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Preoperative chemoimmunotherapy vs chemoradiotherapy in cT4 ESCC: a multicenter retrospective study
Kanghua Zhang1, Chang Yuan2, Xiaofang Chen3
1State Key Laboratory of Metabolic Dysregulation & Prevention and Treatment of Esophageal Cancer, Zhengzhou, Henan Province, 450052, China; Department of Thoracic Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, 450052, China.
Importance:
Clinical T4 (cT4) esophageal squamous cell carcinoma (ESCC) remains challenging, and evidence for preoperative strategies in surgical candidates is limited.
Design:
Retrospective study at 3 centers in China. Patients with AJCC 8th edition clinical T4 ESCC who received preoperative chemoimmunotherapy (pre-CIT) or preoperative chemoradiotherapy (pre-CRT), underwent reassessment, and completed esophagectomy were included in the primary surgical cohort (n = 235; pre-CIT 124, pre-CRT 111). Propensity score matching was performed to reduce baseline imbalances, and additional analyses restricted to patients who achieved R0 resection were performed as supplementary analyses.
Main Outcomes:
Two-year OS and DFS were higher in the pre-CIT group than in the pre-CRT group (OS, 76.4% vs 55.2%; P = 0.032; DFS, 73.6% vs 51.6%; P = 0.024). In multivariable Cox models with pre-CIT as the reference, pre-CRT was associated with worse OS (HR, 1.80; 95% CI, 1.07-3.02; P = 0.027) and DFS (HR, 2.01; 95% CI, 1.22-3.30; P = 0.006). After propensity score matching, pre-CIT remained associated with better OS and DFS than pre-CRT. Overall postoperative complications were comparable between groups (Clavien-Dindo grade ≥ I, 59.7% vs 63.1%; P = 0.595), and major complications did not differ significantly (grade ≥ IIIa, 28.2% vs 36.9%; P = 0.154). Overall recurrence rates were not significantly different (21.8% vs 27.9%; P = 0.292), but distant metastasis occurred less often with pre-CIT (11.3% vs 20.7%; P = 0.048). Consistently, 2-year locoregional recurrence-free survival did not differ (83.5% vs 91.4%; P = 0.106), whereas 2-year distant metastasis-free survival favored pre-CIT (87.2% vs 71.2%; P = 0.044). After propensity score matching, neither locoregional recurrence-free survival nor distant metastasis-free survival differed significantly between groups (P = 0.225 and P = 0.106, respectively).
Conclusions And Relevance:
In this surgical cT4 ESCC cohort, pre-CIT was associated with improved OS/DFS. Prospective validation is warranted.