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Resectability and Neoadjuvant Chemoimmunotherapy in Stage II-III Non-Small Cell Lung Cancer: A European Case-Vignette
Savvas Lampridis1,2, Akshay J Patel3,4, Eleni Josephides5
1Department of Thoracic Surgery, 424 General Military Hospital, Thessaloniki, Greece.
Objectives:
Immunotherapy has expanded curative-intent options in non-small cell lung cancer (NSCLC), but management recommendations remain variable. This survey examined variation in resectability assessment and treatment sequencing among thoracic oncology clinicians managing stage II-III NSCLC.
Methods:
A web-based case-vignette survey was distributed to thoracic oncology clinicians, primarily in Europe. Seven stage II-III NSCLC vignettes, based on the ninth-edition TNM classification, were presented. Treatment options were recorded as independent yes/no endorsements. The primary outcome was endorsement of neoadjuvant chemoimmunotherapy among vignette evaluations considered resectable. Vignette-level binary outcomes were analysed using exploratory generalized estimating equations clustered by respondent.
Results:
Sixty-eight respondents provided vignette-level assessments. Resectability was generally endorsed in the N0/N1 and selected single-station N2 scenarios but was substantially lower in the multi-station and T3/T4 N2 scenarios. Among cases considered resectable, endorsement of neoadjuvant chemoimmunotherapy increased markedly in N2 scenarios, whereas cases considered unresectable were commonly associated with endorsement of concurrent chemoradiotherapy. In an exploratory model restricted to resectable-branch evaluations (249 observations from 57 respondents), any N2 involvement was associated with endorsement of neoadjuvant chemoimmunotherapy (adjusted odds ratio 28.42, 95% CI 7.31-110.42; P < .001), though the wide interval reflects the limited effective sample.
Conclusions:
Variation was greatest in borderline N2 disease, particularly multi-station and higher-T N2 scenarios, where clinicians diverged in defining resectability and in selecting surgery-based vs chemoradiotherapy-based pathways. These findings support the need for clearer multidisciplinary frameworks in stage II-III NSCLC, within the limits of a surgeon-weighted respondent pool and an anatomically focused vignette set.
