The Society of Thoracic Surgeons/American Society for Radiation Oncology Updated Clinical Practice Guidelines on Multimodality Therapy for Locally Advanced Cancer of the Esophagus or Gastroesophageal Junction

Patient, facility, and surgical factors associated with significant delays to esophagectomy and subsequent poor outcomes: An analysis of 16,486 cases

OBJECTIVE

Delays to definitive surgery in esophageal cancer may be associated with disease progression and worsened survival. The objective of this study was to perform a national assessment for predictors of delay to esophagectomy and to assess for their impact on oncologic and survival outcomes.

METHODS

The National Cancer Database, 2010 to 2020, was queried for patients with locally advanced esophageal adenocarcinoma (stage I-III). Patients were divided into up-front and postneoadjuvant chemoradiation cohorts. The primary outcome was time to surgery. Time to surgery was examined as a continuous and categorical variable, where patients were divided into timely and delayed cohorts (96 days for up-front cohort; 56 days for postneoadjuvant chemoradiation cohort).

RESULTS

Of 16,486 patients, 4066 (24.7%) underwent up-front surgery and 12,420 (75.3%) underwent postneoadjuvant chemoradiation surgery. In the up-front surgery group, median [interquartile range] time to surgery was 61 [40-96] days. Risk-adjusted predictors of delay included lack of insurance, lowest quartile of education, biopsy-based staging or surgical staging, and robotic-assisted approach. In the postneoadjuvant chemoradiation, cohort time to surgery was 55 [44-70] days. Risk-adjusted predictors of delay included Hispanic ethnicity, Medicaid or other government-based insurance, lowest quartile of educational status, and robotic approach. In the up-front surgery group, patients who received delayed surgery had increased odds of pathologic upstaging (1.31, 95% CI, 1.06-1.61). In the postneoadjuvant chemoradiation group, patients with surgical delay had increased odds of 90-day mortality (1.27, 95% CI, 1.06-1.51).

CONCLUSIONS

After risk adjustment for patient, oncologic, facility, and surgical characteristics, there were several predictors of increased time to esophagectomy associated with consequences of upstaging and survival.

Association between prognostic immune nutritional index and disease-free survival in adults with esophageal cancer following surgery: A retrospective cohort study

INTRODUCTION

The clinical significance of the prognostic immune nutritional index in esophageal cancer has not been elucidated. The aim of this study was to evaluate the utility of the preoperative prognostic immune nutritional index in predicting oncological outcomes and the incidence of surgical site infection in patients with esophageal cancer.

METHODS

We analyzed preoperative prognostic immune nutritional index from 150 esophageal cancer patients who underwent surgical treatment between 2008 and 2018 to clarify its clinical relevance.

RESULTS

Patients with low preoperative prognostic immune nutritional index exhibited poor disease-free survival and overall survival (P = 0.030 and P < 0.001, respectively). Although statistical significance was not observed in the multivariate analysis, low prognostic immune nutritional index showed a tendency toward poorer disease-free survival (hazard ratio [HR]: 2.02; 95% confidence interval [CI]: 0.88-4.61; P = 0.096). Regarding overall survival, multivariate analysis revealed that low preoperative prognostic immune nutritional index was an independent prognostic factor for overall survival (HR: 2.67; 95% CI: 1.39-5.16; P = 0.003). Moreover, the low preoperative prognostic immune nutritional index was associated with a tendency toward an increased risk of surgical site infection (odds ratio: 2.38; 95% CI: 0.96-5.91; P = 0.062). In the subgroup analysis of patients who did not receive neoadjuvant therapy, low preoperative prognostic immune nutritional index was identified as an independent prognostic factor for disease-free survival (HR: 3.11; 95% CI: 1.00-9.71; P = 0.050) and overall survival (HR: 5.04; 95% CI: 1.80-14.13; P = 0.002).

CONCLUSION

The preoperative prognostic immune nutritional index is a useful marker for perioperative and oncological management of esophageal cancer patients.

