Reduction in surgical scope after neoadjuvant chemotherapy and immunotherapy for non‑small cell lung cancer

Introduction

Neoadjuvant chemotherapy has long been an established treatment for resectable non-small cell lung cancer (NSCLC). It has demonstrated enhanced efficacy compared with surgery alone, with a 5% increase in 5-year survival rates (1). NSCLC accounts for ~85% of all lung cancer cases and remains the leading cause of cancer-related mortality worldwide. The integration of immunotherapy with traditional chemotherapy in the neoadjuvant setting represents a paradigm shift in the management of resectable NSCLC. Preoperative chemotherapy combined with immunotherapy has gained traction due to its potential to enhance antitumor immune responses while targeting tumor cells directly. Multiple clinical trials and meta-analyses have shown that this combined approach not only improves pathological responses but also boosts overall survival compared to chemotherapy alone (2–4). For instance, programmed death-1 (PD-1) inhibitors like nivolumab and pembrolizumab have been pivotal in eliciting durable immune-mediated tumor regression, paving the way for more favorable surgical conditions.

Combined neoadjuvant chemotherapy and immunotherapy can transform initially unresectable tumors into resectable tumors, potentially enhancing surgical outcomes and prognosis (5,6). For patients with locally advanced NSCLC, particularly those initially evaluated for pneumonectomy, the combination of neoadjuvant chemotherapy and immunotherapy offers a strategy to potentially minimize the scope of surgery. This approach allows more patients to undergo lobectomy instead of pneumonectomy by shrinking the tumor and downstaging the disease (7). Reducing the scope of surgery not only decreases surgical trauma but may also improve prognosis and quality of life. Furthermore, this downstaging effect is attributed to the synergistic action of chemotherapy in debulking the tumor and immunotherapy in activating T-cell responses against residual disease. However, challenges such as treatment-related toxicities, including immune-related adverse events, must be carefully managed to optimize patient outcomes. Recent guidelines from organizations like the National Comprehensive Cancer Network (NCCN) emphasize multidisciplinary evaluation to balance the benefits and risks of neoadjuvant therapies (8).

However, the impact of reducing the surgical scope in patients receiving neoadjuvant chemoimmunotherapy on the final efficacy remains a critical question. The safety, efficacy and long-term survival associated with this treatment approach still require validation through large-scale clinical studies. Whilst existing trials (such as CheckMate 816) have demonstrated the efficacy of neoadjuvant chemoimmunotherapy in enabling downstaging (9–11), they lack detailed real-world comparisons of surgical scope reduction after therapy. Retrospective data uniquely capture intraoperative decision-making and long-term outcomes in heterogeneous patient populations, filling this gap. Thus, the present study aimed to retrospectively analyze real-world data to compare the safety and long-term efficacy of several surgical methods following neoadjuvant treatment, thereby providing a foundation for clinical decision-making. In addition, real-world evidence is crucial for addressing gaps in randomized controlled trials, such as patient diversity, comorbidities and long-term follow-up beyond trial endpoints. By leveraging data from a cohort of 195 patients, this study provides insights into perioperative complications, pathological responses and survival metrics, which could inform future prospective studies and refine clinical protocols for NSCLC management.

Materials and methods

Patient selection

A retrospective analysis was performed, including data from 195 patients with NSCLC who were hospitalized between December 2018 and February 2022 at Hunan Cancer Hospital (Changsha, China). All patients received neoadjuvant chemotherapy in combination with immunotherapy, followed by curative-intent surgery. The timing of surgery was determined by the surgeons after 2–4 cycles of neoadjuvant therapy. Patients were categorized into three groups according to the type of surgery performed: Lobectomy group (n=137), reduced surgical scope group (initially assessed as requiring pneumonectomy but ultimately undergoing lobectomy or bilobectomy; n=42), and pneumonectomy group (n=16). The reduced surgical scope group consisted of patients initially assessed by a multidisciplinary team (MDT) as requiring pneumonectomy based on preoperative imaging showing extensive tumor involvement, but who underwent lobectomy or bilobectomy following a neoadjuvant response. This included patients downgraded specifically to bilobectomy from pneumonectomy, distinct from bilobectomy patients in the lobectomy group who were initially planned for bilobectomy without reduction from pneumonectomy. Decisions were made collaboratively by the MDT preoperatively and were confirmed intraoperatively by at least two senior surgeons. The present study received approval from the Ethics Review Committee of Hunan Cancer Hospital, and written informed consent was obtained from all patients. The study adhered to the Declaration of Helsinki (2013 revision).

