Endoscopic and surgical management of early esophageal cancer: Current evidence and evolving oncologic strategies

Table 1 Ongoing and recent clinical trials evaluating endoscopic treatment for early esophageal cancer

Trial/registry	Study design	Population	Intervention	Primary outcome	Study status
JCOG0508	Prospective multicenter phase II	Superficial ESCC with minimal submucosal invasion	ESD followed by selective chemoradiotherapy	Overall survival, local control	Completed
JCOG1009/1010	Prospective multicenter	Superficial ESCC	ESD with adjuvant therapy	Disease-free survival	Completed
NCT02304181	Prospective cohort	Early esophageal neoplasia	ESD	En bloc and R0 resection rates	Completed
NCT03470246	Randomized controlled trial	Barrett’s-associated neoplasia	EMR + RFA vs EMR alone	Eradication of dysplasia	Completed
ChiCTR1800018892	Multicenter prospective	Early ESCC	ESD	Long-term survival and recurrence	Ongoing

ESCC: Esophageal squamous cell carcinoma; ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection; RFA: Radiofrequency ablation.

Table 2 Comparative outcomes of treatment modalities for early esophageal cancer

Outcome	EMR	ESD	Esophagectomy
En bloc resection rate	Low–moderate (piecemeal common for larger lesions)	High (> 90%-95%)	Not applicable
R0 resection rate	Moderate (lower for large lesions)	High (approximately 85%-95%)	High
Local recurrence rate	Higher (up to 10%-20%)	Low (< 1%-5%)	Very low
5-year overall survival	Approximately 85%-98% (selected patients)	Approximately 90%-99% (selected patients)	Approximately 85%-95%
Procedure-related mortality	Very low (< 0.5%)	Very low (< 0.5%)	Higher (2%-9%)
Major adverse events	Bleeding, stricture	Perforation, stricture	Pulmonary complications, anastomotic leak

ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection.

Table 3 Comparison of treatment strategies for early esophageal cancer

Treatment strategy	Advantages	Limitations
Esophagectomy	Complete tumor and lymph node removal; established oncologic standard for invasive disease	Highly invasive; significant perioperative morbidity and mortality; long recovery; loss of gastroesophageal junction; impaired quality of life
Endoscopic mucosal resection	Minimally invasive; low procedure-related mortality; effective for small, superficial mucosal lesions; short recovery time	Limited to small lesions; often requires piecemeal resection; reduced accuracy of pathological margin assessment; higher local recurrence for large lesions
Endoscopic submucosal dissection	En bloc resection regardless of lesion size; precise pathological evaluation; lower recurrence rates; organ preservation	Technically demanding; longer procedure time; higher risk of perforation and stricture; limited availability in some regions

Table 4 Risk stratification and treatment recommendations for early esophageal cancer

Risk category	Tumor characteristics	Lymph node risk	Recommended treatment
Ultra-low risk	T1a (M1-M2), well differentiated, no LVI	Minimal (< 1%)	EMR or ESD
Low risk	T1a (M3), small lesions, no LVI	Low (approximately 1%-5%)	ESD preferred
Intermediate risk	T1b (SM1), no LVI, favorable histology	Moderate (approximately 5%-15%)	ESD ± additional therapy or surgery
High risk	T1b (deep SM), LVI+, poor differentiation	High (> 20%)	Surgical resection ± chemoradiotherapy

ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection; LVI: Lymphovascular invasion.

Table 5 Stratified treatment considerations based on tumor characteristics

Factor	Category	Clinical implication	Preferred approach
Tumor size	≤ 2 cm	Higher likelihood of en bloc resection	EMR or ESD
	> 2 cm	Increased risk of incomplete resection	ESD preferred
Depth of invasion	M1-M2	Minimal nodal risk	Endoscopic therapy
	M3-SM1	Intermediate nodal risk	ESD ± surgery
Histology	ESCC	Higher nodal risk with invasion	Careful selection
	EAC	Lower nodal risk in early stage	Endoscopic therapy favored

ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection; ESCC: Esophageal squamous cell carcinoma; EAC: Esophageal adenocarcinoma.