Response to neoadjuvant immune checkpoint inhibitors and chemotherapy in Chinese patients with esophageal squamous cell carcinoma: the role of tumor immune microenvironment

Outcomes of neoadjuvant immunochemotherapy and neoadjuvant chemoradiotherapy in patients with locally advanced esophageal squamous cell carcinoma

BACKGROUND

Esophageal squamous carcinoma is a prevalent cancer worldwide, particularly in China. Few studies have compared the treatment effects of neoadjuvant immunochemotherapy and neoadjuvant chemoradiotherapy on the long-term prognosis of patients with esophageal squamous carcinoma. This study analyzed the 3-year overall survival rate of patients with locally advanced esophageal squamous carcinoma treated with esophagectomy after neoadjuvant immunochemotherapy or neoadjuvant chemoradiotherapy.

METHODS

A total of 309 patients with esophageal squamous carcinoma who underwent neoadjuvant chemoradiotherapy between 2010 and 2020 and 88 who underwent neoadjuvant immunochemotherapy between 2019 and 2020 at Zhejiang Cancer Hospital were included in this study. Propensity score matching with a 1:1 ratio and a caliper of 0.02 was used to balance the baseline characteristics.

RESULTS

The study included 397 patients with locally advanced thoracic segmental esophageal squamous carcinoma, including 88 who received neoadjuvant immunochemotherapy and 309 who received neoadjuvant chemoradiotherapy. After propensity score matching, there were no significant differences in pathologic complete response between the 2 groups (21.3% vs 33.3%, χ2 = 2.148, P = .143), and the neoadjuvant immunochemotherapy group demonstrated a greater 3-year overall survival rate (73.8% vs 54.8%, P = .003), particularly for patients with a primary stage Ⅲ diagnosis (T3N1M0, T1-3N2M0) or an initial suspicion of lymph node metastases. Pathologic complete response emerged as a reliable predictor of long-term outcomes in patients receiving neoadjuvant chemoradiotherapy, but not in those receiving neoadjuvant immunochemotherapy.

CONCLUSION

Neoadjuvant immunochemotherapy was associated with improved long-term prognosis in patients with a primary stage Ⅲ diagnosis or an initial suspicion of lymph node metastases. Neoadjuvant immunochemotherapy plus surgery emerged as an effective therapeutic strategy for treating locally advanced thoracic segmental esophageal squamous carcinoma.

A preoperative predictive model based on multi-modal features to predict pathological complete response after neoadjuvant chemoimmunotherapy in esophageal cancer patients

Background

This study aimed to develop a multi-modality model by incorporating pretreatment computed tomography (CT) radiomics and pathomics features along with clinical variables to predict pathologic complete response (pCR) to neoadjuvant chemoimmunotherapy in patients with locally advanced esophageal cancer (EC).

Method

A total of 223 EC patients who underwent neoadjuvant chemoimmunotherapy followed by surgical intervention between August 2021 and December 2023 were included in this study. Radiomics features were extracted from contrast-enhanced CT images using PyrRadiomics, while pathomics features were derived from whole-slide images (WSIs) of pathological specimens using a fine-tuned deep learning model (ResNet-50). After feature selection, three single-modality prediction models and a combined multi-modality model integrating two radiomics features, 11 pathomics features, and two clinicopathological features were constructed using the support vector machine (SVM) algorithm. The performance of the models were evaluated using receiver operating characteristic (ROC) analysis, calibration plots, and decision curve analysis (DCA). Shapley values were also utilized to explain the prediction model.

Results

The predictive capability of the multi-modality model in predicting pCR yielded an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.75-1.00), outperforming the radiomics model (AUC 0.70 [95% CI 0.54-0.85]), pathomics model (AUC 0.77 [95% CI 0.53-1.00]), and clinical model (AUC 0.63 [95% CI 0.46-0.80]). Additionally, both the calibration plot and DCA curves support the clinical utility of the integrated multi-modality model.

Conclusions

The combined multi-modality model we propose can better predict the pCR status of esophageal cancer and help inform clinical treatment decisions.

From tumor microenvironment to emerging biomarkers: the reshaping of the esophageal squamous cell carcinoma tumor microenvironment by neoadjuvant chemotherapy combined with immunotherapy

Esophageal squamous cell carcinoma is a cancer with high morbidity and mortality. The advent of immune checkpoint inhibitors has significantly increased complete response rates and postoperative R0 resection rates after neoadjuvant therapy. These drugs can largely reverse the suppression of the immune system caused by the tumor microenvironment, allowing the reactivation of anti-tumor immune infiltrating cells, significantly improving the patient's tumor microenvironment, and thus preventing tumor development. However, there are still some patients who respond poorly to neoadjuvant combined immunotherapy and cannot achieve the expected results. It is now found that exploring changes in the tumor microenvironment not only elucidates patient responsiveness to immunotherapy and identifies more reliable biomarkers, but also addresses the limitations of prediction with imaging examination such as CT and the instability of existing biomarkers. In light of these considerations, this review aims to delve into the alterations within the tumor microenvironment and identify potential predictive biomarkers ensuing from neoadjuvant immunotherapy in the context of esophageal squamous cell carcinoma.