Perioperative the BTLA inhibitor (tifcemalimab) combined with toripalimab and chemotherapy for resectable locally advanced thoracic esophageal squamous cell carcinoma trial (BT-NICE trial): a prospective, single-arm, exploratory study

Background

The treatment of cancer has brought about a paradigm shift with the introduction of immune checkpoint blockade (ICB) therapy, which is mostly dependent on inhibiting PD-1/PD-L1 and CTLA-4. However, recent studies have shown limited efficacy of this treatment in esophageal squamous cell carcinoma (ESCC). Preliminary studies have found that tifcemalimab (the world's first anti-BTLA blocking monoclonal antibody) combined with toripalimab (PD-1) and chemotherapy has shown favorable safety and efficacy in several solid cancers. This study aimed to evaluate the safety and efficacy of neoadjuvant tifcemalimab combined with toripalimab and chemotherapy following esophagectomy for resectable ESCC, and the association of adjuvant immunotherapy with improved survival outcomes.

Methods

Patients with pathologically confirmed cT1b-3N1-3M0 or cT2-3N0M0 thoracic ESCC were treated with neoadjuvant tifcemalimab (200mg, iv, d1) in combination with toripalimab (240mg, iv, d1) and chemotherapy (paclitaxel 135-175 mg/m2, d1 + cisplatin 75 mg/m2, d1) every 3 weeks for 2 cycles. Patients undergoing esophagectomy with pathological complete response (pCR) were administered up to 15 cycles of adjuvant tifcemalimab (200 mg) and toripalimab (240 mg), whereas patients without pCR received tifcemalimab in combination with toripalimab and adjuvant chemotherapy for 2 cycles, followed by tifcemalimab in combination with toripalimab immunotherapy up to 13 cycles. The patient with incomplete resection was decided to receive radiotherapy after a multidisciplinary consultation. The primary endpoint of this study was the pCR rate. The secondary endpoints include major pathological response rate (MPR), objective response rate (ORR), disease control rate (DCR), adverse events, R0 resection rate, event-free survival (EFS), and overall survival (OS).

Discussion

The Ethics Committee of Henan Provincial People's Hospital has approved the protocol (No 2024-132-03). This study is the world's first prospective clinical trial to evaluate the safety and efficacy of the BTLA inhibitor in combination with PD-1 and chemotherapy as neoadjuvant/adjuvant therapy for locally advanced thoracic ESCC. We predicted that perioperative combination immunotherapy as a potentially preferred and effective treatment strategy may lead to better survival outcomes.

2024 Update of The Society of Thoracic Surgeons Short-term Esophagectomy Risk Model: More Inclusive and Improved Calibration

BACKGROUND

The Society of Thoracic Surgeons General Thoracic Surgery Database (STS-GTSD) previously reported short-term risk models for esophagectomy for esophageal cancer. We sought to update existing models using more inclusive contemporary cohorts, with consideration of additional risk factors based on clinical evidence.

METHODS

The study population consisted of adult patients in the STS-GTSD who underwent esophagectomy for esophageal cancer between January 2015 and December 2022. Separate esophagectomy risk models were derived for 3 primary end points: operative mortality, major morbidity, and composite morbidity or mortality. Logistic regression with backward selection was used, with predictors retained in models if P < .10. All derived models were validated using 9-fold cross-validation. Model discrimination and calibration were assessed for the overall cohort and specified subgroups.

RESULTS

A total of 18,503 patients from 254 centers underwent esophagectomy for esophageal cancer. Operative mortality, morbidity, and composite morbidity or mortality rates were 3.4%, 30.5%, and 30.9%, respectively. Novel predictors of short-term outcomes in the updated models included body surface area and insurance payor type. Overall discrimination was similar or superior to previous STS-GTSD models for operative mortality (C statistic = 0.72) and for composite morbidity or mortality (C statistic = 0.62), Model discrimination was comparable across procedure- and demographic-specific subcohorts. Model calibration was excellent in all patient subgroups.

CONCLUSIONS

The newly derived esophagectomy risk models showed similar or superior performance compared with previous models, with broader applicability and clinical face validity. These models provide robust preoperative risk estimation and can be used for shared decision making, assessment of provider performance, and quality improvement.