Do you recommend esophagectomy vs adjuvant chemoradiation vs surveillance for an otherwise healthy patient with a pT1b cN0 cM0 lower thoracic esophagus SCC status post endoscopic submucosal dissection?

NCCN guidelines recommend esophagectomy for pT1b SCC. This is in part because the risk of metastasis to regional lymph nodes for T1b tumor can be upwards of 30% with an even greater likelihood in tumors penetrating into the lower two thirds (sm2 and sm3) of the submucosal layer (some series showing >50%). For patients who decline esophagectomy, definitive chemoradiation is an alternative, noting that SCC tends to respond better to radiation than adenocarcinomas.

That being said, there is a small subset of patients with pT1b tumors for which risk of residual disease including nodal involvement is low, such that endoscopic treatment can be curative. Pathologic findings from the ESD can help define this population. For patients with small tumor...