Table 7 Advantages and disadvantages of neoadjuvant immunotherapy

⦁ Completion of more systemic therapy before surgery than after surgery

⦁ Early elimination of micrometastasis and prevention of tumor recurrence

⦁ Increase in R0 resection rate

⦁ Downstage of tumor (i.e., Decrease in the TNM stage)

⦁ Assessment of the in vivo effect of systemic therapy (i.e., sensitivity or resistance) by radiographic and pathological evaluations when the tumor is intact

⦁ Understanding of the resistance mechanism(s) for residual tumor and select potential adjuvant therapy

⦁ Immune modulation leading to antigen priming and counteracting immunosuppressive effect of surgery

⦁ Shorter time of ICI treatment compared to adjuvant ICI therapy

⦁ More time for physical and psychological preparation for surgery (i.e., control comorbidities) and smoking cessation

⦁ Requirement of a timely multidisciplinary collaboration of patient care

⦁ Risk of tumor progression during neoadjuvant treatment

⦁ Toxicities, including bone marrow suppression and immune mediated adverse effects, might delay to curative surgery

⦁ Increased technical difficulty and risks with the operation due to various degrees of fibrosis at the trachea and pulmonary vasculature

⦁ Prognostic significance of MPR not well established

⦁ Lack of validated predictive biomarkers to select the patients for neoadjuvant ICIs

⦁ Lack of validated predictive biomarker to predict the success of surgery (i.e., hyper-progression induced by immunotherapy)