The most conspicuous difference between Japan and Western countries in the treatment strategy for esophageal cancer is the attitude to lymph node dissection. Japanese surgeons have aimed at complete eradication of lymphatic spread of cancer cells and have reached the level of three-field lymph node dissection. In Western countries, however, surgeons rely more on chemotherapy or radiotherapy because they consider that most patients who present with esophageal cancer already have disseminated disease. Phase II studies of neoadjuvant chemotherapy and chemoradiotherapy have yielded encouraging results, and recently, positive reports on phase III studies of neoadjuvant therapy vs. surgery alone began to be announced. No such studies have included surgery with radical lymph node dissection. With the rapid advance in information technology, radical esophagectomy has gradually gained acceptance in the West, while many trials of neoadjuvant therapy have been carried out in Japan. Theoretically, the next step should be a phase III study of neoadjuvant therapy vs. surgery in which highly radical procedures such as three-field lymph node dissection are carried out.