Pathological response to neoadjuvant chemoradiotherapy for oesophageal squamous cell carcinoma: multicentre East Asian and Dutch database comparison

Characterization of novel mouse esophageal squamous cell carcinoma cell lines and their utility as preclinical models

Esophageal squamous cell carcinoma (ESCC) has a high incidence, poor treatment response, and high mortality. Subcutaneous transplant tumor models are commonly used to study the immunosuppressive tumor microenvironment and its impact on immunotherapy. In this study, we established two new ESCC mouse cell lines, mEC525M and mEC586F, from 4NQO-induced ESCC mouse models of different sexes. We compared their proliferation, motility, and molecular characteristics with existing lines (HNM007, AKR, mEC25) using in vitro experiments and whole-exome sequencing. Treatment sensitivity analysis of all murine ESCC tumor cell lines revealed that AKR and HNM007 cells were more responsive to chemotherapy, mEC25 cells were more sensitive to radiotherapy, whereas mEC525M and mEC586F cells exhibited greater sensitivity to immunotherapy. Multiplex immunohistochemistry (mIHC) staining analysis revealed differences in immune infiltration among the tumors derived from the five mouse ESCC cell lines, with the highest proportion of T cells in mEC525M tumors, the highest proportion of CD11b+ myeloid cells in mEC586F tumors and the highest proportion of CD19+ B cells in mEC25 tumors. In addition, RNA sequencing results also revealed differences in immune responses exhibited by tumor tissues derived from the five mouse ESCC cell lines after anti-PD1 treatment. Therefore, this study offers a valuable tool for investigating the immune microenvironment in ESCC and supports the selection of mouse models for preclinical ESCC research.

Efficacy and safety of PD-1/PD-L1 inhibitors as first-line treatment for esophageal squamous cell carcinoma: a systematic review and meta-analysis

Purpose

This study aims to investigate the efficacy and safety of PD-1/PD-L1 inhibitors in the first-line treatment of esophageal squamous cell carcinoma (ESCC) and identify factors influencing efficacy through a meta-analysis of multiple phase 3 randomized controlled trials (RCTs).

Methods

A systematic literature search was conducted in Cochrane, PubMed, and Embase databases. Two researchers independently extracted trial data, including efficacy-related outcomes such as overall survival (OS), progression-free survival (PFS), objective response rate (ORR), and duration of response (DoR), along with their subgroup data and safety-related indicators. The overall hazard ratio (HR) and 95% confidence interval (CI) were calculated for OS and PFS, while the overall odds ratio (OR) and 95% CI were computed for ORR to compare the classification and predictive abilities of combined positive score (CPS) and tumor proportion score (TPS) for PD-L1 status. Additionally, survival outcomes across different subgroups were evaluated to explore the potential influencing factors for the efficacy of PD-1/PD-L1 inhibitors in ESCC.

Results

This meta-analysis included eight phase 3 RCTs encompassing 4,479 participants. PD-1/PD-L1 inhibitors combined with chemotherapy significantly improved OS (HR: 0.68, 95% CI: 0.63-0.74) and PFS (HR: 0.62, 95% CI: 0.58-0.67) in ESCC patients compared to non-combination therapy. Patients with higher PD-L1 expression (CPS>1 or TPS>1) demonstrated superior responses to PD-1/PD-L1 inhibitions, with CPS identified as a stronger predictor of therapeutic benefit, particularly at a threshold of CPS =10. Subgroup analysis revealed that male, Asian, smoking, and liver metastasis patients exhibited a greater trend toward improved disease control with PD-1/PD-L1 inhibitors. However, there was no significant difference in treatment efficacy between immune therapy combined with TP (taxol [paclitaxel] + cisplatin) and FP (5-fluorouracil [5-FU] + cisplatin) regimens (POS =0.51, PPFS =0.11). Finally, PD-1/PD-L1 inhibition was associated with a higher incidence of grade ≥3 adverse events compared to chemotherapy alone (HR: 1.21, 95% CI: 1.07-1.37).

