Surgery After Induction Therapy for Cervical Esophageal Cancer: A Systematic Review and Proposed Multidisciplinary...

Background/Objectives: Management of cervical esophageal cancer after induction therapy remains unsettled. Definitive chemoradiotherapy is the guideline default, but a subset of patients with residual but resectable disease may still benefit from surgery. No validated multidisciplinary selection framework exists for this subsite. Methods: We conducted a systematic review registered in the International Prospective Register of Systematic Reviews (PROSPERO; CRD420261369102) and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement, using searches of PubMed/MEDLINE, Web of Science, Scopus, and the Cochrane Library from inception through 14 April 2026. We identified 1779 records, removed 873 duplicates, and screened 906 records; 87 full-text reports were assessed, of which 67 were excluded at the full-text stage (66 on population grounds-disease not cervical esophageal; and 1 because cervical-direct outcomes were not separable within a mixed cervical/thoracic cohort), leaving 20 cervical-direct studies included in the primary synthesis. Thoracic and meta-analytic sources are cited for indirect comparison and biological rationale but are not counted in the included set. Included studies were evaluated using the Newcastle-Ottawa Scale (NOS) and Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I); certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework. Formal meta-analysis was not performed because study design, treatment approach, and outcome reporting were too heterogeneous. Results: Cervical-specific evidence is predominantly retrospective but consistent in direction. Available cervical-specific observational data suggest benefit mainly in patients with biopsy-confirmed incomplete response, resectable residual disease, preserved performance status, and access to experienced centers. Larynx-preserving resection is feasible in 90% of T1-2 tumors and 54% of T3-4 responders. In thoracic esophageal squamous cell carcinoma, neoadjuvant chemoimmunotherapy yields pathologic complete response rates of approximately 29-48%; in cervical disease, the SCENIC trial has reported interim clinical response of approximately 50% in 28 patients, but pathology-confirmed response is not yet available. We present a proposed multidisciplinary selection framework integrating response depth, post-induction stage, laryngeal preservation feasibility, sarcopenia, circulating tumor DNA dynamics, and programmed death-ligand 1 (PD-L1) expression. The framework has not been prospectively validated and is presented as a hypothesis-generating, conceptual tool for multidisciplinary discussion rather than a clinically validated instrument. Adjuvant nivolumab is recommended for residual pathologic disease after margin-negative (R0) resection when surgery follows preoperative chemoradiotherapy; after PD-1-based induction, adjuvant checkpoint inhibition remains investigational. Conclusions: The available cervical-direct evidence is predominantly retrospective and selection-prone, and several inputs supporting the framework are extrapolated from thoracic ESCC cohorts; conclusions about the survival benefit of surgery should therefore be read as associations rather than causal claims. Surgery has a role after induction therapy in carefully selected incomplete responders. The proposed framework is designed for multidisciplinary use and requires prospective validation before routine clinical application.