Lung autotransplantation for advanced central lung cancer after neoadjuvant immuno-chemotherapy: a case series study

Background: For locally advanced central lung cancer, lung autotransplantation allows for complete tumor resection while maximizing the preservation of lung parenchyma. Neoadjuvant chemotherapy combined with immunotherapy has shown benefits for patients with advanced lung cancer, providing longer progression-free survival compared to chemotherapy alone. This study aims to evaluate the feasibility and safety of neoadjuvant immuno-chemotherapy followed by lung autotransplantation in the treatment of locally advanced central non-small cell lung cancer (NSCLC).

Methods: We retrospectively analyzed ten patients with central NSCLC who underwent lung autotransplantation after neoadjuvant immuno-chemotherapy from June 2019 to December 2023. Of the grafts, there was 1 right upper lobe, 3 right lower lobe, 1 left lower lobe, 5 basal segments (3 right and 2 left). Nine cases were performed ex situ except one in situ without graft perfusion. All patients were followed up regularly.

Results: Ten cases received neoadjuvant immuno-chemotherapy [programmed cell death protein 1 (PD-1) inhibitor combined with platinum plus paclitaxel], the average number of cycles was 2.3±0.5 cycles, and the average interval between neoadjuvant therapy and surgery was 35.0±13.3 days. Following treatment, there was 1 complete response (CR), 6 partial responses (PRs), and 3 stable diseases (SDs). All cases achieved R0 resection, with 6 cases attaining complete pathological remission (CPR) and 2 cases exhibiting major pathological remission (MPR). No operative death occurred within 30 days. Six cases developed perioperative complications, with five cases being mild to moderate in severity, all of which recovered after standardized treatment. Only one instance of severe pulmonary artery embolism was observed, which improved with systemic anticoagulation therapy. The median follow-up time was 9.5 (range, 1.1-54.2) months. One patient had 4R lymph node recurrence (improved after radiotherapy and immunotherapy), and seven patients survived without recurrence.

Conclusions: Lung autotransplantation for advanced central NSCLC after neoadjuvant immuno-chemotherapy is feasible and safe, with maximal preservation of lung function and a high rate of R0 resection. This also demonstrates the advantages of organ preservation strategies. The procedure can be technically challenging, but lethal complications are uncommon. Overall, outcomes are satisfactory, and patients achieved reasonable survival during the follow-up period.