Neoadjuvant Chemotherapy and Perioperative Complications Associated with Pulmonary Toxicity

Neoadjuvant chemotherapy (NAC) is widely used in multimodal cancer treatment and can improve surgical conditions and patient prognosis. However, NAC-related pulmonary toxicity may impair respiratory function and warrants attention during perioperative risk assessment.

This narrative review summarizes evidence on chemotherapy-associated pulmonary toxicity, focusing on underlying mechanisms, clinical characteristics, diagnostic strategies, and perioperative anesthetic management. Direct clinical evidence from patients receiving NAC is distinguished from findings in other treatment settings and experimental models.

Several chemotherapeutic agents, including bleomycin, methotrexate, taxanes, gemcitabine, and cisplatin, as well as selected targeted therapies, have been associated with drug-induced lung injury, often presenting as interstitial lung disease. Clinical and experimental evidence implicates mitochondrial dysfunction, oxidative stress, immune-mediated injury, inflammatory activation, and alveolar-capillary barrier disruption. Advanced age, pre-existing lung disease, reduced diffusing capacity, metabolic abnormalities, smoking history, and multi-agent treatment may indicate increased susceptibility, although their relevance varies by drug and treatment setting. Evidence from broader perioperative settings and experimental models suggests that mechanical ventilation, excessive oxygen exposure, and surgical stress may aggravate existing pulmonary injury.

NAC-related pulmonary toxicity merits consideration in perioperative assessment, but direct evidence linking it to perioperative outcomes remains limited. Pulmonary function testing and clinically indicated imaging can inform individualized risk assessment. Lung-protective ventilation, appropriate oxygen therapy, individualized anesthetic management, and postoperative respiratory support draw largely on evidence from other populations; their effectiveness specifically in patients with NAC-related pulmonary injury requires further evaluation.