Abstract
Background: Centrally located non-small cell lung cancer (NSCLC) traditionally requires sleeve resection or pneumonectomy. We investigated whether neoadjuvant chemoimmunotherapy (NeoCIT) could enable conversion to standard lobectomy and evaluated an artificial intelligence (AI)-assisted pure-vision and hyperspectral imaging (HSI) system for intraoperative margin assessment. Methods: This multicenter cohort study enrolled patients from six tertiary referral centers in China between January 2019 and December 2025. The retrospective cohort (n = 56, January 2019–December 2024) and prospective exploratory cohort (n = 28, January–December 2025) included adults with histologically confirmed centrally located NSCLC, who were initially indicated for sleeve resection and received NeoCIT followed by surgical resection. Primary endpoints were event-free survival (EFS) and overall survival (OS), analyzed using Kaplan-Meier methods and multivariable Cox regression. The prospective cohort additionally underwent intraoperative bronchial margin assessment using an AI-assisted system combining HSI (600–950 nm and 16 spectral bands) with a multi-layer perceptron-based deep learning classifier for real-time pixel-wise tissue classification. Results: In the retrospective cohort, 57.1% of patients achieved major pathologic response (MPR) or pathologic complete response (pCR) and 71.4% of them transitioned from sleeve lobectomy to lobectomy. The postoperative complication rate was significantly lower in the lobectomy group (10.0%) compared to the sleeve lobectomy group (38.5%, P = 0.031). Two-year EFS was 69.9% for lobectomy versus 80.2% for sleeve resection (HR = 0.76, P = 0.665), with similar OS (84.0 vs. 90.9%, HR = 0.68, P = 0.713). Multivariable analysis identified pCR/MPR, age, Eastern Cooperative Oncology Group status, and pathological nodal stage after neoadjuvant therapy stage as independent prognostic factors. For the prospective cohort, the AI-assisted pure-vision and HSI system accurately assessed negative margins in real-time, showing high sensitivity (100%) and specificity (96.2%) compared to frozen-section pathology. Conclusion: NeoCIT safely enables surgical conversion from sleeve resection to lobectomy in centrally located NSCLC without compromising oncologic outcomes, and AI-assisted HSI provides accurate real-time intraoperative bronchial margin assessment.