Commentary: Neoadjuvant immunotherapy: A brave new world

Abstract

Central MessageMIS is both safe and feasible after neoadjuvant immunotherapy.See Article page XXX. MIS is both safe and feasible after neoadjuvant immunotherapy. See Article page XXX. Cancer immunotherapy rose to the forefront in 2013 when it was named the “breakthrough of the year” by Science.1McNutt M. Cancer immunotherapy.Science. 2013; 342: 1417Crossref PubMed Scopus (130) Google Scholar However, this promise has largely been viewed through the lens of advanced-stage cancers or otherwise inoperable cancers.2Antonia S.J. Villegas A. Daniel D. Vicente D. Murakami S. Hui R. et al.Durvalumab after chemoradiotherapy in stage III non-small-cell lung cancer.N Engl J Med. 2017; 377: 1919-1929Crossref PubMed Scopus (2469) Google Scholar It was not for another 5 years that the glimmer of its impact on thoracic surgeons became clear. Initially, a single-arm, single-agent trial using neoadjuvant nivolumab for resectable early-stage disease demonstrated a high rate of major pathologic responses and pathologic downstaging. However, conversions from minimally invasive surgery (MIS) approaches were frequent.3Forde P.M. Chaft J.E. Smith K.N. Anagnostou V. Cottrell T.R. Hellmann M.D. et al.Neoadjuvant PD-1 blockade in resectable lung cancer.N Engl J Med. 2018; 378 (Epub 2018 Apr 16. Erratum in: N Engl J Med. 2018;379:2185. https://10.1056/NEJMoa1716078): 1976-1986Crossref PubMed Scopus (1027) Google Scholar Despite this, the oncologic benefits were clear, and enthusiasm for neoadjuvant immunotherapy persisted. The landmark Checkmate 816 trial is demonstrating that breakthrough of immunotherapy is here to stay,4Forde P.M. Spicer J. Lu S. Provencio M. Mitsudomi T. Awad M.M. et al.Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer.N Engl J Med. 2022; 386: 1973-1985Crossref PubMed Scopus (204) Google Scholar and the current practicing thoracic surgeon should be aware not only of treatment options for locally advanced tumors but also of surgical options. This makes the analysis by Mathey-Andrews and colleagues5Mathey-Andrews C. McCarthy M. Potter A. Beqari J. Wightman S.C. Liou D. et al.Safety and feasibility of minimally invasive lobectomy after neoadjuvant immunotherapy for non-small cell lung cancer.J Thorac Cardiovasc Surg. 2022; (XXX:XXX)Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar all the more prescient and timely. In this issue of the Journal, Mathey-Andrews and colleagues5Mathey-Andrews C. McCarthy M. Potter A. Beqari J. Wightman S.C. Liou D. et al.Safety and feasibility of minimally invasive lobectomy after neoadjuvant immunotherapy for non-small cell lung cancer.J Thorac Cardiovasc Surg. 2022; (XXX:XXX)Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar present a retrospective analysis of the National Cancer Data Base, specifically evaluating the surgical outcomes of patients from 2010 to 2018 who underwent neoadjuvant chemotherapy versus neoadjuvant immunotherapy with or without chemotherapy. Of the 4229 patients in the study period, only 5% underwent neoadjuvant immunotherapy. There was no difference in the rate of open versus minimally invasive lobectomy and no difference in conversion rates. Likewise, readmission, short-term mortality, margin status, and nodal downstaging were similar between the groups. Perhaps reflecting the increasing adoption of the robotic platform for MIS procedures, the majority of MIS cases were performed robotically compared with traditional thoracoscopic techniques. Of note, the neoadjuvant immunotherapy group was more likely to undergo surgery at an academic institution, likely reflecting the probability that these patients were enrolled in trials and are therefore a highly selected cohort while potentially accounting for the success using the MIS approach. This is the first analysis using national data regarding the feasibility of a MIS postneoadjuvant immunotherapy, and given the findings of the Checkmate 816 trial, this report is both timely and important. Although initial experiences suggested that neoadjuvant immunotherapy could add another point on the decision tree as to whether a patient should be offered a MIS approach, these data suggest that may not necessarily be true. Although this analysis is limited to a small group of patients, the findings suggest that thoracic surgeons should be free to hold fast to their previous decision tree regarding surgical approach, irrespective of the type of neoadjuvant therapy. Safety and feasibility of minimally invasive lobectomy after neoadjuvant immunotherapy for non–small cell lung cancerThe Journal of Thoracic and Cardiovascular SurgeryPreviewThe objective of this study was to evaluate the feasibility of minimally invasive surgery (MIS) and perioperative outcomes following neoadjuvant immunotherapy for resectable non–small cell lung cancer (NSCLC). Full-Text PDF