J.Jpn. Surg. Soc.. 127(2): 164-171, 2026

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Feature topic

CONVERSION SURGERY FOR UNRESECTABLE ADVANCED ESOPHAGEAL CANCER

Recent advances in systemic therapy, particularly the introduction of immune checkpoint inhibitors (ICIs), have markedly transformed treatment strategies for unresectable advanced esophageal cancer. Conversion surgery (CS) is defined as resection performed after initially unresectable disease becomes resectable through systemic therapy or chemoradiotherapy and is considered for both cT4 locally advanced and cM1 metastatic cases. For cT4 disease, previous studies demonstrated that patients achieving R0 resection following induction therapy, including conventional chemoradiotherapy or triplet chemotherapy, can obtain favorable long-term outcomes, and a growing body of evidence now supports this approach. In particular, CS after definitive chemoradiotherapy (i.e., salvage surgery) remains the only potentially curative option for cT4 disease, although it is technically demanding and high risk, requiring careful attention to surgical techniques and perioperative management. In contrast, in cM1 cases, ICI-based induction regimens have enabled stronger systemic control and increased consideration of CS. However, evidence regarding its efficacy and safety remains limited. Critical clinical questions persist regarding patient selection, optimal timing, management of regressed metastases, immune-related adverse events, and the necessity of postoperative ICI continuation. Redefining the role of surgical treatment in the ICI era is essential for establishing optimal strategies to improve long-term outcomes in esophageal cancer.

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