Zhang YJ, Wen W, Li F, Yuan J, Zou DH, Shi HP, Liang C, Yang Y. Proportion of esophageal keratinized area ≥ 30% reduces accuracy of preoperative endoscopic evaluation in early esophageal squamous cell carcinoma. World J Gastrointest Oncol 2026; 18(11): 121634 [DOI: 10.4251/wjgo.121634]
Corresponding Author of This Article
Ying-Jie Zhang, Digestive Diseases, West China School of Medicine, Sichuan University, Sichuan University Affiliated Chengdu People's Hospital, Chengdu Second People's Hospital, No. 10 Qingyun South Street, Chengdu 610000, Sichuan Province, China. 13890410927@163.com
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Gastroenterology & Hepatology
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Zhang YJ, Wen W, Li F, Yuan J, Zou DH, Shi HP, Liang C, Yang Y. Proportion of esophageal keratinized area ≥ 30% reduces accuracy of preoperative endoscopic evaluation in early esophageal squamous cell carcinoma. World J Gastrointest Oncol 2026; 18(11): 121634 [DOI: 10.4251/wjgo.121634]
World J Gastrointest Oncol. Nov 15, 2026; 18(11): 121634 Published online Nov 15, 2026. doi: 10.4251/wjgo.121634
Proportion of esophageal keratinized area ≥ 30% reduces accuracy of preoperative endoscopic evaluation in early esophageal squamous cell carcinoma
Ying-Jie Zhang, Wu Wen, Fan Li, Jing Yuan, De-Hong Zou, Hai-Peng Shi, Chuan Liang, Ye Yang
Ying-Jie Zhang, Digestive Diseases, West China School of Medicine, Sichuan University, Sichuan University Affiliated Chengdu People's Hospital, Chengdu Second People's Hospital, No. 10 Qingyun South Street, Chengdu 610000, Sichuan Province, China
Wu Wen, Jing Yuan, De-Hong Zou, Department of Digestive Diseases, Chengdu Second People’s Hospital affiliated to West China School of Medicine, Sichuan University, Chengdu 610000, Sichuan Province, China
Fan Li, Hai-Peng Shi, Department of Pathology, Chengdu Second People’s Hospital affiliated to West China School of Medicine, Sichuan University, Chengdu 610000, Sichuan Province, China
Chuan Liang, Ye Yang, Department of Digestive Diseases, Chengdu Qingbaijiang District People's Hospital, Chengdu 610300, Sichuan Province, China
Author contributions: Zhang YJ and Wen W designed and conducted the study and wrote the paper; Yuan J contributed to the analysis; Li F, Zou DH, and Liang C provided clinical advice; Yang Y and Shi HP supervised the study. All authors commented on subsequent versions of the manuscript and have read and approved the final manuscript. All authors contributed to the study conceptualization and methodology.
AI contribution statement: AI tools (specifically ChatGPT) were used solely for linguistic refinement and formatting assistance. No AI tool was involved in the generation of research data, interpretation of results, or formulation of conclusions. All AI-generated outputs were critically reviewed and revised by the authors.
Institutional review board statement: This study was approved by the Ethics Committee of Sichuan University Affiliated Chengdu Second People's Hospital prior to data collection, No. [KY]PJ2026049.
Informed consent statement: The requirement for an informed consent form was waived owing to the retrospective nature of the study, and it has little risk to patients.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: Based on privacy reasons, data will be made available on request.
Corresponding author: Ying-Jie Zhang, Digestive Diseases, West China School of Medicine, Sichuan University, Sichuan University Affiliated Chengdu People's Hospital, Chengdu Second People's Hospital, No. 10 Qingyun South Street, Chengdu 610000, Sichuan Province, China. 13890410927@163.com
Received: April 2, 2026 Revised: June 25, 2026 Accepted: October 9, 2026 Published online: November 15, 2026 Processing time: 207 Days and 17.9 Hours
Abstract
BACKGROUND
Esophageal epidermoid metaplasia, also known as esophageal keratosis, can occur on the normal esophageal epithelium and surface of esophageal squamous cell carcinoma (ESCC). However, its endoscopic characteristics and clinical significance in early ESCC remain underexplored.
AIM
To investigate endoscopic characteristics and clinical significance of keratosis in early ESCC and assess its impact on endoscopic assessment accuracy.
METHODS
This retrospective cross-sectional study included 107 consecutive patients (121 pathologically confirmed early ESCC lesions) treated at Sichuan University Affiliated Chengdu Second People’s Hospital between January 2022 and December 2024. Based on white-light endoscopy, lesions were categorized into epithelial keratosis and nonepithelial keratosis groups. Clinical, pathological, and endoscopic appearances were analyzed. Baseline characteristics were compared, and logistic regression analysis was performed to examine associations of keratosis with age, tumor infiltration, smoking history, and alcohol consumption history.
RESULTS
Among the 121 early ESCC lesions, esophageal keratosis was detected in 46 (38.02%). Age > 60 years and history of smoking and alcohol consumption were associated with a higher incidence of esophageal keratosis (P < 0.05). Infiltrative lesions were more frequently associated with keratosis and showed increased lamina propria invasion (P < 0.05), with a trend toward better differentiation (P = 0.086). Sex, family history, tumor size, anatomical location, and morphology showed no significant differences between the groups. Keratinized area ≥ 30% reduced preoperative endoscopic diagnostic accuracy (P < 0.05). When we further compared groups based on the proportion of keratinized area, we found that larger esophageal lesions had greater keratinized areas, although there was no significant difference (P = 0.06).
CONCLUSION
Keratosis is associated with tumor infiltration. The accuracy of preoperative endoscopy is reliable for most early ESCCs but may decrease when the keratinized area exceeds 30% of the lesion.
Core Tip: Esophageal keratosis in early esophageal squamous cell carcinoma (ESCC) is associated with tumor infiltration and may reflect invasion depth. Preoperative endoscopic assessment based on intraluminal papillary capillary loop morphology in nonkeratinized areas is reliable for most early ESCCs; however, its accuracy may decrease when the keratinized area accounts for ≥ 30% of the lesion. The extent of keratinization may also be related to lesion size, although further studies are needed to confirm these associations.
