G. I. WolfeH. J. KaminskiI. B. AbanG. MinismanH. C. KuoA. MarxP. StröbelC. MaziaJ. OgerJ. G. CeaJ. M. HeckmannA. EvoliW. NixE. CiafaloniG. AntoniniR. WitoonpanichJ. O. KingS. R. BeydounC. H. ChalkA. C. BarboiA. A. AmatoA. I. ShaibaniB. KatirjiB. R.F. LeckyC. BuckleyA. VincentE. Dias-TostaH. YoshikawaM. Waddington-CruzM. T. PulleyM. H. RivnerA. Kostera-PruszczykR. M. PascuzziC. E. JacksonG. S. Garcia RamosJ. J.G.M. VerschuurenJ. M. MasseyJ. T. KisselL. C. WerneckM. BenatarR. J. BarohnR. TandanT. MozaffarR. ConwitJ. OdenkirchenJ. R. SonettA. JaretzkiJ. Newsom-DavisG. R. CutterUniversity at Buffalo, State University of New YorkUniversity of Rochester Medical CenterColumbia University Medical CenterGeorge Washington University School of Medicine and Health SciencesUniversity of Alabama at BirminghamUniversitatsklinikum MannheimUniversität GöttingenJohannes Gutenberg Universität MainzUniversidad de Buenos AiresThe University of British ColumbiaMcGill UniversityUniversidad de ChileUniversity of Cape TownUniversità Cattolica del Sacro Cuore, RomeUniversità degli Studi di Roma La SapienzaMahidol UniversityUniversity of MelbourneUniversity of Southern CaliforniaUCI Medical CenterMedical College of WisconsinHarvard Medical SchoolNerve and Muscle Center of TexasUniversity of Texas Health Science Center at San AntonioCase Western Reserve UniversityOhio State UniversityWalton Centre for Neurology and Neurosurgery NHS TrustUniversity of OxfordUniversidade de BrasiliaUniversidade Federal do Rio de JaneiroUniversidade Federal do ParanaKanazawa UniversityUniversity of FloridaUniversity of Miami Leonard M. Miller School of MedicineAugusta UniversityMedical University of WarsawIndiana School of MedicineInstituto Nacional de la Nutricion Salvador ZubiranLeiden University Medical Center - LUMCDuke University Medical CenterUniversity of Kansas Medical CenterUniversity of Vermont College of MedicineNational Institute of Neurological Disorders and Stroke2018-12-112019-03-142018-12-112019-03-142016-08-11New England Journal of Medicine. Vol.375, No.6 (2016), 511-52215334406002847932-s2.0-84981743104https://repository.li.mahidol.ac.th/handle/123456789/41229Copyright © 2016 Massachusetts Medical Society. BACKGROUND: Thymectomy has been a mainstay in the treatment of myasthenia gravis, but there is no conclusive evidence of its benefit. We conducted a multicenter, randomized trial comparing thymectomy plus prednisone with prednisone alone. METHODS: We compared extended transsternal thymectomy plus alternate-day prednisone with alternate-day prednisone alone. Patients 18 to 65 years of age who had generalized nonthymomatous myasthenia gravis with a disease duration of less than 5 years were included if they had Myasthenia Gravis Foundation of America clinical class II to IV disease (on a scale from I to V, with higher classes indicating more severe disease) and elevated circulating concentrations of acetylcholine-receptor antibody. The primary outcomes were the time-weighted average Quantitative Myasthenia Gravis score (on a scale from 0 to 39, with higher scores indicating more severe disease) over a 3-year period, as assessed by means of blinded rating, and the time-weighted average required dose of prednisone over a 3-year period. RESULTS: A total of 126 patients underwent randomization between 2006 and 2012 at 36 sites. Patients who underwent thymectomy had a lower time-weighted average Quantitative Myasthenia Gravis score over a 3-year period than those who received prednisone alone (6.15 vs. 8.99, P<0.001); patients in the thymectomy group also had a lower average requirement for alternate-day prednisone (44 mg vs. 60 mg, P<0.001). Fewer patients in the thymectomy group than in the prednisone-only group required immunosuppression with azathioprine (17% vs. 48%, P<0.001) or were hospitalized for exacerbations (9% vs. 37%, P<0.001). The number of patients with treatment-associated complications did not differ significantly between groups (P=0.73), but patients in the thymectomy group had fewer treatment-associated symptoms related to immunosuppressive medications (P<0.001) and lower distress levels related to symptoms (P=0.003). CONCLUSIONS: Thymectomy improved clinical outcomes over a 3-year period in patients with nonthymomatous myasthenia gravis.Mahidol UniversityMedicineArticleSCOPUS10.1056/NEJMoa1602489