Surgery for NSCLC: Multidisciplinary Panel Discusses Operative Considerations

At the 2025 American Society of Clinical Oncology (ASCO) Annual Meeting, a panel of multidisciplinary experts convened to discuss non–small cell lung cancer (NSCLC).

Moderated by Balazs Halmos, MD, of the Montefiore Einstein Comprehensive Cancer Center, the roundtable featured perspectives from Jay Lee, MD, of the University of California, Los Angeles (UCLA), Mary Pasquinelli, DNP, APRN, FNP-BC, of the University of Illinois Chicago (UIC), and Momen Wahidi, MD, MBA, of Northwestern Medicine.

In the seventh segment of this roundtable discussion, the panel discusses how multidisciplinary teams help prepare patients with NSCLC to undergo surgery, and how they ensure patients are in optimal health for surgery through efforts such as pulmonary rehabilitation and smoking cessation. They also discuss how thoracic surgeons assess medical operability and resectability.

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Dr. Halmos: We want the surgery to go well. So, in the presurgical period, is there anything that the team can do to get the patient into the best possible shape in terms of pulmonary rehab? Any other thoughts, comments?

Dr. Wahidi: Optimizing management, we sometimes find these patients are not optimized—from an inhaler regimen; some of them, they might be in a COPD flare, infection, or chronic infection—so, this is where we can try to optimize them medically.

Some of them may not have had a lot of medical attention prior to the lung cancer diagnosis, so this is where we step in and optimize them. Again, pulmonary rehab is a great option. It does take time, but even if we initiate treatment and the patient can start, it’s always helpful.  But it’s certainly a multidisciplinary [effort] and some patients may need oxygen. It’s a lot of effort, but we want to get them to you optimized so that you can operate on them, you can give them the IO, and hopefully they’ll tolerate it.

Dr. Pasquinelli: You mentioned smoking cessation before. I’m a certified tobacco treatment specialist, and we incorporate smoking cessation throughout the whole care journey, no matter where they are. We start this early, we get them on medications, and then we continue to follow them.

Any patient I put on varenicline or combination nicotine replacement, I will be reaching out to that patient, because we know that smoking cessation not only is better for surgery, but it also improves survival and has less side effects. People have less side effects if they quit smoking, even after a diagnosis of lung cancer, so we try to work with our patients as much as we possibly can to quit smoking.

Dr. Halmos: Fantastic. Maybe I can ask you, Jay—we spoke about how to optimize the patient for the surgery—but we also need to reassess the tumor as to how it responded to the neoadjuvant treatment. How do you see the role of imaging in that space? There’s a bit of confusion as to pseudo-progression, things of that nature. What do you do in your practice to make sure that you’re taking patients to the OR [operating room] who you can resect?

Dr. Lee: Yes. I think most of us are just repeating a PET CT scan. It’s not unusual to not see a dramatic response—but yet, pathologically, there may be a significant response—because it’s a very short interval between completion of the neoadjuvant chemo IO then [being] reimaged, because we’re in a rush to get that patient to surgery. We don’t necessarily have a long interval from the IO to assess a response.

There have been exploratory analyses for PET CTs and how they do not necessarily show a significant response. The other flipside is that, as you pointed out, there can be nodal reactive lymph nodes and it can be anywhere in the body, so it’s important to [assess] tissue [to] pathologically confirm that it is a distant metastasis.

I think surgeons sometimes get fooled, where a higher lymph node may light up or a mediastinal lymph node lights up, and that doesn’t necessarily mean that the patient progressed. It just may be reactive lymphadenopathy. It’s important to do restaging—not necessarily routine restaging of lymph nodes, but if it’s clinically, radiographically abnormal—to confirm that it’s a metastasis.

Dr. Halmos: Momen, I presume that’s your job again.

Dr. Wahidi: Yes, and that’s an area of research interest for us. As Jay mentioned, we see—not infrequently—that patients getting IO can have reactive lymph nodes, granulomatous inflammation, and then you do a PET for restaging, these lymph nodes light up.

I think it’s important then, in those instances, to do a bronchoscopy, do an endobronchial ultrasound, sample those lymph nodes, because the intervention down the road or the treatment will be different.

If this is a reactive lymph node, great, we’re all happy, the patient’s happy. But if it’s cancer spread, then I think for you guys—for the medical oncologists—that then changes the game and maybe then takes them out of the surgery if they haven’t had surgery.

I think this is an important area that we’re stressing: Don’t presume they’re cancer right away because we’ve seen a lot of IO-related reactivity in the lymph nodes.

Dr. Halmos: Absolutely. So now, let’s imagine that the patient has successfully made it to your operating room. You have to make some big decisions in the OR [operating room]: margin, status, things of that nature. How do you come up with the optimal decisions for the borderline-resectable patient?

Dr. Lee: To me, the patient had to have resectable disease, and I had to be confident that I could do a sleeve resection if the patient couldn’t tolerate a pneumonectomy. But if they needed a pneumonectomy from the beginning and they can’t tolerate a pneumonectomy, I’m not going to offer that patient an operation because I’m hoping that we’re going to get the response that we want. If you don’t and you’re still left with pneumonectomy, I think that’s a scenario that we want to avoid. To me, they had to be operable and resectable to begin with.

Achieving margin negativity is a very sensitive subject for the surgeon. It’s taken very personally. We want to achieve margin negativity. But having said that, the next-generation phase 3 trials in the space are including R1 and R-uncertain patients, because as our systemic therapies improve, some of this may be cleaned up by the systemic therapies. Then, the role of post-operative radiation for margin positivity is what our standard has been. I think achieving margin negativity is good, and we try to do that. I think we’re doing a lot more sleeve resections to avoid a pneumonectomy. But yes, all of those are still important factors.

Dr. Wahidi: I have a follow-up question for you, Jay. There’s emerging evidence and interest that maybe segmentectomy is as good as lobectomy and more of a lung-sparing surgery for stage I cancer. What is your take on this? Are you in your practice trying to do more segmentectomy than lobectomy?

Dr. Lee: Yes. So, in the treatment-naive patients, less than 2 centimeters, we’ve had two phase 3 surgical trials, 11 from Japan, and then one from CALGB in the US. So, [when it’s] peripheral less than 2 centimeters, we try to, but it’s much more complicated than that because of the high-risk features, and in this era, what about the ctDNA, MRD-positive patients? Should they have gotten a segmentectomy? And maybe it doesn’t matter because it’s a systemic problem, rather than a local one.

The patients with high-risk features like visceral pleural invasion, LVI [lymphovascular invasion], STAS [spread through air spaces], and all these other high-risk [features], poorly differentiated [types]—all these factors play in whether it’s appropriate to do a sublobar resection.

In the era of chemo-IO, neoadjuvant chemo-IO, do we need to resect to the extent that you started with? Going back to: Can we do a segmentectomy or sublobar resection post-chemo-IO because it’s a smaller tumor and get away with that? Is that survival the same? Or are we going to be missing intranodal lymph nodes that needed to come out? It’s a surgical question that is up for future trials. As your systemic therapies improve, we do need to alter our extent of resection.

Dr. Halmos: Absolutely. We want the best outcome, not just curing our patients, but making sure that they can have highly functioning lives.