Background: The oncological outcomes of transthoracic esophagectomy (TTE) and definitive chemoradiotherapy (dCRT) as initial treatment in patients with esophageal squamous cell carcinoma (ESCC) who could tolerate TTE remains unclear.Methods: Consecutive patients histologically diagnosed with stage I/II/III ESCC (excluding cT4 or cN3) or stage IV ESCC due to supraclavicular lymph node metastasis were eligible for inclusion in this retrospective study. To select patients who could tolerate TTE, respiratory function, Eastern Cooperative Oncology Group performance status, and preoperative complications were considered. Patient characteristics, recurrence-free survival (RFS), 3- and 5-year overall survival (OS), pattern of recurrence, and treatments after initial treatment failure were investigated.Results: Overall, 112 patients were included in the TTE group and 65 were included in the dCRT group. No significant differences were observed in patient characteristics and clinical stage between the TTE and dCRT groups (stage I/II/III/IV of 29/27/46/10 in the TTE group and 23/15/20/7 in the dCRT group). The R0 resection rate was 87 % in the TTE group, and complete response rate was 68 % in the dCRT group. In intention-to-treat analysis, there was no significant difference in RFS. In contrast, 3-year OS of non-stage IA patients was significantly longer in the TTE group than the dCRT group (TTE 66.9 %; dCRT 49.8 %; p = 0.023). In non-stage IA patients, after initial treatment failure significantly more patients could undergo local treatment (radiotherapy or surgery in the TTE group; surgery or endoscopic resection or photodynamic therapy in the dCRT group) in the TTE group than the dCRT group (TTE 74 %; dCRT 40 %; p = 0.003).Conclusions: In locally advanced ESCC patients who could tolerate TTE, TTE extended 3-year OS, which might have been encouraged by utilizing local treatment after initial treatment failure.
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