Conclusions

This study confirms that the combination of PD-1/PD-L1 inhibitors and chemotherapy provides significant clinical benefits in ESCC. CPS =10 serves as a key threshold for predicting treatment response. There is a trend suggesting that male, Asian, smoking, and liver metastasis patients may experience better survival benefits, while no significant difference was observed between TP- and FP-based regimens.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero, identifier CRD42024536221.

Real-world outcomes of the CROSS regimen in patients with resectable esophageal or gastro-esophageal junction adenocarcinoma: a nationwide cohort study in the Netherlands

Background

Recent studies in patients with resectable adenocarcinoma of the esophagus or gastroesophageal junction (GEJ)-Neo-AEGIS and ESOPEC-have explored the comparison of neoadjuvant chemoradiotherapy (nCRT) with chemotherapy, with conflicting results. To contextualize the findings from these studies using nCRT as a comparator, we aimed to investigate contemporary real-world outcomes of nCRT in patients with adenocarcinoma of the esophagus or GEJ.

Methods

From the Netherlands Cancer Registry, patients were selected who were diagnosed between 1 January 2015 and 31 December 2022 with a resectable (cT1N+M0 or cT2-4aNanyM0) esophageal, GEJ or gastric cardia adenocarcinoma and started treatment with nCRT according to the CROSS regimen, that is 5 weekly cycles of carboplatin (AUC 2 mg/mL per minute) and paclitaxel (50 mg/m2) combined with concurrent radiotherapy (41.4 Gy in 23 fractions of 1.8 Gy). Pathologic complete response (pCR) according to Mandard was the primary outcome of this study and defined as complete tumor regression of the primary tumor (Mandard grade I) irrespective of residual nodal involvement.

Findings

Of the 4765 included patients, 4170 (87.5%) completed the full CROSS regimen of radiotherapy and chemotherapy. A pCR was observed in 704 (20.5%) of 3439 patients who underwent surgical resection within 16 weeks after completing the CROSS regimen. In the complete study population, the median overall survival (OS) was 33.7 months (95% CI 32.0-35.6), with a 3-year OS rate of 48.1%.

Interpretation

Although survival rates in real-world settings are often lower compared to clinical trials, in our real-world cohort the 3-year OS was only 2.6% lower compared to that reported for the group that underwent nCRT in ESOPEC. These real-world results underscore the potential of the CROSS regimen in daily clinical practice.

Funding

None.

Detecting residual disease after neoadjuvant chemoradiotherapy for oesophageal squamous cell carcinoma: The prospective multicentre preSINO trial

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRT) in patients with oesophageal squamous cell carcinoma (OSCC) may lead to clinical complete response (cCR). It is important to know the accuracy of clinical response evaluations (CREs) before advocating active surveillance instead of oesophagectomy.

METHODS

This was a prospective, multicentre study of patients with locally advanced OSCC. They received the first CRE (bite-on-bite biopsies) 4-6 weeks after nCRT. Patients with residual tumour underwent surgery. Patients with a cCR at CRE-1 underwent a second CRE 10-12 weeks after nCRT using PET-CT, bite-on-bite biopsies and endoscopic ultrasound fine-needle aspiration (EUS-FNA). All patients without distant metastases underwent surgery. Primary endpoint was the accuracy of CREs for detecting Tumour Regression Grade (TRG)3-4 or TRG1-2 with ypN+ residual tumour with a prespecified false-negative rate (FNR) of 19.5%. Circulating-tumour DNA (ctDNA) at CREs was performed for exploratory analysis.

RESULTS

In total 309 patients were included. Eighteen of 133 patients with TRG3-4 or TRG1-2 with ypN+ residual tumours were not detected by bite-on-bite biopsies and EUS-FNA (FNR: 13.5%). Sensitivity, specificity, negative predictive value and positive predictive value of detecting any residual tumour were 81.7%, 93.2%, 68.7% and 96.5% respectively. PET-CT detected interval distant metastases in 13 (4.9%) of 268 patients presurgically. After a minimum 12-month follow-up, systemic recurrence rates were 28.0% in patients with positive ctDNA at CREs and 5.3% in those with negative ctDNA.

