Endoscopic submucosal dissection in early esophageal neoplasia: Celebrating efficacy, confronting heterogeneity, and refining surveillance for high-risk patients

Esophageal cancer poses a severe global healthcare burden, with a dismal prognosis primarily due to late-stage diagnosis - only 10%-30% of patients survive 5 years when symptoms trigger medical attention. Endoscopic submucosal dissection (ESD) has emerged as a transformative minimally invasive therapy for early esophageal neoplastic lesions, offering curative potential while preserving organ function. However, the clinical landscape of early esophageal neoplasia is highly heterogeneous, with low-grade intraepithelial neoplasia, high-grade intraepithelial neoplasia, early-stage carcinoma, and superficial carcinoma differing significantly in biological behavior, endoscopic features, and treatment response. This article examines the recent retrospective study published by Zhang <i>et al</i>, which analyzed 245 patients with 264 lesions treated with ESD between 2014 and 2022. The study fills a critical gap in understanding this heterogeneity by systematically linking lesion stage to clinicopathological characteristics, ESD efficacy, and long-term prognosis. It not only validates ESD's role in early disease but also raises urgent questions about refining stratified management and addressing unmet needs in high-risk populations. This article discusses the implications of the study's findings, contextualizes them within current clinical practice, and outlines directions for future research to advance care for patients with early esophageal neoplasia.