Perioperative immune optimization and surgical readiness in thymoma-associated myasthenia gravis: current evidence and emerging strategies
- 1Department of Thoracic Surgery, Shenyang Tenth People’s Hospital, Shenyang
- 2Department of Neurology, Shenyang Tenth People’s Hospital, Shenyang
Abstract
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.
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BibTeX
@article{wang2026perioperative,
title = {{Perioperative immune optimization and surgical readiness in thymoma-associated myasthenia gravis: current evidence and emerging strategies}},
author = {Linlin Wang and Zhihan Wang and Yong Feng},
journal = {Frontiers in Immunology},
year = {2026},
month = nov,
doi = {10.3389/fimmu.2026.2032777},
url = {https://www.frontiersin.org/articles/10.3389/fimmu.2026.2032777/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Perioperative immune optimization and surgical readiness in thymoma-associated myasthenia gravis: current evidence and emerging strategies
AU - Linlin Wang
AU - Zhihan Wang
AU - Yong Feng
PY - 2026
DA - 2026/11/09
JO - Frontiers in Immunology
DO - 10.3389/fimmu.2026.2032777
UR - https://www.frontiersin.org/articles/10.3389/fimmu.2026.2032777/full
AB - 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.
SN - 1664-3224
ER -