Patients who met the following criteria were included in the present study: i) Pathologically confirmed NSCLC with clinical stage II–III disease (12) that was initially evaluated as resectable based on enhanced chest and abdominal CT, bone scans, MRI or PET-CT imaging; ii) age of 18–80 years; iii) no evidence of distant organ metastasis; and iv) normal organ function. The exclusion criteria were as follows: i) Pathological results indicating small cell lung cancer; ii) history of lung or mediastinal surgery; iii) severe, uncontrolled comorbidities or active bacterial infections; iv) determination of lack of fitness for intubation and general anesthesia by the anesthesiologist; v) pregnant or breastfeeding status; and vi) Eastern Cooperative Oncology Group performance status (13) score of >2.

Neoadjuvant chemotherapy and immunotherapy

All patients received neoadjuvant chemotherapy in combination with immunotherapy. The chemotherapy regimen was customized according to the characteristics and tumor profile of each patient, including the use of agents such as cisplatin, carboplatin, paclitaxel and pemetrexed. The immunotherapy agents primarily consisted of programmed cell death protein 1/programmed death-ligand 1 inhibitors, including pembrolizumab and nivolumab. Treatment generally involved 2–4 cycles, depending on patient tolerance and response, with efficacy evaluated according to the Response Evaluation Criteria in Solid Tumors (14).

Surgical procedures

Surgical procedures included lobectomy, bilobectomy and pneumonectomy, with the surgical approach determined by the tumor response and the overall condition of the patient following neoadjuvant therapy. All surgeries aimed at radical resection and emphasized the importance of achieving clear margins and adequate lymph node dissection. Pathological complete response (pCR) and major pathologic response (MPR) were defined as the presence of 0 and ≤10% residual viable tumor cells in the primary tumor and resected lymph nodes, respectively.

Postoperative adjuvant therapy and follow-up

Individualized postoperative adjuvant therapy plans, which included immunotherapy maintenance, chemotherapy and radiotherapy, were established by an MDT based on postoperative pathology and patient recovery. Follow-up data were gathered through outpatient visits and phone calls.

Data collection and statistical analysis

Patient baseline characteristics, treatment response, perioperative data, postoperative pathology results, recurrence and survival data were collected. Categorical variables were compared using χ2 or Fisher's exact tests, where appropriate. Continuous variables were assessed for normality, with nonnormally distributed data (such as hospital stay and operative time) compared using the Kruskal-Wallis test, followed by pairwise Mann-Whitney U-tests with Bonferroni correction for post-hoc analysis where the Kruskal-Wallis result was significant, whereas normally distributed data were compared using one-way ANOVA, followed by Tukey's honestly significant difference post-hoc test for significant results. Survival analyses were performed using the Kaplan-Meier method with log-rank tests. Proportional hazards assumptions for Cox models were tested using Schoenfeld residuals (no violations found). Missing data were minimal (<5% for all variables) and handled using listwise deletion; no imputation was needed owing to low rates. Data analysis was performed using SPSS Statistics, version 27 (IBM Corp.), including χ2 tests, unpaired t-tests (used for preliminary pairwise comparisons between specific subgroups or variables with only two groups, such as in exploratory analyses of binary outcomes). Disease-free survival (DFS) and overall survival (OS) curves were generated using R software package (version 4.4; The R Foundation). P<0.05 was considered to indicate a statistically significant difference.

