Endoscopic submucosal dissection and chemoradiotherapy versus esophagectomy for T1a-m3 or T1b esophageal squamous cell carcinoma: a meta-analysis

Background and study aims Esophagectomy is the standard treatment for superficial esophageal squamous cell carcinoma (ESCC) but carries substantial morbidity. Endoscopic submucosal dissection (ESD) followed by adjuvant chemoradiotherapy (CRT) is an organ-preserving alternative, but its oncological efficacy in T1aM3 disease with lymphovascular invasion (LVI) and in T1b disease remains uncertain. We compared ESD+CRT with esophagectomy for these lesions. Patients and methods Medline, Embase, and Google Scholar were searched through June 2024 (PROSPERO CRD42024593581). Primary endpoints were the risk differences (RD) between esophagectomy and ESD+CRT for 3-year disease-free survival (DFS), 3-year overall survival (OS), and 5-year OS; the secondary endpoint was serious adverse events (SAEs). Cumulative DFS and OS were estimated by Kaplan–Meier analysis and compared with the log-rank test. Results Six retrospective studies (16 centers; 306 patients treated 2002–2021; ESD+CRT n=170, esophagectomy n=136) were included; mean follow-up was 49.8 and 53.1 months, respectively. Baseline age, LVI, and tumor depth were comparable. Three-year DFS was similar between groups (86.4% vs 92.6%; RD 0.92, 95%CI 0.85–1.00), as was OS at 3 years (RD −0.02, 95%CI −0.08 to 0.45) and 5 years (RD −0.09, 95%CI −0.18 to 0.01). SAEs were significantly less frequent with ESD+CRT than with esophagectomy (RD 0.55, 95%CI 0.35–0.86; p=0.009). Conclusions In selected superficial ESCC, ESD+CRT achieved disease-free and overall survival comparable to esophagectomy while significantly reducing serious adverse events. These retrospective data support ESD+CRT as a viable organ-preserving option, particularly for patients at high surgical risk.