Clinical efficacy of methylprednisolone combined with immunosuppressants and CAPP chemotherapy in the treatment of thymoma with Myasthenia Gravis

Clinical efficacy of methylprednisolone combined with immunosuppressants and CAPP chemotherapy in the treatment of thymoma with Myasthenia Gravis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Clinical efficacy of methylprednisolone combined with immunosuppressants and CAPP chemotherapy in the treatment of thymoma with Myasthenia Gravis Yuanyuan Geng, Guoyan Qi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6961194/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To evaluate the clinical efficacy of cyclophosphamide, doxorubicin, cisplatin plus prednisone (CAPP), and methylprednisolone (mPSL) plus immunosuppressants in the treatment of thymoma patients with myasthenia gravis (TMG), which provides new treatment ideas for clinicians. Methods: 1. The clinical data of TMG who were treated with CAPP or high-dose mPSL from 2018 to 2023 were collected and divided into CAPP group and mPSL group. 2. The myasthenia gravis muscular endurance score (MGMES) is used to quantify the severity of the disease. The MGMES and the therapeutic effect of thymoma were compared between the two groups, and the side effects were recorded. Results: 1. The response rate (PR or CR) for the TMG of the CAPP group and the mPSL group was respectively 41.4% and 89.2%. The difference was statistically significant (P<0.05). 2. In the CAPP group, the MGMES of the TMG decreased by an average of 10.55±13.86. In the mPSL group, the MGMES decreased by an average of 24.83±22.26. The difference was statistically significant ( P <0.05). 3. The incidence of toxic and side effects was 48.28% in the CAPP group and 45.95% in the mPSL group. During the course of treatment, Myasthenia crisis occurred in 3 cases in the mPSL group. Conclusions: 1. The mPSL combined with immunosuppressants is more effective in the TMG. 2. There is no difference in the incidence of side effects between the two groups, but there was a possibility of myasthenia gravis crisis in the mPSL group. Biological sciences/Cancer/Cancer therapy Biological sciences/Cancer/Tumour immunology Biological sciences/Drug discovery/Toxicology Biological sciences/Drug discovery/Drug safety Recurrent thymoma Myasthenia gravis Methylprednisolone Classic treatment Figures Figure 1 Figure 2 1. INTRODUCTION Thymic Epithelial Tumor is a common primary tumor in the anterior mediastinum, accounting for 30% of adult anterior mediastinal tumors [ 1 ] . In China, the incidence rate of thymic epithelial tumors is about 4.09/1 million people [ 2 ] . The thymus is an immune organ, and thymic epithelial tumors often accompany autoimmune diseases such as myasthenia gravis (MG), polymyositis, red blood cell aplastic anemia, autoimmune hypothyroidism, and Good syndrome. Among them, the most common is MG, and about 30–50% of thymoma patients have myasthenia gravis [ 3 ] . MG is an acquired immune disease caused by the production of autoantibodies, which leads to the transmission barrier of neuromuscular junction. The most common is acetylcholine receptor antibody [ 4 ] , whose incidence rate is 0.3–2.8/100,000 people [ 5 ] . For thymoma patients with myasthenia gravis, thymectomy is currently the preferred treatment. However, there is no clear treatment plan for recurrent thymoma and inoperable thymoma with MG in existing thymoma diagnosis and treatment guidelines or expert consensus on MG. There have also been no reports of clinical trials on the efficacy of chemotherapy regimens. Steroids have immunosuppressive and anti-inflammatory effects, and are widely used in the treatment of immune diseases. They are the core drugs for the treatment of MG. As early as 1990, they were proposed to be suitable for thymoma patients with myasthenia gravis who have failed surgery, radiotherapy, and chemotherapy [ 6 ] . Previous studies have also shown that high-dose methylprednisolone (mPSL) shock therapy is effective for thymoma patients with myasthenia gravis [ 7 ][ 8 ] . The combination of cyclophosphamide, doxorubicin, cisplatin, and prednisone (CAPP) is a first-line chemotherapy regimen in the treatment guidelines for thymoma, but there are no relevant reports on its efficacy in thymoma patients with myasthenia gravis. Clinically, we have found that mPSL also have a therapeutic effect on thymomas in myasthenia gravis patients with thymoma (Fig. 1 ). This experiment compares the therapeutic effects of CAPP and high-dose methylprednisolone shock therapy on thymoma patients with myasthenia gravis through a retrospective study, hoping to provide more economical and effective treatment options for clinical doctors and such patients. 2. MATERIALS AND METHODS 2.1 Scheme design Collect clinical data of thymoma patients with MG treated with CAPP or mPSL shock at Hebei Provincial Clinical Research Center for Myasthenia Gravis of Shijiazhuang People's Hospital from 2018 to 2023, and divide them into CAPP group and mPSL group according to treatment plan. General information includes the patient's name, gender, age, pathological classification of thymoma, and whether there is a history of treatment. Other information includes laboratory tests (blood routine, liver function, kidney function, Anti-acetylcholine receptor antibody), chest computed tomography, myasthenia gravis classification, and myasthenia gravis muscular endurance score (MGMES) [ 9 ] (Table 1 ). The evaluation of myasthenia gravis in the past was expressed using the quantitative myasthenia gravis score [ 10 ] (QMGS), the myasthenia gravis composite scale (MGC) and the absolute and relative score of MG (ARS-MG). Our center has developed the MGMES based on these common myasthenia gravis scoring scales, and confirmed the reliability and effectiveness of MGMES. Therefore, MGMES was used in this study. Build a case report form (CRF) and apply Statistical Product and Service Solutions 21 (SPSS21.0) to analyze data. All procedures were performed in compliance with relevant laws and institutional guidelines and have been approved by the Ethics Committee of Shijiazhuang People's Hospital (NO.[2022]047). The data are anonymous,and the requirement for informed consent was therefore waived. 2.2 Diagnostic criteria The diagnosis and pathological classification of thymoma are mainly based on the patient's history of thymoma, chest computed tomography (CT) results, and pathological diagnosis. The chest CT examination is used to evaluate thymoma, and pathological diagnosis is based on the 2015 World Health Organization (WHO) classification of thymic epithelial tumors [ 11 ] , which are classified into A type, AB type, B1 type, B2 type, B3 type, and C. The diagnosis of MG is based on the "Chinese Guidelines for Diagnosis and Treatment of Myasthenia Gravis 2020" [ 12 ] . On the basis of typical clinical characteristics of fluctuating myasthenia gravis, it meets the diagnostic criteria of positive neostigmine test, decreased low-frequency repetitive electrical stimulation in electromyography, and positive serum acetylcholine receptor antibody. The MG classification adopts the American Myasthenia Gravis Foundation (MGFA) classification [ 13 ] , which is divided into Type I, IIa/IIb, IIIa/IIIb, IVa/IVb, and V. 2.3 Inclusion criteria (1) MG diagnosis is clear and there are symptoms of muscle weakness; (2) The diagnosis of thymoma is clear, and there is no surgical treatment or multiple metastases of thymoma after surgery; (3) Age ranges from 18 to 70 years old. 2.4 Exclusion criteria (1) Malignant tumors (excluding thymoma), history of HIV infection, or severe immunodeficiency; (2) Concomitant severe heart disease or mental illness;(3) Tuberculosis patients with positive tuberculin test or T-SPOT test; (4) Due to the difference in treatment between thymic cancer and other subtypes of thymic epithelial tumors, excluding pathological subtype C thymic epithelial tumors;(5) Incomplete clinical data. 2.5 The dosage of the drugs CAPP group: Cyclophosphamide 500mg/m² day1, doxorubicin 20mg/m² day1-3, cisplatin 30mg/m² day1-3,80mg mPSL day1-5. The treatment cycle is 21 days. mPSL group: The initial dosage of methylprednisolone is 1g, and the dosage is halved for 2 or 3 days. Finally, it was changed to oral prednisone 60mg. When oral immunosuppressants are needed, generally, 100mg of cyclophosphamide per day or 100mg of azathioprine per day. 2.6 Efficacy evaluation The efficacy evaluation of MG is based on the recording of the MGMES, and the MGMES difference and decline rate are calculated. The decline rate below 50% is defined as no significant relief, a decrease rate above 50% is defined as effective, with 50–70% indicating improvement, 70–90% indicating significant improvement, and over 90% indicating complete relief. The efficacy evaluation of thymoma is based on chest CT results, with reference to Response Evaluation Criteria in Solid Tumors [ 14 ] (RECIST). Define complete relief (CR): Measurable thymic tumor lesion completely disappears. Partial relief (PR): The total diameter of thymic tumor lesions has decreased by ≥ 30% compared to before treatment. Stable disease (SD): The degree of change in thymoma lesions is between PR and PD. Disease progression (PD): The total diameter of thymic tumors increases by ≥ 20% compared to before treatment or new clear tumor lesions appear. 2.7 Safety evaluation Record and evaluate adverse reactions (including myasthenia crisis, pre-myasthenia crisis status) that occur during the patient's treatment process, as well as any adjustments to the treatment plan for poor efficacy. 