CONCLUSIONS

Bite-on-bite biopsies and EUS-FNA were accurate in detecting residual disease after nCRT in OSCC. Positive ctDNA at CREs may indicate an increased risk of systemic metastases.

Neoadjuvant chemoradiation therapy application in radical esophagectomy surgery: Safety and feasibility: A descriptive study in Vietnam

Esophageal cancer (EC) ranks as the 7th most prevalent form of cancer and the 6th leading cause of cancer-related mortality globally. Neoadjuvant therapy, encompassing neoadjuvant chemotherapy or chemoradiotherapy, has shown promise in reducing the staging of EC and mitigating the risk of early systemic spread. This study seeks to assess the safety and viability of implementing neoadjuvant chemoradiotherapy (nCRT) in conjunction with radical esophagectomy surgery for Vietnamese patients diagnosed with locally advanced EC. Safety was evaluated based on the incidence of grade ≥3 treatment-related adverse events, while feasibility was assessed through indicators such as pathological complete response, major pathological response, and R0 resection rates. The study analyzed data from 30 patients, following specific inclusion criteria. Baseline characteristics analysis revealed a participant cohort entirely composed of males, wherein 83.3% were identified as smokers, with tumors predominantly located in the middle (46.7%) and lower (53.3%) regions of the thoracic esophagus. The predominance of clinical stages II and III was observed. The nCRT protocol resulted in a substantial reduction in dysphagia score, with a statistically significant P < .001. The median duration from the conclusion of radiation treatment to surgery was 62 days, with a median operative time of 302 minutes and a median estimated blood loss of 189 mL. Surgical complications primarily included anastomotic leakage and pneumonia, occurring in 23.3% and 16.7% of cases, respectively. R0 resection was achieved in 29 (96.7%) patients, with 43.4% attaining pathological complete response and 56.7% demonstrating tumor complete response. The study's outcomes emphasize the safety and feasibility of employing esophagectomy subsequent to nCRT in Vietnamese patients, as evidenced by the absence of mortality, low complication rates, and favorable surgical results. It also suggests the potential advantages of utilizing a lower daily Gy dose for enhanced safety and considering squamous cell carcinoma as a specific criterion for nCRT.

Effects of Neoadjuvant Therapy on Tumour Target Expression of Oesophageal Cancer Tissue for NIR Fluorescence Imaging

PURPOSE

Oesophaegal cancer patients with a clinical complete response (CR) after neoadjuvant chemoradiotherapy (nCRT) are candidates for an active surveillance strategy. Regrowth rates of 40% after initial clinical CR indicate that identification of a true complete response to nCRT remains challenging. Near-infrared tumour-specific fluorescence endoscopic imaging might help to discriminate patients with a true complete response from patients with residual disease. This study aims to find potential markers to enable molecular imaging in oesophageal cancer and to assess the effect of nCRT on marker expression.

PROCEDURES

Oesophageal cancer tissue slides of diagnostic biopsies (n = 41) (pre-treatment) and paired surgical specimens (n = 31) (post-treatment) were collected. Tissue slides of patients with adenocarcinoma (n = 29) and squamous cell carcinoma (n = 12)) were included. Immunohistochemistry was performed to assess expression of the tumour markers CEA, EpCAM, VEGF-α, EGFR, and c-MET in the tumour and compared to the expression of these markers in surrounding healthy tissue. A total immunostaining score (TIS, range 0-12), which combines the percentage and intensity of stained cells, was calculated. The TIS of pre-treated biopsies were compared with the TIS of the post-treatment surgical specimens to assess the effect of neoadjuvant therapy on the marker expression.

RESULTS

The median TIS of EpCAM in adenocarcinomas was 10, vs. 0 in healthy mucosa (p < 0.001). The median TIS of EGFR in squamous cell carcinoma was 12, vs. 4 in healthy mucosa (p < 0.001). Neoadjuvant therapy did not affect the expression of the markers.

