Salvage esophagectomy versus photodynamic therapy for localized residual or recurrent esophageal squamous cell carcinoma after definitive chemoradiotherapy or radiotherapy: a single-center comparative study

BACKGROUND: Salvage esophagectomy is considered the standard curative treatment for localized residual or recurrent esophageal cancer after definitive chemoradiotherapy (CRT), but it is associated with substantial morbidity. Photodynamic therapy (PDT) has emerged as a less invasive alternative. We compared the outcomes of salvage esophagectomy and PDT for localized residual or recurrent esophageal squamous cell carcinoma (ESCC) after definitive CRT or radiotherapy (RT). METHODS: We retrospectively reviewed 91 patients with cT1-2N0M0 residual or recurrent ESCC after definitive CRT or RT who underwent salvage esophagectomy (n = 33) or PDT (n = 58) at a single institution. Overall survival (OS), disease-specific survival (DSS), and treatment-related outcomes were evaluated. RESULTS: Patients treated with PDT were significantly older and had a higher comorbidity burden than those undergoing salvage esophagectomy. Salvage esophagectomy achieved an R0 resection rate of 94.0% but was associated with severe postoperative complications in 48.5% of patients, including one treatment-related death. In the PDT group, initial local complete response was achieved in 74.1% of patients, with one grade 3 adverse event and no treatment-related mortality. No significant differences were observed between the groups in OS (p = 0.597) or DSS (p = 0.670). CONCLUSIONS: This study does not establish equivalence or non-inferiority between PDT and salvage esophagectomy. PDT demonstrated a favorable safety profile and may offer an organ-preserving salvage treatment option for carefully selected patients with localized residual or recurrent ESCC after definitive CRT or RT, particularly those unsuitable for surgery because of advanced age, substantial comorbidities, or limited surgical tolerance.