Perioperative immune optimization and surgical readiness in thymoma-associated myasthenia gravis: current evidence and emerging strategies

Thymoma-associated myasthenia gravis (TAMG) complicates perioperative management because neurological vulnerability must be weighed against the physiological demands of tumor resection. This review examines operation-specific assessment and rapid immune optimization, compares established treatments with emerging neonatal Fc receptor (FcRn) inhibition, and proposes a dual-axis framework integrating myasthenia gravis (MG)-related vulnerability and anticipated operative burden. Intravenous immunoglobulin and plasma exchange remain the established rapid-treatment options when clinically meaningful improvement is needed before surgery. FcRn inhibition provides a mechanistically distinct means of lowering circulating immunoglobulin G. Among FcRn inhibitors, efgartigimod has the most direct perioperative evidence in TAMG, but available studies are small, nonrandomized, and largely confined to selected adults with acetylcholine receptor antibody-positive disease undergoing planned surgery. No randomized trial or TAMG-specific active-comparator study has demonstrated that perioperative efgartigimod reduces postoperative myasthenic crisis or other surgical complications. Its optimal preoperative schedule and the value of routine postoperative continuation remain uncertain. Decisions about rapid immune optimization should consider the recent MG trajectory, bulbar and respiratory function, secretion clearance, operative demands, and available postoperative support. Surgical readiness requires multidisciplinary judgment tailored to the planned operation; it cannot be determined by a single clinical score, antibody level, or predetermined treatment course. The proposed dual-axis framework is intended to structure this discussion but has not been validated.