Safety and Feasibility of Minimally Invasive Lobectomy After Neoadjuvant Immunotherapy for NSCLC
Camille A. Mathey-Andrews1, Alexandra Potter1, Meghan McCarthy1, Jorind Beqari1, *Sean C. Wightman3, *Douglas Liou2, Chi-Fu Jeffrey Yang1
1Department of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, United States, 2Department of Thoracic Surgery, Stanford University School of Medicine, Stanford, California, United States, 3Department of Thoracic Surgery, Keck School of Medicine, Los Angeles, California, United States
Prior studies have suggested that neoadjuvant immunotherapy for non-small-cell lung cancer contributes to hilar and mediastinal fibrosis, potentially increasing the complexity of subsequent operations. It remains unclear, however, whether this in turn increases perioperative morbidity and the likelihood of requiring a more invasive operation. The objective of this study was to evaluate the feasibility of minimally invasive surgery and short-term outcomes after neoadjuvant immunotherapy for stage I-III NSCLC.
Patients in the National Cancer Data Base with stage cI-III NSCLC who underwent lobectomy after chemotherapy or immunotherapy +/- chemotherapy (hereafter referred to as “immunotherapy”) between 2010-2018 were identified for analysis. We evaluated the percentage of operations performed minimally invasively after immunotherapy vs. chemotherapy alone. Using multivariable regression and propensity score-matching, we assessed whether patients treated with neoadjuvant immunotherapy were more likely than those treated with chemotherapy to undergo conversion from MIS to open lobectomy. We also examined whether there were differences in nodal upstaging, margin positivity, 30-day readmission, and 30- and 90-day mortality between patients receiving either neoadjuvant treatment.
Of the 4,229 patients diagnosed with stage I-III NSCLC in our cohort, 4,011 (95%) patients received neoadjuvant chemotherapy and 218 (5%) received neoadjuvant immunotherapy. In unadjusted and multivariable-adjusted analysis, patients who were treated with neoadjuvant chemotherapy were more likely to undergo an open operation than those who were treated with neoadjuvant immunotherapy (62.6% vs. 39.4%, p<0.0001; OR 2.4, [1.5-3.7], p<0.000). Following propensity score-matching, however, there were no significant differences in the rate of open vs. MIS lobectomy among patients in either treatment group (46.1% vs. 40.6%, p= 0.60). There were also no significant differences in the likelihood of conversion from MIS to open lobectomy in propensity-score matched and multivariable-adjusted analysis (6.7% vs. 8.5%, p=0.53; OR 1.5 [0.8-2.9], p=0.19). Finally, there were no significant differences in 30-day readmission, 30- or 90-day mortality, nodal upstaging or margin positivity between the two groups.
In this national analysis, treatment with neoadjuvant immunotherapy for stage I-III NSCLC did not increase the likelihood of receiving an open operation when compared to neoadjuvant chemotherapy. Moreover, there were no significant differences in conversion rates from MIS to open lobectomy, as well as 30-day readmission, 30- or 90-day mortality, nodal upstaging or margin positivity, between patients receiving either neoadjuvant treatment modality. These findings suggest that MIS lobectomy is both feasible and safe after preoperative immunotherapy.
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