Determinants of Successful Minimally Invasive Surgery (MIS) for Resectable Non-Small Cell Lung Cancer (NSCLC) after Neoadjuvant Therapy

Objective MIS (VATS, RATS) for pulmonary resection is standard in early stage NSCLC as it is associated with better perioperative outcomes than thoracotomy. MIS for resection of more advanced NSCLC (Stages IB-IIIB) treated with neoadjuvant therapy has been utilized. However, the determinants of success are not well-defined. Methods A single institution retrospective review of a prospectively maintained database was conducted, querying for patients with clinical Stage IB-IIIB NSCLC who had resection after neoadjuvant systemic therapy without radiation from 2013-2022. Patients were grouped by surgical approach, open vs. MIS. Successful MIS was defined by no conversion, R0 resection, and no major (≥grade 3) morbidity. Analyses by intent-to-treat assessed outcomes by Wilcoxon rank sum test and Fisher's exact test. (MVA identified variables that contributed to successful MIS resection. Results Of 627 eligible patients, 360 (57%) had open and 267 (43%) had MIS procedures. Most patients (79.1%) received neoadjuvant platinum-based chemotherapy, and 21.9% were treated with immunotherapy or targeted therapy alone or combined with chemotherapy. Among MIS resections, 179 (67%) were performed by VATS and 88 (33%) by RATS. The conversion rate was 16% (n=43). Successful MIS resection was achieved in 77% of patients. MVA showed that pre-treatment clinical N stage was a significant determinant of success, but not pre-treatment clinical T stage or type of neoadjuvant therapy. Conclusion Following neoadjuvant systemic therapy for clinical stage IB-IIIB NSCLC, MIS resection can be successfully accomplished and should be considered in appropriate patients. Presence of pre-treatment nodal disease is associated with higher odds of conversion, major morbidity, and incomplete resection.