Surgical strategy after neoadjuvant immunochemotherapy for central-type NSCLC: restaging-guided versus pre-treatment-guided decision-making.

BACKGROUND

Effective neoadjuvant immunochemotherapy (nICT) can downstage central-type non-small cell lung cancer (NSCLC) and reopen previously obstructed bronchi, but surgical decisions are frequently still anchored to pre-treatment staging. This study aimed to evaluate whether a standardized post-nICT restaging-guided surgical strategy could safely support surgical de-escalation while maintaining oncologic safety in selected patients with central-type NSCLC.

METHODS

We conducted a single-center retrospective cohort study of central-type NSCLC involving or abutting the lobar/main bronchus, initially considered to require at least sleeve resection or pneumonectomy. Patients with clinical stage I-III disease who received platinum-based nICT and subsequently showed radiologic partial response (PR)/complete response (CR) and no visible residual endobronchial tumor were included. Surgical management followed either a pre-nICT staging-guided surgery (TN-pre) or a post-nICT restaging-guided surgery (PRS), which linked specific post-nICT computed tomography (CT) and bronchoscopic criteria to de-escalation from pneumonectomy/sleeve resection to lobectomy when R0 resection was deemed feasible. Inverse probability of treatment weighting (IPTW) was used to adjust for baseline imbalances. We compared pathologic response, margin status, perioperative outcomes, overall survival (OS), disease-free survival (DFS), and recurrence patterns.

RESULTS

A total of 122 patients were analyzed (78 PRS, 44 TN-pre). After IPTW, demographic and clinicopathologic features were well balanced. Post-neoadjuvant therapy pathologic tumor-node-metastasis (ypTNM) stage distribution, major pathological response (MPR) rates (83.6% vs. 70.7%; P=0.10), and R0 resection rates were comparable between PRS and TN-pre, with a trend toward fewer R1 margins in PRS (1.6% vs. 7.3%; P=0.07). PRS significantly reduced operative time, chest drainage duration, and intensive care unit (ICU) stay, while intraoperative blood loss, postoperative hospital stay, and 30-day mortality remained similar. No significant differences were observed in OS, DFS, or patterns of locoregional and distant recurrence.

CONCLUSIONS

A post-treatment restaging-guided strategy that explicitly incorporates CT and bronchoscopic response allows safe de-escalation of surgery in selected central-type NSCLC after nICT, converting many planned pneumonectomies or sleeve resections to lobectomy. This response-adapted approach improves perioperative metrics without an early detrimental impact on oncologic outcomes. However, these survival findings should be considered hypothesis-generating and warrant further validation through long-term prospective studies.