CHEST (NTMG) (VATS) (MGFA) VATS. NTMG Kaplan-Meier (CSR) y CSR Kaplan-Meier. (minimally invasive surgery); (myasthenia gravis);

Transcription

1 CHEST Anthony Manlulu, DPBS; Tak Wai Lee, FRCS; Innes Wan, FRCS; Chun Yat Law, MBChB; Carlin Chang, MBChB; Juan Carlos Garzon, MD; and Anthony Yim, MD, FCCP (NTMG) (VATS) (MGFA) 12 y VATS NTMG Kaplan-Meier (CSR) 38NTMG VATS 3d mo91.6 CSR 22.2 Kaplan-Meier 10 y CSR mo (P = 0.03) CSR VATS NTMG CSR (minimally invasive surgery); (myasthenia gravis); (thymectomy); (video-assisted thoracic surgery) CSR = complete stable remission; MG = myasthenia gravis; MGFA = Myasthenia Gravis Foundation of America; NTMG = nonthymomatous myasthenia gravis; VATS = video-assisted thoracic surgery 292

2 (MG) CT NTMG75 MG FVC MG MG 4 MG MG MG VATS MG 1992 (VATS) 0º MG 3 (MGFA) [1] 6 (NTMG) VATS [24] NTMG ICU MGFA (1) 6 1 MG MG MGFA 1 (2) CT From the Division of Cardiothoracic Surgery, the Chinese University of Hong Kong, Hong Kong, SAR, China. Correspondence to: Anthony P. C. Yim, MD, FCCP, Professor of Surgery, Chief of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, SAR, China; yimap@cuhk.edu.hk Kaplan-Meier (CSR) Kaplan-Meier CSR (40 / 40 ) (12 mo / 13 mo) CHEST

3 1 MGFA a b a b a b () () () () () () () () () ( ) ( b ) (Statistical Package for the Social Sciences SPSSChicagoIL) P %) ( ) mo (2 204 mo) 3 MGFA % 47 VATS 38 NTMG min ( ) NTMG 36( min 2 (5.5%) 2 MGFA CSR MG 1 y CSR MG ( ) MG CSR MM-0 1y MG MM-1 ( ) MM-2 ( <120mg/d) 1y MM-3 1 y MG MG MG CSR 30 d MG 294

4 3 36 (/ ) / 36.1 / 63.8 / /mo 35.1 /mo 6933 / / CSR (P =0.82) (12 mo / 13 mop = 0.03) (P =0.75) (P =0.68) ( 41) CSR CSR (12 mo) MG 1 73 MG 8mo MG 3d [5, 6] 22 (61.1%)6 (16.6%)8 (22.2%) [5] 11% CSR 1 1 5d1 VATS ( ) [7] 1 69 mo 91.6% CSR (2.6% 5.5) 22.2% (5) 2 1 [8] VATS 42 MGFA 11 MG MGFA A 4mo VATS [9] MG 4 MGFA MGFA CSRKaplan-Meier 13 mo 10 y 75% 117 mo (1) MG Kaplan-Meier () MGFA () 8(22.2) a 4 (11.1) a 13 (36.1) b 1 (2.7) b 2 (5.5) 1(2.7) 7(19.4) CHEST

5 5 MGFA () () 33 (91.6) MM-3 16 (44.4) CSR 8 (22.2) 2(5.5) MM-2 9 (25.0) MG 1 (2.7) 36.1 MGFA Mantegazza [5] [10] CSR ( ) (MG ) ( ) Mantegazza [5] [11] ( ) CSR [6, 12, 13] CSR VATS 35 mo Mineo [18] VATS 14.8 mo de Perrot [6] 10 mo CSR VATS (19) [6] (27) [14] VATS [11] CSR 22.2Savcenko [15] CSR 14 CSR [16] VATS Kaplan-Meier 10 y CSR 75 CSR (6) [17] MG CSR 1 /mo Kaplan-Meier VATS MGFA CSR 296

