PD01.08. Optimizing Postoperative Systemic Therapy Following Neoadjuvant Chemoimmunotherapy and Resection for Locally Advanced Esophageal Cancer: A Multicenter Real-World Analysis

Abstract

Esophageal Cancer: Adjuvant and Neo-Adjuvant Therapies Neoadjuvant chemoimmunotherapy (nICT) followed by surgical resection has emerged as a standard approach for locally advanced esophageal cancer. However, the role and optimal modality of postoperative immunotherapy in patients who have already received immune checkpoint blockade remain uncertain, particularly outside the context of prospective trials. We sought to evaluate the impact of different adjuvant immunotherapy strategies on survival in a real-world, multicenter cohort. We retrospectively analyzed 556 consecutive patients with locally advanced esophageal cancer who underwent nICT followed by curative-intent surgery across multiple centers. According to postoperative management, patients were classified into an observation cohort (n = 251) and an adjuvant immunotherapy cohort (n = 305). The latter was further stratified into two predefined strategies: postoperative chemoimmunotherapy (2–4 cycles of chemotherapy combined with immunotherapy; n = 164) and immunotherapy maintenance (continued immunotherapy with or without preceding chemotherapy; n = 141). Overall survival (OS) and disease-free survival (DFS) were estimated using Kaplan–Meier methods and compared across groups. Subgroup analyses were conducted based on pathological nodal status, tumor regression grade (TRG), and pathological response. In the overall population, postoperative immunotherapy was associated with a trend toward prolonged OS and DFS compared with observation, although the difference did not reach statistical significance. Notably, patients with pathological lymph node involvement (ypN+) and those demonstrating favorable tumor regression (TRG 0–1) appeared to derive greater benefit. When stratified by treatment strategy, short-course postoperative chemoimmunotherapy did not confer a survival advantage relative to observation. In contrast, immunotherapy maintenance was independently associated with improved OS and DFS, with the magnitude of benefit most evident among patients with ypN+ disease, non-pathological complete response, and TRG 0–1. In patients receiving nICT followed by surgery for locally advanced esophageal cancer, the effect of postoperative immunotherapy varies according to therapeutic strategy and residual pathological risk. Maintenance immunotherapy, rather than short-course chemoimmunotherapy, was associated with superior survival outcomes, particularly in patients with residual nodal disease and favorable response to neoadjuvant therapy. These findings highlight the importance of individualized, risk-adapted postoperative treatment planning in the contemporary nICT era.