Immunological biomarkers and predictive model for recurrence of esophageal squamous cell carcinoma after combined immunotherapy and neoadjuvant chemotherapy

OBJECTIVE

To investigate the association between preoperative immunological biomarkers and risk of esophageal squamous cell carcinoma (ESCC) recurrence within 3 years after combined immunotherapy and neoadjuvant chemotherapy.

METHODS

This retrospective case-control study included 348 ESCC patients who received immunotherapy and neoadjuvant chemotherapy in Henan Provincial People's Hospital between 2021 and 2023. Patients were divided into a recurrence (n=197) group and a non-recurrence (n=151) group based on their recurrence within 3 years. Tumor-infiltrating lymphocytes, serum tumor-specific antibodies, immune checkpoint expression, and HLA expression were analyzed and compared between groups. Correlation and regression analyses evaluated associations between biomarkers and recurrence risk. Then, a joint prediction model was established.

RESULTS

The study revealed that CD8+ and Perforin+ cell percentages were significantly associated with a lower risk of recurrence (P<0.001), while EGFR, HER2, p53, PD-L1, CTLA-4, Tim-3, and LAG-3 were linked to an increased risk of recurrence (P<0.001). Lifestyle factors like salted food consumption, regular hot drink intake, gastric atrophy, and vitamin A deficiency also contributed to ESCC recurrence prediction (all P<0.05). A predictive model incorporating immune markers and risk factors for predicting ESCC recurrence within three years post-treatment demonstrated an AUC of 0.986.

CONCLUSION

Immunological biomarkers, including tumor-infiltrating lymphocytes, serum tumor antibodies, immune checkpoint expression, and HLA expression are associated with ESCC recurrence risk within 3 years of combined immunotherapy and neoadjuvant chemotherapy. These biomarkers may help stratify patients and guide management decisions.

Immune cell patterns before and after neoadjuvant immune checkpoint blockade combined with chemoradiotherapy in locally advanced esophageal squamous cell carcinoma

BACKGROUND

Neoadjuvant immune checkpoint blockade (ICB) combined with chemoradiotherapy offers high pathologic complete response (pCR) rate for patients with locally advanced esophageal squamous cell carcinomas (ESCC). But the dynamic tumor immune microenvironment modulated by such neoadjuvant therapy remains unclear.

PATIENTS AND METHODS

A total of 41 patients with locally advanced ESCC were recruited. All patients received neoadjuvant toripalimab combined with concurrent chemoradiotherapy. Matched pre- and post-treatment tissues were obtained for fluorescent multiplex immunohistochemistry (mIHC) and IHC analyses. The densities and spatial distributions of immune cells were determined by HALO modules. The differences of immune cell patterns before and after neoadjuvant treatment were investigated.

RESULTS

In the pre-treatment tissues, more stromal CD3 + FoxP3 + Tregs and CD86+/CD163 + macrophages were observed in patients with residual tumor existed in the resected lymph nodes (pN1), compared with patients with pCR. The majority of macrophages were distributed in close proximity to tumor nest in pN1 patients. In the post-treatment tissues, pCR patients had less CD86 + cell infiltration, whereas higher CD86 + cell density was significantly associated with higher tumor regression grades (TRG) in non-pCR patients. When comparing the paired pre- and post-treatment samples, heterogeneous therapy-associated immune cell patterns were found. Upon to the treatment, CD3 + T lymphocytes were slightly increased in pCR patients, but markedly decreased in non-pCR patients. In contrast, a noticeable increase and a less obvious decrease of CD86 + cell infiltration were respectively depicted in non-pCR and pCR patients. Furthermore, opposite trends of the treatment-induced alterations of CD8 + and CD15 + cell infiltrations were observed between pN0 and pN1 patients.

CONCLUSIONS

Collectively, our data demonstrate a comprehensive picture of tumor immune landscape before and after neoadjuvant ICB combined with chemoradiotherapy in ESCC. The infiltration of CD86 + macrophage may serve as an unfavorable indicator for neoadjuvant toripalimab combined with chemoradiotherapy.

Prognostic implication of UBE2C + CD8 + T cell in neoadjuvant immune checkpoint blockade plus chemotherapy for locally advanced esophageal cancer

BACKGROUND

Immune checkpoint blockers (ICBs) plus chemotherapy as neoadjuvant therapy for patients with esophageal cancer (EC) has gained substantial attention. This study aimed to investigate the early and mid-term outcome of neoadjuvant ICBs plus chemotherapy and discover immune-associated predictors of major pathological response (MPR) for locally advanced EC.

METHOD

Patients with locally advanced EC who received neoadjuvant ICBs plus chemotherapy were retrospectively included between June 2019 to December 2021. Conjoint analysis of Bulk-RNA seq (GSE165252) and scRNA seq (GSE188900) were used to investigate potential prognostic factors and immunological mechanisms, then multiplexed immunofluorescence was applied to validate.