6 6 MG /mo /% /% VATS Zielinski [20] /2004 TC-Sx-VATS Hsu [21] / 2004 SxVATET NA Mantegazza [5] / 2003 VATET NA de Perrot [6] / 2003 TC NA Shrager [13] / 2002 TC NA Savcenko [15] /2002 VATS Wright [19] /2002 VATS Uchiyama [22] / Mineo [18] /2000 VATS Calhoun [12] / 1999 TC (1) TC-Sx-VATS SxVATET VATET TC NA MG (CSR) MGFA CSR de Perrot [6] Shrager ( ) [13] 2 [18, 19] CSR 1 Jaretzki A, at al. Neurology 2000;55: Yim APC. ANZ J Surg 2002;72: Yim APC, et al. Semin Thorac Cardiovasc Surg 1999;11:65 MG 73 [20] GM CSR Saunders, 2000; Mantegazza R, et al. J Neurol Sci 2003;212:31 36 ( [17, 18] 12 mo) CSR 7 Yim APC, et al. Chest 1995;108: Bulkley GB, et al. Ann Surg 1997;226: Yim APC, et al. VATS approach to the thymus. In: Yim APC, et al, eds. Minimal access cardiothoracic surgery. PA: W.B. 6 de Perrot M, et al. Eur J Cardiothorac Surg 2003;24: Ruckert JC, et al. Ann Thorac Surg 2000;70: Kalso E, et al. Acta Anaesthesiol Scand 2001;45: Pompeo E, et al. Ann Thorac Surg 2000;70: VATS NTMG 12 Calhoun RF, et al. Ann Surg 1999;230: CSR 13 Shrager JB, et al. Ann Thorac Surg 2002;74: Henze A, et al. Scand J Thorac Cardiovasc Surg 1984;18: CHEST

7 15 Savcenko M, et al. Eur J Cardiothorac Surg 2002;22: Mack MJ, et al. J Thorac Cardiovasc Surg 1996;112: Gronseth GS, et al. Neurology 2000;55: Mineo T, et al. Ann Thorac Surg 2000;69: Wright GM, et al. Intern Med J 2002;32: Zielinski M, et al. Ann Thorac Surg 2004;78: Hsu CP, et al. Surg Endosc 2004;18: Uchiyama A, et al. Ann Thorac Surg 2001;72: Budde JM, et al. Ann Thorac Surg 2001;72: CHEST 2005;128: CHEST 291 CHEST E. Start liposomal amphotericin B at 6 mg/kg/d. The correct answer is to administer liposomal amphotericin B (LAMB) at 6 mg/kg/d (choice E). Neutropenic fever may be treated empirically for fungi if the patient remains febrile after 3 to 5 days of standard broad spectrum antibiotic therapy. Although many agents have been used, at the present time the accepted and approved agent is amphotericin B deoxycholate (AMB) when aspergillosis is suspected. The reason aspergillosis is suspected in this patient is because the fever persisted after 2 days offluconazole therapy. Because the patient s creatinine is elevated,lamb should be used in preference to AMB to reduce the likelihood of further renal damage. Although two new agents have been introduced (voriconazole and caspofungin), neither agent has documented superiority to LAMB. In a recent article, voriconazole performed almost as well as LAMB, but the composite end point did not reach equivalence. Caspofungin was also shown to be effective, but no carefully done randomized controlled trial has been published comparing caspofungin to LAMB. While aspergillosis remains the most common fungal infection (after candidiasis), other mold infections may also occur. Because the patient still has a clear chest radiograph and the results of the BAL from 2 days ago shows no pathogens, repeat bronchoscopy and BAL is not indicated (choice A). Changing antibacterial antibiotics is not likely to add anything, because there are no organisms to target (choice B). While oral itraconazole has been used in this setting, it is inferior to LAMB (choice C). Although an additive effect is not yet proven, increasingly clinicians are using combinations of LAMB and caspofungin. While this combination makes sense (the agents have different molecular targets), at the present time this should be considered experimental therapy. 298