Results

Patient characteristics

The present study included 195 patients diagnosed with NSCLC. This cohort comprised 137 individuals in the lobectomy group [129 men; mean age, 60.6±7.1 years; central tumors in 98 patients (71.5%)], 42 patients in the reduced surgical scope group (39 men; mean age, 57.9±6.8 years) and 16 individuals in the pneumonectomy group (all men; mean age, 54.4±7.1 years). The distribution of lesions was as follows: 49 cases (25.1%) in the left upper lobe, 39 cases (20.0%) in the left lower lobe, 53 cases (27.2%) in the right upper lobe, 8 cases (4.1%) in the right middle lobe and 46 cases (23.6%) in the right lower lobe. Initial clinical staging revealed stage II disease in 37 patients (19.0%) and stage III disease in 158 patients (81.0%). All patients were deemed operable, with surgical plans that included lobectomy, bilobectomy, sleeve resection and pneumonectomy. A total of 66 patients who were initially evaluated for lobectomy underwent the procedure as planned in the lobectomy group, whereas 28/29 patients assessed for bilobectomy ultimately received that procedure in the lobectomy group. Only one patient who was initially evaluated for bilobectomy finally received a right pneumonectomy due to tumor invasion and was assigned to the pneumonectomy group. In summary, the reduced surgical scope group (n=42) specifically included patients initially planned for pneumonectomy but downgraded to lobectomy (n=36) or bilobectomy (n=6) after neoadjuvant therapy; these bilobectomy patients were distinct from the 28 bilobectomy patients in the lobectomy group who were initially planned for bilobectomy (Table I).

Table I. Patient characteristics.

Table I.

Patient characteristics.

		Final surgical scope grouping
Variable	Total (n=195)	Lobectomy group (n=137)	Reduced surgical scope group (n=42)	Pneumonectomy group (n=16)
Sex
Male	184 (94.4)	129 (94.2)	39 (92.9)	16 (100.0)
Female	11 (5.6)	8 (5.8)	3 (7.1)	0 (0.0)
Age, years	59.5±7.2	60.6±7.1	57.9±6.8	54.4±7.1
Smoking history
Non-smoker	18 (9.2)	13 (9.5)	3 (7.1)	2 (12.5)
Former smoker	177 (90.8)	124 (90.5)	39 (92.9)	14 (87.5)
Location
LU	49 (25.1)	12 (8.8)	24 (57.1)	13 (81.2)
LL	39 (20.0)	28 (20.4)	9 (21.4)	2 (12.5)
RU	53 (27.2)	46 (33.6)	7 (16.7)	0 (0.0)
RM	8 (4.1)	8 (5.8)	0 (0.0)	0 (0.0)
RL	46 (23.6)	43 (31.4)	2 (4.8)	1 (6.3)
Clinical staging (pretreatment)
II	37 (19.0)	31 (22.6)	4 (9.5)	2 (12.5)
III	158 (81.0)	106 (77.4)	38 (90.5)	14 (87.5)
Planned operation before treatment
Lobectomy	66 (33.9)	66 (48.2)	0 (0.0)	0 (0.0)
Bilobectomy	29 (14.9)	28 (20.4)	0 (0.0)	1 (6.2)
Sleeve resection	43 (22.1)	43 (31.4)	0 (0.0)	0 (0.0)
Pneumonectomy	57 (29.1)	0 (0.0)	42 (100.0)	15 (93.8)

[i] Data are presented as n (%) or mean ± standard deviation. LU, left upper lobe; LL, left lower lobe; RU, right upper lobe; RM, right middle lobe; RL, right lower lobe.