2.8 Statistical methods Construct a case report form table (CRF) and use Statistical Product and Service Solutions 21 (SPSS21.0) data analysis software. The measurement data is represented by x ± s and compared between groups using independent t-test; The inter group count data was analyzed using chi-square test. 3. RESULTS 102 patients with thymoma and myasthenia gravis treated with CAPP or mPSL shock from 2018 to 2023, of which 66 met the inclusion criteria, including 35 males and 31 females, aged between 24 and 70 years, with an average age of 44.05 ± 11.82. There were 32 patients (48.48%) with postoperative recurrence of thymoma, an average course of 35.65 ± 40.84 months for thymic tumor onset, and 43.58 ± 47.41 months for myasthenia gravis. There were 2 patients with type A thymoma, 3 patients with type AB thymoma, 9 patients with type B1 thymoma, and 2 patients with B1/B2 thymoma. There were 30 cases of B2 type thymoma, 8 cases of B2/B3 type thymoma and 12 cases of B3 type thymoma. Among thymoma patients with MG, B2 type thymoma accounts for 45.45%, with up to 96.97% of patients containing B-type thymoma components. There were 29 cases enrolled in the CAPP group and 37 cases enrolled in the mPSL group (with immunosuppressive agents such as cyclophosphamide in 17 cases and azathioprine in 20 cases). There was no statistically significant difference in gender, age, disease course, and subtype between the two groups of patients (Table 2 , P > 0.05). 3.1 Therapeutic efficacy of thymoma The efficacy of thymoma treatment in two groups of patients was tested using Fisher's exact probability method. The results showed that the CAPP group had an effective rate of 41.4% for thymoma treatment, while the mPSL group had an effective rate of 89.2% for thymoma treatment. The difference was statistically significant, and high-dose mPSL shock had a more significant therapeutic effect on thymoma in patients with myasthenia gravis (Table 3 , P < 0.05). 3.2 The therapeutic effect of MG Compare the difference in MGMES and AChR-Ab levels before and after treatment. The difference is statistically significant (Table 4 , P < 0.05). The Fisher's exact probability method was applied to test the decline rate of MGMES in two groups of patients. The results showed that the effective rate of treating myasthenia gravis in the CAPP group was 58.6%, and the effective rate of treating myasthenia gravis in the mPSL group was 73%. The difference was not statistically significant (Table 5 , P > 0.05). 3.3 The relationship between age and treatment efficacy Patients were divided into early-onset myasthenia gravis (< 50 years old) and late-onset myasthenia gravis (≥ 50 years old) by age, with 46 early-onset myasthenia gravis and 21 late-onset myasthenia gravis. Comparing the prognosis of two groups of thymoma patients with myasthenia gravis, there was no statistically significant difference (Table 6 – 7 , P > 0.05), indicating that prognosis is not correlated with age. Table 1 Myasthenia gravis muscular endurance score muscle groups Scoring items normal low-grade moderate severe musculus ocularis The upper eyelid covers the pupil (Clock position, Score separately on the left and right sides) 11 ~ 1 (0 points) 10 ~ 2 (1points) 9 ~ 3 (2points) Below 8 ~ 4 (3points) upward gaze (Record the time when the eyelids droop to 9 − 3, Score separately on the left and right sides) Above 60s (0 points) 31 ~ 60s (1points) 1 ~ 30s (2points) 0 (3points) Eye abduction with white exposure and adduction with white exposure, diplopia (Score separately on the left and right sides) ≤ 2mm (0 points) 3 ~ 7mm or diplopia (1points) 8 ~ 12mm (2points) >12mm (3points) Eyeball up and down vision normal (0 points) The upper and lower eyes of the binocular are not at the same level (1points) The two eyes are not at the same level when looking at eye level (2points) Fixed eyes, unable to move (3points) facial muscles Closing eye power normal (0 points) Close your eyes completely, passively open without resistance (1points) Incomplete closure of eyes, passive opening without resistance (2points) Incomplete closure of eyes (3points) Chime strength normal (0 points) Weak cheek drumming strength (1points) Leakage during cheek swelling (2points) Cheeks cannot be swollen (3points) Masticatory muscles normal (0 points) Chewing hard food fatigue (1points) Chewing soft food fatigue (2points) Eating liquid food (3points) Trunk muscles Head up to 45 in the supine position Above 60s (0 points) 31 ~ 60s (1points) 11 ~ 30s (2points) 0 ~ 10s (3points) Sitting, with both upper limbs raised horizontally (Score separately on the left and right sides) Above 120s (0 points) 31 ~ 120s (1points) 11 ~ 30s (2points) 0 ~ 10s (3points) Lying flat, raise your legs to 45 degrees (Score separately on the left and right sides) Above 100s (0 points) 31 ~ 100s (1points) 11 ~ 30s (2points) 0 ~ 10s (3points) Medullary muscles Swallowing power normal (0 points) Rarely experience coughing or difficulty swallowing (5points) Frequent swallowing difficulties lead to changes in dietary habits (10points) Nasogastric feeding tube diet (15points) speak normal (0 points) Occasional unclear pronunciation or nasal sound (5points) Pronunciation unclear or nasal sounds can be understood (10points) Difficult to understand the meaning of language (15points) breathe normal (0 points) Short breath after the activity (5 points) Short breath during rest (15points) The patient requires artificial respiration assistance (25points) Table 2 General information of the enrolled population Items CAPP Group mPSL Group t P Gender Male Female 15 14 20 17 1 Age 45.55 ± 11.70 42.87 ± 11.95 0.915 0.364 Duration of thymoma/months 33.69 ± 41.13 37.19 ± 41.10 0.343 0.733 Duration of MG/months 42.00 ± 44.95 44.81 ± 49.84 0.237 0.813 Allergy history/cases (%) 6(20.7) 7(18.9) 1 Thymectomy surgery/cases (%) 15(51.7) 28(75.7) 0.077 Thymoma subtypes 0.742 A 0 2 AB 1 2 B1 5 4 B1/B2 or B2 13 19 B2/B3 or B3 10 10 MGFA 0.107 I 3 0 II 3 5 III 9 8 IV 9 9 V 5 15 Table 3 Evaluation of curative effect of thymoma Groups Effective invalid Effective rate P CR PR SD PD CAPP Group 7 5 16 1 41.4% 0.000 mPSL Group 22 11 4 0 89.2% Table 4 MGMES and AChR-Ab Items CAPP Group mPSL Group t P MGMES before treatment 20.83 ± 20.35 31.68 ± 21.09 -2.106 0.039 MGMES after treatment 10.28 ± 17.88 6.84 ± 8.38 1.035 0.305 MGMES difference before and after treatment 10.55 ± 13.86 24.83 ± 22.26 -3.193 0.002 AChR-Ab before treatment 11.29 ± 4.09 12.63 ± 4.42 -1.256 0.214 AChR-Ab after treatment 10.45 ± 4.14 9.62 ± 5.25 0.686 0.496 AChR-Ab difference before and after treatment 0.85 ± 2.08 2.98 ± 3.42 -3.074 0.003 Table 5 The effect of the myasthenia gravis Groups Effective rate Effective invalid P complete relief significant improvement improvement CAPP Group 58.6% 8(27.6%) 4(13.8%) 5(17.2%) 12(41.4%) 0.335 mPSL Group 73% 16(43.2%) 8(21.6%) 3(8.1%) 10(27%) Table 6 Age and efficacy of myasthenia gravis Groups MG P invalid Effective Early-MG 13(28.9%) 32(71.1%) 0.400 Late-MG 9(42.9%) 12(57.1%) Table 7 Age and efficacy of thymoma Groups Thymoma P SD/PD PR/CR Early-MG 12(26.7%) 33(73.3%) 0.302 Late-MG 9(42.9%) 11(57.1%) Table 8 Record of adverse events Groups None Adverse events Drug induced bone marrow suppression pulmonary infection Myasthenic crisis Adjust treatment plan Others CAPP group/cases(%) 15(51.72) 6(20.69) 1(3.45) 0(0) 6(20.69) 1(3.45) mPSL group/cases(%) 20(54.05) 2(5.41) 8(21.62) 3(8.11) 0(0) 4(10.81) 3.4 Safety evaluation There were 14 cases (48.28%) of major adverse events in the CAPP group, including 7 cases of bone marrow suppression or pulmonary infection, and 6 cases of ineffective treatment. Among them, 4 cases were adjusted to receive mPSL shock combined with cyclophosphamide treatment, and 2 cases were adjusted to receive mPSL shock combined with azathioprine treatment. In the mPSL group, there were 17 cases (45.95%) with major adverse events, including 3 cases of myasthenia crisis, 10 cases of bone marrow suppression or pulmonary infection, and 4 cases of steroid diabetes. There were 15 cases in the CAPP group with no adverse events detected, accounting for 51.72%, and 20 cases in the mPSL group, accounting for 54.05%(Table 8 ). After the combination of antifungal therapy and pulmonary infection that occurred during the treatment process, chest CT showed significant improvement. Bone marrow suppression (grade II-III) is a drug-related adverse reaction. Bone marrow suppression occurred in all 6 patients in the CAPP group during 2 cycles of CAPP treatment and recovered after symptomatic treatment. Bone marrow suppression in 2 patients in the mPSL group was considered a toxic side effect of azathioprine, and the immunosuppressive agent was changed to cyclophosphamide. White blood cells returned to normal after symptomatic treatment. In patients with steroid diabetes, insulin was given to reduce blood sugar, blood sugar was monitored during hospitalization, and blood sugar gradually returned to normal after the withdrawal of mPSL outside the hospital and diet control. 