CT imaging biomarkers after neoadjuvant immunotherapy in resectable non-small cell lung cancer: from response assessment to surgical decision-making.

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Abstract

Neoadjuvant immune checkpoint blockade, usually combined with platinum-based chemotherapy, has improved pathologic response and event-free survival in patients with resectable non-small cell lung cancer (NSCLC). Preoperative assessment remains difficult, however, because radiographic change does not directly represent the amount of residual viable tumor. Immune-cell infiltration, edema, necrosis, granulomatous nodal reactions, and reparative fibrosis may preserve tumor size despite major or complete pathologic response, whereas small viable tumor nests may remain within an apparently fibrotic bed. This Mini Review examines computed tomography (CT) biomarkers after neoadjuvant immunotherapy, focusing on conventional and dual-energy CT, radiomics, delta-radiomics, and deep-learning models. Size-based response criteria are reproducible but insufficient for tissue characterization. Selected, predominantly retrospective studies suggest that temporal models can add information, but transportability and clinical utility remain uncertain. We distinguish four intended uses: pathologic-response prediction, nodal restaging, technical resectability and operative-complexity assessment, and prognosis. Conventional CT informs anatomy and complication assessment; quantitative response models remain investigational. Suspicious new or enlarging nodes warrant tissue confirmation when the result would alter curative surgery. A structured reporting checklist links imaging uncertainty to multidisciplinary action. Imaging biomarkers should complement clinical, pathologic, and molecular data and should not currently be used to omit surgery.

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