Surgical treatment and perioperative data

A total of 52 patients (26.7%) underwent open thoracotomy, 80 patients (41%) underwent video-assisted thoracoscopic surgery (VATS), and 63 patients (32.3%) who were initially assigned to VATS were reassigned to open surgery. The primary reasons for conversion included local invasion of the primary tumor and severe tissue adhesions. Ultimately, 145 patients (74.4%) underwent lobectomy, 34 patients (17.4%) underwent bilobectomy and 16 patients (8.2%) underwent pneumonectomy, which included 15 left pneumonectomies and 1 right pneumonectomy. The mean operative times for the lobectomy, reduced scope and pneumonectomy groups were 165 min (range, 133–194), 180 min (range, 150–206) and 150.5 min (range, 140–180.8), respectively (P=0.083). There was no significant difference in intraoperative blood loss among the three groups (P=0.406). R0 resection was achieved in 182 patients (93.3%), whereas 13 patients (6.7%) required palliative resection due to factors such as tumor invasion of the pericardium. The rates of palliative resection in the groups were 4 cases (2.9%), 2 cases (4.8%) and 5 cases (31.3%), respectively (P<0.001). Postoperative intensive care unit (ICU) admission was necessary for 15 patients (11%), 6 patients (14.3%) and 5 patients (31.3%), respectively (P=0.076). Severe postoperative complications occurred in 29 patients (21.2%), 6 patients (14.3%) and 4 patients (25%) in the lobectomy, reduced scope and pneumonectomy groups, respectively (P=0.542). Only one patient in the pneumonectomy group died within 30 days due to severe pulmonary infection. The median postoperative hospital stay was 6 days (range, 5–8) for the lobectomy group, 6 days (range, 6–7) for the reduced scope group and 8 days (range, 7–10) for the pneumonectomy group (P=0.002) (Table II).

Table II. Clinical staging.

Table II.

Clinical staging.

		Final surgical scope grouping
Variable	Total (n=195)	Lobectomy group (n=137)	Reduced surgical scope group (n=42)	Pneumonectomy group (n=16)	P-value
Preoperative clinical RECIST evaluation
CR	16 (8.2)	14 (10.2)	2 (4.8)	0 (0.0)
PR	146 (74.9)	96 (70.1)	38 (90.5)	12 (75.0)
SD	31 (15.9)	25 (18.3)	2 (4.8)	4 (25.0)
PD	2 (1.0)	2 (1.5)	0 (0.0)	0 (0.0)
Surgical procedures
VATS	80 (41.0)	72 (52.6)	4 (9.5)	4 (25.0)
Thoracotomy	52 (26.7)	27 (19.7)	15 (35.7)	10 (62.5)
Conversion to open surgery	63 (32.3)	38 (27.7)	23 (54.8)	2 (12.5)
Reason for conversion					0.109
Tumor invasion	16 (8.2)	6 (4.4)	8 (19.1)	2 (12.5)
Calcification of lymph nodes	6 (3.1)	3 (2.2)	3 (7.1)	0 (0.0)
Intraoperative bleeding	4 (2.1)	3 (2.2)	1 (2.4)	0 (0.0)
Tissue fibrosis adhesions	10 (5.1)	8 (5.8)	2 (4.8)	0 (0.0)
Pleural adhesion	2 (1.0)	2 (1.5)	0 (0.0)	0 (0.0)
Procedure					<0.001
Lobectomy	145 (74.4)	109 (79.6)	36 (85.7)	0 (0.0)
Bilobectomy	34 (17.4)	28 (20.4)	6 (14.3)	0 (0.0)
Pneumonectomy	16 (8.2)	0 (0.0)	0 (0.0)	16 (100.0)
Sleeve resection					<0.001
Bronchial sleeve lobectomy	58 (29.7)	41 (29.9)	17 (40.5)	0 (0.0)
Lobectomy with pulmonary artery angioplasty	3 (1.5)	2 (1.5)	1 (2.4)	0 (0.0)
Lobectomy with bronchovascular sleeve resection	20 (10.3)	6 (4.4)	14(31.8)	0 (0.0)
Operation time, min	167.0	165.0	180.0	150.5	0.083
	(139.0–195.0)	(133.0–194.0)	(150.0–206.0)	(140.0–180.8)
Blood loss, ml	200.0	200.0	200.0	200.0	0.406
	(100.0–200.0)	(100.0–200.0)	(100.0–250.0)	(187.5–225.0)
Resection					0.499
Complete (R0)	182 (93.3)	128 (93.4)	40 (95.2)	14 (87.5)
Incomplete (R1/R2)	13 (6.7)	9 (6.6)	2 (4.8)	2 (12.5)
Postoperative admission to ICU	26 (13.3)	15 (10.9)	6 (14.3)	5 (31.3)	0.076
Postoperative hospital stay, days	6 (6–8)	6 (5–8)	6 (6–7)	8 (7–10)	0.002
Serious postoperative complications	39 (20.0)	29 (21.2)	6 (14.3)	4 (25.0)	0.542

[i] Data are presented as n (%) or median (interquartile range). RECIST, Response Evaluation Criteria in Solid Tumors; CR, complete remission; PR, partial response; SD, stable disease; PD, progressive disease; VATS, video-assisted thoracoscopic surgery; ICU, intensive care unit.

