JIA Zhuoqi , BAI Liaoliao , WANG Xiao , CHEN Hongqing , DANG Haizhou , ZHANG Wei
  • Department of Thoracic Surgery, Xi'an People’s Hospital (Xi’an Fourth Hospital), Xi’an, 710004, P. R. China;
ZHANG Wei, Email: Zw0009@126.com
Esophageal cancer; organ preservation; neoadjuvant chemoradiotherapy; clinical complete response; active surveillance; salvage esophagectomy; circulating tumor DNA; risk stratification
10.7507/1007-4848.202602039
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The evidence base, technical specifications and clinical implementation conditions of organ preservation strategies after neoadjuvant therapy for esophageal cancer were systematically reviewed, to provide an integrated framework for precise clinical decision-making. Based on the SANO randomized controlled trial and a series of diagnostic accuracy studies, the evolution of active surveillance (AS), the performance of multimodal evaluation techniques, and the outcomes of salvage treatment after recurrence were summarized. The SANO trial demonstrated that patients with rigorously selected clinical complete response (cCR) who received AS had a 2-year overall survival rate of 74%, which was non-inferior to the immediate surgery group (71%; absolute difference 0%, 95%CI –7% to 7%). Thirty-one percent of patients successfully avoided esophagectomy by the end of follow-up. However, the 2-year disease-free survival rate was significantly lower in the AS group than that in the surgery group (74% vs. 92%). The locoregional recurrence rate was 48%, the 30-day mortality rate after salvage esophagectomy following definitive chemoradiotherapy reached 11%, which was 3.7-fold higher than that of elective surgery (RR=3.67, 95%CI 2.89-4.66); whereas in the SANO study, the 30-day mortality rate of salvage surgery after neoadjuvant chemoradiotherapy with active surveillance for recurrence was 4%, showing no significant difference compared with the 5% observed in the immediate surgery group. The false-negative rate of cCR assessment was 13.5%-19.2%, with a negative predictive value of only 68.7%, indicating that approximately one in three patients judged as cCR actually had residual disease. Current evidence with immature long-term survival data does not support AS as a routine recommendation. This strategy should be strictly limited to high-volume esophageal cancer centers, patients with esophageal squamous cell carcinoma, highly consistent multimodal evaluations, and fully informed and highly compliant patients. Future studies are needed to optimize risk stratification using biomarkers such as circulating tumor DNA, and to balance quality-of-life benefits and oncological safety through adaptive therapeutic strategies.

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