Perioperative Outcomes of Neoadjuvant Immunochemotherapy for Locally Resectable Oesophageal Squamous Cell Carcinoma in Geriatric Patients Aged 70 Years or Older

Background: Neoadjuvant chemoradiotherapy (nCRT) followed by surgery has become the standard treatment for oesophageal cancer. However, data on the outcomes of neoadjuvant immunochemotherapy (nICT) in geriatric patients (≥70 years) who face higher perioperative risks are limited. Objective: This study aimed to compare the perioperative outcomes of nICT versus nCRT in elderly patients with locally advanced oesophageal squamous cell carcinoma (ESCC). Method: This retrospective cohort study included 132 geriatric patients (median age: 72 years) treated with nICT (n = 51) or nCRT (n = 81) followed by esophagectomy at Sichuan Cancer Hospital (2021–2024). Intraoperative outcomes, postoperative pathologic stages, and complications, including pneumonia and anastomotic leakage, were assessed. Propensity score matching (PSM), overlap weighting (OW), and inverse probability of treatment weighting (IPTW) were used to adjust for baseline covariate imbalances in the sensitivity analysis. Results: Pathologic ypT0 stage tended to be higher in the nCRT group (p = 0.014), whereas ypN0 was higher in the nICT group (p = 0.035). No significant differences in intraoperative or postoperative outcomes between the two groups, except for pulmonary complications (p > 0.05). Compared with nCRT patients, nICT patients had significantly lower pulmonary complication rates (13.7% vs. 32.1%, p = 0.030), and multivariable analysis confirmed these findings (adjusted OR = 0.26; 95% CI: 0.08–0.85; p = 0.026). Sensitivity analyses showed consistent results. Conclusions: The safety of nICT is comparable to that of nCRT in geriatric ESCC patients, with significantly fewer pulmonary complications. These findings support nICT as a valuable alternative for elderly populations.