Article Figures & Data
Figures
- Figure 1
Flow chart for article identification and exclusion process.
- Figure 2
Forest plot of the meta-analysis on prevalence of myasthenia gravis recurrence post-thymectomy. CI - confidence interval
Tables
s/no Author, (year) Countries Study period Type of MG Total number of Patients Recurrence Mean/Median Follow-up period (years) 1 Palmisani, (1994) Italy 1971-1991 Thymoma 111 20 >1 2 Mano, (1993) Japan N/A Both 105 50 9.8 3 Ohmi, (1991) Japan 1977 – 1989 Both 166 3 >1 4 Abo Elnasr, (2016) Egypt 2013-2015 Non-thymoma 38 9 0.5 5 Budde, (2001) USA 1974-1999 Both 92 23 4.3 6 Meyer, (2009) USA 1992-2006 Both 81 3 6.0±4.0 7 Masaoka, (1996) Japan 1973 – 1993 Both 321 47 1 8 Bachmann, (2009) Germany 1980 – 2005 Non thymoma 84 23 9.8 9 Maggi, (2008) Italy 1986 - 2006 Thymoma 197 62 7.69±6.0 10 Venuta, (1999) Italy 1970 – 1997 Both 204 51 9.92 11 Kaufman, (2016) USA 1941-2013 Both 1002 647 6 12 Poomthong, (2012) Thailand 2010 Non thymoma 51 25 1 13 Glinjongol, (2004) Thailand 1990-2004 Both 30 6 3.4 14 Ozdemir, (2003) Turkey 1990-2000 Both 61 11 3.83 15 Takanami, (2009) Japan 1991-2005 Both 54 18 6.0 ± 3.9 16 Soleimani, (2004) Iran 1985 - 2002 Both 110 20 6.4 ± 4.3 17 1Nazarbaghi, (2015) Iran 1999 - 2013 Both 25 0.5 7.3±4.2 18 Kumar, (2011) India 1991 - 2007 Both 73 15 5.65 19 De Roxas, (2016) Philippines 2009 – 2014 Both 69 27 1 year 20 Frist, (1994) USA 1971 – 1992 Both 46 6 1 21 Gao, (2016) China 2010 – 2014 Both 130 28 1.5 22 Hsu, (2006) Taiwan 1986 - 2001 Both 154 62 1 23 Kim, (2018 ) South Korea 1994 - 2016 Both 179 14 1 24 Muhammed, (2016) Malaysia 2002 – 2012 Both 16 2 1 year 25 Mulder, (1989) USA 1983 – 1987 Both 84 17 3.6 26 El-Medany, (2003) Saudi Arabia 1986 – 2001 Both 100 18 7.6 27 Romi, (2003) Norway 1973 - 2002 Both 48 33 8.7 28 Téllez-Zenteno, (2001) Mexico 1987 – 1997 Both 132 41 3 29 Tsinzerling, (2007) Sweden 1956 – 2006 Both 537 88 1.5 30 Werneck, (2000) Brazil 1973 – 1995 Both 28 2 6.3 31 Yang, (2017) China 2003 – 2013 Non-thymoma 123 19 4.42 32 Yu, (2015) China 1984 – 2001 Both 297 56 8.6 33 Dube, (2017) India 1993 – 2014 Thymoma 8 1 4.6 34 Zheng, (2017) China 2013 – 2016 Both 73 16 2.2 35 Lin, (2010) Taiwan 1995 – 2004 Non thymoma 60 9 3.7 36 Bachmann, (2008) Germany 1980 - 2005 Both 98 17 8 37 Nieto, (1999) Spain 1977 – 1994 Both 61 2 1 38 Jaretzki, (1988) USA 1997 – 1985 Both 95 7 0.5 39 Calhoun, (1999) USA 1989 – 1998 nonthymoma 78 12 5.0 40 Shrager, (2002) USA 1992 – 1999 Both 78 8 4.6 41 Detterbeck, (1996) USA 1977 – 1993 Both 100 22 5.4 42 de Perrot, (2001) Switzerland 1979 – 1999 Both 35 26 8 43 Tansel, (2003) Turkey 1980 – 2001 nonthymoma 204 20 7.2± 1.2 44 Siwachat, (2018) Thailand` 2006 – 2013 Both 98 11 3.48 45 Seyfari, (2018) Iran 2011 – 2015 Both 47 7 1 46 Waitande, (2007) India 1994 – 2003 Both 57 17 2.4 47 Kattach, (2006) United Kingdom 1987 - 1998 Both 85 3 4.5 48 Huang, (2005) Taiwan 1986 - 2000 Both 154 18 8.2 49 Hase, (2006) Japan 1987 – 2001 Both 17 4 0.5 50 Remes-Troche, (2002) Mexico 1989 – 2000 Both 152 49 2 51 Pompeo, (2009) Italy 