Postoperative pathology and follow-up

Postoperative pathological evaluation revealed that 75 patients (54.7%) in the lobectomy group, 28 patients (66.7%) in the reduced scope group and 6 patients (37.5%) in the pneumonectomy group achieved a pCR or MPR (P=0.114). The median postoperative follow-up duration was 32.26 months (interquartile range 27.33–42.55), with 170 patients (87.2%) still alive and 149 patients (76.4%) exhibiting no signs of recurrence at that time (Table III).

Table III. Surgical details.

Table III.

Surgical details.

		Final surgical scope grouping
Variable	Total (n=195)	Lobectomy group (n=137)	Reduced surgical scope group (n=42)	Pneumonectomy group (n=16)	P-value
Histology					<0.001
Squamous cell carcinoma	151 (77.4)	99 (72.3)	39 (92.9)	13 (81.3)
Adenocarcinoma	37 (19.0)	35 (25.6)	1 (2.4)	1 (6.3)
Adenosquamous carcinoma	3 (1.5)	0 (0.0)	1 (2.4)	2 (12.5)
Sarcomatoid carcinoma	3 (1.5)	2 (1.5)	1 (2.4)	0 (0.0)
Mucoepidermoid carcinoma	1 (0.5)	1 (0.7)	0 (0.0)	0 (0.0)
ypTNM					0.051
T0N0M0	67 (34.4)	51 (37.2)	12 (28.6)	4 (25.0)
T1N0	49 (25.1)	34 (24.8)	14 (33.3)	1 (6.3)
T2aN0	15 (7.7)	9 (6.6)	5 (11.9)	1 (6.3)
T2bN0	3 (1.5)	2 (1.5)	0 (0.0)	1 (6.3)
T3N0/T1-2N1	20 (10.3)	10 (7.3)	7 (16.7)	3 (18.8)
T3N1/T1-2N2/T4N0-1	36 (18.5)	28 (20.4)	3 (7.1)	5 (31.3)
T3-4N2/T1-2N3	5 (2.6)	3 (2.2)	1 (2.4)	1 (6.3)
Pathological response					0.114
pCR	67 (34.4)	51 (37.2)	12 (28.6)	4 (25.0)
MPR	42 (21.5)	24 (17.5)	16 (38.1)	2 (12.5)

[i] Data are presented as n (%). T, tumor; N, node; M, metastasis; pCR, pathological complete response; MPR, major pathological remission.

Survival analysis

The DFS curve of the pneumonectomy group decreased relatively quickly, and the median DFS was shorter, suggesting that this surgical method had the worst effect. By contrast, the patients in the reduced surgical scope group and the lobectomy group had improved DFS curves in the first 36 months, and their long-term survival was also longer. However, there was no significant difference in DFS among the three groups (P=0.22; Fig. 1).

Figure 1. Kaplan-Meier curves of DFS. DFS, disease-free survival.

The Kaplan-Meier survival curves also indicated that there was no statistically significant difference in OS among the three surgical approaches evaluated for patients with NSCLC (P=0.47; Fig. 2). Although the reduced surgical scope group exhibited a greater trend in the survival curve compared with the other groups, it was not possible to clearly determine which surgical method was superior due to the small sample size and lack of statistical significance.

Figure 2. Kaplan-Meier curves of OS. OS, overall survival.

Discussion

Perioperative treatment for NSCLC aims to improve surgical outcomes and reduce recurrence, thereby increasing OS rates. Neoadjuvant therapy focuses on shrinking tumors before surgery, eliminating micrometastatic foci, increasing the likelihood of complete resection and ultimately reducing postoperative recurrence whilst extending DFS (15,16). Recent advancements in perioperative treatment, particularly the combination of neoadjuvant chemotherapy with immunotherapy, have yielded promising results (17). Neoadjuvant chemotherapy, particularly platinum-based regimens, has been reported to markedly enhance surgical outcomes and decrease recurrence rates (18). Previous studies have indicated that neoadjuvant immunotherapy, such as nivolumab, combined with chemotherapy can notably increase downstaging rates, resulting in higher event-free and OS rates for patients with NSCLC than chemotherapy alone (19,20). In the present study, the rates of pCR across the three groups ranged from 25–37.2%, which is consistent with other reports (21–23).

