Backgrounds: Esophageal squamous cell carcinoma (ESCC) is highly invasive, with over half of patients presenting with locally advanced disease, and the optimal radical strategy remains controversial. Recent advances have further blurred the distinction between radical esophagectomy (RE) and definitive chemoradiotherapy (dCRT). This study compared survival outcomes and failure patterns between these two approaches. Methods: We retrospectively analyzed 770 patients with locally advanced ESCC (630 RE; 140 dCRT). Event-free survival (EFS), overall survival (OS), and post-progression survival (PPS), as well as recurrence and metastasis patterns, were compared between groups before and after propensity score matching (PSM). In patients with progression, we further examined the prognostic impact of different failure patterns. Results: The RE group had significantly better OS and EFS than the dCRT group, both before and after PSM. Before PSM, HRs were 0.477 ( P < 0.001) for OS and 0.455 ( P < 0.001) for EFS; after PSM, HRs were 0.450 ( P < 0.001) and 0.400 ( P < 0.001), respectively. Distant metastasis (DM) was the predominant failure pattern after RE (53% before vs 55% after PSM), whereas local recurrence (LR) was most common after dCRT (51% vs 55%). Regional lymph nodes were the main LR site after RE, while the primary lesion predominated after dCRT; the lungs were the most frequent DM site in both groups. Within the RE cohort, non-local progression was associated with longer OS (HR = 0.654, P = 0.017) and PPS (HR = 0.698, P = 0.042) than local progression. Supraclavicular or cervical nodal (SCLN) metastases were more frequent after RE and were associated with better OS and PPS than other distant sites. Conclusion: Under comparable conditions, RE confers superior survival to dCRT, likely owing to better local control. Efforts to further enhance local control are essential when considering organ-preserving dCRT for locally advanced ESCC.
Fan et al. (Tue,) studied this question.