PD04.01. Multimodal Treatment Strategies Incorporating Conversion Therapy for Thoracic Esophageal Cancer With Adjacent Organ Invasion

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Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer Background Management of thoracic esophageal cancer with suspected adjacent organ invasion remains challenging because of diagnostic uncertainty and limited curative options. Recent advances in induction chemotherapy, including DCF and immune checkpoint inhibitors, have enabled downstaging and subsequent conversion to curative-intent treatment in selected patients. Methods We retrospectively reviewed 57 patients with locally advanced, initially unresectable thoracic esophageal squamous cell carcinoma without distant metastasis except supraclavicular lymph nodes, who initiated treatment with induction chemotherapy (DCF or immune checkpoint inhibitor plus chemotherapy) or definitive chemoradiotherapy between January 2014 and December 2024. Patients achieving complete response after non-surgical treatment or R0 resection were defined as cancer free. Cases diagnosed before the 12th edition of the Japanese Classification of Esophageal Cancer were reclassified as cT3br or cT4 based on endoscopic circumferential involvement and computed tomography findings, including compression or displacement of adjacent organs. Treatment pathways, conversion therapy, short-term surgical outcomes, and survival were analyzed. Results The cohort included 34 cT3br and 23 cT4 patients. Initial induction chemotherapy achieved downstaging to resectable disease in 85% of cT3br and 57% of cT4 cases. Conversion surgery was performed in 27 patients, with R0 resection achieved in 25. Median blood loss was 190 mL, operative time 524 minutes, and no in-hospital mortality occurred. Cancer-free status was associated with significantly improved survival in both cT3br and cT4 groups (2-year overall survival: 74% vs 11% and 100% vs 7%, respectively; both p<0.001). Among surgical cases, patients achieving pathological response grade ≥2 showed superior survival compared with non-responders (2-year overall survival: 100% vs 53%, p=0.01). Prognosis did not differ according to the invaded organ. Conclusion In thoracic esophageal cancer with adjacent organ invasion, achieving cancer-free status is strongly associated with improved survival regardless of initial T classification. A multimodal treatment strategy incorporating induction therapy and conversion treatment, including definitive chemoradiotherapy or surgery, represents a feasible curative approach. Careful treatment selection remains essential given the limitations of diagnostic accuracy in assessing organ invasion.

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