Integrating Preoperative Preserved Ratio Impaired Spirometry and Inflammatory Markers to Predict Postoperative Complications and Survival in Esophageal Squamous Cell Carcinoma After Neoadjuvant Therapy

Qichang Xie,1– 3,* Qiong Lin,4,* Junpeng Zhan,1– 3,* Chun Chen,1– 3 Bin Zheng,1– 3 Guobing Xu,1– 3 Yong Zhu,1– 3 Zhang Yang1– 3 1Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, People’s Republic of China; 2Key Laboratory of Cardio-Thoracic Surgery (Fujian Medical University), Fuzhou, Fujian, People’s Republic of China; 3Clinical Research Center for Thoracic Tumors of Fujian Province, Fuzhou, Fujian, People’s Republic of China; 4Department of Pulmonary and Critical Care Medicine, Fujian Medical University Union Hospital, Fuzhou, Fujian, People’s Republic of China*These authors contributed equally to this workCorrespondence: Yong Zhu; Zhang Yang, Department of Thoracic Surgery, Fujian Medical University Union Hospital, No. 29 Xinquan Road, Fuzhou, 350000, People’s Republic of China, Email zhuyong@fjmu.edu.cn; zhangyang@fjmu.edu.cnBackground: Severe postoperative complications (SPCs) adversely affect outcomes in esophageal squamous cell carcinoma (ESCC) following neoadjuvant therapy. The prognostic significance of preserved ratio impaired spirometry (PRISm) and inflammation-based biomarkers such as the systemic inflammation response index (SIRI) and lymphocyte-to-monocyte ratio (LMR) remains unclear.Methods: We retrospectively analyzed 224 ESCC patients who underwent esophagectomy after neoadjuvant therapy. PRISm was defined by FEV1 < 80% predicted and FEV1/FVC ≥ 0.7. Preoperative inflammatory indices, including SIRI, NLR, and LMR, were collected. The primary endpoint was the incidence of SPCs (Clavien–Dindo grade ≥ III); secondary endpoints included overall survival (OS) and recurrence-free survival (RFS). Multivariate regression was used to identify independent predictors. Nomograms were developed and validated using ROC curves, calibration plots, and decision curve analysis (DCA).Results: PRISm and decreased SIRI independently predicted higher SPC risk (p < 0.05). The SPC nomogram demonstrated good discrimination (AUC = 0.726). PRISm was also associated with significantly worse OS and RFS (p < 0.001). Elevated SIRI and low LMR correlated with poor long-term outcomes. OS and RFS nomograms showed good calibration and outperformed TNM staging in clinical utility.Conclusion: PRISm and systemic inflammatory markers are independent predictors of complications and prognosis in ESCC after neoadjuvant therapy. The proposed nomograms offer practical tools for individualized preoperative risk stratification and may support tailored perioperative management, especially in older or high-risk patients.Keywords: esophageal squamous cell carcinoma, ESCC, preserved ratio impaired spirometry (PRISm), postoperative complications, nomogram