Predicting pathological complete response to chemoradiotherapy using artificial intelligence-based magnetic resonance imaging radiomics in esophageal squamous cell carcinoma

BACKGROUND Advanced esophageal squamous cell carcinoma (ESCC) has an extremely poor prognosis. Preoperative chemoradiotherapy (CRT) can significantly prolong survival, especially in those who achieve pathological complete response (pCR). However, the pretherapeutic prediction of pCR remains challenging. AIM To predict pCR and survival in ESCC patients undergoing CRT using an artificial intelligence (AI)-based diffusion-weighted magnetic resonance imaging (DWI-MRI) radiomics model. METHODS We retrospectively analyzed 70 patients with ESCC who underwent curative surgery following CRT. For each patient, pre-treatment tumors were semi-automatically segmented in three dimensions from DWI-MRI images (b = 0, 1000 second/mm²), and a total of 76 radiomics features were extracted from each segmented tumor. Using these features as explanatory variables and pCR as the objective variable, machine learning models for predicting pCR were developed using AutoGluon, an automated machine learning library, and validated by stratified double cross-validation. RESULTS pCR was achieved in 15 patients (21.4%). Apparent diffusion coefficient skewness demonstrated the highest predictive performance area under the curve (AUC) = 0.77. Gray-level co-occurrence matrix (GLCM) entropy (b = 1000 second/mm²) was an independent prognostic factor for relapse-free survival (RFS) (hazard ratio = 0.32, P = 0.009). In Kaplan-Meier analysis, patients with high GLCM entropy showed significantly better RFS (P < 0.001, log-rank). The best-performing machine learning model achieved an AUC of 0.85. The predicted pCR-positive group showed significantly better RFS than the predicted pCR-negative group (P = 0.007, log-rank). CONCLUSION AI-based radiomics analysis of DWI-MRI images in ESCC has the potential to accurately predict the effect of CRT before treatment and contribute to constructing optimal treatment strategies.