Surgical experience after perioperative chemoimmunotherapy for non-small cell lung cancer: technical considerations and operative complexity

Background: Perioperative systemic therapy incorporating immune checkpoint inhibitors has expanded surgical indications for locally advanced non-small cell lung cancer (NSCLC). However, treatment-related inflammation and fibrosis may increase operative complexity. This study aimed to describe surgical experience and technical considerations following perioperative chemoimmunotherapy across different surgical approaches.

Methods: We retrospectively reviewed eight patients with locally advanced NSCLC who received neoadjuvant chemoimmunotherapy at a single institution between January 2024 and October 2025. Six patients who proceeded to surgical resection were included. Clinical characteristics, operative findings, and pathological outcomes were analyzed, with particular attention to operative complexity and perioperative outcomes.

Results: Among the six surgical patients (median age, 75 years), four completed the planned neoadjuvant treatment, and three achieved pathological complete response (pCR). Surgical approaches included thoracotomy (n=3), video-assisted thoracoscopic surgery (VATS) (n=1), and robotic-assisted thoracic surgery (RATS) (n=2), selected based on tumor location and anticipated technical complexity. Operative time ranged from 163 to 437 minutes, and intraoperative blood loss ranged from <10 to 481 mL. RATS was successfully performed in two selected patients; however, operative difficulty varied considerably depending on tumor characteristics, fibrosis, emphysema, and fissure development. In one RATS case, dense fibrosis and emphysema were associated with prolonged operative time and delayed resolution of postoperative air leakage. Across all cases, operative complexity appeared to be influenced more by anatomical and treatment-related factors than by the surgical approach itself.

Conclusions: Surgery following perioperative chemoimmunotherapy is feasible across different surgical approaches in selected patients with locally advanced NSCLC. However, operative complexity varies substantially depending on tumor characteristics and treatment-related changes. Careful patient selection, thorough preoperative assessment, and readiness to convert to thoracotomy are essential to ensure safe and effective surgical management.