Esophageal cancer (EC) continues to pose a major global health burden, ranking as the ninth most common malignancy and sixth leading cause of cancer mortality, with over 600,000 new cases and 500,000 deaths annually as of 2025. While esophagectomy has long been the standard for curative intent in resectable disease, organ preservation strategies have advanced significantly, offering viable alternatives for patients with locally advanced esophageal squamous cell carcinoma (ESCC) or those unsuitable for surgery due to comorbidities. These approaches encompass definitive chemoradiotherapy (dCRT), neoadjuvant chemoradiotherapy (nCRT) followed by active surveillance (“watch-and-wait”), and innovative integrations of immunotherapy and targeted therapies. This narrative review synthesizes evidence from recent clinical trials, systematic reviews, and international guidelines up to 2025, demonstrating that organ-sparing protocols can achieve comparable overall survival (OS) rates—often exceeding 50% at 5 years in selected cohorts-while substantially enhancing quality of life (QoL) by preserving esophageal function. For instance, the SANO trial (2025) confirmed non-inferiority of active surveillance post-nCRT, with 2-year OS of 74% versus 71% for standard surgery. Key challenges include imprecise response assessment, locoregional recurrences (20–30%), and treatment-related toxicities such as esophageal strictures. Emerging trials like ESOSTRATE and PALACE3 are evaluating immunotherapy-enhanced regimens, potentially expanding organ preservation to esophageal adenocarcinoma (EAC). With genomic biomarkers and novel modalities like proton therapy, personalized organ preservation promises to broaden applicability, reduce morbidity, and improve outcomes across histological subtypes. Additionally, recent studies emphasize the role of liquid biopsies, such as circulating tumor DNA (ctDNA), in monitoring treatment response and guiding surveillance, potentially reducing the need for invasive procedures and improving detection of minimal residual disease. The aim of this review is not only to summarize recent trials but to synthesize them into an operational framework that clinicians and researchers can apply: a decision algorithm for selecting organ preservation candidates. This is the novel element that distinguishes this work from prior narrative reviews.
食管癌（EC）仍然是全球重大的健康负担，截至2025年，其年新发病例超过60万、死亡病例达50万，位列全球第九大常见恶性肿瘤和第六大癌症死亡原因。虽然食管切除术长期以来是可切除食管癌的标准根治手段，但器官保留策略已取得显著进展，为局部晚期食管鳞状细胞癌（ESCC）或因合并症不适合手术的患者提供了可行的替代方案。这些策略包括根治性放化疗（dCRT）、新辅助放化疗（nCRT）后主动监测（“观察等待”），以及免疫治疗和靶向治疗的创新性整合。本文综述综合了截至2025年的近期临床试验、系统评价和国际指南的证据，表明器官保留方案在特定患者群体中可实现相当的总生存（OS）率（5年OS率常超过50%），同时通过保留食管功能显著提升生活质量（QoL）。例如，SANO试验（2025年）证实了nCRT后主动监测的非劣效性，其2年OS率为74%，而标准手术为71%。关键挑战包括疗效评估不精确、局部区域复发（20-30%）以及食管狭窄等治疗相关毒性。ESOSTRATE和PALACE3等新兴试验正在评估免疫治疗增强方案，可能将器官保留策略扩展至食管腺癌（EAC）。随着基因组生物标志物和质子治疗等新技术的应用，个体化器官保留策略有望扩大适用人群、降低并发症发生率并改善不同组织学亚型的预后。此外，近期研究强调了液体活检（如循环肿瘤DNA）在监测治疗反应和指导随访中的作用，可能减少侵入性操作的需求并提高微小残留病的检出率。本综述的目的不仅是总结近期试验，更在于将其整合成一个可供临床医生和研究人员应用的实操框架：即器官保留候选者的选择决策算法。这是本综述区别于既往叙述性综述的创新之处。
Organ Preservation in Esophageal Cancer: Current Strategies, Challenges, and Future Directions
肿瘤(癌症)患者之家