CONCLUSION

EpCAM and EGFR appear to be the most suitable targets for tumour-specific NIR fluorescence imaging of oesophageal adenocarcinoma and squamous cell carcinoma, respectively. Unaffected expression of all suitable markers by neoadjuvant therapy implies that the diagnostic biopsy can be used to select a patient-specific target for response evaluation by molecular imaging.

Neoadjuvant chemotherapy with or without camrelizumab in resectable esophageal squamous cell carcinoma: the randomized phase 3 ESCORT-NEO/NCCES01 trial

Recent single-arm studies involving neoadjuvant camrelizumab, a PD-1 inhibitor, plus chemotherapy for resectable locally advanced esophageal squamous cell carcinoma (LA-ESCC) have shown promising results. This multicenter, randomized, open-label phase 3 trial aimed to further assess the efficacy and safety of neoadjuvant camrelizumab plus chemotherapy followed by adjuvant camrelizumab, compared to neoadjuvant chemotherapy alone. A total of 391 patients with resectable thoracic LA-ESCC (T1b-3N1-3M0 or T3N0M0) were stratified by clinical stage (I/II, III or IVA) and randomized in a 1:1:1 ratio to undergo two cycles of neoadjuvant therapy. Treatments included camrelizumab, albumin-bound paclitaxel and cisplatin (Cam+nab-TP group; n = 132); camrelizumab, paclitaxel and cisplatin (Cam+TP group; n = 130); and paclitaxel with cisplatin (TP group; n = 129), followed by surgical resection. Both the Cam+nab-TP and Cam+TP groups also received adjuvant camrelizumab. The dual primary endpoints were the rate of pathological complete response (pCR), as evaluated by a blind independent review committee, and event-free survival (EFS), as assessed by investigators. This study reports the final analysis of pCR rates. In the intention-to-treat population, the Cam+nab-TP and Cam+TP groups exhibited significantly higher pCR rates of 28.0% and 15.4%, respectively, compared to 4.7% in the TP group (Cam+nab-TP versus TP: difference 23.5%, 95% confidence interval (CI) 15.1-32.0, P < 0.0001; Cam+TP versus TP: difference 10.9%, 95% CI 3.7-18.1, P = 0.0034). The study met its primary endpoint of pCR; however, EFS is not yet mature. The incidence of grade ≥3 treatment-related adverse events during neoadjuvant treatment was 34.1% for the Cam+nab-TP group, 29.2% for the Cam+TP group and 28.8% for the TP group; the postoperative complication rates were 34.2%, 38.8% and 32.0%, respectively. Neoadjuvant camrelizumab plus chemotherapy demonstrated superior pCR rates compared to chemotherapy alone for LA-ESCC, with a tolerable safety profile. Chinese Clinical Trial Registry identifier: ChiCTR2000040034 .

Pathological response to neoadjuvant chemoradiotherapy for oesophageal squamous cell carcinoma in Eastern versus Western countries: meta-analysis

OBJECTIVE

Locally advanced oesophageal squamous cell carcinoma can be treated with neoadjuvant chemoradiotherapy or chemotherapy followed by oesophagectomy. Discrepancies in pathological response rates have been reported between studies from Eastern versus Western countries. The aim of this study was to compare the pathological response to neoadjuvant chemoradiotherapy in Eastern versus Western countries.

METHODS

Databases were searched until November 2022 for studies reporting pCR rates after neoadjuvant chemoradiotherapy for oesophageal squamous cell carcinoma. Multi-level meta-analyses were performed to pool pCR rates separately for cohorts from studies performed in centres in the Sinosphere (East) or in Europe and the Anglosphere (West).

