Sleeve resection after neoadjuvant chemoimmunotherapy in the treatment of locally advanced non-small cell lung cancer

Background: We aimed to characterize the outcomes of sleeve resection after neoadjuvant chemoimmunotherapy for the treatment of non-small cell lung cancer (NSCLC), including perioperative and oncologic outcomes, and to identify any impact of operative approach on resultant findings. Methods: We identified patients with NSCLC who underwent sleeve resection after >= 2 cycles of neoadjuvant chemoimmunotherapy between May 2019 and April 2021 and retrospectively reviewed clinical records. Perioperative data were collected and compared between video-assisted thoracoscopic surgery (VATS) (n=8) and thoracotomy (n=15) groups. Immunohistochemistry (IHC) scores were compared between tumors with and without major pathological response (MPR). Results: Twenty-three patients met inclusion criteria, with clinical stages as follows: IB, 2 (8.7%); IIIA, 14 (60.9%); and IIIB, 7 (30.4%). Treatment-related adverse events (TRAE) were recorded in 17 patients (73.9%), including anemia and neutropenia, with no patients exhibiting serious TRAE. Radiological evaluation revealed 5 (21.7%) patients with complete response (CR), 14 (60.9%) with partial response (PR), and 4 (17.4%) with stable disease (SD). Complete resection was accomplished for all patients. One VATS procedure was converted to thoracotomy due to extensive pleural adhesions. There were no significant differences in intraoperative blood loss (87.5 +/- 51.8 vs. 193.9 +/- 145.3 mL), operative time (198.8 +/- 79.7 vs. 225.5 +/- 55.0 min), number of lymph node examined (16.9 +/- 6.6 vs. 18.2 +/- 6.5), and hospital stay (5.5 +/- 2.8 vs. 9.2 +/- 11.2 days) between the VATS and thoracotomy groups (all P>0.05). Postoperative complications occurred in 3 patients, and 1 patient died of bronchopleural fistula (BPF) in the thoracotomy group. Complete pathological response (CPR) and MPR were achieved in seven (30.4%) and 13 (56.5%) patients, respectively. Both preoperative histopathology (P=0.024) and radiological response (P=0.002) were significantly associated with MPR. In postoperative specimens with MPR, the IHC scores of cluster of differentiation (CD)4, CD8, and CD20 were modestly higher, while programmed cell death receptor 1 (PD-1), lymphocyte-activation gene 3 (LAG3) and T cell immunoglobulin and ITIM domain (TIGIT) were lower compared with non-MPR specimens, albeit insignificantly. Conclusions: Sleeve resection after neoadjuvant chemoimmunotherapy was feasible in patients with locally advanced NSCLC. Perioperative outcomes were comparable between the VATS and thoracotomy groups.