Ten-Year Outcome of Neoadjuvant Chemoradiotherapy Plus Surgery for Esophageal Cancer: The Randomized Controlled CROSS Trial

Determining the optimal radiation dose for locally advanced esophageal cancer: A pooled analysis of reconstructed individual patient data from randomized clinical trials

BACKGROUND

The optimal radiation dose of definitive concurrent chemoradiotherapy (dCCRT) for esophageal cancer (EC) has always been a concern in radiation oncology and has remained controversial for several decades, we performed a meta-analysis based on individual patient data (IPD) to explore the optimal dose.

METHODS

Randomized clinical trials (RCTs) comparing high-dose radiotherapy (HD-RT,≥59.4 Gy) with standard-dose radiotherapy (SD-RT, 50 Gy/50.4 Gy) were identified. Graphical reconstructive algorithms were employed to extract time-to-event outcomes from Kaplan-Meier curves presented in the original RCTs. Using reconstructed individual patient data, summary overall survival (OS), progression-free survival (PFS) and locoregional progression-free survival (LRPFS) for HD-RT versus SD-RT were recalculated. Hazard Ratios (HRs) of OS, PFS and LRPFS reported were also pooled by the fixed or random effects model.

RESULTS

Six RCTs, including 1722 patients, were included. IPD for OS, PFS, and LRPFS were from 1287, 462, and 722 patients, respectively. Overall, HD-RT had no significant benefits in 3-year OS (RR = 1.00, P = 0.990), 3-year progression-free survival (PFS) (RR = 0.96, P = 0.320) and 3-year locoregional progression-free survival (LRPFS) (RR = 0.88, P = 0.204), compared with SD-RT. Consistent with above results, the pooled HRs of OS, PFS and LRPFS for HD-RT versus SD-RT were 0.99 (P = 0.854), 0.94 (P = 0.628) and 0.91 (P = 0.410), respectively. However, HD-RT had higher grade ≥ 3 treatment-related adverse effects (TRAEs) (OR = 1.26, P = 0.025). Subgroup analyses were also performed based on the RT techniques, histology, size of the RT target, dose-escalation mode, and stage editions. We found that dose escalation, even in subgroups, did not benefit long-term survival but resulted in a higher incidence of grade ≥ 3 TRAEs.

CONCLUSION

The results provide robust evidence that corroborates current guidelines and supports the clinical practice of employing SD-RT. Additionally, it provides implications for the feasibility of further research into novel drug combinations (e.g., immunotherapy) rather than radiation dose escalation.

Prognostic value of immunotrophic inflammatory markers in ESCC undergoing chemoradiotherapy combined with immunotherapy

This study aimed to investigate the role of immunotrophic inflammatory markers in assessing the prognosis and treatment-related toxicity in patients with esophageal squamous cell carcinoma (ESCC) undergoing first-line radiotherapy and chemotherapy combined with immunotherapy. We retrospectively enrolled 67 patients with ESCC and determined the optimal cutoff values for prognostic nutrition index (PNI), neutrophil to lymphocyte ratio (NLR), and platelet to lymphocyte ratio (PLR) using receiver operating characteristic (ROC) curve analysis. Statistical analysis was performed using SPSS 25.0. The one-, two-, and three-year overall survival (OS) rates were 88.1%, 62.3%, and 57.6%, respectively. The overall effective rate was 82.1% (55/67). ROC curve analysis revealed optimal cutoff values for PNI, NLR, and PLR as 48.35, 3.84, and 150.49, respectively. Patients in the high PNI group, low NLR group and PLR group exhibited significantly higher mOS and mPFS time compared to the control group. Notably, the incidence of grade 2 toxicity and side effects in the PNI ≥ 48.35 group was significantly lower than that in the PNI < 48.35 group. Our findings suggest that pretreatment values of PNI, NLR, and PLR can serve as valuable biomarkers for evaluating the prognosis of ESCC patients undergoing first-line radiotherapy and chemotherapy combined with immunotherapy. Further studies with larger cohorts are warranted to validate these results.

Sentinel Lymph Node Mapping in Esophageal Cancer: Current Status and Future Directions

OBJECTIVE

This review provides a comprehensive discussion about the importance of adequate lymphadenectomy, its anatomic and oncologic significance, principles and rationale of sentinel lymph node mapping, current evidence stratified by tracer substrate, challenges, and future directions. Esophageal cancer has one of the worst cancer-related survival rates, and nodal status is the single most significant prognostic factor. Submucosal penetration generally demands esophagectomy, often following neoadjuvant therapy in the presence of deeper extension. Guidelines recommend resecting ≥15 lymph nodes. Variability in surgical approach and dissection in concert with aberrant esophageal lymphatic anatomy make adequate lymphadenectomy difficult.

METHODS

A narrative review was conducted to explore existing literature regarding lymphadenectomy with its requisite anatomic and oncologic significance in esophageal cancer, as well as the rationale for and present state of sentinel lymph node mapping stratified by substrates. Tables and figures were constructed by the authors using Microsoft Office applications and Biorender software, respectively.

RESULTS

Sentinel lymph node mapping exploits the tumoral lymphatic network to identify the nodes most prone to metastasis, directing further dissection. Targeting sentinel lymph nodes with dyes, radiotracers, or hybrid tracers can assist surgeons with lymphadenectomy, potentially improving staging accuracy and personalizing care to individual anatomy.

CONCLUSIONS

While this approach would benefit from larger studies and long-term data, early evaluations suggest improved detection of metastases outside the en bloc field without significantly increasing morbidity.

Outcomes of Neoadjuvant Chemoradiotherapy Using Volumetric Modulated Arc Therapy in Locally Advanced Squamous Cell Oesophageal Cancers

PURPOSE

Neoadjuvant chemoradiotherapy has been established as the standard of care for locally advanced oesophageal cancers. Most of the evidences on neoadjuvant chemoradiotherapy (NACTRT) comes from the Western world where the predominant histology is adenocarcinoma. This study aimed to study the outcomes of neoadjuvant chemoradiotherapy using CROSS protocol and volumetric modulated arc therapy (VMAT) in locally advanced squamous cell oesophageal cancers.

CASE PRESENTATION

We report a multicentric abdominal inflammatory myofibroblastic tumor in a 6-year-old girl who presented with massive abdominal distention. The sheer size of the mass, coupled with multicentric presentation and absent mobility on clinical examination, would have led to a very morbid surgical exploration. This patient was treated with initial chemotherapy, which led to a dramatic response in both symptoms and size of masses, facilitating a complete surgical resection with negligible postoperative morbidity.

METHODS

This was a single-institute retrospective analysis utilizing a prospectively collected database where all patients with locally advanced operable oesophageal cancers with squamous histology diagnosed between 2021 and 2022 were screened and included. All patients received neoadjuvant chemoradiotherapy in accordance with the CROSS protocol with all patients receiving radiotherapy using VMAT technique.

RESULTS

A total of 102 patients with locally advanced oesophageal cancers with squamous histology were included in the study. The median follow-up for the cohort was 29 months. The 3-year overall survival (OS), disease-free survival (DFS), and local control (LC) were 72%, 59.1%, and 72%, respectively. Pathological complete response was 59.4%. The major Clavien-Dindo classification (≥ class 3) of surgical complications was 32%. Lower incidence of pulmonary (17.7%) and cardiac (5.2%) complications was observed in this cohort.

CONCLUSIONS

NACTRT using the CROSS protocol enhances the pathological complete response rates and the survival outcomes in locally advanced oesophageal cancers with squamous histology. The utilization of VMAT has been associated with a reduction in postoperative cardiopulmonary toxicities. However, further prospective randomised studies are required to validate the technique's superiority.

Dual energy CT-derived quantitative parameters and hematological characteristics predict pathological complete response in neoadjuvant chemoradiotherapy esophageal squamous cell carcinoma patients

PURPOSE

There is no gold standard method to predict pathological complete response (pCR) in esophageal squamous cell carcinoma (ESCC) patients before surgery after neoadjuvant chemoradiotherapy (nCRT). This study aims to investigate whether dual layer detector dual energy CT (DECT) quantitative parameters and clinical features could predict pCR for ESCC patients after nCRT.

PATIENTS AND METHODS

This study retrospective recruited local advanced ESCC patients who underwent nCRT followed by surgical treatment from December 2019 to May 2023. According to pCR status (no visible cancer cells in primary cancer lesion and lymph nodes), patients were categorized into pCR group (N = 25) and non-pCR group (N = 28). DECT quantitative parameters were derived from conventional CT images, different monoenergetic (MonoE) images, virtual non-contrast (VNC) images, Z-effective (Zeff) images, iodine concentration (IC) images and electron density (ED) images. Slope of spectral curve (λHU), normalized iodine concentration (NIC), arterial enhancement fraction (AEF) and extracellular volume (ECV) were calculated. Difference tests and spearman correlation were used to select quantitative parameters for DECT model building. Multivariate logistic analysis was used to build clinical model, DECT model and combined model.

RESULTS

A total of 53 patients with locally advanced ESCC were enrolled in this study who received nCRT combined with surgery and underwent DECT examination before treatment. After spearman correlation analysis and multivariate logistic analysis, AEF and ECV showed significant roles between pCR and non-pCR groups. These two quantitative parameters were selected for DECT model. Multivariate logistic analysis revealed that LMR and RBC were also independent predictors in clinical model. The combined model showed the highest sensitivity, specificity, PPV and NPV compared to the clinical and DECT model. The AUC of the combined model is 0.893 (95%CI: 0.802-0.983). Delong's test revealed the combined model significantly different from clinical model (Z =-2.741, P = 0.006).

CONCLUSION

Dual-layer DECT derived ECV fraction and AEF are valuable predictors for pCR in ESCC patients after nCRT. The model combined DECT quantitative parameters and clinical features might be used as a non-invasive tool for individualized treatment decision of those ESCC patients. This study validates the role of DECT in pCR assessment for ESCC and a large external cohort is warranted to ensure the robustness of the proposed DECT evaluation criteria.

The genomic landscape of esophageal squamous cell carcinoma cell lines

BACKGROUND

Research on the genomic characteristics of common esophageal squamous cell carcinoma (ESCC) cell lines, including exome mutations and mRNA expression, is limited. This study aims to elucidate the malignancy, invasion capability, classical cancer-related signaling pathways, and immune status of ESCC cell lines, providing a detailed genomic landscape and highlighting the unique features of each cell line.

METHODS

Whole exome and RNA sequencing were conducted on ESCC cell lines TE-1, ECA-109, KYSE-30, KYSE-150, KYSE-180, KYSE-450, and KYSE-510, with the normal epithelium cell line Het-1a as a comparison. Bioinformatics methods analyzed gene mutation types, mutation frequencies, RNA expression, and classical cancer-related signaling pathways. Specific analyses were also performed on tumor burden, genes related to differentiation, invasion, immunity, and gene enrichment in each cell line.

