Surgery after chemo and immunotherapy
for lung cancer

MDT stands for Multidisciplinary Team. It is a meeting where specialists from different fields discuss your case together before agreeing on a treatment plan.

For lung cancer, the MDT includes thoracic surgeons, medical oncologists (who give chemotherapy and immunotherapy), clinical oncologists (who specialise in radiotherapy), thoracic radiologists (who read the scans), pulmonologists (lung specialists), and pathologists (who analyse tissue samples).

Your scans, biopsy results, and biomarker tests are reviewed together. The team then agrees on the best treatment sequence for your cancer.

Dr Okiror is one of the thoracic surgeons at the London Bridge Hospital lung cancer MDT. Every private patient under his care is discussed at this meeting. No treatment plan is made by a single doctor.

The operation is planned before treatment starts, against the size and position of the tumour at diagnosis. It is reassessed on the restaging scan. Where the tumour and lymph nodes have shrunk, the operation can often be smaller than first planned: a pneumonectomy (removing the whole lung) can become a sleeve resection or a lobectomy.

A lobectomy removes one lobe of the lung and is the most common operation after chemoimmunotherapy. A sleeve resection removes the lobe together with a short section of the main airway, which is then rejoined, so that the rest of the lung is kept. A pneumonectomy removes the whole lung and is reserved for tumours that cannot be cleared any other way.

Patients are sometimes told to prepare for the whole lung to be removed. The final decision is made on the restaging scan, and sometimes during the operation itself once the airway and blood vessels can be seen directly. Dr Okiror explains before surgery which operation is planned and which alternatives may be possible on the day.

Usually, yes. A clear scan and a clear specimen are different findings. After treatment, the scan often shows only scar tissue where the tumour was. Scar tissue can still contain living cancer cells, and the scan cannot tell the two apart. The operation removes that area, and the pathologist then examines it.

Where the specimen contains no living cancer cells, this is called a complete pathological response. It is the most favourable result the treatment can produce, and it can only be confirmed by removing the tissue. Where cancer cells remain, the result guides the treatment given after surgery.

Whether to operate after a complete response on the scan is decided at the multidisciplinary meeting for each patient, with the reasons explained to you.

The multidisciplinary team reviews the restaging scans and decides the next step. A tumour that is the same size, with no new disease anywhere else, can often still be removed, and many of these patients go on to surgery as planned. The scan size does not always reflect how much of the tumour has died.

Where the tumour has grown, or new disease has appeared, the plan changes. That may mean radiotherapy, a different drug treatment, or both. The reasons are explained to you at the consultation.

If you have been told after treatment that surgery is not an option, the reasons given and which of them can change are set out on the page told surgery is not an option. Where the cancer has spread to one place outside the chest, treatment with chemotherapy and immunotherapy followed by surgery is sometimes still used: see stage 4 lung cancer with a single site of spread.

Surgery after chemoimmunotherapy is more demanding than surgery on an untreated tumour. The treatment causes inflammation and scarring inside the chest, called fibrosis, which makes the tissues stick together.

In a straightforward case, a surgeon dissects along clean planes between anatomical structures. After chemoimmunotherapy, these planes may be obliterated. Many centres respond by switching to open thoracotomy, a much larger operation that spreads the ribs apart.

By this point you have spent months on chemotherapy and immunotherapy and are less able to tolerate a large open operation. Keyhole surgery, when it can be done, shortens hospital stay, reduces pain and gets you home faster.

Dr Okiror operates at a high-volume robotic centre where these cases are common. The magnified 3D vision and wristed instruments of the robotic platform are designed for this kind of precise dissection through scarred tissue.

Most patients who come to Dr Okiror for surgery after chemoimmunotherapy have keyhole surgery. A minority require conversion to open surgery during the operation if the anatomy is too distorted to continue safely. This decision is always made in the interests of safe cancer clearance.

For patients whose tumour tests positive for an EGFR mutation or ALK rearrangement, the treatment pathway is different.

Chemoimmunotherapy is generally avoided for these patients because the international trial data shows less benefit than for other types of lung cancer. Instead, surgery is usually the first step, followed by targeted therapy given as tablets.

For EGFR-positive patients, the tablet is called osimertinib, taken once daily for three years after surgery. The ADAURA trial, a large international study, showed that this approach achieved 5-year survival of 85% compared to 73% with placebo. That is a 51% reduction in risk of death.

A more recent phase 3 trial called NeoADAURA, presented at ASCO 2025 and published in the Journal of Clinical Oncology, tested giving osimertinib before surgery, either alone or combined with chemotherapy. It showed significantly higher rates of tumour shrinkage at the time of surgery compared to chemotherapy alone. This suggests that in future, some EGFR-positive patients may be offered osimertinib as part of the pre-surgery plan, not only after surgery. However, at the time of writing, neoadjuvant osimertinib is not licensed in the UK and has not been appraised by NICE for pre-surgery use. The established UK pathway therefore remains surgery followed by three years of adjuvant osimertinib. Dr Okiror will discuss what is available to you as part of the MDT plan.

For ALK-positive patients, similar targeted therapy approaches are being established. Your oncologist will discuss the current options.

• →Your CT and PET-CT scans (on CD, USB, or via image transfer)
• →The pathology report from your biopsy
• →Biomarker test results (EGFR, ALK, PD-L1) if available
• →Any letters or treatment recommendations already received
• →A list of current medications and medical conditions
• →A family member or friend if you wish; two sets of ears help

A note on insurance: Multi-modality treatment involves several components and hospital stays. Some insurance policies require prior authorisation for specialist cancer treatments. Patients are advised to check with their private medical insurer early in the pathway. Self-pay options are available for all elements of treatment; Jo Mitchelson can provide an estimate on request.

You can see Dr Okiror at either London Bridge Hospital or The Lister Hospital in Chelsea, whichever is more convenient.

For most lung cancer surgery, either hospital works well.

For more complex cases, for instance surgery forming part of multi-modality treatment, Dr Okiror will usually recommend London Bridge Hospital, which has more experience with complex thoracic surgery and the full support these operations need.

If you prefer, you can have your consultation and follow-up at The Lister, and surgery at LBH. Dr Okiror will make the recommendation that matches your case.