Surgical resection remains the cornerstone of treatment for stage I–III NSCLC (8). Neoadjuvant therapy does not notably increase perioperative complication rates, and OS is markedly improved with integrated treatment strategies, resulting in substantial increases in 5-year survival rates. This multimodal approach not only enhances disease control but also provides higher success rates for surgery and DFS (3,24).

For centrally located NSCLC, determining the necessity of pneumonectomy is a critical consideration. According to data from the Checkmate 816, Rationale 315 and AEGEAN studies, 8–25% of patients with NSCLC receive pneumonectomy after neoadjuvant therapy (11,25,26). Whilst pneumonectomy may offer benefits for certain patients (27–29), it is not necessary for all patients. The goal of lung cancer surgery is to remove tumors effectively whilst preserving as much lung tissue and function as possible. Particularly after neoadjuvant therapy, patients who were initially assessed as requiring pneumonectomy may instead be candidates for lobectomy, which can preserve more lung function without compromising treatment efficacy. With advancements in surgical techniques, alternatives such as bronchoplasty, angioplasty, sleeve lobectomy and bronchovascular sleeve resection can help avoid pneumonectomy whilst still achieving radical resection of locally advanced tumors (30–32).

The high pCR rate of 25% observed in the pneumonectomy group in the present study suggests that pneumonectomy may not be necessary for all patients. The potential to achieve similar outcomes with lobectomy in locally advanced cases warrants further investigation. Additionally, segmentectomy or wedge resection in early-stage NSCLC can provide survival rates comparable with those of lobectomy whilst reducing surgical risk (33,34). Therefore, for locally advanced cases, lobectomy as a substitute for pneumonectomy may also be a feasible strategy.

The present study performed comparisons of baseline characteristics, perioperative data, postoperative pathology, recurrence rates and survival outcomes among the lobectomy, reduced scope and pneumonectomy groups. The results indicated that reducing the extent of surgery after neoadjuvant therapy, specifically switching from pneumonectomy to lobectomy, does not lead to increased local recurrence rates or adversely affect DFS or OS. Patients in the pneumonectomy group experienced higher rates of ICU admission, longer hospital stays and increased perioperative mortality, with only 37.5% achieving pCR or MPR. Therefore, pneumonectomy should be avoided whenever possible. Based on the present findings, an individualized multidisciplinary evaluation after neoadjuvant chemotherapy and immunotherapy-to determine the feasibility of downstaging and reducing surgical extent (e.g., from pneumonectomy to lobectomy or bilobectomy)-appears safe and effective in appropriately selected patients, though this requires further prospective validation.

The cohort in the present study was predominantly male, which may reflect the higher incidence of NSCLC in male smokers in China (35), but limits generalizability to female patients. In the present study, the underrepresentation of women may have masked potential sex-specific benefits or risks of reduced surgical scope post-neoadjuvant chemoimmunotherapy, such as differences in recurrence rates or survival trends. Future research should aim for more balanced cohorts to explore these interactions and enhance applicability across the sexes.

Additionally, the uneven group sizes [70% of patients in the lobectomy group (n=137)] stem from real-world neoadjuvant chemoimmunotherapy dynamics, which enable downstaging to less extensive resections such as lobectomy in certain cases, reserving pneumonectomy for a minority. However, this may reflect therapeutic efficacy, not design flaws. Moreover, it may introduce bias and reduce statistical power for detecting differences in survival or recurrence, elevating type II error risks in smaller subgroups. This common retrospective challenge calls for larger, balanced prospective studies with propensity matching to improve generalizability.