RESULTS

The highest tumor mutation burden (TMB) was 70.4 mutations per megabase (mut/MB) in KYSE-150, while the lowest was 48.7 mut/MB in KYSE-510. Mutations in the Hippo, Notch, PI3K, RTK-Ras, and Wnt signaling pathways were present in all cancer cell lines. Mutations were significantly enriched in signature 3, associated with defective homologous recombination deficiency (HRD). The NRF2 signaling pathway exhibited mutations in KYSE-180, KYSE-450, and TE-1 cell lines. The cell cycle gene mutation frequency was low, occurring only in KYSE-30 and TE-1 cell lines. The expression profiles of KYSE-510 and ECA-109 were similar. The KYSE-150 cell line showed up-regulated invasion genes, while the KYSE-450 cell line had significantly down-regulated poor differentiation-related genes. Immune-related genes were up-regulated in the ECA-109 cell line.

CONCLUSION

The molecular profiles generated in this study provide detailed information on gene mutations and expression in common ESCC cell lines. The KYSE-150 cell line exhibited a prominent invasion capability, while the ECA-109 cell line showed up-regulated immune properties. This genomic landscape offers valuable insights for future research and therapeutic strategies in ESCC.

The Evolving Role of Immunotherapy for Gastroesophageal Malignancies

The incorporation of immunotherapy has transformed the treatment landscape for advanced, unresectable, or metastatic gastroesophageal cancers (GECs), with improved survival outcomes. These improvements in outcomes for advanced GECs have led to clinical trials evaluating the role of immunotherapy in patients with resectable early-stage GECs. However, there remains a high burden of morbidity and mortality, and ongoing trials utilizing novel immunotherapy agents and combinations are underway. This review summarizes the findings of previous and ongoing clinical trials related to immunotherapy for patients with early- and late-stage GECs.

Comparative Analysis of Long-Term Outcomes Between Near-Infrared Fluorescence Imaging with Indocyanine Green-Guided Mediastinal Lymphadenectomy and Conventional Surgery for Esophageal Cancer

BACKGROUND

This study aimed to compare the long-term oncologic outcomes of NIRF-guided mediastinal lymphadenectomy during esophagectomy with those of conventional surgery.

METHODS

The study enrolled consecutive patients who underwent esophagectomy for esophageal cancer by a single surgical team between September 2017 and July 2021. Patients treated after September 2019 received NIRF-guided mediastinal lymphadenectomy (NIRF group) and were compared with the earlier cohort (historical control group). Propensity-matching analysis was used to compare 3-year overall survival (OS), disease-free survival (DFS), and recurrence patterns between the groups. Survival outcomes were analyzed using Kaplan-Meier curves and Cox regression analysis.

RESULTS

The final analysis included 118 matched patients (NIRF group, 59; historical control group, 59). The median follow-up period for all the patients was 38 months (range, 33-42 months). The NIRF group showed a significantly higher number of total lymph nodes (P = 0.010) and mediastinal lymph nodes (P = 0.045) dissected than the historical control group. The 1- and 3-year DFS rates were 68.1% and 45.2% for the NIRF group versus 74.3% and 55.2% for the historical control group. The OS rates for the NIRF group were 90.6% (1-year rate) and 72.0% (3-year rate) versus 98.3% (1-year rate) and 76.9% (3-year rate) for the historical control group. Both OS and DFS were comparable between the two groups (P = 0.271 and P = 0.356, log-rank test, respectively). Additionally, the two groups had similar recurrence patterns (P = 0.053).

CONCLUSION

The use of NIRF imaging during esophagectomy facilitates precise resection of mediastinal lymph nodes. However, its impact on patient survival remains limited.

Neoadjuvant Immunochemoradiation Therapy Versus Chemoradiation Therapy in Esophageal Cancer: A Systematic Review and Meta-Analysis of Reconstructed Individual Patient Data

Neoadjuvant immunochemoradiation therapy (nICRT) is emerging as a promising treatment for resectable esophageal cancer, but comprehensive analyses comparing it with standard neoadjuvant chemoradiation therapy (nCRT) are limited. This meta-analysis aimed to evaluate the efficacy, safety, and survival outcomes of nICRT versus nCRT. A systematic search of PubMed, Embase, the Cochrane Library, and major conference proceedings up to October 30, 2024, identified studies involving resectable esophageal cancer treated with nICRT or nCRT. Data on pathologic complete response, major pathologic response, treatment-related adverse events, overall survival (OS), and progression-free survival were extracted. A one-stage meta-analysis using reconstructed individual patient data was performed, calculating hazard ratios with 95% CIs. Thirty-seven studies were included, comprising 811 patients treated with nICRT and 1796 with nCRT. nICRT demonstrated significantly longer OS than nCRT (hazard ratio, 0.714; 95% CI, 0.550-0.926; P = .011). The 1-, 2-, and 3-year OS rates were 89.9%, 76.0% and 66.4%, respectively, for nICRT, compared with 85.0%, 66.5%, and 57.3% for nCRT. The pathologic complete response rate was significantly higher in nICRT (50% vs 38%; P = .040) for squamous cell carcinoma. Safety profiles were comparable, with no significant differences in grades 3 and 4 treatment-related adverse events or postoperative complications between the groups. nICRT showed potential for superior survival compared with standard nCRT in resectable esophageal cancer and showed enhanced pathologic response in squamous cell carcinoma, with a possibly acceptable safety profile. These findings support future trials integrating immunotherapy into neoadjuvant treatment regimens for esophageal cancer.

Tislelizumab for the treatment of advanced esophageal squamous cell carcinoma

Advanced esophageal squamous cell carcinoma (ESCC) patients had poor prognosis and few effective drugs based on the randomized controlled trials (RCTs). In such a circumstance, recent RCTs have shown the clinical efficacy of immune checkpoint inhibitors (ICIs) as first- or second-line treatment for advanced ESCC patients. Tislelizumab is one of the anti-Programmed-Death-1 (PD-1) antibodies; at first, tislelizumab monotherapy showed clinical efficacy as a second-line treatment for advanced ESCC patients based on the results of the RATIONALE-302 trial. Since then, tislelizumab plus doublet chemotherapy has shown superiority in overall survival compared to doublet chemotherapy for untreated advanced ESCC patients in the RATIONALE-306 trial. In this review, we share the overview of the development of tislelizumab and discuss the future perspectives on ICIs for advanced ESCC patients. In our opinion, tislelizumab plus doublet chemotherapy is one of the first-line standard treatments for advanced ESCC patients regardless of Programmed cell Death ligand 1 expression. Some other ICI-containing treatments showed clinical efficacy for untreated ESCC patients; we need further investigation to select these treatments appropriately.

Neoadjuvant chemoradiotherapy plus sequential tislelizumab followed by surgery for esophageal carcinoma (CRISEC study): A single-arm, bicentric, phase 2 trial

BACKGROUND AND PURPOSE

To explore the efficacy and safety of neoadjuvant chemoradiotherapy (NCRT) plus sequential tislelizumab followed by surgery for esophageal squamous cell carcinoma (ESCC).

MATERIALS AND METHODS

This single-arm, bicentric, phase 2 trial enrolled patients with resectable or potentially resectable thoracic ESCC to receive neoadjuvant radiotherapy (41.4 Gy in 23 fractions) with concurrent chemotherapy (albumin-bound paclitaxel, 50-100 mg/m2, and carboplatin, area under the curve of 2 mg/ml/min, once weekly, five times) plus sequential tislelizumab (200 mg Q3W, three cycles) followed by surgery. The primary endpoint was pathologic complete response (pCR) rate. The secondary endpoints included safety, R0 resection rate, major pathologic response (MPR) rate, disease-free survival (DFS), and overall survival (OS).

RESULTS

Of the 30 patients enrolled from January 2021 to October 2022, 24 (80.0 %) completed planned surgery and gained R0 resection (100 %). Among the 24 patients, nine (37.5 %) achieved pCR and 21 (87.5 %) achieved MPR. Ten patients (35.7 %) developed grade 3-4 toxicities during tislelizumab therapy, including lymphopenia (32.1 %), neutropenia (3.6 %), and thrombocytopenia (3.6 %). Grade 5 hematemesis occurred in two patients and both were attributed to aortic invasion. Three patients (12.5 %) developed grade 3 postoperative complications, including pulmonary infection (8.3 %) and hoarseness (4.2 %). After a median follow-up of 35.4 months, the 2-year OS and DFS rates were 83.3 % and 79.2 %, respectively.

CONCLUSION

Sequential tislelizumab after NCRT in ESCC is safe and feasible. Further study is warranted to validate the efficacy of this combination mode.

Neoadjuvant Chemoradiotherapy vs Chemoimmunotherapy for Esophageal Squamous Cell Carcinoma

Importance

The association of neoadjuvant chemoimmunotherapy (NCIT) vs chemoradiotherapy (NCRT) with tumor downstaging and survival in locally advanced esophageal squamous cell carcinoma (ESCC) remains unclear because of limited evidence.

Objective

To compare the associations of NCIT and NCRT with tumor regression and long-term survival in patients with locally advanced ESCC.

Design, Setting, and Participants

In this comparative effectiveness research study, from January 2016 to March 2023, patients with locally advanced ESCC who underwent esophagectomy following NCRT or NCIT were identified from a prospective database of 8 high-volume esophageal surgery centers in China. Follow-up began on the date of surgery and continued until the last recorded contact or March 2024, whichever occurred first. Data were analyzed between April and September 2024.

Main Outcomes and Measures

The primary end points were 2-year overall survival (OS) and disease-free survival (DFS). Secondary end points included major pathologic response (MPR) and pathologic complete response (pCR). Cox proportional hazard regression analysis was used to investigate the risk factors for OS and DFS.

Results

The study included 1428 patients (median [IQR] age, 63 [57-68] years; 1184 men [82.9%]), with 704 patients in the NCRT group and 724 patients in the NCIT group. After propensity score matching, there were 532 patients in each group. The 2-year OS (81.3% vs 71.3%; hazard ratio, 1.57; 95% CI, 1.26-1.96; P < .001) and DFS (73.9% vs 63.4%; hazard ratio, 1.37; 95% CI, 1.11-1.69; P < .001) rates were significantly higher in NCIT group than in the NCRT group. The NCRT group had a higher MPR rate than that of the NCIT group (71.8% vs 61.5%), whereas the pCR rates were similar (25.9% vs 22.9%). Multivariable Cox analysis demonstrated that NCIT and MPR were independently associated with both OS and DFS. The NCIT group exhibited a lower overall recurrence rate (126 patients [23.7%] vs 190 patients [35.7%]) and distant metastasis rate (72 patients [13.5%] vs 133 patients [25.0%]), although locoregional metastasis rates were similar (98 patients [18.4%] vs 111 patients [20.9%]). Better OS and DFS were obtained for the NCIT group than for the NCRT group, regardless of whether adjuvant immunotherapy was given.

