Objective To evaluate the long-term efficacy, safety and risk of pathological upstaging in patients with endoscopic submucosal dissection (ESD) for precancerous lesions and early esophageal cancer.

Methods A retrospective analysis was conducted on the clinicopathological and follow-up data of 125 patients with ESD for precancerous lesions and early esophageal cancer from January 2017 to December 2023. Univariate analysis was performed on variables potentially associated with pathological upstaging, followed by multivariate Logistic regression for variables with P value < 0.20. Survival curves were plotted using the Kaplan-Meier method, and survival rates were calculated.

Results Among 125 patients, a total of 154 lesions were identified, including 17 patients with two lesions and 6 patients with three lesions. No cases of delayed esophageal fistula or bleeding were observedafter ESD. Esophageal stenosis occurred in 14 patients three weeks postoperatively and was significantly correlated with the circumferential ratio (P < 0.001). Endoscopic and CT examination follow-ups were conducted for all 125 patients, with a 1-year follow-up rate of 100%. No local recurrence or lymph node metastasis was observed, and the 1-year overall survival rate was 100%. The 3-year follow-up rate was 84.8% (106/125), with a 3-year overall survival rate of 99.1% (105/106); the single death was unrelated to the primarytumor. The 5-year follow-up rate was 71.2% (89/125), with a 5-year overall survival rate of 96.6% (86/89); among the three deaths, two cases were unrelated to the primary tumor, and one case was related. Pathological assessment revealed that all 154 lesions were completely resected (complete resection rate of 100%), with 152 achieving curative resection (curative resection rate of 98.7%). Lesion lengths ranged from 0.6 to 8.0 cm, with a mean of (3.16±1.19) cm. After ESD, pathological upstaging was observed in 52 patients (60 lesions) compared to preoperative biopsy results. Postoperative pathological upstaging was positively correlated with lesion length, circumferential ratio, and the pink color sign (P < 0.05). The circumferential ratio (OR=10.273, 95%CI, 2.932 to 35.993, P < 0.001) was an independent risk factor for postoperative pathological upstaging, and a circumferential ratio ≥1/2 was a significant predictorarea under the curve (AUC)=0.980, 95%CI, 0.955 to 1.000.

Conclusion Implementing a secondary prevention strategy centered on early screening and ESD is of great significance in high-incidence regions of esophageal cancer. This study validates the predictive value of a circumferential ratio ≥1/2 for pathological upstaging in a population from a high-incidence region of esophageal cancer in China.