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Objectives: Neoadjuvant therapy has been theorized to increase complexity of non–small cell lung cancer resections; however, specific factors that contribute to intraoperative challenges after induction therapy have not been well described. We aimed to characterize the effect of nodal involvement and nodal treatment response on surgical complexity after neoadjuvant therapy. Methods: We identified patients treated with neoadjuvant therapy followed by anatomic lung resection for cN + non–small cell lung cancer between 2010 and 2020. Patients were categorized according to clinical N1 versus N2 disease. To evaluate the effect of nodal response to therapy, thoracic radiologists measured clinically suspected and pathologically involved lymph nodes before and after induction therapy. Operative reports were reviewed to identify technical challenges specifically related to nodal disease. Categorical outcomes were compared using Fisher exact test. Results: One hundred twenty-four patients met inclusion criteria, among whom 107 (86.3%) were treated with neoadjuvant chemotherapy, whereas chemoradiation (n = 8) and targeted therapy (n = 9) were less common. In cases with N1 disease, 8/38 (21.0%) required proximal pulmonary arterial control, whereas this was necessary in only 2/88 (2.3%) of N2 cases (P = .001). Likewise, sleeve resection and arterioplasty were needed more frequently during resection of N1 disease (7/38, 18.4%) versus N2 disease (0/88, P

Introduction: Pulmonary resection has been established as an important component of local consolidative therapy (LCT) for oligometastatic NSCLC. However, technical aspects of such surgical procedures have not been well characterized. We sought to review the complexity of operations performed within a large cohort of patients with oligometastatic NSCLC. Methods: We identified patients treated at a single institution between 2000 and 2017 with stage IV NSCLC, with three or fewer synchronous metastases, and who underwent surgical resection of the primary tumor. Medical records were reviewed, and aspects of surgical complexity were recorded. Descriptive analyses were performed. Results: Among 194 patients with oligometastatic NSCLC, 173 (89%) received LCT and 30 (15%) underwent resection of the primary tumor. Thoracotomy was performed in 25 patients (83%), and procedures included 25 (83%) lobectomies, three (10%) pneumonectomies, and two (7%) sublobar resections. Mean blood loss was 200 (50–600) mL, and operative time was 200 (72–492) minutes. Proximal pulmonary artery control was needed in four (15%). Sleeve resection was needed in four (15%). Unplanned procedural change was required in two patients (7%). Chest wall resection occurred in three patients (11%). Lymph nodes were characterized as hard or densely adherent in nine (33%), and operations were described as more difficult than usual in 16 cases (59%). Conclusions: Surgery has emerged as a key strategy for LCT among patients with oligometastatic NSCLC. These operations can be performed safely, yet frequently require advanced techniques and complex resection strategies. As such, health care teams must be prepared for the technical challenges of these cases.