Organ preservation after neoadjuvant therapy for esophageal cancer has gained significant attention. While the CROSS trial established neoadjuvant chemoradiotherapy (nCRT) followed by surgery as standard care, approximately 30% of patients achieve pathological complete response (pCR), prompting exploration of active surveillance (AS). The landmark SANO phase Ⅲ trial (2025) demonstrated non-inferior 2-year overall survival (74% AS vs. 71% surgery), with 31% of patients avoiding surgery. Multimodal assessment (endoscopic deep biopsy+endoscopic ultrasound+PET-CT) reduced residual disease misdiagnosis to 10%. The Asian-led NEEDS trial is evaluating definitive chemoradiotherapy with salvage surgery. Although immunotherapy boosts pCR rates to 40%-55%, challenges persist, including 8%-12% false-negative cCR assessments, limited long-term data, and East-West histological disparities. The 2024 NCCN guidelines conditionally recommend AS (Category 2B, prioritized for squamous cell carcinoma), emphasizing centralized implementation. Future directions involve circulating tumor DNA and radiomics for risk stratification to advance precise organ-preserving strategies.
Citation：
LI Hui. From CROSS to SANO: Evidence-based breakthroughs and clinical practice challenges in organ-preservation strategies for esophageal cancer in the era of neoadjuvant therapy. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2026, 33(3): 347-352. doi: 10.7507/1007-4848.202508031
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Copyright ? the editorial department of Chinese Journal of Clinical Thoracic and Cardiovascular Surgery of West China Medical Publisher. All rights reserved
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