Neoadjuvant immunotherapy for resectable esophageal cancer: A review

Vaccinia virus-mediated oncolytic immunotherapy: Emerging strategies for gastrointestinal cancer treatment at dawn

Oncolytic vaccinia virus (VVs) based immunotherapy is a rapidly developing treatment for gastrointestinal (GI) cancers. Conventional treatments, such as chemotherapy, radiotherapy and surgery achieve good effects in early-stage GI cancers, but effects are limited in advanced disease. Immunotherapy has limited efficacy in GI cancers due to tumor heterogeneity and complex immunosuppressive mechanisms. Oncolytic VV immunotherapy is a novel treatment approach showing promising results in preclinical and clinical trials. Oncolytic VV's intracytoplasmic replication and assembly mechanism, diverse mature forms, and use methods make it extremely safe and versatile for drug delivery. Combining oncolytic VV with conventional therapies and immunotherapy (e.g., ICIs, CAR-T) enhances tumor regression and survival compared to monotherapies. Researchers are establishing response protocols and improvement strategies, rapidly developing VV tumor oncolytic immunotherapy. This article focuses on oncolytic vaccinia development and outlook in gastrointestinal cancer therapy, advantages when combined with other drugs to improve clinical survival, safety, and risk reduction for patients.

Advancements and challenges in the treatment of esophageal cancer: A comprehensive review

Esophageal cancer (EC) is an aggressive malignancy with a poor prognosis, ranking seventh in incidence and sixth cancer-related deaths globally. EC is classified in two main types, the esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC), with ESCC being more common in Eastern Europe, South Asia, and Africa, while EAC is prevalent in Western Europe and North America. Molecular analysis identifies three subgroups of ESCC, each with distinct genetic mutations and treatment responses. Early-stage EC is often difficult to detect, leading to late-stage diagnoses that necessitate systemic drug therapies, including molecular-targeted therapies and immunotherapies. Immunotherapy, particularly immune checkpoint inhibitor, has shown promising results in improving survival rates for metastatic or persistent EC. It is particularly important to target to multidisciplinary combination therapies, integrating surgery, chemoradiotherapy, targeted therapy and immunotherapy. Additionally, radioimmunotherapy is being explored for its potential to enhance treatment efficacy, especially in advanced and metastatic tumors. However, the pathological complete response rate to neoadjuvant chemoradiotherapy remains suboptimal, highlighting the need for novel treatment strategies. Future research should focus on optimizing treatment combinations and identifying predictive biomarkers to improve clinical outcomes for EC patients.

Role of Neoadjuvant Immunotherapy in Genitourinary Malignancies

Genitourinary (GU) malignancies are common and associated with significant morbidity and mortality. In patients with localized GU cancers, surgical resection or definitive radiation remain the mainstays of treatment. Despite definitive treatment, many patients with high-risk localized disease experience recurrence. There is growing interest in using neoadjuvant immunotherapy to improve outcomes. This narrative review summarizes the current evidence for neoadjuvant immunotherapy in patients with localized high-risk GU cancers including renal cell carcinoma, urothelial carcinoma, prostate cancer, penile squamous cell carcinoma, and testicular germ cell tumors. We also discuss ongoing clinical trials and candidate biomarkers to optimize patient selection and improve treatment outcomes.

From tumor microenvironment to emerging biomarkers: the reshaping of the esophageal squamous cell carcinoma tumor microenvironment by neoadjuvant chemotherapy combined with immunotherapy

Esophageal squamous cell carcinoma is a cancer with high morbidity and mortality. The advent of immune checkpoint inhibitors has significantly increased complete response rates and postoperative R0 resection rates after neoadjuvant therapy. These drugs can largely reverse the suppression of the immune system caused by the tumor microenvironment, allowing the reactivation of anti-tumor immune infiltrating cells, significantly improving the patient's tumor microenvironment, and thus preventing tumor development. However, there are still some patients who respond poorly to neoadjuvant combined immunotherapy and cannot achieve the expected results. It is now found that exploring changes in the tumor microenvironment not only elucidates patient responsiveness to immunotherapy and identifies more reliable biomarkers, but also addresses the limitations of prediction with imaging examination such as CT and the instability of existing biomarkers. In light of these considerations, this review aims to delve into the alterations within the tumor microenvironment and identify potential predictive biomarkers ensuing from neoadjuvant immunotherapy in the context of esophageal squamous cell carcinoma.

