Total Robotic Left Pneumonectomy Following Neoadjuvant Chemoimmunotherapy

Neoadjuvant chemoimmunotherapy has emerged as a treatment option for advanced lung cancer (1). There has been concern about the technical difficulty of pulmonary resection due to inflammatory changes in vascular structures, loss of tissue planes, and vascular fragility following chemoimmunotherapy; however, reports have demonstrated the safety and feasibility of resection following neoadjuvant treatment (2, 3). Previous reports have also demonstrated the safety of a minimally invasive approach to pulmonary resection following neoadjuvant treatment (4, 5). It is preferable to avoid pneumonectomy, but it has been demonstrated to be a valuable and safe treatment option after neoadjuvant therapy (6). 

Robotic pneumonectomy was recently described in detail (7), but there are few videos on the technique of robotic pneumonectomy (8, 9). Total robotic left pneumonectomy has been demonstrated on several recent videos (10, 11). However, there have been no videos on total robotic left pneumonectomy following neoadjuvant chemoimmunotherapy. 

This video demonstrates the technique of total robotic left pneumonectomy following neoadjuvant chemoimmunotherapy. The patient was a 70-year-old woman with a history of cough. A CT chest scan demonstrated a left lower lobe (LLL) mass abutting the descending thoracic aorta. A PET scan showed a 5.4 x 4.4 x 11.8 cm central LLL mass with a standardized uptake value (SUV) of 15.0. Endoluminal bronchoscopy with ION and biopsy of the LLL mass revealed adenocarcinoma. Endobronchial ultrasound and biopsy of the station 7 lymph node were negative for metastatic disease (cT4N0M0, Stage IIIA). MRI of the brain was negative for metastatic disease. 

The patient was treated with chemoimmunotherapy consisting of three cycles of cisplatin and pemetrexed. She only tolerated one treatment of nivolumab. A repeat PET scan showed a slight decrease in size and SUV uptake in the LLL mass. A quantitative ventilation perfusion scan demonstrated predicted postoperative values for left lower lobectomy and pneumonectomy: forced expiratory volume in one second (FEV1) was 86 percent and 74 percent, and diffusing capacity of the lungs for carbon monoxide (DLCO) was 67 percent and 60 percent, respectively. 

Intraoperatively, the mass was bridging the fissure but not invading the descending thoracic aorta. Therefore, a total robotic left pneumonectomy was performed. Postoperatively, the patient did well and was discharged home on the second postoperative day. Final pathology revealed adenocarcinoma-T4N0M0 (Stage IIIA) with 0 of 11 total lymph nodes positive for cancer. 

The robotic approach offered improved vision and provides a stable platform safely allowing left pneumonectomy and lymphadenectomy following neoadjuvant chemoimmunotherapy. This approach results in reduced pain, shorter hospital length of stay, and enhanced patient recovery.

References

1. Forde PM, Spicer J, Shun L, et al. Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer. N Engl J Med 2022;386:1973-19.
2. Yang CFJ, McSherry F, Mayne NR, et al. Surgical outcomes after neoadjuvant chemotherapy and ipilimubab for non-small cell lung cancer. Ann Thorac Surg 2018;105:924-9.
3. Roman AR, Campo-Canaveral de la Cruz JL, Macia M, et al. Outcomes of surgical resection after neoadjuvant chemoimmunotherapy in locally advanced stage IIIA non-small-cell lung cancer. European J Cardio-Thorac Surg 2021;60:81-88.
4. Kamel MK, Nasar A, Stiles BM, et al. Video-assisted thoracoscopic lobectomy is the preferred approach following induction chemotherapy. J Laparendosc Adv Surg Tech 2017;27:495-500.
5. Matsuoka K, Yamada T, Matsuoka T, et al. Video-assisted thoracoscopic surgery for lung cancer after induction therapy. Asian Cardiovasc Thorac Ann 2018;26:608-14.
6. Weder W, Collaud S, Eberhart WEE, et al. Pneumonectomy is a valuable treatment option after neoadjuvant treatment for stage III non-small-cell lung cancer. J Thorac Cardiovasc Surg 2010;139:1424-30.
7. Amirkhosravi F, Kim M. Complex robotic lung resection. Thorac Surg Clin. 2023; 33: 51-60.
8. Vidanapathirana CP, Papoulidis P, Nardini M, et al. Subxiphoid robotic-assisted right pneumonectomy. J Thorac Dis. 2019; 11: 1629-1631.
9. Jett GK, Nguyen A, Afolayan O. Total Robotic Right Pneumonectomy. January 2023. doi:10.25373/ctsnet.21842919.v1.
10. Dylewski M. Robotic XI 4-Arm Total Port Video-Assisted Left Pneumonectomy. April 2018. doi:10.25373/ctsnet.6122189.
11. Romano G, Bagalà E, Davini F, Melfi F. Totally Endoscopic Robotic Left Pneumonectomy. March 2024. doi:10.25373/ctsnet.25407745.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.