Thoracic: Lung Cancer
Safety and feasibility of minimally invasive lobectomy after neoadjuvant immunotherapy for non–small cell lung cancer

https://doi.org/10.1016/j.jtcvs.2022.12.006Get rights and content

Abstract

Objective

The objective of this study was to evaluate the feasibility of minimally invasive surgery (MIS) and perioperative outcomes following neoadjuvant immunotherapy for resectable non–small cell lung cancer (NSCLC).

Methods

Patients with stage I to III NSCLC treated with immunotherapy with or without chemotherapy or chemotherapy alone prior to lobectomy were identified in the National Cancer Database (2010-2018). The percentage of operations performed minimally invasively, conversion rates, and perioperative outcomes were evaluated using propensity-score matching. Propensity-score matching was also used to compare perioperative outcomes between patients who underwent an open lobectomy and those who underwent an MIS lobectomy after neoadjuvant immunotherapy.

Results

Of the 4229 patients identified, 218 (5%) received neoadjuvant immunotherapy and 4011 (95%) received neoadjuvant chemotherapy alone. There was no difference in the rate of MIS lobectomy among patients who received immunotherapy compared with those who received chemotherapy alone in propensity score–matched analysis (60.8% vs 51.6%; P = .11). There also were no significant differences in the rate of conversion from MIS to open lobectomy (14% vs 15%, P = .83; odds ratio, 1.1; 95% confidence interval, 0.51-2.24) or in nodal downstaging, margin positivity, 30-day readmission, and 30- and 90-day mortality between the 2 groups. In a subgroup analysis of only patients treated with neoadjuvant immunotherapy, there were no differences in pathologic or perioperative outcomes between patients who underwent open lobectomy and those who underwent MIS lobectomy.

Conclusions

In this national analysis, neoadjuvant immunotherapy for resectable NSCLC was not associated with an increased likelihood of the need for thoracotomy, conversion from MIS to open lobectomy, or inferior perioperative outcomes.

Section snippets

Data Source

The Institutional Review Board of Massachusetts General Hospital approved the study protocol and publication of data (approval 2020P004110; February 2, 2021). The need for patient written consent for the publication of the study data was waived, given that all patient data were deidentified prior to analysis and publication. The data used for this study were obtained from the National Cancer Database (NCDB), a joint project of the Commission on Cancer of the American College of Surgeons and the

Patient and Treatment Characteristics of the Overall Cohort

We initially identified 5878 patients who were treated with chemotherapy alone or immunotherapy with or without chemotherapy (“immunotherapy”) followed by surgery. Among these patients, lobectomy was the most common operation performed (in 72% of patients treated with chemotherapy alone vs 76% in those treated with immunotherapy), followed by pneumonectomy (13% vs 10%), and extended lobectomy or bilobectomy (9% vs 8%). Sublobar resection was performed in <6% of patients who received either

Discussion

In this national analysis, we found that patients with stage I to III NSCLC treated with neoadjuvant immunotherapy were not more likely than patients treated with neoadjuvant chemotherapy alone to require a thoracotomy or to have a higher rate of conversion from MIS to open surgery. There also were no significant differences in surgical margin positivity, nodal stage migration, hospital length of stay, 30-day readmission, or 30- or 90-day mortality between patients receiving neoadjuvant

Conclusions

In summary, in this national analysis, treatment with neoadjuvant immunotherapy for stage I-III NSCLC did not increase the likelihood of receiving an open versus a MIS lobectomy or contribute to worse perioperative outcomes when compared with neoadjuvant chemotherapy alone. Moreover, although future studies are needed to further power these results, we found that patients who underwent a thoracoscopic or robotic lobectomy after neoadjuvant immunotherapy had favorable and similar perioperative

REview Board footnote: This work was supported by National Institutes of Health grant 1R01HL159170-01A1 (to C.J.Y., M.M.), National Cancer Institute training grant 5T32CA092203 (to C.M.A.), the CRICO Risk Management Foundation (to C.J.Y.), and the American Association for Thoracic Surgery Foundation Surgical Investigator Award (to C.J.Y.).

Institutional Review Board approval number/date: 2020P004110, 2 February, 2021. Patient written consent for the publication of the study data was waived by the Institutional Review Board given that all patient data were deidentified prior to analysis and publication.

Read at the 48th Annual Meeting of the Western Thoracic Surgical Association, Koloa, Hawaii, June 22-25, 2022.

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