Surgical Challenges and Experiences in Extended Resection After Neoadjuvant Chemoimmunotherapy According to Checkmate 816 Protocol for Non-Small-Cell Lung Cancer – a Case Series

Background Continuous progress in the field of immunotherapy improved the therapeutic options and outcome in non-small-cell lung cancer (NSCLC) over the last decades. Thanks to promising data regarding immunochemotherapy in a neoadjuvant or perioperative setting, first checkpoint-inhibitors were approved and included in the current treatment guidelines. Although the oncological results are encouraging, reports about the surgical experience after neoadjuvant chemoimmunotherapy are scarce.

Methods & Materials We retrospectively analyzed all 13 Patients who underwent anatomical resection for NSCLC after neoadjuvant chemoimmunotherapy according to checkmate 816 protocol between 09/2023 and 09/2024 with special regard to surgical feasibility, extend of resection and perioperative complications.

Results In total, 110 patients underwent anatomical resection between 09/2023 and 09/2024 whereof 13 received neoadjuvant nivolumab plus chemotherapy. Thereof four patients where initially classified as stage IIB, eight as IIIA and one as IVA with oligometastatic disease. Due to initial tumor extent prior to neoadjuvant therapy in 5 cases pneumonectomy was assessed probable, but could be avoided in all cases. In all 13 cases, a pathological R0 resection was achieved. Five patients had a simple lobectomy whereas in eight cases extended resection was necessary (two bronchial sleeve-resections, three extrapleural lobectomies, one intrapericardial lobectomy, one bronchoplastic resection and one lower bilobectomy). Only 3 of 13 procedures were conducted thoracoscopically, 10 were open surgeries, including all eight cases of extended resection. We recorded no perioperative mortality, no intraoperative complications and five cases with minor postoperative complications.

Conclusion Surgical resection after neoadjuvant chemoimmunotherapy, especially for patients with advanced tumor stage, is feasible and not associated with higher intraoperative complications. The advanced tumor stage as well as the jet unfamiliar changes in tissue after neoadjuvant chemoimmunotherapy might enhance the surgeons wish for central control and haptic feedback. Higher rates of open approaches are to be expected at the beginning of the surgent’s learning curve regarding this new preoperative therapy. However, preoperative neoadjuvant chemoimmunotherapy – especially in patients with advanced stage NSCLC – can spare the patient a pneumonectomy and render a parenchyma sparing resection possible, thus assigning more patients to surgical treatment.