Conclusions and Relevance

Compared with NCRT, patients with locally advanced ESCC receiving NCIT had better 2-year OS and DFS. The decrease in distant metastasis may be the main reason, but further prospective randomized clinical trials are needed to verify this finding.

Neoadjuvant radiochemotherapy in patients with high-risk locally advanced cervical cancer-results of a clinical series

PURPOSE

Neoadjuvant radiochemotherapy (NARCT) is an established standard of care in various tumor entities, promoting high response rates at commonly lower toxicities as compared to adjuvant approaches. This retrospective analysis was designed to investigate NARCT in early-stage high-risk cervical cancer.

METHODS

Forty patients with early-stage high-risk cervical cancer (i.e., L1, V1, G3, N+, > 2/3 stromal invasion, > 4 cm tumor size, borderline resectability) were treated with NARCT prior to surgical resection. Downstagings based on clinical, imaging, and pathological responses were recorded. Survival rates were calculated according to Kaplan-Meier, and prognostic factors were analyzed with uni- and multivariable Cox regression analyses using SPSS software (v. 26; IBM Corp., Armonk, NY, USA).

RESULTS

Both NARCT and subsequent tumor resection were feasible and conducted in 39 of 40 patients (95%). Early toxicity was moderate, with no grade 3 or higher toxicities following NARCT and surgery. NARCT yielded significant downstaging in all patients, and pathological complete remission (pCR) was achieved in 14 patients (36%). After 5 years, overall survival (OS), freedom from local progression (FFLP), and freedom from distant progression (FFDP) rates were 84.2%, 75.9%, and 73.1%, respectively. Late proctitis (grade 1 in 8%) and urinary cystitis (grade 1-3 in 35%) occurred at acceptable rates.

CONCLUSION

In resectable early-stage high-risk cervical cancer, NARCT is feasible and safe. Clinical, imaging, and pathological response rates are high. Impressive long-term survival and tumor control rates at modest toxicities encourage the initiation of a prospective and randomized trial.

Pristimerin induces Noxa-dependent apoptosis by activating the FoxO3a pathway in esophageal squamous cell carcinoma

Pristimerin, which is one of the compounds present in Celastraceae and Hippocrateaceae, has antitumor effects. However, its mechanism of action in esophageal squamous cell carcinoma (ESCC) remains unclear. This study aims to investigate the efficacy and mechanism of pristimerin on ESCC in vitro and in vivo. The inhibitory effect of pristimerin on cell growth was assessed using trypan blue exclusion and colony formation assays. Cell apoptosis was evaluated by flow cytometry. Gene and protein expressions were analyzed through quantitative reverse transcription-polymerase chain reaction (qRT-PCR), Western blotting, and immunohistochemistry. RNA sequencing (RNA-Seq) was employed to identify significantly differentially expressed genes (DEGs). Cell transfection and RNA interference assays were utilized to examine the role of key proteins in pristimerin?s effect. Xenograft models were established to evaluate the antitumor efficiency of pristimerin in vivo. Pristimerin inhibited cell growth and induced apoptosis in ESCC cells. Upregulation of Noxa was crucial for pristimerin-induced apoptosis. Pristimerin activated the Forkhead box O3a (FoxO3a) signaling pathway and triggered FoxO3a recruitment to the Noxa promoter, leading to Noxa transcription. Blocking FoxO3a reversed pristimerin-induced Noxa upregulation and cell apoptosis. Pristimerin treatment suppressed xenograft tumors in nude mice, but these effects were largely negated in Noxa-KO tumors. Furthermore, the chemosensitization effects of pristimerin in vitro and in vivo were mediated by Noxa. This study demonstrates that pristimerin exerts an antitumor effect on ESCC by inducing AKT/FoxO3a-mediated Noxa upregulation. These findings suggest that pristimerin may serve as a potent anticancer agent for ESCC treatment.

Outcomes of Intraoperative Radiotherapy for Locally Advanced Adenocarcinoma of the Esophagogastric Junction After Neoadjuvant Therapy: A Single-Arm, Phase 1 Trial From the Chinese National Cancer Center

BACKGROUND

The role of intraoperative radiotherapy (IORT) for adenocarcinoma of the esophagogastric junction (AEG) remains uncertain. Therefore, a prospective phase 1 trial was conducted to assess the safety and feasibility of IORT for locally advanced AEG.

METHODS

The study enrolled patients with AEG at stages II-IVA from January 2019 to September 2019. Eligible patients received esophagectomy and a single fraction of electron beam radiotherapy. The primary endpoint of the study was a safety profile for IORT. Additionally, survival outcomes and the locoregional recurrence rate (LRR) were compared between the non-IORT and IORT cohorts using propensity score-matching.

RESULTS

For 15 (93.8 %) of the 16 patients in the study, R0 resection was successfully achieved, with only one patient undergoing R1 resection. A total postoperative complication morbidity rate of 43.8 % (7/16) was observed, with major complications (Clavien-Dindo classification ≥3) in 12.5 % of the cases (2/16). Total treatment-related adverse events were reported for seven patients (43.8 %, 7/16). After matching, a lower LRR was observed in the IORT group than in the non-IORT group (0 % [0/12] vs 33.3 % [4/12]; p = 0.028). However, the two groups did not differ significantly in 3-year progression-free survival (PFS: IORT [50.9 %] vs non-IORT [53.4 %]; p = 0.93) or 3-year overall survival (OS: IORT [58.3 %] vs IORT [72.9 %]; p = 0.23).

CONCLUSIONS

The current study demonstrated favorable feasibility and safety of IORT for locally advanced AEG. Although IORT is beneficial for improving local control, it may not prolong PFS or OS for patients with locally advanced AEG. A phase 2 trial is warranted for further validation of these outcomes.

Defining the Optimal Radiation-induced Lymphopenia Metric to Discern Its Survival Impact in Esophageal Cancer

PURPOSE

A detrimental association between radiation-induced lymphopenia (RIL) and oncologic outcomes in patients with esophageal cancer has been established. However, an optimal metric for RIL remains undefined but is important for the application of this knowledge in clinical decision-making and trial designs. The aim of this study was to find the optimal RIL metric discerning survival.

METHODS AND MATERIALS

Patients with esophageal cancer treated with concurrent chemoradiation therapy (CRT; 2004-2022) were selected. Studied metrics included absolute lymphocyte counts (ALCs) and neutrophil counts-and calculated derivatives-at baseline and during CRT. Multivariable Cox regression models for progression-free survival (PFS) and overall survival (OS) were developed for each RIL metric. The optimal RIL metric was defined as the one in the model with the highest c-statistic.

RESULTS

Among 1339 included patients, 68% received photon-based and 32% proton-based CRT (median follow-up, 24.9 months). In multivariable analysis, the best-performing models included "ALC in week 3 of CRT" (corrected c-statistic 0.683 for PFS and 0.662 for OS). At an optimal threshold of <0.5 × 103/μL (ie, grade ≥3 RIL), ALC in week 3 was significantly associated with PFS (adjusted hazard ratio, 1.64; 95% CI, 1.27-2.13) and OS (adjusted hazard ratio, 1.56; 95% CI, 1.15-2.08), with 5-year PFS of 29% vs 40% and OS of 38% vs 51%, respectively.

CONCLUSIONS

Reaching grade ≥3 RIL in week 3 of CRT for esophageal cancer is the strongest RIL metric to distinguish survival outcomes. We suggest that this metric should be the target for lymphopenia-mitigating strategies and propose this metric to be included in future trials.

Neoadjuvant immunochemotherapy for locally advanced esophageal squamous cell carcinoma in real-world practice: an analysis of the clinical outcomes and long-term survival, and the feasibility of using major pathological response as a surrogate endpoint

BACKGROUND

Neoadjuvant immunochemotherapy is expected to become the standard treatment mode for locally advanced esophageal squamous cell carcinoma (ESCC). This study aims to analyze the clinical outcomes and long-term survival of neoadjuvant immunochemotherapy for locally advanced ESCC, and explore the feasibility of using major pathological response (MPR) as a surrogate endpoint.

METHODS

This real-world retrospective study consecutively included eligible patients with stage II-IVA locally advanced ESCC who received neoadjuvant immunochemotherapy and surgery between 2019 and 2022 at the Department of Thoracic Surgery, the First Affiliated Hospital, Zhejiang University School of Medicine.

RESULTS

This study collected a total of 166 patients, and ultimately included 126 patients after screening. The objective response rate (ORR) was 69.8% (88/126). The incidence of grade 3-4 adverse events (AEs) was 13.5% (17/126). MPR was observed in 49 (38.9%) patients, and 24 (19.0%) patients achieved a complete pathological response (pCR). The median progression-free survival (PFS) was 31.7 months and the 3-year PFS rate was 56.3%. The median overall survival (OS) was not reached and the 3-year OS rate was 70.6%. The median PFS of the non-MPR group was 25.0 months, with the MPR group not achieved (hazard ratio [HR], 2.503; 95% CI 1.359-4.610; P = 0.0022). The median OS in the non-MPR group was 31.7 months and not reached in the MPR group (HR, 3.607; 95% CI 1.576-8.254; P = 0.0012). MPR is an independent prognostic factor affecting OS (HR, 2.522; 95% CI 1.018-6.401; P = 0.046).

CONCLUSIONS

Neoadjuvant immunochemotherapy is safe and effective for locally advanced ESCC, and can result in certain survival benefits. MPR can serve as a surrogate endpoint for predicting long-term OS.

Identification and validation of poor prognosis immunoevasive subtype of esophageal cancer with tumor-infiltrating SAMD3 + NK cell abundance

INTRODUCTION

Esophageal cancer (EC) remains highly lethal due to tumor microenvironment (TME)-mediated immune evasion. While natural killer (NK) cells are central to antitumor immunity, their functional states in EC are poorly characterized.

METHODS

We integrated bulk RNA-seq (TCGA/GEO) and single-cell data to construct an NK cell-derived prognostic signature (NK score) via LASSO-Cox regression. Immunofluorescence was applied to assess the clinical relevance of SAMD3 + NK cells in EC. Using both xenograft mouse models and in vitro co-culture procedures, the impact of SAMD3 on NK cell function was confirmed.

RESULTS

In EC patients, the prognostic NK score-which is generated from important NK cell markers including SAMD3-was substantially correlated with a worse chance of survival. NK cells within the TME had significant levels of SAMD3 expression, as seen by immunofluorescence labeling. Moreover, NK cells with SAMD3 knockdown exhibited enhanced antitumor activity, leading to decreased tumor development in the xenograft model.