RESULTS

For neoadjuvant chemoradiotherapy, 51 Eastern cohorts (5636 patients) and 20 Western cohorts (3039 patients) were included. Studies from Eastern countries included more men, younger patients, more proximal tumours, and more cT4 and cN+ disease. Patients in the West were more often treated with high-dose radiotherapy, whereas patients in the East were more often treated with a platinum + fluoropyrimidine regimen. The pooled pCR rate after neoadjuvant chemoradiotherapy was 31.7% (95% c.i. 29.5% to 34.1%) in Eastern cohorts versus 40.4% (95% c.i. 35.0% to 45.9%) in Western cohorts (fixed-effect P = 0.003). For cohorts with similar cTNM stages, pooled pCR rates for the East and the West were 32.5% and 41.9% respectively (fixed-effect P = 0.003).

CONCLUSION

The pathological response to neoadjuvant chemoradiotherapy is less favourable in patients treated in Eastern countries compared with Western countries. Despite efforts to investigate accounting factors, the discrepancy in pCR rate cannot be entirely explained by differences in patient, tumour, or treatment characteristics.

Online tools to predict individualised survival for primary oesophageal cancer patients with and without pathological complete response after neoadjuvant therapy followed by oesophagectomy: development and external validation of two independent nomograms

OBJECTIVE

This study aimed to develop and validate robust predictive models for patients with oesophageal cancer who achieved a pathological complete response (pCR) and those who did not (non-pCR) after neoadjuvant therapy and oesophagectomy.

DESIGN

Clinicopathological data of 6517 primary oesophageal cancer patients who underwent neoadjuvant therapy and oesophagectomy were obtained from the National Cancer Database for the training cohort. An independent cohort of 444 Chinese patients served as the validation set. Two distinct multivariable Cox models of overall survival (OS) were constructed for pCR and non-pCR patients, respectively, and were presented using web-based dynamic nomograms (graphical representation of predicted OS based on the clinical characteristics that a patient could input into the website). The calibration plot, concordance index and decision curve analysis were employed to assess calibration, discrimination and clinical usefulness of the predictive models.

RESULTS

In total, 13 and 15 variables were used to predict OS for pCR and non-pCR patients undergoing neoadjuvant therapy followed by oesophagectomy, respectively. Key predictors included demographic characteristics, pretreatment clinical stage, surgical approach, pathological information and postoperative treatments. The predictive models for pCR and non-pCR patients demonstrated good calibration and clinical utility, with acceptable discrimination that surpassed that of the current tumour, node, metastases staging system.

CONCLUSIONS

The web-based dynamic nomograms for pCR (https://predict-survival.shinyapps.io/pCR-eso/) and non-pCR patients (https://predict-survival.shinyapps.io/non-pCR-eso/) developed in this study can facilitate the calculation of OS probability for individual patients undergoing neoadjuvant therapy and radical oesophagectomy, aiding clinicians and patients in making personalised treatment decisions.

Two-year outcomes of clinical N2-3 esophageal squamous cell carcinoma after neoadjuvant chemotherapy and immunotherapy from the phase 2 NICE study

OBJECTIVE

This study aims to report the 2-year outcomes of patients with clinical stage N2-3 esophageal squamous cell carcinoma who received neoadjuvant chemotherapy and immunotherapy followed by surgery from a phase 2 NICE trial.

METHODS

Eligible patients with clinical stage N2-3 esophageal squamous cell carcinoma were screened and enrolled, then treated with regimen of nab-paclitaxel (100 mg/m2, days 1, 8, 15), carboplatin (area under the curve = 5, day 1), camrelizumab (200 mg, day 1) of two 21-day cycles and esophagectomy 4 to 6 weeks after the last chemotherapy. Oncologic outcomes, recurrence patterns, overall survival (OS), and recurrence-free survival (RFS) were explored.

RESULTS

From November 20, 2019, to December 22, 2020, 60 patients were recruited. After a median follow-up of 27.4 months, disease recurrence was observed in 19 (37.3%) patients, with 5 (9.8%) locoregional recurrence, 9 (17.6%) distant metastasis, and 5 (9.8%) combined recurrence. Lung was the most commonly involved metastatic site. The median time to recurrence was 10.8 months (interquartile range, 7.5-12.7 months). The 2-year OS and RFS rates were 78.1% and 67.9%, respectively. Patients who achieved major pathologic response (MPR) had a significantly greater 2-year OS rate (91.4% vs 47.7%; P < .001) and RFS rate (77.1% vs 45.9%; P = .003). On multivariable analysis, MPR was indicated as an independent prognostic factor for disease recurrence (hazard ratio, 0.39; 95% confidence interval, 0.21-0.82; P = .029).