Systemic approaches in biliary tract cancers: a review in the era of multidirectional precision medicine

INTRODUCTION

Despite a rising incidence, biliary tract cancers (BTCs) are still considered a rare tumor entity. The disease's subtle clinical presentation and lack of effective early detection strategies often lead to a diagnosis at an advanced or unresectable stage, where curative options are limited.

AREAS COVERED

This review provides an overview of current systemic therapies and emerging novel approaches for BTC. For decades, the combination of gemcitabine with cisplatin (GemCis) has been the standard of care for palliative treatment. However, since 2020, the diagnostic and therapeutic landscape for BTC has evolved considerably, not only in the first-line setting but also beyond, driven by the development of clinical trials exploring immunotherapy and molecularly targeted agents. Due to the high frequency of targetable genetic alterations in BTC patients, there is a growing emphasis on obtaining tissue or liquid biopsy samples to identify markers like microsatellite instability and other actionable oncogenic driver genes.

EXPERT OPINION

Early initiation of systemic therapies in combination with multimodal approaches is essential for maximizing survival outcomes in patients with BTC.

Fecal Microbiome Composition Correlates with Pathologic Complete Response in Patients with Operable Esophageal Cancer Treated with Combined Chemoradiotherapy and Immunotherapy

Background: Preclinical and clinical data indicate that chemoradiotherapy (CRT) in combination with checkpoint inhibitors may prime an anti-tumor immunological response in esophageal cancer. However, responses to neoadjuvant therapy can vary widely and the key biomarkers to determine response remain poorly understood. The fecal microbiome is a novel and potentially modifiable biomarker of immunotherapy response, and both fecal and tumor microbes have been found to associate with outcomes in esophageal cancer. Methods: Fecal and tumor samples were collected from patients with stage II-III resectable esophageal or gastroesophageal junction carcinoma treated with neoadjuvant immune checkpoint inhibitors (ICIs) plus CRT prior to surgical resection. Microbiome profiles were analyzed by 16S rRNA amplicon sequencing and taxonomic data were integrated with fecal metabolite analysis to assess microbial function. Results: The fecal microbiome of patients with pathological complete response (PCR) grouped in distinct clusters compared to patients with residual viable tumor (RVT) by Bray-Curtis diversity metric. Integrated taxonomic and metabolomic analysis of fecal samples identified a sphingolipid and primary bile acid as enriched in the PCR, the levels of which correlated with several bacterial species: Roseburis inulinivorans, Ruminococcus callidus, and Fusicantenibacter saccharivorans. Analysis of the tumor microbiome profiles identified several bacterial genera previously associated with esophageal tumors, including Streptococcus and Veillonella. Conclusions: These results further characterize the fecal and tumor microbiome of patients with operable esophageal cancer and identify specific microbes and metabolites that may help elucidate how microbes contribute to tumor response with neoadjuvant CRT combined with ICI.

Prognostic role of lymph node regression in patients with esophageal cancer undergoing neoadjuvant therapy

Purpose

To clarify the prognostic value of lymph node regression (LNR) status including the lymph node regression grade (LNRG) and N downstaging in patients with esophageal cancer receiving neoadjuvant therapy based on available evidence.

Methods

Several databases were searched up to 25 March 2024. The main outcomes included overall survival (OS), disease-free survival (DFS) and cancer-specific survival (CSS). Hazard ratios (HRs) and 95% confidence intervals (CIs) were combined. Subgroup analyses based on the neoadjuvant therapy and pathological type were also conducted.

Results

In total, 14 retrospective studies with 3,212 participants were included. Nine and five studies explored the relationship between LNRG and N downstaging and survival, respectively. Pooled results indicated that complete LNR predicted significantly improved OS (HR = 0.47, 95% CI: 0.41-0.55, P < 0.001) and DFS (HR = 0.42, 95% CI: 0.32-0.55, P < 0.001) and subgroup analysis based on neoadjuvant therapy and pathological type manifested similar results. Besides, N downstaging was also significantly related to improved OS (HR = 0.40, 95% CI: 0.21-0.77, P = 0.006) and CSS (HR = 0.27, 95% CI: 0.12-0.60, P < 0.001).