DISCUSSION

Our results demonstrate the predictive significance of NK cell markers in EC and pinpoint SAMD3 as a critical modulator of NK cell activity. We pioneer SAMD3 + NK cells as architects of TME immunosuppression in EC. Our findings nominate SAMD3 inhibition as a combinatorial strategy to overcome immune checkpoint blockade resistance.

Long-term trends in the clinical management and outcomes of patients with gastroesophageal cancer in Norway

BACKGROUND AND PURPOSE

Gastroesophageal cancers are highly prevalent internationally, with many patients diagnosed with metastatic disease, leading to challenging treatment and poor survival. This study uses real-world evidence from a population-level database to describe demographics, clinical characteristics, initial treatment patterns, and survival for patients with gastroesophageal cancer in Norway.

MATERIAL AND METHODS

Individual patient data was sourced from the Cancer Registry of Norway for patients diagnosed with oesophageal squamous cell carcinoma (ESCC), oesophageal adenocarcinoma (EAC), gastroesophageal junction cancer (GEJC), and gastric cancer from 2001 to 2021, with follow-up from diagnosis to death or last follow-up. Treatment patterns were captured from 2010 to 2022, defined as curative or palliative based on surgery, chemotherapy, and radiotherapy.

RESULTS AND INTERPRETATION

The cohort included 14,334 Norwegian patients with gastroesophageal cancer; predominantly male, mean age 69-73 years, with a median follow-up of 9-11 months across cancer subtypes. Approximately 40% of patients received curative treatment, and multi-modality treatments increased for EAC, GEJC, and ESCC. Median survival ranged from 6 to 11 months for patients treated palliatively, and 17-95 months for those treated with curative intent. Interestingly, median survival was higher for patients with EAC and GEJC treated with neoadjuvant chemotherapy (86.1 and 75.1 months) versus neoadjuvant chemoradiotherapy (49.1 and 42.1 months), which was confirmed by a multivariate Cox regression model adjusted for age, sex, and disease stage. This study demonstrates that multimodal treatment strategies, consisting of chemotherapy and surgery, may be associated with improved survival outcomes for gastroesophageal cancers. Future studies are required to identify optimum treatment strategies for gastroesophageal cancer subtypes.

Regulatory T Cell Infiltration-Driven Single-Cell Transcriptomic Analysis Identifies SAP18 as a Prognostic Marker for Esophageal Squamous Cell Carcinoma

BACKGROUND

Advanced esophageal squamous cell carcinoma (ESCC) is characterized by molecular heterogeneity and distinct patterns of immune cell infiltration. Regulatory T cells (Tregs), in particular, play a critical role in shaping an immunosuppressive tumor microenvironment (TME), which is associated with poor clinical outcomes.

METHODS

We developed a prognostic model by integrating GEO-derived bulk RNA sequencing data and single-cell transcriptome. Model predictions were confirmed through RT-qPCR, Western blot, and immunohistochemistry on clinical specimens, while in vitro assays (CCK8, transwell invasion, scratch, colony formation, and immunofluorescence) validated the function of SAP18 in cell proliferation, invasion, and ECM remodeling.

RESULTS

Expression patterns of the 5 Tregs-associated genes in clinical specimens aligned with model predictions, underscoring the model's robustness. The high-risk subgroup was associated with upregulated extracellular matrix (ECM) remodeling, an abundance of immune-suppressive cells, higher TP53 mutation rate, and limited benefit from immunotherapy. In contrast, the low-risk subgroup exhibited anti-tumor immunity. Cell-cell communication analysis also implicated the collagen pathway in Tregs-mediated immune evasion in ESCC. Functional assays indicated that SAP18 in the prognostic model significantly promotes proliferation, invasion, and ECM reconstruction, further highlighting its potential as a therapeutic target.

CONCLUSION

Our findings elucidate the role of Tregs in the TME, underscoring significant potential of SAP18, which is essential for assessing patient prognosis and may facilitate the development of personalized therapies for ESCC.

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.

Adjuvant TRastuzumab deruxtecan plus fluoropyrimidine versus standard chemotherapy in HER2-positive gastric or gastroesophageal cancer patients with persistence of minimal residual disease in liquid biopsy after pre-operative chemotherapy and radical surgery: the multicentre, phase II randomized TRINITY trial

BACKGROUND

The standard treatment for localized/locally advanced gastroesophageal adenocarcinoma (GEA) is radical surgery and peri-operative FLOT treatment (5-fluorouracil plus leucovorin, oxaliplatin, and docetaxel), but around half patients still experience disease relapse. In gastrointestinal cancers, the presence of circulating tumor DNA (ctDNA) after surgery is associated with a high risk of relapse, and the lack of ctDNA clearance after post-operative treatment is strongly associated with early relapse. Therefore, liquid biopsy may guide the selection of patients with micrometastatic disease after preoperative chemotherapy and surgery for non-cross resistant regimens in the post-operative setting. Trastuzumab deruxtecan (T-DXd) is approved in patients with HER2-positive advanced gastric or gastroesophageal adenocarcinoma after failure of at least one prior trastuzumab-based regimen. The DESTINY-Gastric01 and 02 trials showed remarkable activity and efficacy of T-DXd, thus supporting the investigation of this agent in early-stage disease to increase the chance of achieving disease eradication. Finally, the DESTINY-Gastric03 trial showed the safety profile and feasibility, with preliminary promising activity results of the combination of T-DXd with a fluoropyrimidine.

TRIAL DESIGN

TRINITY is an ongoing multicentre, randomized, open-label, interventional phase II study which will enroll approximately 46 patients with HER2-positive GEA, treated with pre-operative FLOT and radical surgery, and with the persistence of minimal residual disease detected by the Signatera™ assay in a liquid biopsy collected between 2 and 6 weeks after surgery. The trial is designed with an observational phase enrolling patients with HER2-positive GEA eligible for standard treatment with peri-operative FLOT and surgery. Eligible patients will be randomized on a 1:1 basis to the experimental treatment arm consisting of adjuvant T-DXd (6.4 mg/kg IV on day 1) plus either capecitabine (1000 mg/sqm BID orally on days 1-14) or 5-fluorouracil (600 mg/sqm continuous IV infusion on days 1-5) Q3 W for 6 cycles, or to the control arm with standard post-operative FLOT (at the same dose used during the last pre-operative cycle) for 4 cycles. Patients non-eligible for the interventional trial will continue the standard therapy and follow-up in the frame of the observational phase with collection of exploratory longitudinal liquid biopsies. The primary objective is ctDNA clearance at 1 year after randomization. Considering alpha- and beta-errors of 0.10 and 0.20 and hypothesizing a ctDNA clearance of 10% and 35% in the control and experimental arm, respectively, 23 patients per arm are required to prove the superiority of the experimental strategy. Secondary endpoints include disease-free survival, overall survival, metastases-free survival, patient-reported outcomes and safety. The trial also represents a translational platform, including extensive analysis of circulating, tissue, and immune biomarkers as exploratory endpoints. Enrollment is active and ongoing.

TRIAL REGISTRATION

TRINITY is registered at ClinicalTrials.gov (NCT06253650).

Neoadjuvant sintilimab and chemotherapy for resectable esophageal squamous cell carcinoma: a phase II clinical trial

Background

Combination of anti-PD-1 monoclonal antibody with chemotherapy has been widely used as a first-line treatment for metastatic esophageal squamous cell carcinoma (ESCC). However, the efficacy of this therapeutic combination as a neoadjuvant intervention for resectable ESCC remains inadequately explored. This study aims to evaluate the efficacy and safety of sintilimab in combination with chemotherapy as a neoadjuvant therapy for ESCC.

Methods

In this single-arm, phase II study, patients with histopathologically diagnosed resectable ESCC who had clinical cT1-3/N0-1M0 (stage II-III) were recruited. Sintilimab (200mg, iv, d1) in combined with chemotherapy (nab-paclitaxel 260 mg/m2, d1 and cisplatin 75 mg/m2, d1-3) were administered every 3 weeks for 2 cycles. The primary endpoint was pathological complete response (pCR).

Results

From November 2020 through November 2022, 29 patients were enrolled and 27 completed the two cycles of neoadjuvant therapy. A total of 21 patients underwent surgery. The pCR rate was 28.6% (6/21) and the major pathologic response (MPR) rate was 42.9% (9/21). The most common Grade 3 or 4 treatment-related adverse events were leukopenia (26.7%) and neutropenia (20%). No delays in surgical procedures or unexpected surgical complications attributable to the treatment were reported.

Conclusions

The combination of sintilimab and chemotherapy as a neoadjuvant regimen was tolerable and associated with favorable responses for ESCC patients. Given these favorable results, this regimen could serve as a viable alternative in the neoadjuvant treatment landscape for ESCC, with particular applicability to Chinese patient populations.

Clinical trial registration

https://www.chictr.org.cn/, identifier ChiCTR2000040345.

Trifluridine/Tipiracil and Oxaliplatin as Induction Chemotherapy in Resectable Esophageal and Gastroesophageal Junction Adenocarcinoma: A Phase II Study

BACKGROUND

Preoperative chemoradiation (CRT) followed by surgery for localized esophageal and gastroesophageal junction adenocarcinoma (EGAC) is a standard of care with a pathologic complete response (pCR) rate of 20%. We evaluated a novel combination of trifluridine/tipiracil with oxaliplatin as induction chemotherapy (IC) followed by CRT.

METHODS

We enrolled patients with potentially resectable localized EGAC (T3, T4aN0, or node-positive disease) in this open-label, single-arm, multicenter, Phase II trial between January 2020 and October 2022. Patients received three cycles of IC with trifluridine/tipiracil and oxaliplatin and then underwent concurrent CRT with weekly carboplatin and paclitaxel followed by surgery. The primary objective was to evaluate the pCR rate. The secondary objectives were to evaluate 2-year progression-free survival (PFS), 2-year overall survival (OS), and toxicities. Circulating tumor DNA (ctDNA) was measured at prespecified intervals to assess its correlation with clinical outcomes.

RESULTS

Of the 22 enrolled patients, 19 (86.4%) were male and 20 (90.9%) were Caucasian. The median age was 61 years, and 12 (54.5%) had their primary disease at the gastroesophageal junction. Twenty (90.9%) patients had T3 disease, and 15 (68.2%) had node-positive disease. Only two patients had pCRs, and an additional five had near pCRs. Since we could not meet our predefined pCR rate at the interim analysis, the study was closed. After a median follow-up of 15.8 months, 2-year OS and PFS were 43% and 41%, respectively. ctDNA clearance was associated with a significantly higher OS rate (p = 0.012) and PFS rate (p = 0.008). Nausea (59.1%) and fatigue (59.1%) were common treatment-related adverse events (AEs); nine (40.9%) patients had Grade 3 or higher AEs.

