Perioperative Immunotherapy Has Moved Into the Operating Room
Perioperative immune checkpoint inhibitors have moved well beyond the metastatic setting and now sit inside treatment pathways for several solid tumors, where they may be given before surgery, after surgery, or across both phases. The therapeutic logic is straightforward: amplify antitumor immunity early enough to shrink viable disease, improve pathological response, and reduce the risk of recurrence. The clinical consequence is more complicated. The same immune activation that improves tumor control can trigger organ toxicities that resemble postoperative complications, making the boundaries between cancer treatment, anesthesia, and surgical recovery far less distinct than they once were.
This scoping review mapped the current evidence across adult patients with solid tumors treated with ICIs in relation to surgery. Thirty-three studies formed the evidence base, spanning surgical feasibility, perioperative safety, immune-related adverse events, anesthetic considerations, and oncological outcomes. The review draws a picture of a field that is already influencing real-world care, even though much of the perioperative workflow still relies on extrapolation rather than direct comparative trials.
Non-Small-Cell Lung Cancer Carries the Strongest Perioperative Signal
The most mature evidence comes from resectable non-small-cell lung cancer. In that setting, neoadjuvant or perioperative ICI-based regimens improved pathological response and, in several trials, event-free or overall survival. The biological explanation is compelling. By releasing immune inhibition before resection, these regimens can eliminate micrometastatic disease and attack residual tumor at a time when the intact tumor may still provide abundant antigenic stimulation. When pathological response improves, survival often follows, because the surgery is no longer removing the full burden of resistant disease alone.
Evidence from other tumor types widened the signal but also exposed variability. Triple-negative breast cancer, bladder cancer, gastric or gastroesophageal junction cancer, and ovarian cancer all appeared in the review, yet the efficacy pattern was heterogeneous across tumor types and treatment regimens. Some cancers seem more immunologically responsive than others, and the perioperative setting may magnify those differences by making response dependent not only on drug biology, but also on the pace of surgery, recovery, and subsequent adjuvant treatment delivery.
One result stood out plainly: surgery after ICI exposure was generally feasible.
Surgical Feasibility Does Not Eliminate Toxicity Risk
Across the included studies, there was no consistent increase in postoperative mortality. That finding matters because it argues against an assumption that checkpoint blockade automatically makes surgery unsafe. Instead, the review supports a narrower conclusion: most patients can proceed to surgery after ICI exposure, provided clinicians recognize the toxicity patterns that can complicate perioperative assessment.
Those toxicities are clinically important because they can masquerade as ordinary postoperative events. Pneumonitis may look like postoperative hypoxia or infection. Myocarditis can present with hemodynamic instability, arrhythmia, or unexplained troponin elevation. Endocrinopathies may distort recovery through adrenal insufficiency, thyroid dysfunction, or glycemic instability. Hepatitis and colitis can be mistaken for drug injury, ischemia, antibiotic effects, or routine postoperative gastrointestinal dysfunction. Cytokine release syndrome adds another layer of confusion because it can imitate sepsis or systemic inflammatory response after surgery.
For teams caring for these patients, the practical challenge is not simply whether the operation can proceed. It is whether the postoperative change in vital signs, laboratory results, or organ function reflects expected recovery or evolving immune toxicity. In that context, the review argues for structured preoperative screening and close postoperative surveillance rather than a one-size-fits-all waiting period.
Anesthesia and Corticosteroids Need More Deliberate Planning
Direct evidence comparing anesthetic or perioperative management strategies remained scarce. That gap leaves anesthesiologists and surgeons with an uncomfortable reality: the patient population is expanding faster than the procedural evidence base. There is no uniform rule for airway management, fluid strategy, monitoring intensity, or timing of surgery after treatment exposure, because the literature has not yet produced standardized comparisons.
Corticosteroid decision-making is especially complex. Steroids may be necessary to treat suspected immune-related toxicity, but they can also blunt antitumor immune activity and complicate the interpretation of laboratory and clinical responses. The review does not resolve that tension, and no responsible synthesis should pretend otherwise. What it does support is individualized management based on organ-specific risk, symptom burden, and the urgency of the operation.
Preoperative screening should therefore focus on the toxicities most likely to destabilize perioperative care. A history of dyspnea, chest pain, fatigue, diarrhea, endocrine symptoms, or prior immune toxicity should not be treated as background noise. Those features can change surgical timing, perioperative monitoring, and even the threshold for postponing the procedure until organ function is clarified.
The Evidence Base Is Strongest on Oncology, Weaker on Perioperative Workflow
The review makes clear where the field is advancing fastest and where it is still thin. On the oncologic side, the signal is strongest in resectable lung cancer and encouraging in several other tumor types. On the perioperative side, evidence remains fragmented. Few studies were designed to test anesthesia-specific variables, postoperative monitoring protocols, or standardized toxicity pathways. Fewer still linked short-term surgical outcomes to long-term cancer control in a way that could guide team-based practice.
This imbalance has direct implications. Hospitals are already seeing more patients who arrive for surgery after exposure to checkpoint blockade, yet many operative pathways were built around cytotoxic chemotherapy, radiation, or surgery alone. The immune-toxicology profile of these drugs does not map neatly onto older perioperative templates. A patient with occult myocarditis or adrenal insufficiency can deteriorate quickly if the team assumes routine postoperative fatigue, pain, or fluid shifts are the only issue.
The review also places emphasis on multidisciplinary communication. Surgeons, oncologists, anesthesiologists, pathologists, and postoperative teams need the same treatment history and a shared plan for interpreting abnormal findings. Without that coordination, the first sign of immune toxicity may be a delayed response to a complication that should have been recognized earlier.
Standardized Endpoints Will Decide Whether the Field Can Mature
The review closes with a clear research agenda. Future prospective studies need standardized perioperative endpoints, anesthesia-related variables, biomarker-driven risk stratification, and long-term oncological outcomes. Those elements are not academic luxuries. They are the only way to determine which patients benefit from perioperative immunotherapy, how soon surgery can safely follow treatment, and which toxicities require surveillance beyond routine postoperative checks.
Until then, the clinical message is measured but unmistakable. Perioperative immune checkpoint inhibitor therapy is no longer experimental in spirit, yet safe implementation depends on more than just oncologic enthusiasm. It requires preoperative screening, individualized surgical timing, toxicity surveillance by organ system, careful use of corticosteroids, and active communication across the teams that now share responsibility for these patients.