1995 – 20003 Non thymoma 32 5 9.92 52 Liu, (2016) China 2000 - 2010 Both 31 10 6.9 53 Yu, (2014) China 1997 – 2012 Both 188 36 5.6 54 Busch, (1996) Germany 1976 - 1993 Both 86 25 8.0 55 Bril, (1998) Canada 1977 – 1986 Nonthymoma 52 5 8.4 56 Klein, (1999) Germany 1984 – 1992 Both 51 7 3.9 57 Mineo, (2000) Italy / Belgium 1993 – 1997 Both 31 1 3.3 58 Zielinski, (2004) Poland 2000 – 2003 Nonthymoma 48 8 1 59 Yim, (2002) Hong Kong 1985– 2000 Both 36 8 3.4 60 Manlulu, (2005) China 1992 – 2004 Nonthymoma 36 3 5.8 61 Savcenko, (2002) USA 1992 – 2002 Both 36 6 4.4 62 Uchiyama, (2001) Japan 1998 – 2000 Both 23 2 1 63 Wright, (2002) Australia 1997 – 2001 Nonthymoma 24 2 0.5 64 Nussbaum, (2002) USA 1979 – 1991 Both 48 3 4.3 65 Cooper, (1988) Canada 1977 – 1986 Both 65 3 3.5 66 Olanow, (1987) Canada 1979 – 1986 Both 55 5 3.3 67 DeFilippi, (1994) USA 1977 - 1991 Nonthymoma 21 4 4.3 68 Mack, (1996) USA 1992 – 1995 Both 33 4 1.9 69 Ambrogi, (2012) Italy 1980 – 2005 Nonthymoma 96 24 13.3 70 Mineo, (2013) Italy 1980 - 2007 Nonthymoma 47 9 8.3 1= no recurrence during follow-up, 0.5 was assigned to allow for meta-analysis; N/A = not available
Variables Pooled event rate n/N No. of Studies Heterogeneity I2 (P-value) MG Recurrence % (95% CI) Total 18.0 (14.7 – 22.0) 1865/7287 70 93.6% (<0.001) Stratified by Sex Male 31.3 (24.4 – 39.1) 148/432 13 53.3% (0.012) Female 23.8 (18.7 – 29.8) 206/781 13 64.7% (0.001) Stratified by Histology Thymomatous 33.3 (23.4 – 45.0) 175/682 17 82.2% (<0.001) Non-thymomatous 20.8 (15.3 – 27.5) 2320/1782 17 85.1% (<0.001) - Table 3
Summary of meta-analysis of risk factors of myasthenia gravis recurrence post-thymectomy.
Risk Factor Number of primary studies Effect size Random-effects summary effect size (95% CI) P-value (random) I2 Egger regression test (P–value) Begg and Mazumdar correlation test (P–value) Older age (>35 - 60) years 8 OR 3.45 (2.36 – 5.04) <0.001 0 0.017 0.006 Male sex 5 OR 2.84 (1.51 – 5.35) 0.001 34.8 <0.001 0.027 Higher stage of the MG (>ii) 10 OR 4.80 (3.1 – 7.67) <0.001 39.6 0.033 0.049 Thymomatous MG 9 OR 2.05 (1.56 – 2.68) <0.001 24.3 0.118 0.25 Longer duration of MG before surgery 6 OR 2.27 (1.04 – 4.94) 0.039 79.2 0.433 0.260 Ectopic Thymic tissue 3 OR 6.04 (3.08 – 11.82) <0.001 0 0.687 0.601 Thymic hyperplasia 4 OR 1.12 (0.17 - 757) 0.907 86.3 0.359 0.308 Thymic atrophy 2 OR 2.54 (1.41 – 4.58) 0.002 Higher Pyridostigmine dosage (>240 mg) 2 OR 2.80 (1.48 – 5.28) 0.002 Use of steroid before thymectomy 2 OR 2.58 (1.47 – 4.54) 0.001 MG - myasthenia gravis
Factors Effect size type Effect size (95% CI) Less than six years post-surgery OR 1.37 (0.61 – 3.07) Previous thymectomy OR 4.6 (0.31 – 132.7) Receiving Plasmapheresis post-surgery OR 3.4 (2.6 – 4.5) Hyperthyroidism HR 8.3 (2.1 – 33.3) Preoperative myasthenia gravis crisis OR 4.7 (1.6 – 13.4) Having Bulbar symptom OR 3.3 (1.3 – 8.4) Longer operation time OR 1.03 (1.003 – 1.039) Higher blood loss during surgery OR 1.02 (1.003 – 1.039) HR - hazard ratio, OR - odds ratio
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