Robotic subxiphoid-optical thymectomy for Good's syndrome in a severely immunocompromised patient: a case report

Good's syndrome is a rare adult-onset immunodeficiency characterized by thymoma and hypogammaglobulinemia. The optimal surgical approach for thymoma in patients with severe immunodeficiency remains undefined. In this report, we describe a case of Good's syndrome in an elderly male patient with severe hypogammaglobulinemia, who underwent robotic subxiphoid-optical thymectomy as part of a perioperative strategy aimed at reducing surgical invasiveness.

An 80-year-old man with Good's syndrome presented with hypogammaglobulinemia (serum IgG, 60 mg/dL), complete absence of B cells, and a 5.5-cm anterior mediastinal tumor. Given this pronounced immunodeficiency, robotic subxiphoid-optical thymectomy was indicated to minimize surgical trauma while avoiding median sternotomy. The perioperative management strategy included preoperative intravenous immunoglobulin (IVIG) replacement therapy, extended antibiotic prophylaxis, careful patient selection, and close perioperative monitoring. Complete (R0) resection was achieved, and pathologic examination demonstrated type AB thymoma, Masaoka-Koga stage II. No perioperative infectious complications occurred, allowing timely initiation of cyclosporine when pure red cell aplasia developed eight weeks postoperatively, followed by partial hematologic recovery. Monthly IVIG replacement was continued, and no further infectious complications or thymoma recurrence were observed during 24 months of follow-up.

This case suggests that robotic subxiphoid-optical thymectomy could be an option in selected patients with Good's syndrome and severe immunodeficiency.