Impacts of tumor microenvironment during neoadjuvant chemotherapy in patients with esophageal squamous cell carcinoma

Abstract

With the advent of immune checkpoint inhibitors (ICIs), a better understanding of tumor microenvironment (TME) is becoming crucial in managing esophageal squamous cell carcinoma (ESCC) patients. We investigated the survival impact of TME status and changes in patients with ESCC who underwent neoadjuvant chemotherapy (NAC) followed by surgery (n = 264). We examined immunohistochemical status (CD4⁺, CD8⁺, CD20⁺, Foxp3⁺, HLA class-1⁺, CD204⁺, and programmed death ligand-1 [PD-L1⁺]) on 264 pre-NAC and 204 paired post-NAC specimens. Patients were classified by their pre- and post-NAC immune cell status and their changes following NAC. Our findings showed that pre-NAC TME status was not significantly associated with survival outcomes. In contrast, post-NAC TME status, such as low level of T cells, CD4⁺ T cells, and high PD-L1 combined positive score (CPS), were significantly associated with poor overall survival (OS). Notably, TME changes through NAC exerted significant survival impacts; patients with consistently low levels of T cells, low levels of CD4⁺ T cells, or high levels of PD-L1 (CPS) had very poor OS (3-year OS: 35.5%, 40.2%, and 33.3%, respectively). Tumor microenvironment changes of consistently low T cells, low CD4⁺ T cells, and high PD-L1 were independent predictors of poor OS in multivariate Cox hazards analyses, while factors indicating post-NAC status (T cells, CD4⁺, and PD-L1 [CPS]) alone were not. Therefore, we suggest that the consistently low T/high PD-L1 group could benefit from additional therapies, such as ICIs, and the importance of stratification by the TME, which has recently been recognized.

Keywords: esophageal squamous cell carcinoma; immune checkpoint inhibitor; neoadjuvant chemotherapy; surgery; tumor microenvironment.

FIGURE 1

Immune cells before and after neoadjuvant chemotherapy (NAC) in esophageal squamous cell carcinoma. The densities of (A) T cells (/mm²), (B) CD4⁺ cells (/mm²), (C) CD8⁺ cells (/mm²), (D) CD20⁺ cells (/mm²), (E) Foxp3⁺ cells (/mm²), (F) CD204⁺ cells (%), (G) HLA‐I⁺ cells (%), and programmed death ligand‐1 (PD‐L1⁺) expressions (H) combined positive score (CPS) and (I) tumor proportion score (TPS), were compared between pre‐ and post‐NAC specimens.

FIGURE 2

Chemotherapy effects according to pre‐neoadjuvant chemotherapy (NAC) tumor microenvironment status in esophageal squamous cell carcinoma. Pre‐NAC (A) T, CD4⁺, CD8⁺, CD20⁺, and Foxp3⁺ cell densities, (B) HLA‐I⁺ and CD204⁺ cell proportions, and (C) programmed death ligand‐1 (PD‐L1⁺) expression did not differ significantly between NAC responders and nonresponders (all p > 0.1). CPS, combined positive score; TPS, tumor proportion score.

FIGURE 3

Survival in patients with esophageal squamous cell carcinoma according to post‐neoadjuvant chemotherapy (NAC) tumor microenvironment (TME) status. All examined post‐NAC TME status except for post‐NAC CD8⁺ status showed significant impacts on overall survival outcomes. CPS, combined positive score; TPS, tumor proportion score.

FIGURE 4

Survival outcomes in patients with esophageal squamous cell carcinoma (ESCC) according to tumor microenvironment (TME) status changes. Patients whose tumors had (A) consistently low T cells, (B) consistently low CD4⁺ cells, and (C) persistently high programmed death ligand‐1 (PD‐L1⁺), had very poor overall survival (OS) (3‐year OS: 35.5%, 40.2%, and 33.3%, respectively). (D–F) These survival discrepancies were attributed to ESCC‐specific deaths. CSS, cancer‐specific survival.

FIGURE 5

Representative patterns of CD4⁺, CD8⁺, and programmed death ligand‐1 (PD‐L1⁺) (combined positive score [CPS]) changes in patients with esophageal squamous cell carcinoma.