Perioperative Considerations of Neoadjuvant and Perioperative Chemoimmunotherapy for Resectable Lung Cancer

Erupting evidence for immune checkpoint inhibitors (ICIs) in treating non-small cell lung cancer (NSCLC) has changed the paradigm for resectable NSCLC. Many questions remain regarding how ICIs can affect the perioperative trajectory of patients beyond successful resection and survival benefits, however. The objective of this narrative review is to discuss the evolving perioperative care of ICI-treated patients with NSCLC. This review focuses on the role of anesthesiologists as perioperative experts within a multidisciplinary team and identifies key areas requiring further investigation. Patients presenting for lung cancer resection after immunotherapy must be thoroughly screened for immune-related adverse reactions (irAEs). The most fatal irAEs perioperatively include myocarditis and pneumonitis, which may require immunosuppression and surgical delay up to 6 weeks. A streamlined multidisciplinary approach to preoperative irAE detection and management is ideal. Most recent trials report no increased surgical complexity following immunochemotherapy versus chemotherapy alone. This interpretation is limited by a lack of standardization in the number of immunotherapy cycles, timing of surgery, and grading tools for surgeon-reported difficulty. Development and validation of surgical complexity predictors may help the anesthesiologist in perioperative planning, especially for analgesia. Key areas warranting further research include the negative interaction between opioids and ICI efficacy and the positive effects of prehabilitation, particularly nutrition, on ICI response. Anesthesiologists should be aware of potential irAEs and predictors of surgical complexity, ideally as part of a multidisciplinary, team-based approach in surgical planning for chemoimmunotherapy-treated patients with NSCLC. Emerging areas of interest include the interaction of immunotherapy with opioids and prehabilitation.