Two centres experience of lung cancer resection in patients with advanced non-small cell lung cancer upon treatment with immune checkpoint inhibitors: safety and clinical outcomes

Abstract

OBJECTIVES Recent trials have begun to explore immune checkpoint inhibitors for non-small cell lung cancer in the neoadjuvant setting, but data on tumour response and surgical outcome remain limited. METHODS Retrospective evaluation of clinical data from patients with non-small cell lung cancer treated with immune checkpoint inhibitors followed by lung resection was performed at 2 large volume institutions (1 North American, 1 European). Data were analysed using Chi-squared, Fisher’s and Wilcoxon rank-sum tests where appropriate. RESULTS Thirty-seven patients were identified from 2017 to 2019. Forty-nine per cent were Stage IIIB and IV. Forty-six per cent received immunotherapy alone and 54% in combination with chemo- and/or radiotherapy. Sixteen per cent of cases were successfully performed minimally invasively. Twenty patients were operated with lobectomy (6 of these with wedges or segments of a neighbouring lobe, 2 with sleeve resections and 1 with a chest wall resection), 4 with bilobectomies, 11 with pneumonectomy (including 5 extrapleural pneumonectomies and 1 atrial resection) and 1 with a wedge resection. Overall, 10 patients (27%) developed postoperative complications and the 90-day mortality was zero. One-year recurrence-free survival was 73% for stage II/IIIA and 55% for stage IIIB/stage IV. The major pathologic response rate was 34%. CONCLUSION In this retrospective study, lung resection after immunotherapy (alone or in combination) is safe, although often requires complex surgery. Due to increasing number of clinical trials adopting immunotherapy in the neoadjuvant setting, it is likely that this therapy will become part of standard of care. Immunotherapy may also allow surgery to have a role for selected patients with advanced disease.

Preoperative immunochemotherapy for locally advanced non-small cell lung cancer: an analysis of the clinical outcomes, optimal number of cycles, and peripheral immune markers

“…Published case reports have detailed the outcomes of surgery following immunochemotherapy for stages IIIB-IV lung cancer that achieved a clinical downstaging (23,(46)(47)(48)(49)(50). Furthermore, a few cohort studies involving patients with IIIB diseases (15,23,34,(51)(52)(53) demonstrated that surgeons in experienced centers can safely operate on advanced NSCLCs that re-enter resectability after immunotherapy or its combination with chemotherapy. Moreover, postoperative survival dramatically improved in these patient cohorts compared to those that did not receive surgery (23,53).…”

“…Furthermore, a few cohort studies involving patients with IIIB diseases (15,23,34,(51)(52)(53) demonstrated that surgeons in experienced centers can safely operate on advanced NSCLCs that re-enter resectability after immunotherapy or its combination with chemotherapy. Moreover, postoperative survival dramatically improved in these patient cohorts compared to those that did not receive surgery (23,53). Similar to the aforementioned articles, nearly half of the included patients in the present study had stage IIIB/IIIC diseases (IIIB: n=51; IIIC: n=3).…”

Canadian Consensus Recommendations for the Management of Operable Stage II/III Non-Small-Cell Lung Cancer: Results of a Modified Delphi Process

“…Of the 20 patients enrolled into the Checkmate 157 trial, there were 2 patients had disease progression on their restaging CT scan despite having major pathological response to neoadjuvant nivolumab [82]. However, data from larger retrospective studies report a frequency of 2-4% [83,84].…”

European Respiratory Society International Congress 2021: highlights from best-abstract awardees

“…Recent studies have reported promising rates of pathological response with neo-adjuvant immunotherapy [43,44] and multiple phase III trials are ongoing. Evidence is also emerging regarding the safety and potential complexity of subsequent thoracic surgery in this group [45,46].…”