Consolidation of Toripalimab and Capecitabine After Chemoradiotherapy in ESCC

• toripalimab (Drug), also known as JS001: Patients will receive toripalimab with a maximum treatment duration of one year (240 mg, IV drip, Q3W, for 16 cycles).
• capecitabine (Drug), also known as Xeloda: Patients will receive metronomic capecitabine, with a maximum treatment duration of one year (500 mg, twice daily, orally).

Primary outcomes

• Progression-free survival [From date of enrollment until the date of death from any cause or the date of first documented disease progression whichever came first, assessed up to 36 months]: Three-year follow-up from the date of enrollment to the date of disease progression or last follow-up

Secondary outcomes

• Overall survival [From date of enrollment until the date of death from any cause or the date of last follow-up, whichever came first, assessed up to 36 months]: Three-year follow-up from the enrollment to the date of death from any cause or date of lost follow-up
• Clinical complete response [14-16 weeks after the completion of radiotherapy]: Tumor response was evaluated 14-16 weeks after the completion of radiotherapy based on CT or PET-CT scans, and endoscopy with biopsies.
• Treatment-related adverse events [From date of enrollment to the date of last follow-up, assessed up to 36 months.]: Incidence of treatment-related adverse events as assessed by CTCAE v4.0.

Other outcomes

• Correlation between immune signature and overall survival [From date of enrollment to the date of last follow-up, assessed up to 36 months.]: The correlation between pretreatment immune signature (PD-L1, CD8, CTLA-4, CD56, and CD68) by mIHC and overall survival.
• Correlation between dynamic change of ctDNA and overall survival [From date of enrollment to the date of last follow-up, assessed up to 36 months.]: The correlation between dynamic change of ctDNA during treatment and survival outcomes.

Sex: All, ages: 18 Years to 75 Years

Inclusion Criteria:

1. Histologically confirmed squamous cell carcinoma of the esophagus;
2. Locally advanced esophageal cancer classified as stage I-IVA (inoperable or patient declined surgery) or stage IVB thoracic esophageal cancer with supraclavicular lymph node metastasis only (AJCC 8th edition) prior to treatment;
3. Completion of definitive concurrent chemoradiotherapy without disease progression; radiotherapy dose of 50-50.4 Gy using conventional fractionation and IMRT technique; concurrent platinum- or taxane-based doublet chemotherapy during radiotherapy; ≤4 cycles of induction chemotherapy allowed prior to radiotherapy; PD-1/PD-L1 antibody therapy permitted during induction chemotherapy and radiotherapy; no adjuvant therapy received;
4. Enrollment window: within 1-42 days after completion of chemoradiotherapy;
5. Age 18-75 years;
6. Estimated life expectancy >6 months;
7. Eastern Cooperative Oncology Group performance status ≤ 2;
8. The function of important organs meets the following requirements: a. white blood cell count (WBC) ≥3.5×109/L, absolute neutrophil count (ANC) ≥1.5×109/L; b. platelets ≥75×109/L; c. hemoglobin ≥9g/dL; d. serum albumin ≥2.8g/dL; e. total bilirubin ≤1.5×ULN, ALT, AST and/or AKP ≤2.5×ULN; f. serum creatinine ≤1.5×ULN or creatinine clearance rate >60 mL/min;
9. Ability to understand the trial details and has provided written informed consent.

Exclusion Criteria:

1. Patients who have received antitumor therapy (including adjuvant chemotherapy, surgery, immunotherapy, targeted therapy, etc.) after completion of chemoradiotherapy;
2. Stage IVb patients with metastasis to solid organs (e.g., liver, bone, lung, brain, adrenal gland, peritoneum, etc.) at initial diagnosis;
3. Known or suspected allergy to the investigational drug(s) or any agent related to the trial regimen;
4. Presence of esophageal fistula and/or esophageal hemorrhage prior to enrollment;
5. Disease progression after chemoradiotherapy;
6. ≥Grade 2 radiation pneumonitis prior to enrollment;
7. History of ≥ Grade 3 immune-related adverse events prior to enrollment;
8. Prior treatment with targeted drugs;
9. History of other malignant tumors besides esophageal cancer, except for non-melanoma skin cancer, carcinoma in situ of the cervix, papillary thyroid carcinoma, or cured early-stage prostate cancer;
10. Patients with severe cardiac, pulmonary, hepatic, or renal dysfunction, hematopoietic system diseases, cachexia, or other conditions that make them unfit for chemotherapy;
11. Female patients who are pregnant or breastfeeding;
12. Inability to provide informed consent due to psychological, familial, social, or other factors;
13. Presence of CTC grade ≥2 peripheral neuropathy;
14. Patients with a history of diabetes for more than 10 years and poorly controlled blood glucose levels;
15. History of autoimmune disease or autoimmune disorders (e.g., colitis, systemic lupus erythematosus, rheumatoid arthritis, uveitis, hypophysitis, hyperthyroidism; not limited to these diseases or syndromes), immunodeficiency history, including HIV positivity, or other acquired/congenital immunodeficiency disorders, or history of organ transplantation or allogeneic bone marrow transplantation;
16. History of interstitial lung disease or non-infectious pneumonia;
17. Active hepatitis B (HBV DNA ≥2000 IU/mL or 10⁴ copies/mL) or hepatitis C (HCV antibody positive with HCV-RNA above the lower limit of detection);
18. Any unstable condition that may jeopardize patient safety or compliance.

• Results publication: Zhu Y, Wen J, Li Q, Chen B, Zhao L, Liu S, Yang Y, Wang S, Lv Y, Li J, Zhang L, Hu Y, Liu M, Xi M. Toripalimab combined with definitive chemoradiotherapy in locally advanced oesophageal squamous cell carcinoma (EC-CRT-001): a single-arm, phase 2 trial. Lancet Oncol. 2023 Apr;24(4):371-382. doi: 10.1016/S1470-2045(23)00060-8. PMID 36990609
• Results publication: Bando H, Kumagai S, Kotani D, Mishima S, Irie T, Itahashi K, Tanaka Y, Habu T, Fukaya S, Kondo M, Tsushima T, Hara H, Kadowaki S, Kato K, Chin K, Yamaguchi K, Kageyama SI, Hojo H, Nakamura M, Tachibana H, Wakabayashi M, Fukui M, Fuse N, Koyama S, Mano H, Nishikawa H, Shitara K, Yoshino T, Kojima T. Atezolizumab following definitive chemoradiotherapy in patients with unresectable locally advanced esophageal squamous cell carcinoma - a multicenter phase 2 trial (EPOC1802). Nat Cancer. 2025 Mar;6(3):445-459. doi: 10.1038/s43018-025-00918-1. Epub 2025 Feb 19. PMID 39972105
• Results publication: Jia R, Shan T, Zheng A, Zhang Y, Lu P, Zhang G, Wang F, Xu Z, Zheng G, Tang D, Zhang W, Li W, Li R, Guo Y, Liu L, Luo X, Zheng Y, Chang Z, Wang Q, Wang X, Yuan X, Kong G, Li S, Yang R, Zhou D, Ren J, Yin W, Li J, Zhang J, Wang Z, Sheng M, Xu B, Li L, Liu X, Lu Z, Wan L, Zhou F, Gao S. Capecitabine or Capecitabine Plus Oxaliplatin Versus Fluorouracil Plus Cisplatin in Definitive Concurrent Chemoradiotherapy for Locally Advanced Esophageal Squamous Cell Carcinoma (CRTCOESC): A Multicenter, Randomized, Open-Label, Phase 3 Trial. J Clin Oncol. 2024 Jul 10;42(20):2436-2445. doi: 10.1200/JCO.23.02009. Epub 2024 May 6. PMID 38710003

• Mian Xi, MD, Principal investigator, Sun Yat-Sen University Cancer Center