Salvage Lung Resection after Immunotherapy is Feasible and Safe

Objectives Patients with non-small cell lung cancer (NSCLC) treated with immunotherapy and modern chemoradiation regimens show improved progression-free and overall survival. However, patients with limited oligo-progression represent a potential population in which local therapy such as surgery may have a potential role as salvage treatment. The objectives of our study were to evaluate the feasibility and safety of salvage lung resection after immunotherapy in patients with NSCLC. Methods The National Cancer Database (NCDB) was queried for patients diagnosed and treated for NSCLC stage I-IV, from 2013 to 2020. Patients who underwent surgery as salvage after immunotherapy were defined as undergoing surgery >5 months from the initiation of immunotherapy. As a sensitivity analysis, patients who underwent surgery as salvage after chemoradiation were also analyzed in a similar fashion. Surgical outcomes such as type of surgery, complete resection (R0) rates, and complete pathologic response (cPR) rates were determined for feasibility. Length of stay (LOS), 30-day readmission rates, and 30-day mortality rates were determined and overall survivals were estimated with Kaplan-Meier analysis to evaluate for safety. Results Of the 934,093 patients diagnosed with NSCLC stage I-IV from 2013-2020, 164 patients received immunotherapy and after 5mo underwent surgery. Lobectomy was the most commonly performed operation (74%) and pneumonectomy was required in 9% (n=15). R0 resection was achieved in 89% (n=146) and of these patients, 23% (n=37) had cPR. Median LOS was 4 days, 30-day readmission was 5%, and 30-day mortality was 0.6%. In our sensitivity analysis of chemoradiation patients (n=445), the above data were similar to previously reported cohort studies of patients undergoing chemoradiation and subsequently salvage surgery. Conclusion Lung resection after immunotherapy appears to be a feasible salvage treatment option, with lobectomy being most common and with high R0 resection rates. Low patient morbidity and mortality rates also suggest the safety of this approach. Salvage surgery may be considered in patients who have oligo-progression after immunotherapy within the context of a comprehensive multidisciplinary treatment plan.