Furthermore, although no statistically significant differences were observed in terms of DFS and OS, the observed trends suggest improved outcomes in the reduced-scope group (such as lower recurrence at 14.3 compared with 31.3% in the pneumonectomy group), potentially due to preserved lung function, reduced surgical trauma and improved postoperative recovery. These trends may arise from the selection of patients with favorable neoadjuvant responses, allowing for less invasive surgery without compromising oncologic outcomes. Supporting evidence from previous studies reinforces this, as neoadjuvant chemoimmunotherapy has been reported to enable tumor downstaging and facilitate reduced surgical extent, such as shifting from pneumonectomy to lobectomy, which is associated with improved long-term survival metrics (36). For example, meta-analyses and clinical trials report that neoadjuvant immunotherapy combined with chemotherapy not only enhances pCR but also supports safer resections with higher event-free survival rates, particularly when surgical scope is minimized to preserve pulmonary function (9). Additionally, real-world data highlights that post-neoadjuvant approaches such as robotic-assisted thoracic surgery in downstaged patients reduce ICU stays and complications, contributing to trends in improved DFS by mitigating perioperative risks (37).

Future studies should concentrate on minimizing the need for pneumonectomy following neoadjuvant therapy, increasing the rates of minimally invasive surgeries and reducing perioperative risks. Research, such as the RATIONALE-315 and CheckMate 816 studies, suggests that higher rates of minimally invasive procedures and lobectomies may enhance postoperative recovery and improve quality of life (25,38,39). Avoiding pneumonectomy whilst achieving a high rate of pCR or MPR remains a key focus of future research. The integration of new adjuvant and neoadjuvant therapies has the potential to improve outcomes for patients with resectable NSCLC (40). Identifying patients who can safely avoid pneumonectomy and customizing interventions to reduce invasiveness whilst enhancing prognosis are priorities for ongoing research.

However, the present study had several limitations. The single-center, retrospective design may have introduced selection bias. Additionally, the relatively small sample size could have led to statistical bias. As a retrospective, single-center study without propensity score matching, the results may be confounded by selection bias (such as reduced-scope patients may have had improved neoadjuvant responses or fewer comorbidities). Moreover, comorbidity data were not systematically collected in the present study, which is a limitation as it could influence surgical decisions and outcomes; future studies should include standardized comorbidity assessments (such as the Charlson Comorbidity Index). However, baseline characteristics were comparable across groups (Table I) and multivariate adjustments in survival analyses mitigated bias to a certain extent, supporting the hypothesis-generating nature of the findings without invalidating the observed safety trends.

In conclusion, the results of the present study indicate that reducing the scope of surgery in select patients with NSCLC after neoadjuvant chemotherapy combined with immunotherapy is safe and effective. Future research should focus on identifying patients who are most likely to benefit from this approach and optimizing neoadjuvant therapy to further enhance treatment outcomes and quality of life.

Acknowledgements

The abstract was presented at the 33rd Annual Meeting of the Asian Society for Cardiovascular and Thoracic Surgery 14–17 May, 2025 in Singapore as an oral presentation.

Funding

The present study was supported by the Sanming Project of Medicine in Shenzhen (grant no. SZSM202211011).

Availability of data and materials

The data generated in the present study may be requested from the corresponding author.

Authors' contributions

WL contributed to conceptualization, formal analysis, investigation and software, and led the writing of the original draft. JT contributed to formal analysis, and project administration. XL contributed to project administration. HY contributed to funding acquisition, formal analysis, investigation, project administration, and writing-review and editing. WW contributed to funding acquisition, formal analysis, investigation, project administration, and writing-review and editing. BZ contributed to funding acquisition, formal analysis, investigation, project administration, and writing-review and editing. WL, JT, XL, LG, DY, HY WW and BZ contributed to data curation, which involved the systematic collection, organization, validation, and management of retrospective clinical data from the 195 patients included in the analysis. BZ and WL confirm the authenticity of all the raw data. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The present study conformed to the provisions of the Declaration of Helsinki (as revised in 2013) and was approved by the Ethics Review Committee of Hunan Cancer Hospital (approval no. 2025-30). All patients signed informed consent forms, and the consent process ensured that patients were fully informed about the use of their anonymized data for research and publication purposes, in accordance with ethical guidelines.

Patient consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

References