Next step after endoscopic resection for superficial esophageal squamous cell carcinoma: metastatic risk assessment and management of non-curative resection cases

Endoscopic resection (ER) is an established treatment for early stage esophageal squamous cell carcinoma. However, the management of non-curative resections remains a clinical challenge. This review aimed to evaluate the next steps for patients with non-curative resections based on the existing literature. Relevant studies on ER outcomes in esophageal squamous cell carcinoma, including recurrence rates, metastatic risks, and treatment strategies, were reviewed. The analysis focused on pathological findings, including tumor invasion depth and lymphovascular involvement (LVI). Comparative data on surgical resection and chemoradiotherapy (CRT) as adjuvant treatments were analyzed. Patients with pathological epithelial or lamina propria mucosa LVI-negative tumors showed low recurrence and metastasis rates (0.4%-5.6%). In contrast, those with submucosal or positive LVI cancer demonstrated a higher risk (10%-30%). Adjuvant treatment with surgery or CRT significantly reduced recurrence; however, the risk of complications must be considered. CRT showed favorable outcomes in low metastatic-risk cases, whereas surgery was preferred in high-risk patients. Active surveillance may be appropriate in certain low-risk patients with a poor overall health status. The management of non-curative ER cases requires individualized decision-making based on pathological risk factors. Further research is needed to refine the risk assessment and potentially utilize circulating tumor DNA testing to enhance precision.