Impact of Neoadjuvant Therapy, Tumor Size, and Surgical Approach on Conversion to Open Thoracotomy During Lobectomy

Neoadjuvant therapy options for non-small cell lung cancer (NSCLC) are increasingly used before minimally invasive resection. These operations are generally more challenging and have higher rates of conversion to open surgery. In this context, we compare perioperative outcomes of robotic and video-assisted thoracoscopic surgery (VATS) after neoadjuvant therapy.

We used national hospital-level data to identify adult patients diagnosed with stage II or III NSCLC undergoing minimally invasive lobectomy after neoadjuvant chemoimmunotherapy, chemoradiotherapy, or chemotherapy alone between 2010 and 2022. Patients were split into robotic and VATS cohorts. The primary outcome was conversion to open surgery, and secondary outcomes included lymph node yield, length of stay, readmission, and 30-day and 90-day mortality. Multivariable logistic and negative binomial regressions were created to account for patient demographics and tumor characteristics.

Of 3937 patients fitting inclusion criteria, 515 (13.1%) were converted to open, including 15.1% after chemoradiotherapy, 12.8% after chemotherapy alone, and 9.6% after chemoimmunotherapy (P < .001). Robotic surgery was performed in 1745 patients (44.3%) with 137 (7.9%) conversions, and VATS was used in 2192 patients (55.7%) with 378 (17.2%) conversions (P < .001). VATS was independently associated with conversion to open thoracotomy (adjusted odds ratio, 1.98; P < .001). All other short-term outcomes were similar between groups.

Conversions from minimally invasive to open surgery occur in >1 in 10 patients receiving neoadjuvant therapy for lung cancer. The robotic approach is associated with a 54% relative risk reduction in open conversions compared with VATS.