Background: Localized EC patients should receive chemoradiation followed by surgery (TMT). Nevertheless, some patients decline surgery after preoperative chemoradiation. Reports on the outcome of such patients are scant. Methods: Between 2002 and 2011, we identified 622 TMT-eligible EC patients in our databases. Of 622 patients, 425 achieved clinical complete response (negative biopsy and PET in the physiologic range) after preoperative chemoradiation. Of 425, 244 patients underwent surgery but 61 patients declined surgery. We were able to matched 16 covariates between 36 patients who declined surgery and 36 patients who had TMT. Results: Baseline characteristics between the two groups were well-balanced (p=NS). Within this matched cohort, the median overall survival (OS) and relapse-free survival were 57.9 months (95% CI, 27.7-NA), and 18.5 (95% CI, 11.5-30.4) for the declined surgery group and those were 50.8 months (95% CI, 30.7-NA), and 26.5 months (95% CI, 15.5-NA) for the TMT group. OS and RFS for both groups were not different (p=0.28, and 0.45, respectively). However, 11 of 36 patients in the declined surgery group had salvage surgery (median OS was 66.1 months). Conclusions: These provocative results are in a small series but need to be interpreted with caution. Nevertheless, the results reinforce a possibility of esophageal preservation strategy that could encompass biomarkers and sophisticated imaging. Currently, however, trimodality remains the gold standard. Supported by UTMDACC and generous donors.