{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T04:36:18Z","timestamp":1787027778467,"version":"build-2736575974"},"reference-count":35,"publisher":"MDPI AG","issue":"14","license":[{"start":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T00:00:00Z","timestamp":1784678400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Background: The integration of neoadjuvant and perioperative chemo-immunotherapy (CT-IO) has significantly reshaped the treatment of resectable non-small-cell lung cancer (NSCLC), improving pathological response and survival outcomes. However, its impact on surgical management\u2014particularly robotic-assisted thoracic surgery (RATS)\u2014remains incompletely defined. This review provides a practical overview of current evidence and technical considerations for robotic lung resection following neoadjuvant chemo-immunotherapy. Methods: A narrative review of the literature was performed, focusing on phase III trials, meta-analyses, and surgical series reporting perioperative, oncological, and technical outcomes of minimally invasive\u2014especially robotic\u2014approaches after neoadjuvant or perioperative chemo-immunotherapy. Results: Randomized trials have established CT-IO as a standard treatment option for selected patients with resectable stage II\u2013III NSCLC\u2014although the specific standard varies according to stage, molecular and PD-L1 status, and regulatory approval\u2014significantly improving pathological complete response and event-free survival. However, immune-related fibrosis, nodal scarring, and altered tissue planes increase surgical complexity and intra-postoperative complications. Available evidence, largely retrospective and derived from selected patient populations treated at experienced centers, suggest that RATS is feasible and safe, offering enhanced visualization and dexterity that may facilitate dissection in challenging post-induction settings. Vascular management and lymph node dissection remain critical technical aspects, and early conversion to open surgery, when required, should be regarded as an appropriate safety strategy rather than a complication. Conclusions: RATS after neoadjuvant chemo-immunotherapy appears feasible and promising in selected patients treated at experienced centers, but current evidence does not yet establish it as the preferred approach for all patients. Careful patient selection, adherence to oncological principles, and surgeon experience are essential. Prospective data are needed to define optimal surgical timing and standardize techniques.<\/jats:p>","DOI":"10.3390\/cancers18142365","type":"journal-article","created":{"date-parts":[[2026,7,23]],"date-time":"2026-07-23T01:01:28Z","timestamp":1784768488000},"page":"2365","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Robotic Thoracic Surgery After Neoadjuvant Chemo-Immunotherapy for NSCLC: A Narrative Review"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5986-7811","authenticated-orcid":false,"given":"Monica","family":"Casiraghi","sequence":"first","affiliation":[{"name":"Department of Thoracic Surgery, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy"},{"name":"Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5330-5495","authenticated-orcid":false,"given":"Antonio","family":"Mazzella","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9219-6877","authenticated-orcid":false,"given":"Lara","family":"Girelli","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2629-7781","authenticated-orcid":false,"given":"Giorgio","family":"Lo Iacono","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1153-3334","authenticated-orcid":false,"given":"Luca","family":"Bertolaccini","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy"},{"name":"Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matteo","family":"Chiari","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni","family":"Caffarena","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Claudia","family":"Bardoni","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lorenzo","family":"Spaggiari","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, European Institute of Oncology (IEO) IRCCS, 20141 Milan, Italy"},{"name":"Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1973","DOI":"10.1056\/NEJMoa2202170","article-title":"Neoadjuvant nivolumab plus chemotherapy in resectable lung cancer","volume":"386","author":"Forde","year":"2022","journal-title":"N. Engl. J. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"491","DOI":"10.1056\/NEJMoa2302983","article-title":"Perioperative pembrolizumab for early-stage non-small-cell lung cancer","volume":"389","author":"Wakelee","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1240","DOI":"10.1016\/S0140-6736(24)01756-2","article-title":"Neoadjuvant pembrolizumab plus chemotherapy followed by adjuvant pembrolizumab compared with neoadjuvant chemotherapy alone in patients with early-stage non-small-cell lung cancer (KEYNOTE-671): A randomised, double-blind, placebo-controlled, phase 3 trial","volume":"404","author":"Spicer","year":"2024","journal-title":"Lancet"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1756","DOI":"10.1056\/NEJMoa2311926","article-title":"Perioperative nivolumab in resectable lung cancer","volume":"390","author":"Cascone","year":"2024","journal-title":"N. Engl. J. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"741","DOI":"10.1056\/NEJMoa2502931","article-title":"Overall survival with neoadjuvant nivolumab plus chemotherapy in lung cancer","volume":"393","author":"Forde","year":"2025","journal-title":"N. Engl. J. Med."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1001\/jama.2023.24735","article-title":"Perioperative toripalimab plus chemotherapy for patients with resectable non-small cell lung cancer: The Neotorch randomized clinical trial","volume":"331","author":"Lu","year":"2024","journal-title":"JAMA"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1672","DOI":"10.1056\/NEJMoa2304875","article-title":"AEGEAN Investigators. Perioperative durvalumab for resectable non-small-cell lung cancer","volume":"389","author":"Heymach","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1016\/S2213-2600(24)00269-8","article-title":"RATIONALE-315 investigators. Perioperative tislelizumab plus neoadjuvant chemotherapy for patients with resectable non-small-cell lung cancer (RATIONALE-315): An interim analysis of a randomised clinical trial","volume":"13","author":"Yue","year":"2025","journal-title":"Lancet Respir. Med."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"504","DOI":"10.1056\/NEJMoa2215530","article-title":"Perioperative nivolumab and chemotherapy in stage III non-small-cell lung cancer (NADIM II)","volume":"389","author":"Provencio","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"8045","DOI":"10.1200\/JCO.2024.42.16_suppl.8045","article-title":"Neoadjuvant and perioperative immunotherapy in resectable non-small cell lung cancer (NSCLC): A systematic review and extracted individual patient data meta-analysis","volume":"42","author":"Sperandio","year":"2024","journal-title":"J. Clin. Oncol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1016\/j.jtcvs.2018.11.124","article-title":"Initial results of pulmonary resection after neoadjuvant nivolumab in patients with resectable non-small cell lung cancer","volume":"158","author":"Bott","year":"2019","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1327","DOI":"10.1016\/j.jtcvs.2022.01.019","article-title":"Surgical outcomes after neoadjuvant nivolumab or nivolumab with ipilimumab in patients with non-small cell lung cancer","volume":"164","author":"Sepesi","year":"2022","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Pohlman, A., Marten, A., Coughlin, J.M., Lubawski, J., Raad, W., and Abdelsattar, Z.M. (Ann. Thorac. Surg., 2026). Impact of neoadjuvant therapy, tumor size, and surgical approach on conversion to open thoracotomy during lobectomy, Ann. Thorac. Surg., in press.","DOI":"10.1016\/j.athoracsur.2026.03.046"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Magouliotis, D.E., Androutsopoulou, V., Cioffi, U., Brecher, V., Xanthopoulos, A., Minervini, F., and Scarci, M. (2026). Robotic-assisted thoracic surgery in the immunotherapy era: Navigating altered anatomy, oncologic precision, and the future of integrated platforms. J. Clin. Med., 15.","DOI":"10.3390\/jcm15124485"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1007\/s11701-026-03364-y","article-title":"Robotic-assisted versus video-assisted thoracoscopic surgery for non-small cell lung cancer after neoadjuvant immunotherapy: A systematic review and meta-analysis","volume":"20","author":"Barbosa","year":"2026","journal-title":"J. Robot. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e501","DOI":"10.1016\/S1470-2045(21)00383-1","article-title":"Revisiting neoadjuvant therapy in non-small-cell lung cancer","volume":"22","author":"Saw","year":"2021","journal-title":"Lancet Oncol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1803","DOI":"10.1016\/j.jtcvs.2025.07.030","article-title":"Minimally invasive resection of non-small cell lung cancer after chemoimmunotherapy\u2014A multicenter study in academic hospitals","volume":"170","author":"Kneuertz","year":"2025","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Gao, Y., Jiang, J., Xiao, D., Zhou, Y., Chen, Y., Yang, H., Wang, L., Zeng, J., He, B., and He, R. (2022). Robotic-assisted thoracic surgery following neoadjuvant chemoimmunotherapy in patients with stage III non-small cell lung cancer: A real-world prospective cohort study. Front. Oncol., 12.","DOI":"10.3389\/fonc.2022.969545"},{"key":"ref_19","doi-asserted-by":"crossref","unstructured":"Zhang, B., Xiao, Q., Xiao, H., Wu, J., Yang, D., Tang, J., Li, X., Wu, Z., Zhou, Y., and Wang, W. (2022). Perioperative outcomes of video-assisted thoracoscopic surgery versus open thoracotomy after neoadjuvant chemoimmunotherapy in resectable NSCLC. Front. Oncol., 12.","DOI":"10.3389\/fonc.2022.858189"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e600","DOI":"10.1097\/SLA.0000000000005233","article-title":"Radical Minimally Invasive Surgery After Immuno-chemotherapy in Initially-unresectable Stage IIIB Non-small cell Lung Cancer","volume":"275","author":"Deng","year":"2022","journal-title":"Ann. