Neoadjuvant Therapy Does Not Increase Morbidity Post Sleeve Lobectomy in NSCLC

In patients with non­–small-cell lung cancer (NSCLC) who have undergone neoadjuvant therapy, morbidity following sleeve lobectomy was not increased compared with patients who did not receive neoadjuvant therapy, a study published in The Journal of Thoracic and Cardiovascular Surgery found. The findings suggest sleeve lobectomy is safe to perform in this patient population.

“Neoadjuvant therapy is believed to increase the difficulty and risk of surgery, so the indication of sleeve lobectomy after neoadjuvant therapy is controversial,” the authors wrote. “We demonstrated that neoadjuvant therapy did not increase the incidence of postoperative complications after sleeve lobectomy.”

The retrospective study enrolled a total of 613 patients who underwent sleeve lobectomy for NSCLC at the Shanghai Pulmonary Hospital in China between January 2018 and December 2021. Of those patients, 124 had received neoadjuvant therapy prior to surgery and 489 had not received neoadjuvant therapy. In both groups, the most common procedure was sleeve resection of the right upper lobe (47.6% and 41.5% respectively).

In the neoadjuvant therapy cohort, patients had a higher rate of smoking history vs those in the upfront surgery cohort (45.2% vs 34.8%; P = .032). Tumors in the neoadjuvant therapy group were also larger at diagnosis on average (mean [SD], 4.22 [1.75] vs 3.91 [1.68] cm; P = .022). N2 metastases were also more common among patients in the neoadjuvant therapy group (47.6% vs 17.3%; P < .001), and patients in the neoadjuvant therapy group had more advanced disease on average (stage III, 78.2% vs 31.9%; P < .001).

Of the patients in the neoadjuvant therapy group, 73 (58.9%) received chemotherapy alone and 39 (31.5%) received chemotherapy combined with immunotherapy. Five patients (4%) were treated with neoadjuvant targeted therapy alone, 3 (2.4%) received immunotherapy alone, and 4 (3.2%) received chemotherapy combined with radiotherapy. Chemoimmunotherapy produced a better rate of complete pathologic response vs chemotherapy alone (28.2% vs 4.1%; P = .001).

The overall postoperative complication rate in the study group was 20.9%, and there was not a significant difference in the rate of complications in the neoadjuvant therapy group vs the rest of the study population. However, univariable logistic regression analysis found smoking history, open thoracotomy, and operation time lasting more than 150 minutes to be risk factors for postoperative complications. Thoracotomy was an independent risk factor.

A balanced cohort of 97 paired cases was also created using propensity score matching. No significant differences in postoperative morbidity were seen between the 2 groups (25.8% vs 24.7%; P = 0.869), and there were no significant differences in morbidity between different neoadjuvant therapy types. A lower percentage of patients in the neoadjuvant therapy group had double-sleeve resections (3.1% vs 11.3%; P = .035). They also had longer chest tube drainage postoperatively (mean [SD], 6.67 [3.81] vs 5.13 [3.74] days; P < .001).

“Our current results suggest that neoadjuvant therapy is entirely safe and feasible for patients undergoing sleeve lobectomy, with no increase in postoperative morbidity,” the authors concluded. “In select patients with locally advanced NSCLC, neoadjuvant therapy followed by sleeve lobectomy should be considered a viable treatment option, [and] chemoimmunotherapy should be the preferred neoadjuvant treatment option for eligible patients.”

Reference

Li X, Li Q, Yang F, et al. Neoadjuvant therapy does not increase postoperative morbidity of sleeve lobectomy in locally advanced non-small cell lung cancer. J Thorac Cardiovasc Surg. Published online March 23, 2023. 10.1016/j.jtcvs.2023.03.016