Correspondence Regarding "Sleeve Lobectomy After Neoadjuvant Chemoimmunotherapy Versus Chemotherapy for Squamous Cell Lung Cancer: A Multicenter, Retrospective Study".

We read with great interest the article by Chen et al.1Chen T. Ning J. Shen J. et al.Sleeve lobectomy after neoadjuvant chemoimmunotherapy versus chemotherapy for squamous cell lung cancer: a multicenter, retrospective study.JTO Clin Res Rep. 2023; 4100472Google Scholar recently published in JTO Clinical and Research Reports. The authors retrospectively analyzed the data from five thoracic oncology centers in the People’s Republic of China to investigate the feasibility and efficacy of sleeve lobectomy in patients with squamous cell lung cancer after neoadjuvant immune checkpoint inhibitors (ICIs) combined with chemotherapy compared with chemotherapy alone. Among the results presented in the article, we paid particular attention to the safety results. They reported that adding immunotherapy to chemotherapy as preoperative therapy did not increase the 30-day risk of postoperative complications and concluded that sleeve lobectomy after induction chemoimmunotherapy was safe.1Chen T. Ning J. Shen J. et al.Sleeve lobectomy after neoadjuvant chemoimmunotherapy versus chemotherapy for squamous cell lung cancer: a multicenter, retrospective study.JTO Clin Res Rep. 2023; 4100472Google Scholar These data are very useful for thoracic surgeons, as the clinical use of ICI as preoperative induction therapy is expected to increase in the future. A number of clinical trials are currently underway evaluating ICI-based regimens as neoadjuvant therapy for early-stage NSCLC. However, only a few phase 3 comparative trials directly comparing the safety of neoadjuvant chemotherapy and that of neoadjuvant ICI have been published.2Forde P.M. Spicer J. Lu S. et al.Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer.N Engl J Med. 2022; 386: 1973-1985Crossref PubMed Scopus (421) Google Scholar,3Wakelee H, Liberman M, Kato T, et al. Perioperative pembrolizumab for early-stage non-small-cell lung cancer [e-pub ahead of print]. N Engl J Med. https://doi.org/10.1056/NEJMoa2302983. Accessed June 3, 2023.Google Scholar Therefore, although this was a retrospective study with small sample size, we believe that the results of this study are very important for thoracic surgeons. We think that the strength of this study is that it analyzed not only perioperative complications but also the findings related to surgical procedures, such as the conversion rate from video-assisted thoracic surgery (VATS) to open chest surgery. To evaluate the safety of surgical procedures, it is important to evaluate information about the surgical technique and postoperative complications. The intraoperative open chest transition rate is among them. If surgery was started with VATS but converted to open chest surgery, it is considered that the operation was deemed unsafe during the surgery and was converted to open chest surgery. This could be interpreted as a failure to ensure safety, even if the operation was successfully completed and the postoperative course was favorable. Therefore, many thoracic surgeons are very concerned about the process, including the technical aspects. This is because it is difficult to quantitatively assess the impact of ICI on the technical aspects of lung resection, and it is not possible to learn this from articles. To understand the impact of ICI on the technical aspects of lung resection, we need to know the intraoperative findings. Although this was a retrospective study and the details of intraoperative findings could not be compared, it is worthy to note that there was no difference between the ICI cohort and the chemotherapy cohort in the proportion of VATS cases and the proportion of cases converted from VATS to open chest surgery, and that the ICI cohort had a conversion rate of 0%.1Chen T. Ning J. Shen J. et al.Sleeve lobectomy after neoadjuvant chemoimmunotherapy versus chemotherapy for squamous cell lung cancer: a multicenter, retrospective study.JTO Clin Res Rep. 2023; 4100472Google Scholar Regarding intraoperative findings after ICI, inflammation, adhesions, fibrosis, and enlarged lymph nodes may be observed, which may affect the surgical technique.4Baek J. Owen D.H. Merritt R.E. et al.Minimally invasive lobectomy for residual primary tumors of advanced non-small-cell lung cancer after treatment with immune checkpoint inhibitors: case series and clinical considerations.Clin Lung Cancer. 2020; 21: e265-e269Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,5Cascone T. Weissferdt A. Godoy M.C.B. et al.Nodal immune flare mimics nodal disease progression following neoadjuvant immune checkpoint inhibitors in non-small cell lung cancer.Nat Commun. 2021; 12: 5045Crossref PubMed Scopus (31) Google Scholar Therefore, in the future, it will be necessary to evaluate intraoperative findings in detail in prospective studies. Thank you for publishing this very interesting study. Kazuki Takada: Manuscript preparation. Shinkichi Takamori: Manuscript editing and review.