This review article delves into the advancements of organ preservation strategies in treating esophageal squamous cell carcinoma (ESCC), a malignancy with significant global morbidity and mortality. The article focuses on four treatment pillars: minimally invasive operations, concurrent chemoradiotherapy (CRT), immunotherapy and the challenges currently faced in the organ preservation therapeutic paradigm. Minimally invasive techniques, such as endoscopic resection, offer a less morbid alternative to traditional esophagectomy, preserving esophageal function while effectively treating early-stage ESCC; Concurrent CRT has emerged as a robust option, demonstrating comparable survival outcomes to surgery in locally advanced cases, thus broadening the therapeutic landscape for patients unsuitable for surgical intervention; Immunotherapy has revolutionized cancer treatment, and its integration into organ preservation strategies for ESCC shows promise. Despite the mentioned current advancements, several challenges remain. For instance, the lack of definitive predictive biomarkers hinders the precise selection of patients who will benefit most from organ-sparing approaches. Additionally, the management of treatment-related toxicities and the need for personalized treatment plans based on individual patient characteristics are highly limited to in-vitro and ex-vivo models. While significant strides have been made in organ preservation for ESCC, the journey is far from over. This article serves as a testament to the ongoing commitment of the medical community to push the boundaries of what is possible in the treatment of ESCC. Future research must address the identified challenges, leveraging multidisciplinary collaboration and innovative technologies to reach the ultimate goal, ie. to cure ESCC while preserving the esophagus, thereby improving the quality of life for survivors.

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