Minimally invasive resection of non–small cell lung cancer after chemoimmunotherapy: A multicenter study in academic hospitals

We sought to analyze outcomes of minimally invasive surgery (MIS) and open resection of NSCLC after neoadjuvant chemoimmunotherapy relative to treatment response. Data from 5 centers in the US and Germany were combined for all patients undergoing resection for NSCLC after neoadjuvant chemoimmunotherapy between 2019-2024. Clinical and pathologic factors associated with MIS were analyzed. MIS and open surgery outcomes were compared. A total of 207 patients were included, of which 164 (79.2%) underwent MIS and 43(20.8%) open resection. MIS was more commonly used for lobectomy (93.9% vs. 58.8% open), and less frequently for bilobectomy (2.6% vs. 14.7% open) or pneumonectomy (2.6% vs. 26.5% open, p=<0.0001). Unplanned conversion to thoracotomy (9.1%, n=15) occurred less often for robotic-assisted compared with video-assisted thoracoscopic surgery (4.5% vs. 31%, p=0.001). Open resection was more often used for larger residual tumors (ypT3/4, MIS 8.5% vs. open 32.5%, p=0.0002). A pathologic complete response in 39.1% of patients was an independent predictor of MIS (odds ratio 10.81, 95%confidence interval 2.71-43.20; p=0.001). Complete R0 resection was achieved in 96.1% patients (MIS 98.2% vs. Open 88.4%, p=0.003). MIS was associated with shorter length of stay (adjusted median 3 days vs. 7 days, p<0.0001), and fewer major complications (9.1% vs. 25.6%, p=0.038). The 60-day mortality rate was 1%. Minimally invasive surgery is possible in most patients after neoadjuvant chemoimmunotherapy, especially after complete pathologic response, and is associated with high rates of complete resection and fast recovery. Open surgery is more often performed for patients with large residual tumors or those requiring extended resections.