[Rethinking staging uncertainty and individualized decision-making in the management of clinical T2N0 esophageal...

Clinical T2N0 (cT2N0) esophageal squamous cell carcinoma (ESCC) represents a clinical grey zone between early-stage and locally advanced disease, and remains one of the most controversial scenarios in esophageal cancer management. The choice between upfront surgery and neoadjuvant therapy continues to vary across clinical guidelines and real-world practice. With the release of the 2026 International Society for Diseases of the Esophagus (ISDE) guidelines, this issue has once again drawn considerable attention. However, the existing controversy is not merely driven by differences in treatment strategies, but rather reflects the limited accuracy of pretreatment staging and the marked biological heterogeneity within the cT2N0 population. In this article, we review current evidence and international guidelines to analyze the underlying causes of these discrepancies, discuss the appropriate boundaries between upfront surgery and neoadjuvant therapy, and highlight future directions. We propose that the management paradigm for cT2N0 ESCC should shift from uniform treatment strategies toward precision risk stratification based on multidimensional clinical and biological information, thereby enabling more rational and individualized decision-making.