Objective  To analyze the risk factors for histopathological upgrade after endoscopic submucosal dissection (ESD) of esophageal squamous intraepithelial neoplasia suggested by endoscopic forceps biopsy (EFB).

  Methods  We retrospectively analyzed 255 lesions from 255 patients with esophageal squamous intraepithelial neoplasia suggested by EFB who had undergone ESD in the Affiliated Hospital of North Sichuan Medical College between November 2019 and May 2023. Based on the pathological differences between EFB and ESD, they were assigned into upgraded (n=123) and non-upgraded (n=132) groups. Univariate and multivariate Logistic regression analyses were used to analyze the risk factors.

  Results  The preoperative endoscopic forceps biopsy (EFB) and post-endoscopic submucosal dissection (ESD) pathological concordance rate for low-grade intraepithelial neoplasia (LGIN) group is 42.9% (18/42), with a pathological upgrade rate of 57.1% (24/42). For high-grade intraepithelial neoplasia (HGIN) group, the preoperative EFB and post-ESD pathological concordance rate is 44.1% (94/213), with a pathological upgrade rate of 46.0% (98/213) and 9.9% (21/213) of cases being downgraded to LGIN. The results of the univariate analysis indicate that there is a statistically significant difference in the following factors: alcohol history, intrapapillary capillary loop (IPCL) classification, erosion, ulceration or bleeding, longitudinal diameter of the lesion ≥2 cm, and involvement of more than 1/2 of the lumen (P<0.05). Multivariate analysis showed that B2/B3 IPCL (P=0.001), lesion longitudinal diameter ≥2cm (P=0.014), and lumen involvement ≥1/2 (P<0.001) were independent risk factors for pathological upgrade after ESD.

  Conclusions  Clinicians should be extremely cautious regarding the possibility of underestimating the severity of lesions with endoscopic findings of B2/B3 IPCL, lesion longitudinal diameter ≥2cm, and lesion involvement of the lumen ≥1/2.