Salvage/Conversion Esophagectomy for T4b ESCC

Esophageal squamous cell carcinoma (ESCC) with invasion of adjacent vital structures (cT4b) has traditionally been managed with definitive chemoradiotherapy or systemic chemotherapy, but long-term survival remains poor. This review summarizes evidence for surgery-enabled strategies—salvage esophagectomy after definitive chemoradiotherapy and conversion esophagectomy after induction therapy—and highlights selection criteria, restaging, and perioperative management. Carefully selected, downstaged patients can achieve curative-intent resection with acceptable morbidity and improved survival versus nonsurgical approaches. Key elements include multidisciplinary selection: rigorous restaging with CT, endoscopy, and bronchoscopy; prioritization of R0 resection; and proactive prevention of airway fistula, anastomotic leak, recurrent laryngeal nerve palsy, and pulmonary complications. Minimally invasive and robot-assisted approaches facilitate precise dissection in postradiation fields without compromising oncologic principles. Immune checkpoint inhibitor (ICI)-based chemo-immunotherapy is reshaping induction algorithms and may expand resectability, although immune-related adverse events require vigilance. Standardized indications and prospective validation are urgently needed.