CONCLUSIONS

In patients receiving neoadjuvant chemotherapy and immunotherapy, distant metastasis remains the predominant recurrence pattern. MPR is associated with lower recurrence and better survival. Long-term results derived from randomized controlled trials are further required.

TRIAL REGISTRATION NUMBER

ChiCTR1900026240.

Progenitor-like exhausted SPRY1+CD8+ T cells potentiate responsiveness to neoadjuvant PD-1 blockade in esophageal squamous cell carcinoma

Neoadjuvant immune checkpoint blockade (ICB) demonstrates promise in operable esophageal squamous cell carcinoma (ESCC), but lacks available efficacy biomarkers. Here, we perform single-cell RNA-sequencing of tumors from patients with ESCC undergoing neoadjuvant ICB, revealing a subset of exhausted CD8+ T cells expressing SPRY1 (CD8+ Tex-SPRY1) that displays a progenitor exhausted T cell (Tpex) phenotype and correlates with complete response to ICB. We validate CD8+ Tex-SPRY1 cells as an ICB-specific predictor of improved response and survival using independent ICB-/non-ICB cohorts and demonstrate that expression of SPRY1 in CD8+ T cells enforces Tpex phenotype and enhances ICB efficacy. Additionally, CD8+ Tex-SPRY1 cells contribute to proinflammatory phenotype of macrophages and functional state of B cells, which thereby promotes antitumor immunity by enhancing CD8+ T cell effector functions. Overall, our findings unravel progenitor-like CD8+ Tex-SPRY1 cells' role in effective responses to ICB for ESCC and inform mechanistic biomarkers for future individualized immunotherapy.

A phase II clinical trial of toripalimab combined with neoadjuvant chemoradiotherapy in locally advanced esophageal squamous cell carcinoma (NEOCRTEC1901)

BACKGROUND

To evaluate the efficacy and safety of toripalimab combined with neoadjuvant chemoradiotherapy (NCRT) for locally advanced esophageal squamous cell carcinoma (ESCC).

METHODS

In this single arm, phase II trial, 44 ESCC patients were enrolled from December 2019 to July 2021 at Sun Yat-sen University Cancer Center (Guangzhou, China). All patients received concurrent radiotherapy (44 Gy in 20 fractions), chemotherapy (paclitaxel 50 mg/m2 and cisplatin 25 mg/m2 on days 1, 8, 15, and 22), and toripalimab (240 mg on days 1 and 22). Within 6-8 weeks of neoadjuvant treatment, patients underwent surgery. The results of the study patients were compared with those of 86 matched patients between July 2015 and March 2022. The primary endpoint was pathological complete response (pCR) rate, and the secondary endpoints were treatment-related adverse events and R0 rates. This trail was registered with ClinicalTrails.gov, NCT04006041.

FINDINGS

All patients received neoadjuvant treatment, and 42 completed esophagectomy. Of the 42 patients, 21 (50%; 95% CI 35-65) achieved pCR and 2 (5%) patients were ypT0N+. The R0 resection rate was 98% (41/42). Nine (20%) of 44 patients had grade 3/4 adverse events. Among the perioperative complications (n = 42), anastomotic leakage occurred in five cases (12%), tracheal fistula in three cases (7%), and postoperative death in one case (2%) due to tracheal fistula. Compared with the control cohort, the pCR rate of the study group was higher but without significant difference (50% vs. 36%, P = 0.19).

INTERPRETATION

Toripalimab combined with NCRT failed to show significantly better pCR rate than historical data. Nevertheless, considering the signs of efficacy and acceptable safety of this regimen, further evaluation in phase III randomized trials might be warranted.

FUNDING

National Natural Science Foundation of China.