Sleeve lobectomy versus lobectomy after neoadjuvant chemo-immunotherapy for non-small cell lung cancer invading the lobar bronchial orifice: a multicenter retrospective cohort study.

Background: For non-small cell lung cancer (NSCLC) invading lobar bronchial orifice, sleeve lobectomy is the preferred surgical option. Neoadjuvant chemo-immunotherapy may allow R0 resection with lobectomy. This study aims to compare the long-term outcome of sleeve lobectomy and lobectomy after neoadjuvant chemo-immunotherapy.

Methods: We retrospectively screened patients undergoing neoadjuvant chemo-immunotherapy followed by lobectomy or sleeve lobectomy for NSCLC invading lobar bronchial orifice from March 2019 and April 2022. Event-free survival (EFS) was compared between sleeve lobectomy and lobectomy groups in the original cohort and the inverse probability of treatment weighting (IPTW) adjusted cohort. Cox regression was conducted for the potential association between surgical type and EFS.

Results: We initially enrolled 248 patients. According to the inclusion criteria, the final analysis included 68 (27.4%) patients: 38 undergoing lobectomy and 30 undergoing sleeve lobectomy. The 2-year EFS was 83.3% versus 60.5% in sleeve and lobotomy groups, respectively [hazard ratio (HR) =0.46, 95% confidence interval (CI): 0.210-1.005; P=0.057]. In Cox regression analysis, improved EFS was associated with pathological complete response (pCR) (HR =0.31, 95% CI: 0.11-0.90; P=0.03) but not surgical types (HR =0.54, 95% CI: 0.22-1.5; P=0.20). In the subgroup analysis including pCR patients (n=31), median EFS was not reached (NR) in either group (P=0.8) before and after IPTW. In the non-pCR subgroup (n=37), median EFS was 21 months (95% CI: 13-NR) in lobectomy group versus not achieved (95% CI: 25-NR) in sleeve lobectomy group (P=0.04) after IPTW.

Conclusions: Lobectomy could be feasible for pCR patients and there is survival advantage with sleeve lobectomy in patients failing to achieve pCR after neoadjuvant chemo-immunotherapy.