specific features of preoperative management, anesthesia, and postoperative treatment in this serious category of patients are discussed. It is concluded that it is expedient to hospitalize these patients in special surgical hospitals possessing experience in the treatment of patients with generalized myasthenia and the possibility of conducting long-term ventilation of the lungs and other measures of resuscitation.
Adolescent↗