Definitive radiotherapy versus surgery after neoadjuvant immunochemotherapy for locally advanced esophageal squamous cell carcinoma: a propensity score-matched study of efficacy and safety

Abstract

The optimal local treatment strategy for locally advanced esophageal squamous cell carcinoma (LA-ESCC) following neoadjuvant immunochemotherapy (NICT) remains controversial. This study aimed to compare the survival outcomes and recurrence patterns of radical surgery and definitive radiotherapy (RT) following NICT in patients with LA-ESCC. Patients with LA-ESCC who underwent NICT (2019–2023) were enrolled and categorized into surgery or RT groups. Propensity score matching (PSM) and Kaplan-Meier methods were used to estimate progression-free survival (PFS) and overall survival (OS). The differences in recurrence patterns between the two groups were compared. A total of 278 patients were included, comprising 218 (78.4%) and 60 (21.6%) patients in the surgery and RT groups, respectively. After PSM, the surgery group (n=117) maintained a significant OS benefit over the RT group (n=60) (3-year OS rates: 72.1% vs. 59.5%; P  = 0.028), whereas the PFS rates were comparable between the two groups (3-year PFS rates: 59.4% vs. 46.9%; P  = 0.12). For patients with upper esophageal cancer, RT showed a trend toward improved survival (3-year PFS rates: 76.9% vs. 55.5%, P  = 0.34; 3-year OS rates: 74.0% vs. 61.8%, P  = 0.50). Among the responders after NICT (near-cCR/cPR), PFS and OS were similar between the surgery and RT groups (3-year PFS rates: 68.9% vs. 66.9%, P  = 0.64; 3-year OS rates: 80.2% vs. 70.7%, P  = 0.20). Regional lymph node recurrence predominated in the surgery group (50.0%), whereas locoregional esophageal recurrence was most frequent in the RT group (37.0%). The treatment-related mortality rates were 0.8% (1/117) in the surgery group and 1.7% (1/60) in the RT group, indicating the overall safety of the treatments. Radical surgery remains the standard treatment for LA-ESCC after NICT. Definitive RT may be an organ-preserving option in selected patients, especially those with upper esophageal cancer or a favorable response to NICT.