CONCLUSION

IC with trifluridine/tipiracil and oxaliplatin followed by CRT did not improve pCR rate in resectable EGAC compared to pCR from previous reports with CRT alone. We found a correlation between ctDNA clearance and improved survival, which merits further investigation.

CLINICAL TRIAL INFORMATION

NCT04097028.

Neoadjuvant chemoradiotherapy followed by active surveillance versus standard surgery for oesophageal cancer (SANO trial): a multicentre, stepped-wedge, cluster-randomised, non-inferiority, phase 3 trial

BACKGROUND

A substantial proportion of individuals with oesophageal cancer have a pathological complete response after neoadjuvant chemoradiotherapy and oesophagectomy. We aimed to investigate whether active surveillance could be an alternative for individuals with a clinical complete response after neoadjuvant chemoradiotherapy.

METHODS

We performed a multicentre, stepped-wedge, cluster-randomised, non-inferiority, phase 3 trial in 12 Dutch hospitals. Individuals with locally advanced oesophageal cancer and a clinical complete response after neoadjuvant chemoradiotherapy (ie, no tumour detected with endoscopic biopsies, ultrasound, and PET-CT) underwent active surveillance or standard surgery (ie, oesophagectomy within 2 weeks after reaching clinical complete response). There were no inclusion restrictions regarding comorbidities or performance status, but participants had carcinoma, were age 18 years or older, and were treated with curative intent. Randomisation of hospitals was performed using computer-generated sequences without stratification methods, after an initial phase of all hospitals performing standard surgery. The primary endpoint was overall survival, analysed according to a modified intention-to-treat principle (allowing crossover at time of clinical complete response) and an intention-to-treat principle. Non-inferiority was defined as 2-year survival rate for active surveillance of 15% or less below that for standard surgery. The trial was registered within the Netherlands Trial Register, NTR-6803, and the inclusion phase has been completed.

FINDINGS

Between Nov 8, 2017, and Jan 17, 2021, 1115 individuals were screened, of whom 309 were included. 198 underwent active surveillance and 111 underwent standard surgery. 242 (78%) participants were male and 67 (22%) were female. Median follow-up was 38 months (IQR 32-48). 2-year overall survival for active surveillance (74% [95% CI 69-78]) was non-inferior to standard surgery (71% [62-78]) after modified intention-to-treat analysis (one-sided 95% boundary: 7% lower). It remained non-inferior in the intention-to-treat analysis (75% [68-80] vs 70% [63-77], one-sided 95% boundary: 6% lower). There were no significant differences in overall survival according to modified intention-to-treat analysis (hazard ratio 1·14, two-sided 95% CI 0·74-1·78) or intention-to-treat analysis (0·83, 0·53-1·31). The frequency of postoperative complications and postoperative mortality after standard surgery or postponed surgery after active surveillance was similar between groups.

INTERPRETATION

Overall survival after active surveillance for oesophageal cancer was non-inferior compared with standard surgery after 2 years. For the long-term efficacy of active surveillance, extended follow-up is required. The results of the present trial could be used for patient counselling and shared decision making.

FUNDING

Dutch Cancer Society (KWF) and Netherlands Organisation for Health Research and Development (ZonMw).

Neoadjuvant Therapy-Associated CDX2 Expression and Its Prognostic Implication in Esophageal Adenocarcinoma

Neoadjuvant chemoradiotherapy followed by surgery is the standard care for locally advanced esophageal adenocarcinoma. However, reliable postoperative prognostic biomarkers are still needed to stratify patients with different clinical outcomes. This study aimed to investigate postneoadjuvant expression changes of CDX2 and its association with histopathological features, biomarkers for targeted therapy, distant metastasis, and survival status. A total of 62 esophagogastrectomy specimens from one institution were evaluated. A tissue microarray was constructed, and IHC staining was performed. CDX2 expression was found in 27 (43.5%) cases with well-to-poor differentiation. Compared with preoperative biopsies, 68.8% of cases demonstrated induced or enhanced CDX2 expression. There were no significant differences in age, tumor location, histologic grade, lymph node metastasis, tumor stage, and treatment response between CDX2-positive and CDX2-negative groups. Neuroendocrine and Paneth cell differentiation induced by neoadjuvant therapy were more commonly seen in CDX2-positive cases. CDX2 expression was associated with higher multidrug resistance-1 and HER-2 expression. Patients with CDX2-positive diseases showed a higher risk of distant metastasis and a worse prognosis than those with CDX2-negative diseases.

Voxel-level radiomics and deep learning for predicting pathologic complete response in esophageal squamous cell carcinoma after neoadjuvant immunotherapy and chemotherapy

BACKGROUND

Accurate prediction of pathologic complete response (pCR) following neoadjuvant immunotherapy combined with chemotherapy (nICT) is crucial for tailoring patient care in esophageal squamous cell carcinoma (ESCC). This study aimed to develop and validate a deep learning model using a novel voxel-level radiomics approach to predict pCR based on preoperative CT images.

METHODS

In this multicenter, retrospective study, 741 patients with ESCC who underwent nICT followed by radical esophagectomy were enrolled from three institutions. Patients from one center were divided into a training set (469 patients) and an internal validation set (118 patients) while the data from the other two centers was used as external validation sets (120 and 34 patients, respectively). The deep learning model, Vision-Mamba, integrated voxel-level radiomics feature maps and CT images for pCR prediction. Additionally, other commonly used deep learning models, including 3D-ResNet and Vision Transformer, as well as traditional radiomics methods, were developed for comparison. Model performance was evaluated using accuracy, area under the curve (AUC), sensitivity, specificity, and prognostic stratification capabilities. The SHapley Additive exPlanations analysis was employed to interpret the model's predictions.

RESULTS

The Vision-Mamba model demonstrated robust predictive performance in the training set (accuracy: 0.89, AUC: 0.91, sensitivity: 0.82, specificity: 0.92) and validation sets (accuracy: 0.83-0.91, AUC: 0.83-0.92, sensitivity: 0.73-0.94, specificity: 0.84-1.0). The model outperformed other deep learning models and traditional radiomics methods. The model's ability to stratify patients into high and low-risk groups was validated, showing superior prognostic stratification compared with traditional methods. SHAP provided quantitative and visual model interpretation.

CONCLUSIONS

We present a voxel-level radiomics-based deep learning model to predict pCR to neoadjuvant immunotherapy combined with chemotherapy based on pretreatment diagnostic CT images with high accuracy and robustness. This model could provide a promising tool for individualized management of patients with ESCC.

Hypoxia-Induced Senescent Fibroblasts Secrete IGF1 to Promote Cancer Stemness in Esophageal Squamous Cell Carcinoma

Cancer-associated fibroblasts (CAF) contribute to cancer initiation and progression and play a pivotal role in therapeutic response and patient prognosis. CAFs exhibit functional and phenotypic heterogeneity, highlighting the need to clarify the specific subtypes of CAFs to facilitate the development of targeted therapies against protumorigenic CAFs. In this study, using single-cell RNA sequencing on patient samples of esophageal squamous cell carcinoma (ESCC), we identified a CAF subcluster associated with tumor stemness that was enriched in genes associated with hypoxia and senescence. The CAF subpopulation, termed as hypoxia-induced senescent fibroblasts (hsCAF), displayed high secretion of insulin-like growth factor 1 (IGF1). The hsCAFs inhibited AMP-activated protein kinase (AMPK) activity in cancer cells via IGF1 to promote tumor stemness. The formation of hsCAFs was induced by the synergetic effect of hypoxia and cancer cells. Activation of nuclear factor erythroid 2-related factor 2 (NRF2) in cancer cells under hypoxia drove IL1α production to trigger CAF senescence and IGF1 secretion via nuclear factor I A. Knockout of IGF1 in CAFs or nuclear factor erythroid 2-related factor 2 in ESCC cells suppressed the tumor growth and chemotherapy resistance induced by CAFs in vivo. Importantly, patients with high proportions of hsCAFs showed poor survival and a worse response to chemotherapy. In summary, these findings identify a hsCAF subpopulation generated by interplay between cancer cells and CAFs under hypoxic conditions that promotes ESCC stemness and reveal targeting hsCAFs as an effective therapeutic strategy against chemotherapy-resistant ESCC. Significance: A hypoxic microenvironment and cancer cells cooperate to induce a senescent fibroblast subset that supports tumor stemness, suggesting that targeting this cancer-associated fibroblast subpopulation is a potential therapeutic strategy to overcome chemoresistance.

Radiotherapy quality assurance in the PROTECT trial - a European randomised phase III-trial comparing proton and photon therapy in the treatment of patients with oesophageal cancer

PURPOSE

To present results from the trial radiotherapy quality assurance (RTQA) programme of the centres involved in the randomised phase-III PROton versus photon Therapy for esophageal Cancer - a Trimodality strategy (PROTECT)-trial, investigating the clinical effect of proton therapy (PT) vs. photon therapy (XT) for patients with oesophageal cancer.

MATERIALS AND METHODS

The pre-trial RTQA programme consists of benchmark target and organ at risk (OAR) delineations as well as treatment planning cases, a facility questionnaire and beam output audits. Continuous on-trial RTQA with individual case review (ICR) of the first two patients and every fifth patient at each participating site is performed. Patient-specific QA is mandatory for all patients. On-site visits are scheduled after the inclusion of the first two patients at two associated PT and XT sites. Workshops are arranged annually for all PROTECT participants.

RESULTS

Fifteen PT/XT sites are enrolled in the trial RTQA programme. Of these, eight PT/XT sites have completed the entire pre-trial RTQA programme. Three sites are actively including patients in the trial. On-trial ICR was performed for 22 patients. For the delineation of targets and OARs, six major and 11 minor variations were reported, and for six patients, there were no remarks. One major and four minor variations were reported for the treatment plans. Three site visits and two annual workshops were completed.

INTERPRETATION

A comprehensive RTQA programme was implemented for the PROTECT phase III trial. All centres adhered to guidelines for pre-trial QA. For on-trial QA, major variations were primarily seen for target delineations (< 30%), and no treatment plans required re-optimisation.