3.5 Survival analysis The efficacy of mPSL in myasthenia gravis is very clear, but we need more evidence regarding their efficacy in thymoma. We used GraphPad Prism 9.5.1 software to create survival analysis with the end outcome of the thymoma's progression reaching PR/CR (Fig. 2 ), the mPSL can achieve the expected therapeutic effect in a shorter time. This section of the study is a retrospective study, and thymoma with myasthenia gravis is a rare disease. The sample size that meets the criteria is small, and the CAPP regimen is adjusted after one cycle of ineffective use, making long-term follow-up impossible. The efficacy of mPSL group patients at 6 months and 1 year after treatment was not traceable due to loss of follow-up. Therefore, follow up until March 2024 showed that 5 cases (41.67%) of thymoma recurrence and metastasis occurred after achieving PR or CR in the RECIST assessment of 12 patients in the CAPP group. Among them, 4 cases did not show sustained improvement in muscle weakness symptoms, and only 3 cases had thymoma recurrence; Three patients (25%) with myasthenia gravis post intervention status (PIS) above MMS and thymoma RECIST evaluation reached PR or CR without recurrence after one year in the CAPP group; One patient who underwent thymectomy after 2 cycles of applying the CAPP scheme but did not achieve PR underwent tumor shrinkage. The patient received postoperative radiotherapy and was followed up after treatment. The PIS reached PR, and there was no recurrence or metastasis of thymoma. Seven patients were lost to follow-up or unable to be followed up due to adjustments in treatment plans. In the mPSL group, there were 8 cases (36.36%) of thymoma recurrence and metastasis after PR, and 6 cases (27.27%) of myasthenia gravis recurrence. Among them, 2 cases of myasthenia gravis recurrence occurred due to self discontinuation of medication, 2 cases of untreated myasthenia gravis recurrence due to repeated lung infections, and 2 cases of myasthenia gravis symptoms induced by factors such as fatigue and staying up late. In the mPSL group, there were 4 patients (18.18%) with PIS above MMS and thymoma PR without recurrence, and 15 patients were lost to follow-up. 4. DISCUSSION This section retrospectively analyzes the efficacy of CAPP regimen and high-dose mPSL shock combined with immunosuppressive therapy in patients with thymoma and myasthenia gravis. The research has shown that high-dose mPSL shock therapy is more effective for thymoma patients with MG than the CAPP group, and also better for muscle weakness in thymoma patients with MG than the CAPP group. We also found that the decrease in AChR-Ab levels was more pronounced in the mPSL group, suggesting that steroids reduced serum acetylcholine receptor antibody levels. It is generally believed that this can also reflect the efficacy of steroids therapy for myasthenia gravis. For thymoma-associated multiorgan autoimmunity, it has been found in the literature that the introduction of corticosteroid therapy resulted in unexpected partial remission of thymoma [ 15 ] . This suggests that steroid therapy is effective in treating such thymoma patients, it's consistent with our findings. The current focus of thymoma treatment is on targeted drugs and immune checkpoint inhibitors. A study showed that the effective rate of sunitinib, a multi-target tyrosine kinase inhibitor, in patients with thymoma who failed platinum-based chemotherapy was 6% [ 16 ] . The partial response rate of pembrolizumab, a PD-L1/PD-1 targeted agent, in patients with solitary thymoma who failed chemotherapy was 28.6% [ 17 ] . We observed that the tumor remission rate in thymoma patients with myasthenia gravis treated with high-dose methylprednisolone was not low. The new treatment is expensive and may cause immune disorders in patients with combined myasthenia gravis, exacerbating myasthenia symptoms, increasing treatment costs and reducing quality of life. The existing treatment guidelines for thymic epithelial tumors have not yet included high-dose steroid shock therapy in standardized treatment, and the mechanism of action of steroids on thymoma is also unclear. If high-dose steroid shock therapy is generally effective for thymoma patients, it may be used as an alternative treatment to CAPP chemotherapy regimen, reducing the economic burden on patients. In order to further validate the efficacy of high-dose mPSL shock therapy in thymoma patients, further cell or animal experiments are needed, which requires technical support or a better research team to join and assist. In addition, while applying traditional treatment methods to thymoma patients, we look forward to the emergence of new drugs and guidelines to guide the treatment of thymoma patients with myasthenia gravis. This section retrospectively analyzes the efficacy of CAPP regimen and high-dose mPSL shock combined with immunosuppressive therapy in patients with thymoma and myasthenia gravis. The research has shown that high-dose mPSL shock therapy is more effective for thymoma patients with MG than the CAPP group, and also better for muscle weakness in thymoma patients with MG than the CAPP group. We also found that the decrease in AChR-Ab levels was more pronounced in the mPSL group, suggesting that steroids reduced serum acetylcholine receptor antibody levels. It is generally believed that this can also reflect the efficacy of steroids therapy for myasthenia gravis. For thymoma-associated multiorgan autoimmunity, it has been found in the literature that the introduction of corticosteroid therapy resulted in unexpected partial remission of thymoma [ 15 ] . This suggests that steroid therapy is effective in treating such thymoma patients, it's consistent with our findings. The current focus of thymoma treatment is on targeted drugs and immune checkpoint inhibitors. A study showed that the effective rate of sunitinib, a multi-target tyrosine kinase inhibitor, in patients with thymoma who failed platinum-based chemotherapy was 6% [ 16 ] . The partial response rate of pembrolizumab, a PD-L1/PD-1 targeted agent, in patients with solitary thymoma who failed chemotherapy was 28.6% [ 17 ] . We observed that the tumor remission rate in thymoma patients with myasthenia gravis treated with high-dose methylprednisolone was not low. The new treatment is expensive and may cause immune disorders in patients with combined myasthenia gravis, exacerbating myasthenia symptoms, increasing treatment costs and reducing quality of life. The existing treatment guidelines for thymic epithelial tumors have not yet included high-dose steroid shock therapy in standardized treatment, and the mechanism of action of steroids on thymoma is also unclear. If high-dose steroid shock therapy is generally effective for thymoma patients, it may be used as an alternative treatment to CAPP chemotherapy regimen, reducing the economic burden on patients. In order to further validate the efficacy of high-dose mPSL shock therapy in thymoma patients, further cell or animal experiments are needed, which requires technical support or a better research team to join and assist. In addition, while applying traditional treatment methods to thymoma patients, we look forward to the emergence of new drugs and guidelines to guide the treatment of thymoma patients with myasthenia gravis. Declarations CONFLICT OF INTEREST STATEMENT The authors have no conflict of interest. FUNDING INFORMATION This study was supported by the National Natural Science Foundation of China (No. 82274582), Central guidance for local scientific and technological development funding projects (No.246Z7706G), Key Laboratory Construction Subsidy Fund Project (No. 236790017H). Author Contribution Y.G. wrote the main manuscript. G.Q. reviewed the manuscript. All authors participated in the whole - process management of the paper. Acknowledgement This study received financial support from the Hebei Provincial Key Laboratory of Myasthenia Gravis and Hebei Provincial Clinical Research Center for Myasthenia Gravis. Thanks to the doctors of Hebei Provincial Clinical Research Center for Myasthenia Gravis of Shijiazhuang People's Hospital for providing the enrolled cases. Data Availability All raw data are available upon request. Y.G./G.Q. should be contacted if someone wants to request the data from this study. References Fanjie Meng, Guangshun Wang，Research progress on thymoma and autoimmune diseases [J] Journal of Tianjin Medical University, 2021,27 (02): 195-198. Multidisciplinary Committee of Oncology, Chinese Physicians Association (2021). Zhonghua zhong liu za zhi [Chinese journal of oncology], 43(4), 395–404. Ettinger, D. S., Riely, G. 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Jaretzki, A 3rd et al. “Myasthenia gravis: recommendations for clinical research standards. Task Force of the Medical Scientific Advisory Board of the Myasthenia Gravis Foundation of America.” The Annals of thoracic surgery vol. 70,1 (2000): 327-34. doi:10.1016/s0003-4975(00)01595-2. Marx, A., Chan, J. K., Coindre, J. M., Detterbeck, F., Girard, N., Harris, N. L., Jaffe, E. S., Kurrer, M. O., Marom, E. M., Moreira, A. L., Mukai, K., Orazi, A., & Ströbel, P. (2015). The 2015 World Health Organization Classification of Tumors of the Thymus: Continuity and Changes. Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer, 10(10), 1383–1395. Ting Chang,The Chinese Guidelines for Diagnosis and Treatment of Myasthenia Gravis (2020 ) [J] .Chinese Journal of Neuroimmunology and Neurology, 2021, 28 (01): 1-12. Narayanaswami, P., Sanders, D. B., Wolfe, G., Benatar, M., Cea, G., Evoli, A., Gilhus, N. E., Illa, I., Kuntz, N. L., Massey, J., Melms, A., Murai, H., Nicolle, M., Palace, J., Richman, D., & Verschuuren, J. (2021). International Consensus Guidance for Management of Myasthenia Gravis: 2020 Update. Neurology, 96(3), 114–122. Houdek, Š., Büchler, T., & Kindlová, E. (2017). Souhrnné srovnání kritérií RECIST 1.1 a iRECIST pro hodnocení odpovědi na onkologickou léčbu solidních tumorů [Comparison of RECIST 1.1 and iRECIST for Response Evaluation in Solid Tumours]. Klinicka onkologie : casopis Ceske a Slovenske onkologicke spolecnosti, 30(Supplementum3), 32–39. Wrona E, Dębska-Szmich S, Pastuszka M, Braun M, Czyżykowski R, Potemski P. Remission of Thymoma on Steroid Therapy in a Patient With Atypical Thymoma-Associated Multiorgan Autoimmunity: A Case Report and Literature Review. Front Immunol . 2021;12:584703. Published 2021 Apr 29. Thomas A, Rajan A, Berman A, et al. Sunitinib in patients with chemotherapy-refractory thymoma and thymic carcinoma: an open-label phase 2 trial [published correction appears in Lancet Oncol. 2015 Mar;16(3):e105]. Lancet Oncol. 2015;16(2):177-186. Cho J, Kim HS, Ku BM, et al. Pembrolizumab for Patients With Refractory or Relapsed Thymic Epithelial Tumor: An Open-Label Phase II Trial. J Clin Oncol. 2019;37(24):2162-2170. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6961194","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":476881657,"identity":"06ed3a00-ed40-4455-9804-c5ea794c5e49","order_by":0,"name":"Yuanyuan Geng","email":"","orcid":"","institution":"Hebei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yuanyuan","middleName":"","lastName":"Geng","suffix":""},{"id":476881658,"identity":"d6ee5465-37bb-4a98-a382-4b3204119f5c","order_by":1,"name":"Guoyan Qi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYHCCBIYHQJKfmfnwA+K1JABJyXa2NANS7GFgMDjPoyBBlGr5/gPPJBL+HLY3PszDYMBQYxNNUAtjw4E0icS2w4nbDvMeeMBwLC23gZAWZsaGtBuJDYcTzA7zJRgwNhwmrIWNmSHtBthhzTwGEkRp4WEDaWE7zLiBmVgtEjwM6T8S29ITZxwGBnICMX6R7z+TbPDhj7U9f//hww8+1NgQ1gJ0WgKQaIawEwgrBwH2A0Cijji1o2AUjIJRMDIBAIj3PxI7QUTOAAAAAElFTkSuQmCC","orcid":"","institution":"People's Hospital of Shijiazhuang","correspondingAuthor":true,"prefix":"","firstName":"Guoyan","middleName":"","lastName":"Qi","suffix":""}],"badges":[],"createdAt":"2025-06-24 03:53:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6961194/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6961194/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85755799,"identity":"83c027ed-5cc0-4ece-bea2-b7952ba1522b","added_by":"auto","created_at":"2025-07-01 10:46:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":696891,"visible":true,"origin":"","legend":"\u003cp\u003eThe chest CT of the same patient.\u003c/p\u003e\n\u003cp\u003ea. A patient with B3 type thymoma, the lesion before the mPSL shocktreatment. Examination date:20220809\u003c/p\u003e\n\u003cp\u003eb. A patient with B3 type thymoma, the lesion after the mPSL shock treatment. Examination date:20221025\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6961194/v1/bf96e1fc75863e6c130ccf85.png"},{"id":85755800,"identity":"1a6cebde-fd5a-4b32-aca3-efbffdcc9335","added_by":"auto","created_at":"2025-07-01 10:46:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":17250,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival-analysis of patients\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6961194/v1/e8aeaa8335cd5fc2d39024c5.png"},{"id":91831635,"identity":"b98016f5-c406-4721-987a-3e6be879d3ba","added_by":"auto","created_at":"2025-09-22 09:09:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1731456,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6961194/v1/dda6ef02-e120-4e3b-b901-8d328697ea2a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical efficacy of methylprednisolone combined with immunosuppressants and CAPP chemotherapy in the treatment of thymoma with Myasthenia Gravis","fulltext":[{"header":"1. INTRODUCTION","content":"\u003cp\u003eThymic Epithelial Tumor is a common primary tumor in the anterior mediastinum, accounting for 30% of adult anterior mediastinal tumors \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e1\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. In China, the incidence rate of thymic epithelial tumors is about 4.09/1\u0026nbsp;million people \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e2\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. The thymus is an immune organ, and thymic epithelial tumors often accompany autoimmune diseases such as myasthenia gravis (MG), polymyositis, red blood cell aplastic anemia, autoimmune hypothyroidism, and Good syndrome. Among them, the most common is MG, and about 30\u0026ndash;50% of thymoma patients have myasthenia gravis \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e3\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. MG is an acquired immune disease caused by the production of autoantibodies, which leads to the transmission barrier of neuromuscular junction. The most common is acetylcholine receptor antibody \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e4\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e, whose incidence rate is 0.3\u0026ndash;2.8/100,000 people \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e5\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFor thymoma patients with myasthenia gravis, thymectomy is currently the preferred treatment. However, there is no clear treatment plan for recurrent thymoma and inoperable thymoma with MG in existing thymoma diagnosis and treatment guidelines or expert consensus on MG. There have also been no reports of clinical trials on the efficacy of chemotherapy regimens.\u003c/p\u003e \u003cp\u003eSteroids have immunosuppressive and anti-inflammatory effects, and are widely used in the treatment of immune diseases. They are the core drugs for the treatment of MG. As early as 1990, they were proposed to be suitable for thymoma patients with myasthenia gravis who have failed surgery, radiotherapy, and chemotherapy \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e6\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. Previous studies have also shown that high-dose methylprednisolone (mPSL) shock therapy is effective for thymoma patients with myasthenia gravis \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e7\u003c/sup\u003e\u003csup\u003e][\u003c/sup\u003e\u003csup\u003e8\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. The combination of cyclophosphamide, doxorubicin, cisplatin, and prednisone (CAPP) is a first-line chemotherapy regimen in the treatment guidelines for thymoma, but there are no relevant reports on its efficacy in thymoma patients with myasthenia gravis.\u003c/p\u003e \u003cp\u003eClinically, we have found that mPSL also have a therapeutic effect on thymomas in myasthenia gravis patients with thymoma (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). This experiment compares the therapeutic effects of CAPP and high-dose methylprednisolone shock therapy on thymoma patients with myasthenia gravis through a retrospective study, hoping to provide more economical and effective treatment options for clinical doctors and such patients.\u003c/p\u003e "},{"header":"2. MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Scheme design\u003c/h2\u003e \u003cp\u003e Collect clinical data of thymoma patients with MG treated with CAPP or mPSL shock at Hebei Provincial Clinical Research Center for Myasthenia Gravis of Shijiazhuang People's Hospital from 2018 to 2023, and divide them into CAPP group and mPSL group according to treatment plan.\u003c/p\u003e \u003cp\u003eGeneral information includes the patient's name, gender, age, pathological classification of thymoma, and whether there is a history of treatment. Other information includes laboratory tests (blood routine, liver function, kidney function, Anti-acetylcholine receptor antibody), chest computed tomography, myasthenia gravis classification, and myasthenia gravis muscular endurance score (MGMES)\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e9\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The evaluation of myasthenia gravis in the past was expressed using the quantitative myasthenia gravis score \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e10\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e(QMGS), the myasthenia gravis composite scale (MGC) and the absolute and relative score of MG (ARS-MG). Our center has developed the MGMES based on these common myasthenia gravis scoring scales, and confirmed the reliability and effectiveness of MGMES. Therefore, MGMES was used in this study.\u003c/p\u003e \u003cp\u003eBuild a case report form (CRF) and apply Statistical Product and Service Solutions 21 (SPSS21.0) to analyze data. All procedures were performed in compliance with relevant laws and institutional guidelines and have been approved by the Ethics Committee of Shijiazhuang People's Hospital (NO.[2022]047). The data are anonymous,and the requirement for informed consent was therefore waived.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Diagnostic criteria\u003c/h2\u003e \u003cp\u003eThe diagnosis and pathological classification of thymoma are mainly based on the patient's history of thymoma, chest computed tomography (CT) results, and pathological diagnosis. The chest CT examination is used to evaluate thymoma, and pathological diagnosis is based on the 2015 World Health Organization (WHO) classification of thymic epithelial tumors \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e11\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e, which are classified into A type, AB type, B1 type, B2 type, B3 type, and C.\u003c/p\u003e \u003cp\u003eThe diagnosis of MG is based on the \"Chinese Guidelines for Diagnosis and Treatment of Myasthenia Gravis 2020\"\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e12\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. On the basis of typical clinical characteristics of fluctuating myasthenia gravis, it meets the diagnostic criteria of positive neostigmine test, decreased low-frequency repetitive electrical stimulation in electromyography, and positive serum acetylcholine receptor antibody.\u003c/p\u003e \u003cp\u003eThe MG classification adopts the American Myasthenia Gravis Foundation (MGFA) classification \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e13\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e, which is divided into Type I, IIa/IIb, IIIa/IIIb, IVa/IVb, and V.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Inclusion criteria\u003c/h2\u003e \u003cp\u003e(1) MG diagnosis is clear and there are symptoms of muscle weakness; (2) The diagnosis of thymoma is clear, and there is no surgical treatment or multiple metastases of thymoma after surgery; (3) Age ranges from 18 to 70 years old.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Exclusion criteria\u003c/h2\u003e \u003cp\u003e(1) Malignant tumors (excluding thymoma), history of HIV infection, or severe immunodeficiency; (2) Concomitant severe heart disease or mental illness;(3) Tuberculosis patients with positive tuberculin test or T-SPOT test; (4) Due to the difference in treatment between thymic cancer and other subtypes of thymic epithelial tumors, excluding pathological subtype C thymic epithelial tumors;(5) Incomplete clinical data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5 The dosage of the drugs\u003c/h2\u003e \u003cp\u003eCAPP group: Cyclophosphamide 500mg/m\u0026sup2; day1, doxorubicin 20mg/m\u0026sup2; day1-3, cisplatin 30mg/m\u0026sup2; day1-3,80mg mPSL day1-5. The treatment cycle is 21 days.\u003c/p\u003e \u003cp\u003emPSL group: The initial dosage of methylprednisolone is 1g, and the dosage is halved for 2 or 3 days. Finally, it was changed to oral prednisone 60mg. When oral immunosuppressants are needed, generally, 100mg of cyclophosphamide per day or 100mg of azathioprine per day.