Evolution and reflection of treatment paradigms for resectable esophageal cancer under precision stratification and intelligent medicine

The treatment paradigm for resectable esophageal cancer has undergone profound transformation in recent years, with a widening divergence between esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EAC). The authors examine three major themes-the diversification of neoadjuvant strategies, the wild application of immunotherapy, and the emergence of organ preservation, summarize key milestone trials, comment on critical appraisal of controversies, and look forward to the future perspectives on precision stratification and artificial intelligence(AI). The authors propose that the role of radiotherapy in neoadjuvant therapy for ESCC should be reexa-mined, and strategies for enhancing chemotherapy and immunity should be explored. EAC should adopt perioperative FLOT chemotherapy (fluorouracil+calcium folinate+oxaliplatin+docetaxel) as the basis, with immunotherapy improving efficacy. The clinical translation of organ preservation depends neoadjuvant therapy efficacy and assessment accuracy of clinical complete response. The integration of AI‑based radiomics and circulating tumor DNA‑minimal residual disease detection represents the most promi-sing tool for precision stratification. However, substantial evidence gaps remain-the surrogacy of pathological complete response (pCR) for long‑term survival requires validation, and prospective validation of AI models is largely absent. Therefore, the evaluation of patient prognosis should avoid biases associated with pCR, and further research depends on more rigorous clinical evidence.