PET/CT and MR Improve Interobserver Agreement in Primary Tumor Determination for Radiotherapy in Esophageal Squamous Cell Cancer

Background/Objectives: The aim of the study was to evaluate interobserver variability in the determination of the primary tumor for radiotherapy treatment planning in esophageal squamous cell carcinoma (ESCC). Methods: Sixteen patients with locally advanced ESCC were included in the analysis. In all patients positron emission tomography with computed tomography (PETC/CT) and magnetic resonance (MR) scans for radiotherapy planning were performed. Five experienced radiation oncologists delineated the primary tumor based on CT alone, MR alone, PET/CT, CT with fused MR and PET/CT with fused MR. Mean tumor volumes were calculated for each patient and imaging modality. The generalized conformity index (CIgen) was calculated to assess agreement in tumor determination. Results: The mean tumor volumes and CIgen for CT alone, MR alone, PET/CT, CT with fused MR and PET/CT with fused MR were 33.1 cm3, 30.2 cm3, 38.1 cm3, 31.9 cm3, 36.2 cm3 and 0.59, 0.64, 0.66, 0.63, 0.71, respectively. CIgen was significantly higher using PET/CT with fused MR compared to CT (p < 0.001) and PET/CT (p = 0.002) and using PET/CT compared to CT (alone) (p = 0.003). Conclusions: Our study showed higher agreement in primary tumor determination in ESCC using PET/CT compared to CT alone. Higher agreement was also found using PET/CT with fused MR compared to CT alone and PET/CT.

Effects of different treatments on the prognosis of patients with single-organ oligometastasis of esophageal cancer after surgery-a retrospective single center study

Objective

To investigate the impact of clinicopathological factors on the prognosis of patients with single-organ oligometastasis of esophageal cancer (soOMEC) following surgery and to develop prognostic nomograms.

Methods

This was a retrospective analysis of 144 patients with soOMEC after surgery in a single center who met the inclusion criteria. First, Cox univariate and multivariate models were used to analyze (SPSS 25.0 statistical software) the characteristics of patients, and independent prognostic factors for postoperative overall survival (OS) and OS after oligometastasis (OM-OS) were determined. Prognosis was analyzed using R language software, nomograms were created based on the Cox multivariate analysis results, a bootstrap method (b=200) was used for internal validation, and receiver operating characteristic (ROC) and calibration curves were used to validate the models.

Results

From January 2014 to December 2017, a total of 1595 patients with esophageal cancer received R0 resection. As of the end of the follow-up period, 144 patients had single-organ oligometastasis (soOM). The median time to oligometastasis (TTO) in the whole group of patients was 14.2 months, and the 1-, 3-, and 5-year OS rates were 75.7%, 28.2%, and 13.3%, respectively. The median OS was 25.0 months (95% confidence interval (CI): 21.8-28.2); the 1-, 2-, and 3-year OS rates after distant metastasis (DM-OS) were 25.5%, 13.3%, and 7.2%, respectively, and the median DM-OS was 5.5 months (95% CI: 3.9-7.1). The Cox multivariate analysis results showed that three indicators, i.e., TNM stage (hazard ratio (HR)=2.192, 95% CI: 1.441-3.336, P=0.000), TTO (HR=0.119, 95% CI: 0.073-0.194, P=0.000), and treatment after DM (HR=0.784, 95% CI: 0.970-0.025, P=0.025) were independent prognostic factors affecting the OS of patients; TTO (HR=0.669, 95% CI: 0.455-0.984, P=0.041) and treatment after DM (HR=0.713, 95% CI: 0.559-0.910, P=0.007) were independent prognostic factors affecting the DM-OS of patients. Using the Cox multivariate analysis results, prediction nomograms for total OS and DM-OS of patients were established. In the validation of the nomogram models, the areas under the curve (AUCs) for the 1-, 3-, and 5-year total OS were 0.930, 0.927, and 0.928 in the training set and 0.705, 0.856, and 1 in the validation set, respectively; the AUCs for the 1-, 2-, and 3-year DM-OS were 0.904, 0.923, and 0.908 in the training set and 0.928, 0.842, and 0.895 in the validation set, respectively. The results showed that the two models have strong discriminative ability and good clinical promotion and application value.

Conclusions

Aggressive local therapy combined with systemic chemotherapy can benefit patients with soOMEC after surgery, and for patients with OM appearing at 1 year after surgery, aggressive radiotherapy or combined chemotherapy is expected to improve the prognosis and prolong OS. The nomogram models developed in this study demonstrated strong predictive performance in internal validation and hold potential as clinical tools for estimating the prognosis of patients and assisting in treatment decision-making. However, their true clinical utility and generalizability require further validation through larger, multicenter, and prospective studies.

What are the outcomes for long-term survivors after esophagectomy ? - Evidence from a randomized controlled trial (FFCD9901)

BACKGROUND

Little is known regarding long-term outcomes of survivors beyond 5 years after esophagectomy. This study assesses oncological outcomes of long-term survivors of esophageal cancer.

METHODS

Data is derived from a multi-center randomized controlled trial comparing neoadjuvant chemoradiotherapy (NCRT) and surgery to surgery alone for clinically stage I and II esophageal cancers (FFCD9901). Only patients undergoing esophagectomy were included in this study. Clinicopathological variables of 5-year survivors were analyzed. Multivariate logistic regression analysis identified factors predictive of death prior to 5 years. Patterns of disease recurrence and second primary tumor development were established.

RESULTS

From June 2000 until June 2009, 195 patients from 30 French centers were randomly assigned to NCRT followed by surgery or surgery alone. Of 170 patients who underwent esophagectomy, 70 patients were alive at 5 years - an overall 5-year survival of 41.2 %. In logistic regression multivariate analysis, WHO performance status of ≥1 (p = 0.045), advanced pT category (p = 0.030) and post-operative complications (p = 0.047) predicted death prior to 5 years. Twenty patients died after the 5-year time point, 9 of these due to progression of their esophageal cancer. Nineteen patients developed a second primary malignancy, of whom 14 developed either a head and neck or lung cancers.

CONCLUSIONS

Being alive 5 years after esophagectomy does not equate to cure. In clinically staged early disease, a distinct group of patients develop disease recurrence later than 5 years from treatment. Development of a second primary cancer in this population poses a clinical threat. Surveillance protocols should be adapted accordingly.

Causes of death in locally advanced esophageal cancer undergoing neoadjuvant chemotherapy and neoadjuvant chemoradiotherapy: a retrospective cohort study

PURPOSE

To compare the causes of death in patients with locally advanced esophageal cancer treated with neoadjuvant chemotherapy versus neoadjuvant chemoradiotherapy followed by surgery.

MATERIALS AND METHODS

A retrospective cohort study was conducted on patients with stage T3-4aN0M0/T1-4aN1-3 M0 esophageal cancer who underwent either neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy followed by surgery. Overall survival (OS) and specific causes of death were analyzed and compared between the two treatment groups.

RESULTS

A total of 4528 patients were included: 333 (7.4%) received neoadjuvant chemotherapy, and 4195 (92.6%) underwent neoadjuvant chemoradiotherapy. The 5-year OS was comparable between the two groups, both before (42.4% vs. 39.7%; hazard ratio [HR] = 1.14, 95% confidence interval [CI]: 0.98-1.33; P = 0.097) and after (42.2% vs. 42.2%; HR = 1.07, 95% CI: 0.86-1.31; P = 0.567) propensity score matching. The cumulative 5-year absolute risk of death from esophageal cancer (49.9% vs. 50.6%, P = 0.470), death from non-tumor causes (7.8% vs. 9.7%, P = 0.160), death due to lung causes (2.8% vs. 1.4%, P = 0.432), and death from heart-related causes (2.2% vs. 2.0%, P = 0.524) were similar between the two treatment groups.

CONCLUSION

In patients with locally advanced esophageal cancer, OS and the causes of death were comparable between those receiving neoadjuvant chemotherapy and those undergoing neoadjuvant chemoradiotherapy.

Targeting HER2 in Gastroesophageal Cancer: A New Appetite for an Old Plight

The incidence of gastroesophageal cancers is rising, driven, in part, by an increasing burden of risk factors of obesity and gastroesophageal reflux. Despite efforts to address these risk factors, and a growing interest in methods of population screening, the bulk of these tumours are unresectable at diagnosis. In this setting, effective systemic treatments are paramount to improve survival and quality of life. Early and accurate identification of oncogenic drivers, such as human epidermal growth factor receptor 2 (HER2), present in 5-30% of gastroesophageal adenocarcinomas (GEAs), is integral to guide choice of therapies due to the clear predictive implications that arise from overexpression of this receptor. After trastuzumab, the first anti-HER2 agent with approved use in HER2-positive GEA, the addition of pembrolizumab to first-line trastuzumab-chemotherapy and trastuzumab deruxtecan in the refractory space have more recently changed practice. Yet, the response to these agents has been vastly different across patients with HER2-positive disease, underpinning the need for reliable biomarkers of response. Emergent data have suggested that levels of HER2 expression on tissue or liquid biopsies may predict response to first-generation HER2 therapies while HER2 heterogeneity, receptor changes, co-occurring molecular alterations and oncogenic genomic and metabolic reprogramming may be implicated in resistance. A robust knowledge of the mechanisms of resistance and response to HER2-directed therapies is necessary to inform novel strategies of HER2-targeting and guide choice combinations with other biomarker-directed therapies, to improve outcomes from a new generation of clinical trials in HER2-positive GEA. Understanding and close examination of previous failures in this space form an important part of this assessment, as does correlative biomarker and translational work pertaining to the role of HER2 and dynamic changes that result through treatment exposure. In this review, we aim to provide an overview of strategies for HER2 targeting, summarising both the successes and disappointments in this therapeutic landscape and discuss existing challenges and future perspectives on development in this highly morbid tumour type.

Immunotherapy as a new perspective for the therapy of esophageal cancer

The therapeutic landscape in nearly every therapeutic line in advanced/metastatic patients with squamous cell carcinoma (SCC) and esophagogastric adenocarcinoma (EGC) is enriched by recent approvals of immune checkpoint inhibitors (ICIs). In curative intended therapy, patients without pathological residual disease of SCC or GEJ (esophagogastric junction) cancer after preoperative chemoradiation and complete resection have access to adjuvant immunotherapy (independent of PD-L1 (programmed cell death protein 1) status, nivolumab, CHECKMATE 577). For metastatic SCC in the first-line, nivolumab combined with chemotherapy or with ipilimumab (TPS (tumor proportion score) ≥1 %, SCC, CHECKMATE 648) are approved, as well as second-line nivolumab alone regardless of PD-L1 status (ATTRACTION 03). For both, locally advanced or metastatic SCC and EGC, chemotherapy with pembrolizumab is available for patients with CPS (combined positive score) ≥10 (KEYNOTE 590) and for adenocarcinoma with nivolumab (CPS ≥5, CHECKMATE 649). Recent added approvals are chemotherapy with pembrolizumab in CPS ≥1 patients (KEYNOTE 859) and the addition of trastuzumab for personalized therapy in HER-2 positive/CPS ≥1 gastric and GEJ patients (KEYNOTE 811).

