For a patient with a suspected thymoma, no paraneoplastic or neuromuscular autoimmune syndrome, and negative anti‑acetylcholine‑receptor and MuSK antibodies, is pre‑operative plasma exchange (plasmapheresis) beneficial before thymectomy?

Pre-operative Plasmapheresis for Thymoma Without Paraneoplastic Syndromes

No, your patient does not need plasmapheresis prior to thymectomy if she has no myasthenia gravis or other paraneoplastic syndromes and has negative anti-acetylcholine receptor and MuSK antibodies.

Rationale Based on Current Guidelines

The most recent NCCN guidelines (2025) for thymomas make no recommendation for routine pre-operative plasmapheresis in patients without neuromuscular complications 1. The critical determining factor is the presence or absence of myasthenia gravis, not the thymoma itself.

When Plasmapheresis IS Indicated Before Thymectomy

Only patients with confirmed myasthenia gravis require pre-operative optimization:

• The 2013 NCCN guidelines explicitly state that all patients suspected of having thymomas should have serum anti-acetylcholine receptor antibody levels measured before surgery to identify myasthenia gravis and avoid respiratory failure during the procedure 1
• If myasthenia gravis is present, patients should receive treatment by a neurologist with experience in myasthenia gravis before undergoing surgical resection 1
• Plasmapheresis is used specifically to prevent myasthenic crisis and improve clinical outcomes in patients with myasthenia gravis undergoing thymectomy 2

Why Your Patient Does NOT Need Plasmapheresis

Your patient has already been appropriately screened and ruled out for the indication:

• She has negative anti-acetylcholine receptor antibodies 1
• She has negative MuSK antibodies 1
• She has no clinical paraneoplastic syndromes 1
• Approximately one-third of thymoma patients have myasthenia gravis, but two-thirds do not and proceed directly to surgery 1

Standard Pre-operative Approach for Your Patient

Proceed directly to surgery without plasmapheresis:

• The NCCN panel recommends surgery (total thymectomy and complete excision of tumor) for all patients with resectable thymoma who can tolerate the procedure 1
• Completeness of resection is the most important predictor of outcome, with 10-year survival rates of 76% with complete resection versus 28% with incomplete resection 1
• No pre-operative systemic therapy or plasmapheresis is recommended for resectable thymomas without myasthenia gravis 1

Common Pitfall to Avoid

Do not confuse the association between thymoma and myasthenia gravis with a universal indication for plasmapheresis:

• While thymomas are associated with paraneoplastic syndromes in up to one-third of cases, the presence of the tumor alone without clinical manifestations does not warrant plasmapheresis 1
• Plasmapheresis carries risks including mortality (0.05%), coagulation defects, hemodynamic instability, and infection 3, 4
• The procedure is labor-intensive, requires specialist equipment and trained staff, and should only be used when specifically indicated 3, 4

When to Reconsider

Re-evaluate for plasmapheresis only if:

• New symptoms of myasthenia gravis develop (drooping eyelids, double vision, difficulty climbing stairs, hoarseness, dyspnea) 1
• Antibody testing becomes positive on repeat evaluation 1
• Other paraneoplastic neurological syndromes emerge (though plasmapheresis role would still need neurologist assessment) 1, 5

Your patient should proceed directly to thymectomy without delay, as complete surgical resection offers the best long-term outcome and survival for resectable thymomas 1.