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. 2025 Mar;169(3):753-762.e6.
doi: 10.1016/j.jtcvs.2024.08.012. Epub 2024 Aug 20.

Determinants of successful minimally invasive surgery for resectable non-small cell lung cancer after neoadjuvant therapy

Ngoc-Quynh Chu  1 , Kay See Tan  2 , Joe Dycoco  1 , Prasad S Adusumilli  1 , Manjit S Bains  1 , Matthew J Bott  1 , Robert J Downey  1 , Katherine D Gray  1 , James Huang  1 , James M Isbell  1 , Daniela Molena  1 , Smita Sihag  1 , Gaetano Rocco  1 , David R Jones  1 , Bernard J Park  1 , Valerie W Rusch  3
Affiliations

Determinants of successful minimally invasive surgery for resectable non-small cell lung cancer after neoadjuvant therapy

Ngoc-Quynh Chu et al. J Thorac Cardiovasc Surg. 2025 Mar.

Abstract

Objective: Minimally invasive surgery (MIS) (video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery) for pulmonary resection is standard in early-stage non-small cell lung cancer because it is associated with better perioperative outcomes than thoracotomy. MIS for resection of more advanced non-small cell lung cancer (Stages IB-IIIB) treated with neoadjuvant therapy has been utilized. However, the determinants of success are not well defined.

Methods: A single institution retrospective review of a prospectively maintained database was conducted, querying for patients with clinical Stage IB through IIIB non-small cell lung cancer who had resection after neoadjuvant systemic therapy without radiation from 2013 to 2022. Patients were grouped by surgical approach; that is, open versus MIS. Successful MIS was defined by no conversion, R0 resection, and no major (grade 3 or greater) morbidity. Analyses by intent-to-treat assessed outcomes by Wilcoxon rank-sum test and Fisher exact test. (Multivariable regression analysis identified variables that contributed to successful MIS resection.) RESULTS: Of 627 eligible patients, 360 (57%) had open and 267 (43%) had MIS procedures. Most patients (79.1%) received neoadjuvant platinum-based chemotherapy, and 21.9% were treated with immunotherapy or targeted therapy alone or combined with chemotherapy. Among MIS resections, 179 (67%) were performed by video-assisted thoracoscopic surgery and 88 (33%) by robot-assisted thoracoscopic surgery. The conversion rate was 16% (n = 43). Successful MIS resection was achieved in 77% of patients. Multivariable regression analysis showed that pretreatment clinical N stage was a significant determinant of success, but not pretreatment clinical T stage or type of neoadjuvant therapy.

Conclusions: Following neoadjuvant systemic therapy for clinical stage IB or IIIB non-small cell lung cancer, MIS resection can be successfully accomplished and should be considered in appropriate patients. Presence of pretreatment nodal disease is associated with higher odds of conversion, major morbidity, and incomplete resection.

Keywords: lung cancer; minimally invasive surgery; neoadjuvant therapy.

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Conflict of interest statement

Conflict of Interest Statement Dr Adusumilli declares research funding from ATARA Biotherapeutics; is a Scientific Advisory Board Member and consultant for ATARA Biotherapeutics, Bayer, Bio4T2, Carisma Therapeutics, Imugene, ImmPactBio, Johnston & Johnston, Orion Pharma, and Outpace Bio; and holds patents, royalties, and intellectual property on mesothelin-targeted CAR and other T-cell therapies that have been licensed to ATARA Biotherapeutics, issued a patent method for detection of cancer cells using virus, and has pending patent applications on PD-1 dominant negative receptor, wireless pulse-oximetry device, and on an ex vivo malignant pleural effusion culture system. Memorial Sloan Kettering Cancer Center has licensed intellectual property related to mesothelin-targeted CARs and T-cell therapies to ATARA Biotherapeutics and has associated financial interests. Dr Bott is a consultant for AstraZeneca Pharmaceuticals, Iovance Biotherapeutics, and Intuitive Surgical and receives research support from Obsidian Therapeutics. Dr Isbell has served as an advisory board member for AstraZeneca and Merck, as an uncompensated steering board member for Genentech, has received institutional research support from ArcherDx/Invitae, Guardant Health, GRAIL, and Intuitive Surgical and travel support from Intuitive Surgical, and has equity/ownership interest in LumaCyte. Dr Molena serves on a steering committee for AstraZeneca, as a consultant for Johnson & Johnson, Bristol-Myers Squibb, AstraZeneca, and Boston Scientific, and has been an invited speaker for Merck and Genentech. Dr Sihag is a member of the AstraZeneca Advisory Board. Dr Rocco has received royalties from Scanlan International, has served as an uncompensated advisor for AstraZeneca, and has served as a consultant for Medtronic. Dr Jones is a member of the advisory council for AstraZeneca and receives research grant support from Merck. Dr Park has received honoraria from Intuitive Surgical, AstraZeneca, Medtronic, serves as a consultant to CEEVRA, and has received institutional research support from Intuitive Surgical. Dr Rusch reports unreimbursed participation in Data Safety and Monitoring Committees for Cancer Research UK MARS II and RAMONA trials. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

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