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Efficacy evaluation\u003c/h2\u003e \u003cp\u003eThe efficacy evaluation of MG is based on the recording of the MGMES, and the MGMES difference and decline rate are calculated. The decline rate below 50% is defined as no significant relief, a decrease rate above 50% is defined as effective, with 50\u0026ndash;70% indicating improvement, 70\u0026ndash;90% indicating significant improvement, and over 90% indicating complete relief.\u003c/p\u003e \u003cp\u003eThe efficacy evaluation of thymoma is based on chest CT results, with reference to Response Evaluation Criteria in Solid Tumors \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e14\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e(RECIST). Define complete relief (CR): Measurable thymic tumor lesion completely disappears. Partial relief (PR): The total diameter of thymic tumor lesions has decreased by \u0026ge;\u0026thinsp;30% compared to before treatment. Stable disease (SD): The degree of change in thymoma lesions is between PR and PD. Disease progression (PD): The total diameter of thymic tumors increases by \u0026ge;\u0026thinsp;20% compared to before treatment or new clear tumor lesions appear.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Safety evaluation\u003c/h2\u003e \u003cp\u003eRecord and evaluate adverse reactions (including myasthenia crisis, pre-myasthenia crisis status) that occur during the patient's treatment process, as well as any adjustments to the treatment plan for poor efficacy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.8 Statistical methods\u003c/h2\u003e \u003cp\u003eConstruct a case report form table (CRF) and use Statistical Product and Service Solutions 21 (SPSS21.0) data analysis software. The measurement data is represented by x\u0026thinsp;\u0026plusmn;\u0026thinsp;s and compared between groups using independent t-test; The inter group count data was analyzed using chi-square test.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. RESULTS","content":"\u003cp\u003e102 patients with thymoma and myasthenia gravis treated with CAPP or mPSL shock from 2018 to 2023, of which 66 met the inclusion criteria, including 35 males and 31 females, aged between 24 and 70 years, with an average age of 44.05\u0026thinsp;\u0026plusmn;\u0026thinsp;11.82. There were 32 patients (48.48%) with postoperative recurrence of thymoma, an average course of 35.65\u0026thinsp;\u0026plusmn;\u0026thinsp;40.84 months for thymic tumor onset, and 43.58\u0026thinsp;\u0026plusmn;\u0026thinsp;47.41 months for myasthenia gravis. There were 2 patients with type A thymoma, 3 patients with type AB thymoma, 9 patients with type B1 thymoma, and 2 patients with B1/B2 thymoma. There were 30 cases of B2 type thymoma, 8 cases of B2/B3 type thymoma and 12 cases of B3 type thymoma. Among thymoma patients with MG, B2 type thymoma accounts for 45.45%, with up to 96.97% of patients containing B-type thymoma components.\u003c/p\u003e \u003cp\u003eThere were 29 cases enrolled in the CAPP group and 37 cases enrolled in the mPSL group (with immunosuppressive agents such as cyclophosphamide in 17 cases and azathioprine in 20 cases). There was no statistically significant difference in gender, age, disease course, and subtype between the two groups of patients (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Therapeutic efficacy of thymoma\u003c/h2\u003e \u003cp\u003eThe efficacy of thymoma treatment in two groups of patients was tested using Fisher's exact probability method. The results showed that the CAPP group had an effective rate of 41.4% for thymoma treatment, while the mPSL group had an effective rate of 89.2% for thymoma treatment. The difference was statistically significant, and high-dose mPSL shock had a more significant therapeutic effect on thymoma in patients with myasthenia gravis (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2 The therapeutic effect of MG\u003c/h2\u003e \u003cp\u003eCompare the difference in MGMES and AChR-Ab levels before and after treatment. The difference is statistically significant (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003eThe Fisher's exact probability method was applied to test the decline rate of MGMES in two groups of patients. The results showed that the effective rate of treating myasthenia gravis in the CAPP group was 58.6%, and the effective rate of treating myasthenia gravis in the mPSL group was 73%. The difference was not statistically significant (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.3 The relationship between age and treatment efficacy\u003c/h2\u003e \u003cp\u003ePatients were divided into early-onset myasthenia gravis (\u0026lt;\u0026thinsp;50 years old) and late-onset myasthenia gravis (\u0026ge;\u0026thinsp;50 years old) by age, with 46 early-onset myasthenia gravis and 21 late-onset myasthenia gravis. Comparing the prognosis of two groups of thymoma patients with myasthenia gravis, there was no statistically significant difference (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), indicating that prognosis is not correlated with age.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMyasthenia gravis muscular endurance score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003emuscle groups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eScoring items\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003enormal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003elow-grade\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003emoderate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003esevere\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003emusculus ocularis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe upper eyelid covers the pupil (Clock position, Score separately on the left and right sides)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u0026thinsp;~\u0026thinsp;1 (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u0026thinsp;~\u0026thinsp;2 (1points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9\u0026thinsp;~\u0026thinsp;3 (2points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBelow 8\u0026thinsp;~\u0026thinsp;4 (3points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eupward gaze (Record the time when the eyelids droop to 9\u0026thinsp;\u0026minus;\u0026thinsp;3, Score separately on the left and right sides)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbove 60s (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u0026thinsp;~\u0026thinsp;60s (1points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u0026thinsp;~\u0026thinsp;30s (2points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (3points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEye abduction with white exposure and adduction with white exposure, diplopia (Score separately on the left and right sides)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2mm (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026thinsp;~\u0026thinsp;7mm or diplopia (1points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u0026thinsp;~\u0026thinsp;12mm (2points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;12mm (3points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEyeball up and down vision\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enormal (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe upper and lower eyes of the binocular are not at the same level (1points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe two eyes are not at the same level when looking at eye level (2points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFixed eyes, unable to move (3points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003efacial muscles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClosing eye power\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enormal (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClose your eyes completely, passively open without resistance (1points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIncomplete closure of eyes, passive opening without resistance (2points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIncomplete closure of eyes (3points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChime strength\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enormal (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWeak cheek drumming strength (1points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLeakage during cheek swelling (2points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCheeks cannot be swollen (3points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMasticatory muscles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enormal (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChewing hard food fatigue (1points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eChewing soft food fatigue (2points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEating liquid food (3points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eTrunk muscles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHead up to 45 in the supine position\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbove 60s (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u0026thinsp;~\u0026thinsp;60s (1points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u0026thinsp;~\u0026thinsp;30s (2points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u0026thinsp;~\u0026thinsp;10s (3points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSitting, with both upper limbs raised horizontally (Score separately on the left and right sides)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbove 120s (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u0026thinsp;~\u0026thinsp;120s (1points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u0026thinsp;~\u0026thinsp;30s (2points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u0026thinsp;~\u0026thinsp;10s (3points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLying flat, raise your legs to 45 degrees (Score separately on the left and right sides)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbove 100s (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31\u0026thinsp;~\u0026thinsp;100s (1points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u0026thinsp;~\u0026thinsp;30s (2points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u0026thinsp;~\u0026thinsp;10s (3points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eMedullary muscles\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSwallowing power\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enormal (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRarely experience coughing or difficulty swallowing (5points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFrequent swallowing difficulties lead to changes in dietary habits (10points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNasogastric feeding tube diet (15points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003espeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enormal (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOccasional unclear pronunciation or nasal sound (5points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePronunciation unclear or nasal sounds can be understood (10points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eDifficult to understand the meaning of language (15points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ebreathe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003enormal (0 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eShort breath after the activity (5 points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eShort breath during rest (15points)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThe patient requires artificial respiration assistance (25points)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral information of the enrolled population\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCAPP Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003emPSL Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender Male\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.55\u0026thinsp;\u0026plusmn;\u0026thinsp;11.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.87\u0026thinsp;\u0026plusmn;\u0026thinsp;11.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.915\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.364\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of thymoma/months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.69\u0026thinsp;\u0026plusmn;\u0026thinsp;41.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.19\u0026thinsp;\u0026plusmn;\u0026thinsp;41.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.733\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of MG/months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.00\u0026thinsp;\u0026plusmn;\u0026thinsp;44.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.81\u0026thinsp;\u0026plusmn;\u0026thinsp;49.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.813\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAllergy history/cases (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(20.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7(18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThymectomy surgery/cases (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15(51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28(75.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThymoma subtypes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.742\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB1/B2 or B2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB2/B3 or B3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMGFA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.107\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEvaluation of curative effect of thymoma\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eEffective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003einvalid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEffective rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCAPP Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e41.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emPSL Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e89.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMGMES and AChR-Ab\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eItems\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCAPP Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003emPSL Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMGMES before treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e20.83\u0026thinsp;\u0026plusmn;\u0026thinsp;20.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e31.68\u0026thinsp;\u0026plusmn;\u0026thinsp;21.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-2.106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMGMES after treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.28\u0026thinsp;\u0026plusmn;\u0026thinsp;17.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e6.84\u0026thinsp;\u0026plusmn;\u0026thinsp;8.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.305\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMGMES difference before and after treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.55\u0026thinsp;\u0026plusmn;\u0026thinsp;13.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e24.83\u0026thinsp;\u0026plusmn;\u0026thinsp;22.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-3.193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAChR-Ab before treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e11.29\u0026thinsp;\u0026plusmn;\u0026thinsp;4.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e12.63\u0026thinsp;\u0026plusmn;\u0026thinsp;4.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.256\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.214\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAChR-Ab after treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.45\u0026thinsp;\u0026plusmn;\u0026thinsp;4.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e9.62\u0026thinsp;\u0026plusmn;\u0026thinsp;5.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.686\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.496\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAChR-Ab difference before and after treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e0.85\u0026thinsp;\u0026plusmn;\u0026thinsp;2.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e2.98\u0026thinsp;\u0026plusmn;\u0026thinsp;3.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-3.074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe effect of the myasthenia gravis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEffective rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eEffective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003einvalid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ecomplete relief\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003esignificant improvement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eimprovement\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCAPP Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8(27.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4(13.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5(17.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12(41.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emPSL Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16(43.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8(21.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3(8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10(27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge and efficacy of myasthenia gravis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003einvalid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEffective\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly-MG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(28.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32(71.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.400\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLate-MG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12(57.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge and efficacy of thymoma\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eThymoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSD/PD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePR/CR\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEarly-MG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(26.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33(73.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLate-MG\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9(42.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(57.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRecord of adverse events\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eGroups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c8\" namest=\"c4\"\u003e \u003cp\u003eAdverse events\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDrug induced bone marrow suppression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003epulmonary infection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMyasthenic crisis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAdjust treatment plan\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCAPP group/cases(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e15(51.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6(20.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1(3.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6(20.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1(3.45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emPSL group/cases(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e20(54.