Patterns of recurrence after esophagectomy following neoadjuvant immunochemotherapy in patients with thoracic esophageal squamous cell carcinoma

PURPOSE

To explore the recurrence pattern and risk factors associated with the relapse of thoracic esophageal squamous cell carcinoma (TESCC) among patients who received esophagectomy following neoadjuvant immunochemotherapy (NICT).

METHODS

A total of 191 TESCC patients who received esophagectomy following NICT were retrospectively reviewed from 2019 to 2022. The first recurrence patterns were assessed. The postoperative recurrence-free survival (RFS) was determined using the Kaplan-Meier method. Multivariate recurrence risk factor analysis was performed using the logistic regression model.

RESULTS

As of the December 31, 2023 follow-up, 66 patients experienced recurrence, with a median time to recurrence of 10.8 months (1.2-37.3 months). The recurrence pattern included locoregional recurrence (LR), distant recurrence (DR), and LR + DR, accounting for 69.7 %, 16.7 %, and 13.6 %, respectively. Locoregional lymph node (LN) predominated the pattern of postoperative recurrence (40/66), particularly in the mediastinal station 2R (17.5 %) and 4R (16.5 %). The 2-year RFS rates for groups with dissected LN stations of ≤6, 7-9, and 10-14 were 50.5 %, 72.3 %, and 63.5 %, respectively (P = 0.04). Similarly, the 2-year RFS rates for groups with dissected LNs of <15, 15-29, and ≥30 were 49.7 %, 61.6 %, and 71.6 %, respectively (P = 0.28). Furthermore, tumor length >5 cm, the T-stage evaluation as clinically stable disease, dissected LN stations ≤6, and the ypN2-3 stage were unfavorable factors for postoperative failure in patients.

CONCLUSIONS

The major pattern of LR may be LN recurrence after NICT in TESCC patients, particularly in the station 2R and 4R. In addition, less than 6 LN dissection stations or less than 15 LNs are not recommended.

SPC25 upregulates CCND1 to promote the progression of esophageal squamous cell carcinoma by inhibiting MDM2-mediated E2F1 ubiquitination

Esophageal squamous cell carcinoma (ESCC) is highly malignant worldwide. Despite significant advances in the treatment of ESCC, the prognosis remains unfavourable, necessitating research into its mechanisms and treatments. Spindle component 25 (SPC25) can ensure the fidelity of mitotic progression and the accurate segregation of chromosomes, thus plays an important role in the development of malignant tumors, but its role in ESCC is yet to be determined. In this study, the expression of SPC25 was assessed by IHC in 88 primary ESCC samples, with its expression being correlated with advanced clinical features. The function of SPC25 in the proliferation, migration and tumorigenicity of ESCC cells was verified in vitro and in vivo. Mechanistically, SPC25 facilitated tumorigenesis through promoting CCND1 expression. As the transcription factor for CCND1, E2F1 is stabilized by SPC25 through binding the ubiquitin ligase MDM2, resulting in enhanced E2F1 expression, which in turn promotes the expression of CCND1. In addition, overexpression of CCND1 counteracted the effects of SPC25 silencing. Collectively, we demonstrated that the aberrant expression of SPC25 inhibited E2F1 ubiquitination and promoted CCND1 expression, thus accelerating the progression of ESCC. These findings propose novel insights into the role of SPC25 in ESCC and provide potential therapeutic strategies for targeting SPC25 in ESCC patients.

Recent Noteworthy Studies in Thoracic Oncology

BACKGROUND

In this paper, we review recent prospective surgical studies on resectable esophageal and lung cancer.

METHODS

A narrative literature review was performed using the terms 'resectable esophageal cancer' and 'multimodal therapy' and 'resectable non-small cell lung cancer'. Prospective surgical trials performed from 2010 to 2023 were identified and analyzed.

CLINICALTRIALS

gov was queried for ongoing studies.

RESULTS

The studies on esophageal cancer demonstrate the benefits of neoadjuvant chemoradiation, compared with surgery alone, and the emerging role of immunotherapy as part of induction and adjuvant treatment protocols. The selected studies on lung cancer demonstrate the evolving role of sublobar resection for patients with peripheral node-negative clinical stage IA1 disease and the developing role of neoadjuvant and adjuvant immunotherapy for patients with stage II-IIIA disease.

CONCLUSIONS

The methods of treating patients with resectable esophageal or lung cancer are changing. Efforts to limit patient morbidity and optimize tumor treatment before surgery are increasingly being pursued and these approaches will likely continue to evolve as tumor biology and long-term pharmacologic mechanisms of action become clearer. Personalized medicine strategies that are based on tumor characteristics and the host genetic profile remain on the horizon, not yet ready for adoption in routine clinical practice.

Current Advances in Immunotherapy Management of Esophageal Cancer

Esophageal cancer is one of the most common and deadliest cancers worldwide. Rates of esophageal cancer worldwide have been steadily rising over the past decade due to higher incidence of gastroesophageal reflux disease (GERD). Current therapies include surgical resection, chemotherapy, and limited targeted therapies. One obstacle to care is tumor cells' ability to evade immune surveillance, which can render certain therapeutics ineffective. Immunotherapy provides a new paradigm to cancer treatment, which has proven to be effective in evasive tumors. In recent years, PD-1/PD-L1 and CLTA-4 inhibitors have been used as frontline treatment and have shown to be extremely effective in the treatment of hard-to-treat tumors. Here, we aim to analyze the current literature regarding current therapeutics along with emerging techniques and future receptor targets for immunotherapy.

Survival Impacts of Mitochondrial Status in Esophageal Squamous Cell Carcinoma Patients

BACKGROUND

Little is known about the survival impacts of mitochondrial status in esophageal squamous cell carcinoma (ESCC) patients who undergo neoadjuvant chemotherapy (NAC) followed by surgery.

METHODS

In total, 260 pre-NAC samples from ESCC patients were analyzed. Mitochondrial status was estimated employing an objective, immunohistochemistry-based system (Mito-score). Mito-scores were dichotomized according to the median value of our cohort. We also evaluated the immune microenvironment (CD4, CD8, Foxp3, HLA class-1, Ki-67 and programmed death ligand-1) on pre-NAC specimens. Multivariate Cox hazards models were applied to determine independent predictors of poor overall survival (OS).

RESULTS

Patients with cT3-4 tumors had higher Mito-scores than those with cT1-2 tumors (p = 0.06), and good responders to NAC had significantly higher Mito-scores than poor responders to NAC (p = 0.04). CD8 cells and Ki-67 expression were significantly higher in Mito-high than Mito-low tumors (p = 0.017 and p < 0.001, respectively). Patients with low Mito-scores had significantly poorer OS than those with high Mito-scores (3-year OS: 57.6% vs. 68.2%; p = 0.03). A survival difference by Mito-score was evident in cStage III-IV patients (3-year OS: low 50.6% vs. high 66.1%; p = 0.006). Multivariable analysis revealed that a low Mito-score (hazard ratio 1.59, 95% confidence interval 1.12-2.24; p = 0.009) as well as pT3-4 disease (p < 0.001) and pN2-3 disease (p < 0.001) were independently associated with poor OS outcomes.

CONCLUSIONS

A low Mito-score before NAC had a significant survival impact in ESCC patients, especially in those with advanced disease. Mitochondrial status might be associated with tumor aggressiveness and responsiveness to NAC, thereby possibly affecting the survival outcomes of ESCC patients.

Active surveillance in patients with a complete clinical response after neoadjuvant chemoradiotherapy for esophageal- and gastroesophageal junction cancer

Neoadjuvant chemoradiotherapy in patients with esophageal- and gastroesophageal junction cancer induces tumor regression. In approximately one fourth of patients, this leads to a pathological complete response in the resection specimen. Hence, active surveillance may be an alternative strategy in patients without residual disease after neoadjuvant chemoradiotherapy. Previous studies have shown that the combination of esophagogastroduodenoscopy with bite-on-bite biopsies, endoscopic ultrasound with fine needle aspiration of suspected lymph nodes, and a PET-CT-scan can be considered adequate for the detection of residual disease. So far, it has been unclear whether active surveillance with surgery as needed is a safe treatment option and leads to non-inferior overall survival compared to standard esophagectomy after neoadjuvant chemoradiotherapy. This review will discuss the current status of active surveillance for esophageal and junctional cancer.

Ten-Year Survivals of Right Thoracic vs Left Thoracic Approach for Esophageal Cancer

BACKGROUND

Esophagectomy can be performed using various surgical techniques. The aim of this study was to understand the impact of surgery on long-term survival for esophageal cancer.

METHODS

Between May 2010 and July 2012, 300 patients with esophageal cancer were randomly assigned to undergo esophagectomy with either a left or right thoracic approach. Disease-free survival (DFS) and overall survival (OS) were compared based on the per-protocol principle among 286 patients with esophageal squamous cell carcinoma determined by postoperative pathologic results (146 in the right and 140 in the left thoracic arms).

RESULTS

The median DFS was 92 months in the right thoracic arm and 41 months in the left thoracic arm (hazard ratio, 0.73; 95% CI, 0.54-0.99; P = .045), with a cumulative 10-year DFS of 47.6% and 37.5%, respectively. The median OS was 136 months in the right thoracic arm and 99 months in the left thoracic arm (hazard ratio, 0.75; 95% CI, 0.54-1.04; P = .081), with cumulative 10-year OS of 52.4% and 43.7%, respectively. DFS and OS were comparable between the 2 arms for patients without lymph node metastasis. Conversely, for patients with lymph node metastasis, 10-year DFS was 32.7% and 21.4%, respectively (P = .018), and 10-year OS of the right and left thoracic arms was 37.9% and 25.9%, respectively (P = .012).

CONCLUSIONS

Compared with the left thoracic approach, patients who underwent esophagectomy through the right thoracic approach had better 10-year survival rates, and the survival benefit was significant for those with lymph node metastasis.

Prognostic analysis of esophageal cancer patients after neoadjuvant therapy

Background

Neoadjuvant therapy is widely used for esophageal cancer (EC), but optimal treatment regimens and predictive factors for outcomes remain unclear. This study retrospectively analyzed data from EC patients who underwent neoadjuvant therapy.

Methods

The chi-square test or Fisher's exact test was utilized to examine differences in general clinicopathological data between treatment benefit groups. Survival analyses were conducted using Kaplan-Meier methods. Cox univariate and multivariate regression analyses were employed to identify independent risk factors affecting overall survival (OS) in EC patients receiving different treatment modalities.