Conclusion

LNR could serve as a novel and reliable prognostic factor in patients with esophageal cancer receiving neoadjuvant therapy and complete LNR and N downstaging predict better survival.

A machine learning radiomics based on enhanced computed tomography to predict neoadjuvant immunotherapy for resectable esophageal squamous cell carcinoma

Background

Patients with resectable esophageal squamous cell carcinoma (ESCC) receiving neoadjuvant immunotherapy (NIT) display variable treatment responses. The purpose of this study is to establish and validate a radiomics based on enhanced computed tomography (CT) and combined with clinical data to predict the major pathological response to NIT in ESCC patients.

Methods

This retrospective study included 82 ESCC patients who were randomly divided into the training group (n = 57) and the validation group (n = 25). Radiomic features were derived from the tumor region in enhanced CT images obtained before treatment. After feature reduction and screening, radiomics was established. Logistic regression analysis was conducted to select clinical variables. The predictive model integrating radiomics and clinical data was constructed and presented as a nomogram. Area under curve (AUC) was applied to evaluate the predictive ability of the models, and decision curve analysis (DCA) and calibration curves were performed to test the application of the models.

Results

One clinical data (radiotherapy) and 10 radiomic features were identified and applied for the predictive model. The radiomics integrated with clinical data could achieve excellent predictive performance, with AUC values of 0.93 (95% CI 0.87-0.99) and 0.85 (95% CI 0.69-1.00) in the training group and the validation group, respectively. DCA and calibration curves demonstrated a good clinical feasibility and utility of this model.

Conclusion

Enhanced CT image-based radiomics could predict the response of ESCC patients to NIT with high accuracy and robustness. The developed predictive model offers a valuable tool for assessing treatment efficacy prior to initiating therapy, thus providing individualized treatment regimens for patients.

Advances in the Imaging of Esophageal and Gastroesophageal Junction Malignancies

Accurate imaging is key for the diagnosis and treatment of esophageal and gastroesophageal junction cancers . Current imaging modalities, such as computed tomography (CT) and 18F-FDG (2-deoxy-2-[18F]fluoro-D-glucose) positron emission tomography (PET)/CT, have limitations in accurately staging these cancers. MRI shows promise for T staging and residual disease assessment. Novel PET tracers, like FAPI, FLT, and hypoxia markers, offer potential improvements in diagnostic accuracy. 18F-FDG PET/MRI combines metabolic and anatomic information, enhancing disease evaluation. Radiomics and artificial intelligence hold promise for early detection, treatment planning, and response assessment. Theranostic nanoparticles and personalized medicine approaches offer new avenues for cancer therapy.

SPP1 represents a therapeutic target that promotes the progression of oesophageal squamous cell carcinoma by driving M2 macrophage infiltration

BACKGROUND

Tumour-associated macrophages (TAMs) are an important component of the tumour microenvironment (TME). However, the crosstalk between oesophageal squamous cell carcinoma (ESCC) cells and TAMs remains largely unexplored.

METHODS

Clinical samples and the TCGA database were used to evaluate the relevance of SPP1 and TAM infiltration in ESCC. Mouse models were constructed to investigate the roles of macrophages educated by SPP1 in ESCC. Macrophage phenotypes were determined using qRT‒PCR and immunohistochemical staining. RNA sequencing was performed to elucidate the mechanism.

RESULTS

Increasing expression of SPP1 correlated with M2-like TAM accumulation in ESCC, and they both predicted poor prognosis in the ESCC cohort. Knockdown of SPP1 significantly inhibited the infiltration of M2 TAMs in xenograft tumours. In vivo mouse model experiments showed that SPP1-mediated education of macrophages plays an essential role in the progression of ESCC. Mechanistically, SPP1 recruited macrophages and promoted M2 polarisation via CD44/PI3K/AKT signalling activation and then induced VEGFA and IL6 secretion to sustain ESCC progression. Finally, blockade of SPP1 with RNA aptamer significantly inhibited tumour growth and M2 TAM infiltration in xenograft mouse models.

CONCLUSIONS

This study highlights SPP1-mediated crosstalk between ESCC cells and TAMs in ESCC. SPP1 could serve as a potential target in ESCC therapy.

