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Introduction Endoscopic submucosal dissection (ESD) is the recommended endoscopic resection modality for upper GI early cancers with suspected submucosal invasion. The aim of this study is to evaluate the long-term outcome of high-risk T1b upper GI cancer patients after ESD and the utility of CT and EUS as surveillance methods.Methods This was a retrospective analysis of patients receiving ESD for T1b upper GI cancer between June 2017 and February 2025 at a tertiary hospital. High-risk criteria included all T1b squamous cell carcinoma (SCC), oesophageal adenocarcinoma (OAC) of grade sm2/3 or with features of G3, R1 or lymphovascular invasion, and gastric adenocarcinoma with the same criteria as OAC or with lesion size >30mm. 1 Fisher’s exact test was used to compare the recurrence rates between disease groups.Results There were 42 patients who received ESD with T1b disease, of which 32 had high-risk resections ( table 1).8 patients received surgery, 6 directly after ESD and 2 on recurrence. For those who had immediate surgery, pathology showed no residual cancer in 2 cases, locally advanced cancer in 1 case and lymph node involvement in 3 cases, of which 1 had residual tumour and later developed colon metastases. For those who had surgery on recurrence, 1 had locally advanced disease and 1 had nodal involvement. Of the remaining patients who underwent surveillance, there were 2 nodal recurrences and 1 intraluminal recurrence. 2 cases of nodal recurrences were initially diagnosed on CT and 1 case on EUS.Disease specific mortality occurred in 3 patients (OAC=1; SCC=1; gastric adenocarcinoma=1), two of whom had chemotherapy and surgery.There was a trend towards higher rate of metastatic involvement in SCC patients at 42.8% (3/7) compared to OAC (12.5%; 2/16) and gastric adenocarcinoma (11.1%; 1/9), although this did not reach statistical significance (p > 0.05). There was no significant difference in the rate of local recurrences among the three groups (p > 0.05).Conclusion The rate of intraluminal recurrences in our cohort was 9.4%, and the rate of nodal and distant organ involvement was 18.8%. EUS and CT were useful in their initial detection.Reference Pimentel-Nunes, Pedro, et al. Endoscopic Submucosal Dissection for Superficial Gastrointestinal Lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy 2022;54(6):591–622, pubmed.ncbi.nlm.nih.gov/35523224/, https://doi.org/10.1055/a-1811-7025.Abstract P38 Table 1High-risk patients32Sex Male 20 Female12 Median age (Range) 73 (52-85)Median follow up time (months)32.5Median size of lesion (mm)28.5Stage sm120 sm2/312 R0 12 LV+7 G312 Median no. of CT 1Median no. of EUS1Median no. of gastroscopies3 Chemo/radiotherapy8Intraluminal cancer recurrence 3 Nodal/distant metastases6