Long-term Outcomes of Additional Surgical Versus Non-surgical Treatment After Non-curative Endoscopic Resection for T1 Superficial Esophageal Cancer

Background: Endoscopic resection (ER) is the main treatment for T1 superficial oesophageal cancer (SEC). Additional surgical resection (ASR) is recommended to improve the prognosis of patients with non-curative resection who are at high risk of recurrence and metastasis. However, the survival benefit of ASR compared to non-ASR remains unclear. We conducted a systematic review and meta-analysis to quantify the survival benefits of ASR versus non-ASR, providing robust data for clinical decision-making. Method: We searched PubMed, Cochrane, Embase, and Web of Science for studies published before 24 February 2025. The primary outcome was overall survival (OS), recurrence-free survival (RFS), and disease-specific survival (DSS). Two independent reviewers screened and extracted the data and resolved disagreements by consensus. Risk of bias was assessed with Newcastle-Ottawa Scale. Results: The review identified 15 retrospective studies involving 1348 patients. Analysis showed that ASR patients had significant survival advantages over non-ASR patients in OS, RFS, and DSS. Hazard ratios (HR) with 95% confidence intervals (CI) were: OS (HR = 3.06; 95% CI, 2.11-4.43), RFS (HR = 1.68; 95% CI, 1.16-2.41), and DSS (HR = 4.11; 95% CI, 1.64-10.28). Survival curves indicated that at 3, 5, and 10 years, the OS rates were 95.9% vs 88.0%, 91.4% vs 78.2%, and 86.7% vs 56.9% for ASR and non-ASR groups, respectively. Similarly, RFS rates were 93.4% vs 82.9%, 83.6% vs 73.8%, and 74.5% vs 57.5%. For DSS, the rates were 98.4% vs 94.5%, 97.8% vs 91.1%, and 97.8% vs 87.9%. Log-rank tests confirmed significance for all comparisons except 10-year DSS. Conclusions: For T1 SEC patients who had non-curative ER, ASR therapy provides advantages over non-ASR therapy. However, within 5 years, the DSS difference between ASR and non-ASR groups is likely to be minimal, with a range of approximately 4% to 6%.