Results

The study included 175 EC patients who underwent neoadjuvant therapy. Analysis of clinical benefit differences revealed that patients aged < 65 years (P = 0.028) and those with esophageal squamous cell carcinoma (ESCC) (P = 0.027) were more likely to achieve a complete response, while N1 patients more frequently attained an objective response (P < 0.001). OS analysis indicated that patients who did not receive immunotherapy exhibited better survival outcomes compared to those who did (P = 0.002). Patients with pretreatment N3 status demonstrated poorer survival compared to those with N0 (P = 0.004), N1 (P = 0.003), and N2 (P = 0.003) status. Among post-neoadjuvant EC patients who did not receive immunotherapy, those with primary tumors located in the middle esophagus (hazard ratio [HR], 0.181; 95% Confidence interval (CI) = 0.044-0.739; P = 0.017) and lower esophagus (HR, 0.163; 95%CI = 0.032-0.821; P = 0.028) demonstrated a better prognosis compared to patients with tumors in the upper esophagus. Notably, EC patients who did not receive immunotherapy after neoadjuvant therapy and underwent 3-6 cycles of therapy exhibited a poorer prognosis compared to those who received 1-2 cycles (HR, 2.731; 95%CI = 1.187-6.284; P = 0.018).

Conclusions

In conclusion, this study found that immunotherapy did not play a decisive role in neoadjuvant EC therapy. Instead, 1-2 cycles of chemotherapy or chemoradiotherapy were associated with a more favorable prognosis for these patients.

A nomogram for postoperative pulmonary infections in esophageal cancer patients: a two-center retrospective clinical study

BACKGROUND

Postoperative pulmonary infections (POPIs) occur in approximately 13-38% of patients who undergo surgery for esophageal cancer, negatively impacting patient outcomes and prolonging hospital stays. This study aims to develop a novel clinical prediction model to identify patients at risk for POPIs early, thereby enabling timely intervention by clinicians.

METHODS

This study included 910 patients from two hospitals. Of these, 795 patients from one hospital were randomly assigned to the training cohort (n = 556) and the validation cohort (n = 239) at a 7:3 ratio. The external test cohort consisted of 115 patients from the second hospital. A nomogram was developed via logistic regression to predict the incidence of POPIs. The model's discrimination, precision and clinical benefit were evaluated by constructing a receiver operating characteristic (ROC) curve, calculating the area under the ROC curve (AUC), performing a calibration plot, conducting decision curve analysis (DCA) and clinical impact curves (CIC).

RESULTS

Multivariate logistic regression revealed that age, anemia, neoadjuvant therapy, T stage, thoracic adhesions and duration of surgery were independent risk factors for POPIs. The AUC for the training cohort was 0.8095 (95% CI: 0.7664-0.8527), that for the validation cohort was 0.8039 (95% CI: 0.7436-0.8643), and that for the external test cohort was 0.7174 (95% CI: 0.6145-0.8204). Calibration plots demonstrated good agreement between the predicted and observed probabilities, while DCA and CIC demonstrated good clinical applicability of the model in three cohorts.

CONCLUSION

The nomogram, which incorporates six key factors, effectively predicts the risk of POPIs and can serve as a valuable tool for clinicians in identifying high-risk patients.

Chronic stress-induced cholesterol metabolism abnormalities promote ESCC tumorigenesis and predict neoadjuvant therapy response

Recent studies have demonstrated that chronic stress can enhance the development of multiple human diseases, including cancer. However, the role of chronic stress in esophageal carcinogenesis and its underlying molecular mechanisms remain unclear. This study uncovered that dysregulated cholesterol metabolism significantly promotes esophageal carcinogenesis under chronic stress conditions. Our findings indicate that the persistent elevation of glucocorticoids induced by chronic stress stimulates cholesterol uptake, contributing to esophageal carcinogenesis. The activated glucocorticoid receptor (GCR) enrichment at the promoter region of High Mobility Group Box 2 (HMGB2) facilitates its transcription. As a transcription coactivator, HMGB2 enhances Sterol Regulatory Element Binding Transcription Factor 1 (SREBF1) transcription and regulates cholesterol metabolism through LDL particle uptake into cells via Low Density Lipoprotein Receptor (LDLR). These results emphasize the significant impact of chronic stress on esophageal carcinogenesis and establish cholesterol metabolism disorder as a crucial link between chronic stress and the development of ESCC. The implications suggest that effectively managing chronic stress may serve as a viable strategy for preventing and treating ESCC.

Postoperative Adjuvant Therapy Benefits Non-pCR Patients Rather Than pCR Patients for Locally Advanced ESCC: A Multicenter Real-World Study

BACKGROUND

There is no unified standard in adjuvant therapy (AT) for patients with esophageal squamous cell carcinoma (ESCC) after neoadjuvant therapy and surgery. We evaluated the significance of AT for these patients and explored its influencing factors.

METHODS

ESCC patients who underwent neoadjuvant therapy and surgery from 2019 to 2022 at three centers were divided into AT (n = 227) and non-AT groups (n = 435). Baseline characteristics were balanced using propensity score matching (PSM). Primary endpoints were disease-free survival (DFS) and overall survival (OS), assessed using the Kaplan-Meier method. Subgroup analyses and univariate and multivariate Cox regression analyses were conducted to identify the prognostic factors.

RESULTS

The median follow-up period is 36 (2-72) months. After PSM, the total population had 1-, 2-, and 3-year OS rates of 71.3%, 66.0%, and 64.1%, respectively. There were no statistically significant differences in DFS (HR: 0.79; 95% CI: 0.55-1.14, p = 0.21) or OS (HR: 0.75; 95% CI: 0.49-1.13, p = 0.17) between AT and non-AT groups. Subgroup analysis revealed that non-pCR patients benefited from AT in DFS (p = 0.042) and OS (p = 0.033). Moreover, in non-pCR patients who received AT, BMI ≥ 21.5 kg/m2 and ypN0 were independent protective factors of DFS. ypN0 was an independent protective factor of OS. In terms of AT regimens, the Kaplan-Meier analysis revealed that adjuvant immunochemotherapy (AICT) provided superior survival benefits than adjuvant radiotherapy and adjuvant chemotherapy.

CONCLUSIONS

Postoperative AT benefited ESCC patients with non-pCR, while AICT may be a relatively better AT regimen in real-world data, which deserves further exploration.

Comparative Outcomes and Toxicity in Patients With Esophageal Cancer After Trimodality Therapy With Step-and-Shoot Intensity-Modulated Radiation Therapy Versus Volumetric Modulated Arc Therapy: The MD Anderson Experience

AIMS

To evaluate outcomes and toxicity after intensity-modulated radiation therapy given as step-and-shoot (SS) or volumetric modulated arc therapy (VMAT) for patients with locally advanced esophageal cancer treated with trimodality therapy (i.e. neoadjuvant concurrent chemoradiation therapy followed by surgery).

MATERIALS AND METHODS

Patients consecutively treated with trimodality therapy including IMRT in 2001-2022 (n = 449) were retrospectively reviewed, and 106 pairs of propensity-matched SS and VMAT patients were identified. Survival, recurrence, surgery-related prognostic factors, and chemoradiation-related toxicities were evaluated between groups.

RESULTS

Baseline characteristics were balanced between both groups except for body mass index, history of other cancer, clinical disease stage, and use of induction chemotherapy. Median follow-up time was 40 months. Relative to SS, VMAT led to higher 3-year overall survival (OS; P = 0.028, hazard ratio [HR] 0.645, 95% confidence interval [CI] 0.436-0.954) but not progression-free, locoregional recurrence-free, or distant metastasis-free survival. No predictor of excellent OS by SS versus VMAT was identified in multivariable analyses. However, VMAT was associated with reduced odds of postoperative cardiac complications (P < 0.001, odds ratio [OR] 0.296, 95% CI 0.148-0.591), pulmonary complications (P = 0.048, OR 0.539, 95% CI 0.292-0.994), pathologic partial response or worse (≥10% viable cells; P = 0.003, OR 0.418, 95% CI 0.235-0.743), and positive/close margins (P = 0.023, OR 0.346, 95% CI 0.138-0.867) relative to SS. VMAT was also associated with reduced rates of chemoradiation therapy-related weight loss (33.0% versus 79.2%, P < 0.001), fatigue (40.6% versus 68.9%, P < 0.001), nausea (31.1% versus 58.5%, P < 0.001) and cardiac toxicity (0% versus 6.6%, P = 0.007) than SS.

CONCLUSION

Based on this single institution, retrospective study with a 40-month median follow-up, VMAT utilization in trimodality treatment for locally advanced esophageal cancer appears to be associated with improved OS and rates of concurrent chemoradiation therapy-related toxicity and reduced initial 12-month postoperative complications relative to SS IMRT. Multi-institutional prospective trials addressing the limitations of this study and with longer follow-ups are warranted to validate these findings.

Radiotherapy Quality Assurance in the SCOPE2 Trial: What Lessons can be Learned for the Next UK Trial in Oesophageal Cancer?

AIMS

The SCOPE2 trial evaluates radiotherapy (RT) dose escalation for oesophageal cancer. We report findings from the accompanying RT quality assurance (RTQA) programme and identify recommendations for PROTIEUS, the next UK trial in oesophageal RT.

MAETRIALS AND METHODS

SCOPE2's RTQA programme consisted of a pre-accrual and on-trial component. RTQA pre-accrual requirements included acceptable submission of 3D ± 4D benchmark contouring exercise(s) and a high-dose planning case. On-trial requirements for contouring and planning included prospective reviews (PRs) of each centre's first 3D ± 4D patient and all high-dose cases prior to formal safety review. Further PRs were at the RTQA team's discretion. Timely retrospective reviews (TRRs) were also undertaken for a random 10%. Submissions were assessed against pre-defined criteria and RT planning guidance document (RPGD). This study includes initial submissions only; subsequent resubmissions are not included in this analysis.

RESULTS

For contouring, 30/64 (47%) pre-accrual submissions were approved. 38/64 (59%) contained ≥1 target volume (TV) unacceptable variation from protocol (UV), most commonly in CTVB and ITV. Organ-at-risk (OAR) contour review was undertaken in 28/64 (44%); 6/28 (21%) contained ≥1 UV, most commonly in heart and spinal cord. 82/126 (65%) on-trial submissions were approved. 47/126 (37%) contained ≥1 TV UV, most commonly in CTVB, GTV and ITV. For OARs, 30/126 (24%) contained ≥1 UV, most commonly in heart and lungs. On-trial contour submissions were significantly more likely to be approved than pre-accrual (p = 0.016). For planning, 32/43 (79%) pre-accrual plans were approved, those unacceptable were due to PTV coverage/conformity. 118/120 (98%) on-trial plans were approved, the remaining unacceptable were due to PTV coverage/conformity. No UVs in OAR dose constraints were observed. All on-trial submissions were approved following resubmission where necessary.

CONCLUSION

Despite an RPGD, contouring atlas, and similar contouring protocols from preceding trials, the SCOPE2 RTQA programme demonstrates a high frequency of UVs. Our findings inform recommendations for future oesophageal RT trials.