Perioperative Outcomes of Neoadjuvant Therapy in Resectable Lung Cancer Patients With Endobronchial Disease in the Era of Personalized Medicine.

Abstract

Background: Lung cancer remains the leading cause of cancer-related deaths worldwide. Recent studies have highlighted the benefit of neo-adjuvant therapies in the treatment of resectable stage IB to IIIA cases which will likely increase the use of neoadjuvant therapies (NAT) across multiple stages, both earlier and later. This includes the combination of chemotherapy and immunotherapy as well as the more widespread use of targeted therapies with or without the addition of radiation. This heterogenous group of resectable tumors includes proximal tumors with different levels of endobronchial involvement and secondary distal atelectasis and sometimes superimposed infections which adds a level of concern and complexity when using NAT. In this study, we evaluate the prevalence of endobronchial lesions in patients treated with NAT, as well as the rate of associated complications.

Patients and methods: Data was obtained from a prospectively maintained thoracic surgery database, the Thoracic Oncology Clinical Database and Biobank. Patients with proven clinical stage II-III NSCLC that underwent resection within the Division of Thoracic Surgery at the McGill University Health Centre (Montreal, QC, Canada) from January 2015 to December 2020 were included. Chest computed tomography scans prior to neoadjuvant therapy were reviewed by 2 senior thoracic surgeons to establish the presence of an endobronchial tumor lesion. The presence of an endobronchial lesion was defined by a tumoral lesion obstructing a bronchus or several bronchi AND responsible for lung atelectasis distally (with at least 1 occluded segment). Treatment-related and postoperative complications were collected retrospectively by reviewing patient charts.

Results: Overall, 110 patients met the inclusion criteria, of which 37/110 patients had endobronchial lesions before starting neoadjuvant therapy (33.6%). These patients had a higher rate of global complications 23/37 (62.2%) during neoadjuvant treatment compared to patients without obstruction 30/73 (41.1%) (P = .04). There was no difference in terms of severity of complications between the 2 groups (P = .34). The group with endobronchial lesions was found to have an increased rate of pulmonary complications, of which there were none in the other group (5/37, 13.5% vs. 0/73, 0%, P = .004). There were 2 cases of patients requiring urgent surgeries before completing NAT due to pulmonary complications in the endobronchial lesion group (2/37, 5.4%) and none in the group without obstruction.

Conclusion: Patients who are treated with NAT for locally advanced resectable lung cancer usually have larger tumors, where it is not uncommon to encounter endobronchial lesions responsible for downstream obstruction. In this study, the prevalence of endobronchial lesions was found to be 1 third of the patients undergoing NAT. The presence of endobronchial disease was associated with increased risk of complications during neoadjuvant treatment. These complications presented more frequently as pulmonary complications and required in some cases urgent surgical resection. Therefore, patients with endobronchial tumors undergoing NAT should be identified as a high-risk group and would likely benefit from closer clinical follow-up.