Neoadjuvant Nivolumab Therapy for Esophageal Squamous Cell Carcinoma: A Single-Arm, Phase II Study

PURPOSE

Programmed death-1/programmed death-ligand 1 (PD-L1) inhibitors have shown efficacy in metastatic esophageal squamous cell carcinoma (ESCC) therapy. However, data is still limited regarding neoadjuvant immunotherapy for operable ESCC.

MATERIALS AND METHODS

Patients with clinical stage T2 or T3 and N0 ESCC received three cycles of nivolumab therapy every two weeks before surgical resection. The primary endpoint is major pathologic responses (MPR) rate (≤ 10% of residual viable tumor [RVT]).

RESULTS

Total 20 patients completed the planned nivolumab therapy. Among them, 17 patients underwent surgery as protocol, showing MPR in two patients (MPR rate, 11.8%), including one pathologic complete response, on conventional pathologic response evaluation. Pathologic response was re-evaluated using the immune-related pathologic response criteria based on immune-related RVT (irRVT). Three patients were classified as immunologic major pathologic response (iMPR; ≤ 10% irRVT, iMPR rate: 17.6%), five as pathologic partial response (> 10% and < 90% irRVT), and nine as pathologic nonresponse (≥ 90% irRVT). The combined positive score (CPS) for PD-L1 in the baseline samples was predictable for iMPR, with the probability as 37.5% in CPS ≥ 10 (3/8) and 0% in CPS < 10 (0/9).

CONCLUSION

Although the efficacy of neoadjuvant nivolumab therapy was modest in unselected ESCC patients, further researches on neoadjuvant immunotherapy are necessary in patients with PD-L1 expressed ESCC.

A Correlation Evaluation Between the Peripheral Blood Index and the Prognosis of Advanced Esophageal Squamous Cell Carcinoma Patients Treated with Camrelizumab

Purpose

This study aimed to investigate the relationship between peripheral blood indices and the efficacy and prognosis of advanced esophageal squamous cell carcinoma (ESCC) patients treated with camrelizumab.

Patients and Methods

We retrospectively analyzed 64 patients who received camrelizumab for advanced ESCC at the Second People's Hospital of Lianyungang City between July 2020 and June 2022. The study included examination of the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), the systemic inflammation index (SII), the lymph-to-monocytes ratio (LMR), the absolute lymphocyte count (ALC), and lactate dehydrogenase (LDH). We used multivariate logistic regression analysis to explore the link existing between peripheral blood and the efficacy of treatment. Determination of potential prognostic factors for Progression-free survival (PFS) and Overall survival (OS) using Cox regression analysis. The nomogram model was developed based on the results of the Cox multivariate analysis. Patients were divided into three groups according to the reduction in LDH and LDL levels before treatment, and the Kaplan-Meier survival curves for the three groups were compared and ROC curves for LDH combined with PLR were plotted.

Results

Lower LDH (OR=6.237, 95% CI: 1.625-23.944) were independently associated with disease control rates(DCR). LDH was independently correlated with PFS (HR: 0.227 95% CI: 0.099-0.517). LDH and PLR were independently linked to OS. The C index of the nomogram model is 0.819, indicating good predictive performance. Kaplan-Meier Survival Curve suggested better OS in patients with reduced pretreatment LDH and PLR. The area under the ROC curve showed that the LDH index combined with the PLR index predicts patient survival better than the index alone.

Conclusion

LDH combined with PLR predicted prognosis in patients with ESCC treated with camrelizumab.

Neoadjuvant therapy for non-small cell lung cancer and esophageal cancer

As the major malignant tumors in the chest, non-small cell lung cancer (NSCLC) and esophageal cancer (EC) bring huge health burden to human beings worldwide. Currently, surgery is still the mainstay for comprehensive treatment for NSCLC and EC, but the prognosis is still poor as the results of cancer recurrence and distant metastasis. Neoadjuvant therapy refers to a single or combined treatment before surgery, aiming to improve the therapeutic effects of the traditional therapies. Unfortunately, the clinical outcomes and effects of neoadjuvant therapy are still controversial due to its apparent advantages and disadvantages, and different patients may respond differentially to the same scheme of neoadjuvant therapy, which makes it urgent and necessary to develop personalized scheme of neoadjuvant therapy for different individuals. Therefore, this review summarizes the novel schemes and strategies of neoadjuvant therapy, which may help to significantly improve of life quality of patients suffering from chest-related malignancies.