Unlocking the potential of radiomics in predicting the response of neoadjuvant immunochemotherapy for operable locally advanced esophageal squamous cell carcinoma: a narrative review.

Background and Objective: Esophageal squamous cell carcinoma (ESCC) remains a major global health burden, with limited long-term survival despite advances in multimodal therapy. Neoadjuvant immunochemotherapy (NICT) has emerged as a promising preoperative strategy for operable locally advanced ESCC, demonstrating encouraging short-term efficacy and safety profiles. However, substantial interindividual variability in therapeutic response persists, underscoring the need for accurate predictive tools. Radiomics, which extracts high-dimensional quantitative features from medical images, offers a noninvasive means to characterize tumor heterogeneity and predict treatment outcomes. This review aims to synthesize current evidence on the application of radiomics in predicting NICT response for operable locally advanced ESCC, while discussing its biological interpretability and clinical translation potential. Methods: A comprehensive literature search was conducted in PubMed from January 2020 to November 2025. Search terms included combinations of "esophageal squamous cell carcinoma", "neoadjuvant immunochemotherapy", and "radiomics". Only studies focusing on operable locally advanced ESCC that evaluated radiomics for predictive or analytical purposes were included. Articles lacking methodological rigor or full-text availability were excluded. Evidence was narratively synthesized to identify advances, limitations, and research gaps. Key Content and Findings: NICT has shown comparable pathological complete response (pCR) and major pathological response (MPR) rates to conventional neoadjuvant chemoradiotherapy (NCRT). Radiomics-based models-particularly those integrating clinical and hematologic parameters-have achieved promising predictive performance for treatment response. Nevertheless, most studies remain single-center and lack external validation. Integrating molecular omics approaches, such as transcriptomics, could enhance biological interpretability and clinical applicability. Conclusions: Radiomics holds considerable promise for predicting NICT efficacy and advancing precision treatment in ESCC. Future research should prioritize multicenter validation and integration with molecular profiling to improve interpretability and clinical translation, ultimately guiding personalized therapy and informing future oncologic strategies.