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Zeng, J., Yi, B., Chang, R., Chen, Y., Yu, Z., and Gao, Y. (2023). Safety and feasibility of robotic-assisted thoracic surgery after neoadjuvant chemoimmunotherapy in non-small cell lung cancer. Front. Oncol., 13.","DOI":"10.3389\/fonc.2023.1134713"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Pan, H., Zou, N., Tian, Y., Zhu, H., Zhang, J., Jin, W., Gu, Z., Ning, J., Li, Z., and Kong, W. (2023). Short-term outcomes of robot-assisted versus video-assisted thoracoscopic surgery for non-small cell lung cancer patients with neoadjuvant immunochemotherapy: A single-center retrospective study. Front. Immunol., 14.","DOI":"10.3389\/fimmu.2023.1228451"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"110022","DOI":"10.1016\/j.ejso.2025.110022","article-title":"Advantages of robotic-assisted thoracic surgery after neoadjuvant therapy in NSCLC: A propensity score-matched analysis","volume":"51","author":"Li","year":"2025","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1184","DOI":"10.1016\/j.athoracsur.2025.12.003","article-title":"Perioperative outcomes of robotic versus video-assisted thoracoscopic surgery in non-small cell lung cancer after neoadjuvant therapy","volume":"121","author":"Li","year":"2025","journal-title":"Ann. Thorac. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"109458","DOI":"10.1016\/j.surg.2025.109458","article-title":"Minimally invasive surgery could be attempted with preoperatively predictable difficulty for non-small cell lung cancer after neoadjuvant immunochemotherapy: A large multicenter study","volume":"184","author":"Pan","year":"2025","journal-title":"Surgery"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"111805","DOI":"10.1016\/j.ejso.2026.111805","article-title":"Surgical outcomes after neoadjuvant chemoimmunotherapy for resectable NSCLC: A systematic review and meta-analysis","volume":"52","author":"Bertoglio","year":"2026","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"395","DOI":"10.1016\/j.cllc.2024.03.008","article-title":"Video-assisted thoracoscopic surgery versus thoracotomy following neoadjuvant immunochemotherapy in resectable stage III non-small cell lung cancer among Chinese populations: A multi-center retrospective cohort study","volume":"25","author":"Pan","year":"2024","journal-title":"Clin. Lung Cancer"},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Bardoni, C., Chiari, M., Bertolaccini, L., Diotti, C., De Fabiani, A., Nicolosi, G., Mazzella, A., Casiraghi, M., and Spaggiari, L. (2025). Surgical outcomes after neoadjuvant chemo-immunotherapy for stage III NSCLC: A systematic review and meta-analysis. Cancers, 17.","DOI":"10.3390\/cancers17091426"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"9364","DOI":"10.21037\/jtd-2025-1376","article-title":"Influence of neoadjuvant immunotherapy on surgical approaches in non-small cell lung cancer: Insights from a Chinese expert questionnaire survey on contemporary practices","volume":"17","author":"Wu","year":"2025","journal-title":"J. Thorac. Dis."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"985","DOI":"10.1002\/ijc.70473","article-title":"Effect of interval between neoadjuvant immunochemotherapy and radical resection of non-small cell lung cancer: A multicenter, retrospective cohort study","volume":"159","author":"Wang","year":"2026","journal-title":"Int. J. Cancer"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"5045","DOI":"10.1038\/s41467-021-25188-0","article-title":"Nodal immune flare mimics nodal disease progression following neoadjuvant immune checkpoint inhibitors in non-small cell lung cancer","volume":"12","author":"Cascone","year":"2021","journal-title":"Nat. Commun."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Trabalza Marinucci, B., Mancini, M., Siciliani, A., Messa, F., Piccioni, G., D\u2019andrilli, A., Maurizi, G., Ciccone, A.M., Menna, C., and Vanni, C. (2025). Surgical techniques for non-small-cell lung cancer after neoadjuvant chemo-immunotherapy: State of art and review of the literature. Cancers, 17.","DOI":"10.3390\/cancers17040638"},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Ohara, S., Suda, K., and Tsutani, Y. (2025). Utility and future perspectives of circulating tumor DNA analysis in non-small cell lung cancer patients in the era of perioperative chemo-immunotherapy. Cells, 14.","DOI":"10.20944\/preprints202507.2581.v1"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Chen, H., Fan, B., Yuan, M., Wang, D., Qiao, C., Qiu, N., Quan, X., and Hou, W. (2026). CT-based radiomics in predicting the efficacy of preoperative neoadjuvant chemoimmunotherapy for non-small cell lung cancer: A systematic review and meta-analysis. Front. Immunol., 17.","DOI":"10.3389\/fimmu.2026.1753166"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"103551","DOI":"10.1016\/j.eclinm.2025.103551","article-title":"AI-derived longitudinal and multi-dimensional CT classifier for non-small cell lung cancer to optimize neoadjuvant chemoimmunotherapy decision: A multicentre retrospective study","volume":"89","author":"Ye","year":"2025","journal-title":"eClinicalMedicine"}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/18\/14\/2365\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T04:33:38Z","timestamp":1784867618000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/18\/14\/2365"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,22]]},"references-count":35,"journal-issue":{"issue":"14","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["cancers18142365"],"URL":"https:\/\/doi.org\/10.3390\/cancers18142365","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,22]]}}}