RESULTS

76 patients were included. A total of 21 (27.6 %) patients achieved MPR, with 13 (17.1 %) attaining a pathological complete response. Over a median follow-up of 1.8 years, 6 (7.9 %) patients died and 21 (27.6 %) experienced disease recurrence within 0.6 to 2.1 years after surgery. The overall survival rate and recurrence-free survival rate were 93.3 + 2.9 % and 84.8 + 4.2 % at 12 months, 90.8 + 3.7 % and 67.1 + 6.4 % at 24 months, and 90.8 + 3.7 % and 62.9 + 7.2 % at 36 months, respectively. Patients achieving MPR had a significantly lower risk of recurrence compared to non-responders (9.5 % vs 34.5 %, P = 0.017). Analysis of bulk-RNA seq and scRNA-seq revealed that UBE2C and UBE2C + CD8 + T cells were adverse prognostic factors. Immunohistochemistry demonstrated that the non-MPR group had a higher infiltration of UBE2C + immune cells than MPR group after neoadjuvant treatment. Multiplexed immunofluorescence confirmed that infiltrating UBE2C + CD8 + T cells in MPR group were significantly fewer than non-MPR group after neoadjuvant treatment, indicating their poor prognostic role for EC.

CONCLUSIONS

Neoadjuvant ICBs plus chemotherapy shows promising efficacy in locally advanced EC, with MPR being a significant predictor of lower recurrence risk. Immunological analyses identified UBE2C + CD8 + T cells as adverse prognostic factors, suggesting their potential as biomarkers for patient stratification and treatment response.

Study on the efficacy and safety of neoadjuvant immunotherapy combined with chemotherapy regimen for III-IVA esophageal squamous cell carcinoma post-surgery

BACKGROUND AND AIMS

The treatment of esophageal squamous cell carcinoma is still controversial, and neoadjuvant chemotherapy combined with immunotherapy is a hot topic of current research. We investigated the recent efficacy and surgical safety of patients with III-IVA esophageal squamous cell carcinoma after neoadjuvant regimen of paclitaxel + cisplatin/nedaplatin/carboplatin + sindilizumab, to provide a theoretical basis for evaluating the feasibility of surgery after neoadjuvant therapy.

METHODS

The clinical data of patients with stage III-IVA esophageal squamous cell carcinoma admitted from January 2022 to April 2023 at our hospital were collected for retrospective analysis. The patients were divided into the neoadjuvant combination surgery group (34 patients with the regimen of paclitaxel + cisplatin/nedaplatin/carboplatin + sintilimab two/three cycles of preoperative neoadjuvant therapy) and surgery-only group (36 patients). Statistical analysis was performed to compare the differences between both groups particularly for intraoperative bleeding, operative time, incidence of postoperative pulmonary complications, laryngeal recurrent nerve injury, thoracic duct injury, anastomotic fistula, and postoperative hospital days. Additionally, the pCR/MPR rates of the neoadjuvant group were analysed.

RESULTS

Significant differences were present in the clinical and pathological staging before and after neoadjuvant treatment (P ≤ 0.001). The neoadjuvant group had a pCR rate of 26.47% and an ORR rate of 88.23%. No significant differences were discovered in R0 resection rate between both groups, as well as intraoperative bleeding, operative time, intraoperative laryngeal recurrent nerve injury rate, thoracic duct injury rate, postoperative anastomosis incidence, postoperative hospital days, and postoperative lung infection incidence (P > 0.05).

CONCLUSIONS

The neoadjuvant immune combination chemotherapy regimen had considerable tumor regression and pathological remission benefits, without reducing the safety of surgery, possibly presenting as a new treatment plan.

A novel and robust pyroptosis-related prognostic signature predicts prognosis and response to immunotherapy in esophageal squamous cell carcinoma

Esophageal squamous cell carcinoma (ESCC) is a highly malignant gastrointestinal tumor, has a poor prognosis and high mortality rate. Pyroptosis could regulate tumor cell proliferation, invasion, and metastasis, thereby affecting the prognosis of cancer patients. However, the role of pyroptosis-related genes (PRGs) in ESCC remains unclear. This study selected 33 PRGs, and finally identified 29 PRGs that were differentially expressed between ESCC and normal esophageal tissues. The genetic mutation variation landscape of PRG in ESCC was also summarised. Based on consensus clustering for the 33 PRGs, all ESCC patients could be divided into two subtypes. Functional enrichment analysis revealed that these 33 PRGs were mainly involved in cytokine production, interleukin-1 production, and the NOD-like receptor signalling pathway. We created a prognostic PRG signature based on least absolute shrinkage and selection operator regression and Cox regression analysis with good survival prediction ability in both GEO and TCGA cohorts. Combined with the clinical characteristics, signature-based risk score was found to be an independent factor for predicting the OS of ESCC patients. A nomogram with enhanced precision for forecasting ESCC was established based on various independent prognostic elements. Significant correlation was observed between prognostic PRGs and immune-cell infiltration, tumor mutation burden, microsatellite instability, immune checkpoint, and drug sensitivity. Finally, we validated the expression of four PRGs in ESCC cell lines and tissues samples. In conclusion, the PRGs exerted significant effects on tumor immunity and prognosis of ESCC.