Robotic-Assisted Left Lower Lobectomy for NSCLC After Neoadjuvant Chemoimmunotherapy

Since the publication of the results of the CheckMate 816 trial (1), neoadjuvant chemoimmunotherapy has been introduced as a standard of care for stage IB-IIIA resectable NSCLC without mutations. The use of minimally invasive approaches for this group of patients is still debated. The video highlights the enhanced precision and safety of robotic technology, especially when dealing with complex lymphadenectomy after neoadjuvant treatment. 

The case described in this video is that of a fifty-five-year-old man, active smoker with no relevant previous medical history, who presented with a solid mass in the left lower lobe of the lung on a CT scan in October 2023. The mass was discovered during an assessment of asthenia and chronic cough. An FDG PET/CT scan showed an increased uptake at the level of the lung tumor (SUVmax 11) and at the location of an 11L lymph node (SUVmax 12), that showed a short axis of 11mm on the CT scan. Brain MRI showed no metastases. Due to the suspicion of a NSCLC staged cT2aN1M0 (IIB), a percutaneous lung biopsy was performed, which confirmed a lung adenocarcinoma, EGFR, Alk and ROS-1 wild type, with an expression of PD-L1 of 80 percent. The case was discussed with the multidisciplinary team board and neoadjuvant chemoimmunotherapy was agreed upon due to tumor resectability and patient operability. The respiratory function test revealed an FEV1 of 105 percent  and a DLCO of 72 percent. 

The patient underwent a total of three cycles of carboplatin, pemetrexed, and nivolumab. Overall, the patient tolerated the therapy well with no serious treatment-related adverse events. At the reevaluation CT-scan, following the second cycle, a partial response was found with a RECIST 1,1 of -33 percent. Given these findings, the planned surgery was validated.

The Surgery 

The patient was positioned in the lateral decubitus position. The port positioning followed a four-arm approach for robotic portal lung resections (RP-4) (2-4). Five incisions were made, including an 8 mm port for the 30-degree robotic camera, located on the 7th intercostal space, approximately a hand’s length below the scapula’s tip and on the projection of the middle axillary line. 

The other ports were then placed on the same intercostal space, including a 12 mm trocar incision on the anterior axillary line for arm number one (left hand), a 12 mm trocar incision on the posterior axillary line for arm number three (right hand), and an 8 mm trocar incision laterally to the paravertebral line for arm number four. 

Under visual control, a 12 mm trocar incision was also made two intercostal spaces downward, in the 9th intercostal space, for the assistant port with CO₂ insufflation using AirSeal technology. 

A suction of -20cmH2O was applied to the chest tube immediately after surgery. The patient’s postoperative course was uneventful. The chest tube was removed on postoperative day (POD) two and the patient was discharged on POD three. The pathology report showed a macroscopic solid mass of 22mm, with only 10 percent consisting of viable residual tumor, indicating a major pathological response (MPR). The 11L lymph node presented an intense fibrotic reaction, consistent with post treatment sterilization of a nodal metastasis. The adenocarcinoma was then staged ypT1aN0, and the resection status was R0. No spread through air spaces (STAS) was found, neither vascular invasion nor pleural invasion (PL0). Expression of PD-L1 was 5 percent (20 percent at the level of immune cells). At four months of follow-up, the patient was doing well. 

References

1. Forde PM, Spicer J, Lu S, Provencio M, Mitsudomi T, Awad MM, et al. Neoadjuvant Nivolumab plus Chemotherapy in Resectable Lung Cancer. N Engl J Med. 2022 May 26;386(21):1973-1985. doi: 10.1056/NEJMoa2202170.
2. Wei B, Cerfolio RJ. Robotic Lobectomy and Segmentectomy: Technical Details and Results. Surg Clin North Am. 2017 Aug;97(4):771-782. doi: 10.1016/j.suc.2017.03.008.
3. Mattioni G, Mariolo A, Essid R, Rebei M, Seguin-Givelet A. Robotic Assisted Right Apical S1 Anatomical Segmentectomy for NSCLC. CTSNet. 2024 April. doi:10.25373/ctsnet.25568925
4. Mattioni G, Palleschi A, Mendogni P, Tosi D. Approaches and outcomes of Robotic-Assisted Thoracic Surgery (RATS) for lung cancer: a narrative review. J Robot Surg. 2023 Jun;17(3):797-809. doi: 10.1007/s11701-022-01512-8.

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