Post-CROSS-CRT-then-esophagectomy with residual disease — pathology shows ypT+ and/or ypN...

Deterministic view of the source YAML entity. Clinical authority remains with the cited source IDs and reviewer sign-off state.

ID	`RF-ESOPHAGEAL-POST-CROSS-NON-PCR`
Type	Red flag
Status	reviewed 2026-04-30 \| pending_clinical_signoff
Diseases	`DIS-ESOPHAGEAL`
Sources	`SRC-ESMO-ESOPHAGEAL-2024` `SRC-NCCN-ESOPHAGEAL-2025`

Red Flag Origin

Definition	Post-CROSS-CRT-then-esophagectomy with residual disease — pathology shows ypT+ and/or ypN+ (no pCR). ~70% of CROSS patients fall into this category. Treatment-defining: shifts the patient out of the resectable-1L (CROSS neoadjuvant) pathway into adjuvant nivolumab × 1 year per CheckMate-577 (DFS 22 vs 11 mo placebo, HR 0.69). Eligibility window: initiate within 4-16 weeks post-surgery. Applies to both adenocarcinoma and squamous-cell histology.
Clinical direction	intensify
Category	high-risk-biology
Shifts algorithm	ALGO-ESOPH-RESECTABLE-1L, ALGO-ESOPHAGEAL-ADJUVANT-1L

Trigger Logic

{
  "any_of": [
    {
      "finding": "post_cross_residual_disease_ypT_or_ypN_positive",
      "value": true
    },
    {
      "all_of": [
        {
          "finding": "post_cross_pCR",
          "value": false
        },
        {
          "any_of": [
            {
              "finding": "ypT_residual",
              "value": true
            },
            {
              "finding": "ypN_residual",
              "value": true
            }
          ]
        }
      ]
    }
  ],
  "type": "post_treatment_pathology_composite"
}

Notes

Engine wiring: when post-CROSS non-pCR biology is detected on a patient profile that lacks `disease_state` (so the resectable-1L algorithm is the only line=1 esophageal algorithm reached by load-order fallback), this RedFlag fires inside ALGO-ESOPH-RESECTABLE-1L step 0 to redirect the engine to the adjuvant indication (IND-ESOPH-ADJUVANT-NIVOLUMAB-POST-CROSS) instead of the neoadjuvant default. Once curated patient JSONs migrate to set `disease_state: "adjuvant"`, the dedicated ALGO-ESOPHAGEAL-ADJUVANT-1L picks them up directly and this step 0 becomes redundant (still safe — additive). pCR patients (ypT0N0M0) excluded from CheckMate-577 — adjuvant nivo is contraindicated in that subset.

Used By

Algorithms

ALGO-ESOPH-RESECTABLE-1L - ALGO-ESOPH-RESECTABLE-1L
ALGO-ESOPHAGEAL-ADJUVANT-1L - ALGO-ESOPHAGEAL-ADJUVANT-1L