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2(5.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8(21.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3(8.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0(0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4(10.81)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Safety evaluation\u003c/h2\u003e \u003cp\u003eThere were 14 cases (48.28%) of major adverse events in the CAPP group, including 7 cases of bone marrow suppression or pulmonary infection, and 6 cases of ineffective treatment. Among them, 4 cases were adjusted to receive mPSL shock combined with cyclophosphamide treatment, and 2 cases were adjusted to receive mPSL shock combined with azathioprine treatment. In the mPSL group, there were 17 cases (45.95%) with major adverse events, including 3 cases of myasthenia crisis, 10 cases of bone marrow suppression or pulmonary infection, and 4 cases of steroid diabetes. There were 15 cases in the CAPP group with no adverse events detected, accounting for 51.72%, and 20 cases in the mPSL group, accounting for 54.05%(Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter the combination of antifungal therapy and pulmonary infection that occurred during the treatment process, chest CT showed significant improvement. Bone marrow suppression (grade II-III) is a drug-related adverse reaction. Bone marrow suppression occurred in all 6 patients in the CAPP group during 2 cycles of CAPP treatment and recovered after symptomatic treatment. Bone marrow suppression in 2 patients in the mPSL group was considered a toxic side effect of azathioprine, and the immunosuppressive agent was changed to cyclophosphamide. White blood cells returned to normal after symptomatic treatment. In patients with steroid diabetes, insulin was given to reduce blood sugar, blood sugar was monitored during hospitalization, and blood sugar gradually returned to normal after the withdrawal of mPSL outside the hospital and diet control.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Survival analysis\u003c/h2\u003e \u003cp\u003eThe efficacy of mPSL in myasthenia gravis is very clear, but we need more evidence regarding their efficacy in thymoma. We used GraphPad Prism 9.5.1 software to create survival analysis with the end outcome of the thymoma's progression reaching PR/CR (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), the mPSL can achieve the expected therapeutic effect in a shorter time.\u003c/p\u003e \u003cp\u003eThis section of the study is a retrospective study, and thymoma with myasthenia gravis is a rare disease. The sample size that meets the criteria is small, and the CAPP regimen is adjusted after one cycle of ineffective use, making long-term follow-up impossible. The efficacy of mPSL group patients at 6 months and 1 year after treatment was not traceable due to loss of follow-up. Therefore, follow up until March 2024 showed that 5 cases (41.67%) of thymoma recurrence and metastasis occurred after achieving PR or CR in the RECIST assessment of 12 patients in the CAPP group. Among them, 4 cases did not show sustained improvement in muscle weakness symptoms, and only 3 cases had thymoma recurrence; Three patients (25%) with myasthenia gravis post intervention status (PIS) above MMS and thymoma RECIST evaluation reached PR or CR without recurrence after one year in the CAPP group; One patient who underwent thymectomy after 2 cycles of applying the CAPP scheme but did not achieve PR underwent tumor shrinkage. The patient received postoperative radiotherapy and was followed up after treatment. The PIS reached PR, and there was no recurrence or metastasis of thymoma. Seven patients were lost to follow-up or unable to be followed up due to adjustments in treatment plans.\u003c/p\u003e \u003cp\u003eIn the mPSL group, there were 8 cases (36.36%) of thymoma recurrence and metastasis after PR, and 6 cases (27.27%) of myasthenia gravis recurrence. Among them, 2 cases of myasthenia gravis recurrence occurred due to self discontinuation of medication, 2 cases of untreated myasthenia gravis recurrence due to repeated lung infections, and 2 cases of myasthenia gravis symptoms induced by factors such as fatigue and staying up late. In the mPSL group, there were 4 patients (18.18%) with PIS above MMS and thymoma PR without recurrence, and 15 patients were lost to follow-up.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. DISCUSSION","content":"\u003cp\u003eThis section retrospectively analyzes the efficacy of CAPP regimen and high-dose mPSL shock combined with immunosuppressive therapy in patients with thymoma and myasthenia gravis. The research has shown that high-dose mPSL shock therapy is more effective for thymoma patients with MG than the CAPP group, and also better for muscle weakness in thymoma patients with MG than the CAPP group. We also found that the decrease in AChR-Ab levels was more pronounced in the mPSL group, suggesting that steroids reduced serum acetylcholine receptor antibody levels. It is generally believed that this can also reflect the efficacy of steroids therapy for myasthenia gravis. For thymoma-associated multiorgan autoimmunity, it has been found in the literature that the introduction of corticosteroid therapy resulted in unexpected partial remission of thymoma \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e15\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. This suggests that steroid therapy is effective in treating such thymoma patients, it's consistent with our findings.\u003c/p\u003e \u003cp\u003eThe current focus of thymoma treatment is on targeted drugs and immune checkpoint inhibitors. A study showed that the effective rate of sunitinib, a multi-target tyrosine kinase inhibitor, in patients with thymoma who failed platinum-based chemotherapy was 6%\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e16\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. The partial response rate of pembrolizumab, a PD-L1/PD-1 targeted agent, in patients with solitary thymoma who failed chemotherapy was 28.6%\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e17\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. We observed that the tumor remission rate in thymoma patients with myasthenia gravis treated with high-dose methylprednisolone was not low. The new treatment is expensive and may cause immune disorders in patients with combined myasthenia gravis, exacerbating myasthenia symptoms, increasing treatment costs and reducing quality of life.\u003c/p\u003e \u003cp\u003e The existing treatment guidelines for thymic epithelial tumors have not yet included high-dose steroid shock therapy in standardized treatment, and the mechanism of action of steroids on thymoma is also unclear. If high-dose steroid shock therapy is generally effective for thymoma patients, it may be used as an alternative treatment to CAPP chemotherapy regimen, reducing the economic burden on patients.\u003c/p\u003e \u003cp\u003eIn order to further validate the efficacy of high-dose mPSL shock therapy in thymoma patients, further cell or animal experiments are needed, which requires technical support or a better research team to join and assist. In addition, while applying traditional treatment methods to thymoma patients, we look forward to the emergence of new drugs and guidelines to guide the treatment of thymoma patients with myasthenia gravis.\u003c/p\u003e\u003cp\u003eThis section retrospectively analyzes the efficacy of CAPP regimen and high-dose mPSL shock combined with immunosuppressive therapy in patients with thymoma and myasthenia gravis. The research has shown that high-dose mPSL shock therapy is more effective for thymoma patients with MG than the CAPP group, and also better for muscle weakness in thymoma patients with MG than the CAPP group. We also found that the decrease in AChR-Ab levels was more pronounced in the mPSL group, suggesting that steroids reduced serum acetylcholine receptor antibody levels. It is generally believed that this can also reflect the efficacy of steroids therapy for myasthenia gravis. For thymoma-associated multiorgan autoimmunity, it has been found in the literature that the introduction of corticosteroid therapy resulted in unexpected partial remission of thymoma \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e15\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. This suggests that steroid therapy is effective in treating such thymoma patients, it's consistent with our findings.\u003c/p\u003e \u003cp\u003eThe current focus of thymoma treatment is on targeted drugs and immune checkpoint inhibitors. A study showed that the effective rate of sunitinib, a multi-target tyrosine kinase inhibitor, in patients with thymoma who failed platinum-based chemotherapy was 6%\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e16\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. The partial response rate of pembrolizumab, a PD-L1/PD-1 targeted agent, in patients with solitary thymoma who failed chemotherapy was 28.6%\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e17\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. We observed that the tumor remission rate in thymoma patients with myasthenia gravis treated with high-dose methylprednisolone was not low. The new treatment is expensive and may cause immune disorders in patients with combined myasthenia gravis, exacerbating myasthenia symptoms, increasing treatment costs and reducing quality of life.\u003c/p\u003e \u003cp\u003e The existing treatment guidelines for thymic epithelial tumors have not yet included high-dose steroid shock therapy in standardized treatment, and the mechanism of action of steroids on thymoma is also unclear. If high-dose steroid shock therapy is generally effective for thymoma patients, it may be used as an alternative treatment to CAPP chemotherapy regimen, reducing the economic burden on patients.