<p>The treatment of nonmetastatic esophageal cancer with multimodal therapy, including neoadjuvant chemoradiotherapy in squamous cell carcinoma or perioperative chemotherapy in adenocarcinoma, followed by surgical resection represents the international standard of care. Esophagectomy is associated with high morbidity and mortality as well as impairment to quality of life. Therefore, several studies investigate whether active surveillance can be considered as an alternative to surgery in patients who achieve a&#xa0;clinical complete response after neoadjuvant therapy. Establishing a&#xa0;basis for organ preservation, the national phase&#xa0;III prospective randomized SANO trial in the Netherlands demonstrated noninferiority of active surveillance compared to surgery in terms of overall survival after neoadjuvant chemoradiotherapy according to the CROSS (Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study) protocol in patients with locally advanced esophageal cancer. The diagnosis of clinical complete remission after neoadjuvant therapy forms the basis of the organ preservation concept and proves to be challenging. The complete remission rate in dominant adenocarcinoma is likely to increase if perioperative chemotherapy is supplemented by immunotherapy . In summary, active surveillance following neoadjuvant therapy has the potential to expand individualized esophageal cancer treatment to include an organ-sparing approach for selected patients. At the same time, the integration of immunotherapy represents a&#xa0;crucial advance in multimodal therapy, as it is likely to further increase complete remission rates and thus increase the need for organ-preserving strategies. The organ-sparing approach also poses a&#xa0;challenge for diagnostic imaging. In addition to standardized surveillance protocols, reliable response evaluation after neoadjuvant therapy is essential.</p>