\u003c/p\u003e \u003cp\u003eIn order to further validate the efficacy of high-dose mPSL shock therapy in thymoma patients, further cell or animal experiments are needed, which requires technical support or a better research team to join and assist. In addition, while applying traditional treatment methods to thymoma patients, we look forward to the emergence of new drugs and guidelines to guide the treatment of thymoma patients with myasthenia gravis.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCONFLICT OF INTEREST STATEMENT\u003c/h2\u003e \u003cp\u003eThe authors have no conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFUNDING INFORMATION\u003c/h2\u003e \u003cp\u003eThis study was supported by the National Natural Science Foundation of China (No. 82274582), Central guidance for local scientific and technological development funding projects (No.246Z7706G), Key Laboratory Construction Subsidy Fund Project (No. 236790017H).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eY.G. wrote the main manuscript. G.Q. reviewed the manuscript. All authors participated in the whole - process management of the paper.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis study received financial support from\u0026nbsp;the Hebei Provincial Key Laboratory of Myasthenia Gravis and Hebei Provincial Clinical Research Center for Myasthenia Gravis. Thanks to the doctors of Hebei Provincial Clinical Research Center for Myasthenia Gravis of Shijiazhuang People's Hospital for providing the enrolled cases.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAll raw data are available upon request. Y.G./G.Q. should be contacted if someone wants to request the data from this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFanjie Meng, Guangshun Wang，Research progress on thymoma and autoimmune diseases [J] Journal of Tianjin Medical University, 2021,27 (02): 195-198.\u003c/li\u003e\n\u003cli\u003eMultidisciplinary Committee of Oncology, Chinese Physicians Association (2021).\u0026nbsp;Zhonghua zhong liu za zhi [Chinese journal of oncology],\u0026nbsp;43(4), 395\u0026ndash;404.\u003c/li\u003e\n\u003cli\u003eEttinger, D. S., Riely, G. J., Akerley, W., Borghaei, H., Chang, A. C., Cheney, R. T., Chirieac, L. R., D'Amico, T. A., Demmy, T. L., Govindan, R., Grannis, F. W., Jr, Grant, S. C., Horn, L., Jahan, T. M., Komaki, R., Kong, F. M., Kris, M. G., Krug, L. M., Lackner, R. P., Lennes, I. T., \u0026hellip; National Comprehensive Cancer Network (2013). Thymomas and thymic carcinomas: Clinical Practice Guidelines in Oncology.\u0026nbsp;Journal of the National Comprehensive Cancer Network : JNCCN,\u0026nbsp;11(5), 562\u0026ndash;576.\u003c/li\u003e\n\u003cli\u003eSanders, D. B., Wolfe, G. I., Benatar, M., Evoli, A., Gilhus, N. E., Illa, I., Kuntz, N., Massey, J. M., Melms, A., Murai, H., Nicolle, M., Palace, J., Richman, D. P., Verschuuren, J., \u0026amp; Narayanaswami, P. (2016). International consensus guidance for management of myasthenia gravis: Executive summary.\u0026nbsp;Neurology,\u0026nbsp;87(4), 419\u0026ndash;425.\u003c/li\u003e\n\u003cli\u003eDeenen JC, Horlings CG, Verschuuren JJ, Verbeek AL, van Engelen BG. The Epidemiology of Neuromuscular Disorders: A Comprehensive Overview of the Literature.\u0026nbsp;J Neuromuscul Dis. 2015;2(1):73-85.\u003c/li\u003e\n\u003cli\u003eTandan R, Taylor R, DiCostanzo DP, et al. Metastasizing thymoma and myasthenia gravis. Favorable response to glucocorticoids after failed chemotherapy and radiation therapy.Cancer.1990;65(6):1286-1290.\u003c/li\u003e\n\u003cli\u003eWu Bao, Bai Yuqin Comparison of the efficacy of monotherapy with docetaxel and combination therapy with cisplatin in patients with thymoma and myasthenia gravis [J]. Journal of Chifeng University (Natural Science Edition), 2019, 35 (06): 79-80.\u003c/li\u003e\n\u003cli\u003eGuoyan Qi, Chaoying Liu, Xiaojing Zhang, et al.Comparison of the therapeutic effects of docetaxel combined with cisplatin and high-dose corticosteroid shock therapy on recurrent thymoma with myasthenia gravis [J]. Chinese Journal of Hospital Pharmacy, 2017, 37 (16): 1617-1621.\u003c/li\u003e\n\u003cli\u003eGuoyan Qi, Peng Liu, Shanshan Gu,et al. Reliability and validity evaluation of the myasthenia gravis muscle endurance rating scale [J]. Journal of Hebei Medical University, 2020, 41 (08): 905-909.\u003c/li\u003e\n\u003cli\u003eJaretzki, A 3rd et al. \u0026ldquo;Myasthenia gravis: recommendations for clinical research standards. Task Force of the Medical Scientific Advisory Board of the Myasthenia Gravis Foundation of America.\u0026rdquo;\u0026nbsp;The Annals of thoracic surgery\u0026nbsp;vol. 70,1 (2000): 327-34. doi:10.1016/s0003-4975(00)01595-2.\u003c/li\u003e\n\u003cli\u003eMarx, A., Chan, J. K., Coindre, J. M., Detterbeck, F., Girard, N., Harris, N. L., Jaffe, E. S., Kurrer, M. O., Marom, E. M., Moreira, A. L., Mukai, K., Orazi, A., \u0026amp; Str\u0026ouml;bel, P. (2015). The 2015 World Health Organization Classification of Tumors of the Thymus: Continuity and Changes.\u0026nbsp;Journal of thoracic oncology : official publication of the International Association for the Study of Lung Cancer,\u0026nbsp;10(10), 1383\u0026ndash;1395.\u003c/li\u003e\n\u003cli\u003eTing Chang,The Chinese Guidelines for Diagnosis and Treatment of Myasthenia Gravis (2020 ) [J] .Chinese Journal of Neuroimmunology and Neurology, 2021, 28 (01): 1-12.\u003c/li\u003e\n\u003cli\u003eNarayanaswami, P., Sanders, D. B., Wolfe, G., Benatar, M., Cea, G., Evoli, A., Gilhus, N. E., Illa, I., Kuntz, N. L., Massey, J., Melms, A., Murai, H., Nicolle, M., Palace, J., Richman, D., \u0026amp; Verschuuren, J. (2021). International Consensus Guidance for Management of Myasthenia Gravis: 2020 Update.\u0026nbsp;Neurology,\u0026nbsp;96(3), 114\u0026ndash;122.\u003c/li\u003e\n\u003cli\u003eHoudek, \u0026Scaron;., B\u0026uuml;chler, T., \u0026amp; Kindlov\u0026aacute;, E. (2017). Souhrnn\u0026eacute; srovn\u0026aacute;n\u0026iacute; krit\u0026eacute;ri\u0026iacute; RECIST 1.1 a iRECIST pro hodnocen\u0026iacute; odpovědi na onkologickou l\u0026eacute;čbu solidn\u0026iacute;ch tumorů [Comparison of RECIST 1.1 and iRECIST for Response Evaluation in Solid Tumours].\u0026nbsp;Klinicka onkologie : casopis Ceske a Slovenske onkologicke spolecnosti,\u0026nbsp;30(Supplementum3), 32\u0026ndash;39.\u003c/li\u003e\n\u003cli\u003eWrona E, Dębska-Szmich S, Pastuszka M, Braun M, Czyżykowski R, Potemski P. Remission of Thymoma on Steroid Therapy in a Patient With Atypical Thymoma-Associated Multiorgan Autoimmunity: A Case Report and Literature Review.\u0026nbsp;\u003cem\u003eFront Immunol\u003c/em\u003e. 2021;12:584703. Published 2021 Apr 29.\u003c/li\u003e\n\u003cli\u003eThomas A, Rajan A, Berman A, et al. Sunitinib in patients with chemotherapy-refractory thymoma and thymic carcinoma: an open-label phase 2 trial [published correction appears in Lancet Oncol. 2015 Mar;16(3):e105]. Lancet Oncol. 2015;16(2):177-186.\u003c/li\u003e\n\u003cli\u003eCho J, Kim HS, Ku BM, et al. Pembrolizumab for Patients With Refractory or Relapsed Thymic Epithelial Tumor: An Open-Label Phase II Trial. J Clin Oncol. 2019;37(24):2162-2170.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Recurrent thymoma, Myasthenia gravis, Methylprednisolone, Classic treatment","lastPublishedDoi":"10.21203/rs.3.rs-6961194/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6961194/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To evaluate the clinical efficacy of cyclophosphamide, doxorubicin, cisplatin plus prednisone (CAPP), and methylprednisolone (mPSL) plus immunosuppressants in the treatment of thymoma patients with myasthenia gravis (TMG), which provides new treatment ideas for clinicians.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. The clinical data of TMG who were treated with CAPP or high-dose mPSL from 2018 to 2023 were collected and divided into CAPP group and mPSL group.\u003c/p\u003e\n\u003cp\u003e2. The myasthenia gravis muscular endurance score (MGMES) is used to quantify the severity of the disease. The MGMES and the therapeutic effect of thymoma were compared between the two groups, and the side effects were recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. The response rate (PR or CR) for the TMG of the CAPP group and the mPSL group was respectively 41.4% and 89.2%. The difference was statistically significant (P\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e2. In the CAPP group, the MGMES of the TMG decreased by an average of 10.55±13.86. In the mPSL group, the MGMES decreased by an average of 24.83±22.26. The difference was statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e3. The incidence of toxic and side effects was 48.28% in the CAPP group and 45.95% in the mPSL group. During the course of treatment, Myasthenia crisis occurred in 3 cases in the mPSL group.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1. The mPSL combined with immunosuppressants is more effective in the TMG.\u003c/p\u003e\n\u003cp\u003e2. There is no difference in the incidence of side effects between the two groups, but there was a possibility of myasthenia gravis crisis in the mPSL group.\u003c/p\u003e","manuscriptTitle":"Clinical efficacy of methylprednisolone combined with immunosuppressants and CAPP chemotherapy in the treatment of thymoma with Myasthenia Gravis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 10:45:56","doi":"10.21203/rs.3.rs-6961194/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6e69ac59-3d75-4ff8-b206-862644af0039","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50640371,"name":"Biological sciences/Cancer/Cancer therapy"},{"id":50640372,"name":"Biological sciences/Cancer/Tumour immunology"},{"id":50640373,"name":"Biological sciences/Drug discovery/Toxicology"},{"id":50640374,"name":"Biological sciences/Drug discovery/Drug safety"}],"tags":[],"updatedAt":"2025-09-22T09:09:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-01 10:45:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6961194","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6961194","identity":"rs-6961194","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}