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Background This study aimed to investigate the clinical characteristics and risk factors associated with metachronous recurrence following ESD in patients with superficial esophageal squamous cell carcinoma and precancerous lesions, with the goal of developing a nomogram for personalized risk prediction.Methods We conducted a retrospective study on patients who received ESD for superficial esophageal squamous cell carcinoma or precancerous lesions at two academic hospitals (Tianjin Medical University General Hospital and Second Hospital of Hebei Medical University) from June 2016 to December 2023. Cox regression analysis identified independent risk factors for metachronous recurrence. These factors were then incorporated into a nomogram, the predictive efficacy of which was thoroughly assessed.Results Metachronous recurrence developed in 32 (7.9%) of the 406 patients ( IDDF2026-ABS-0221 Table 1). Multivariate analysis revealed three independent predictors: synchronous multiple lesions (OR=2.941; 95% CI, 1.165–7.424; P=0.022), speckled Lugol-voiding lesions (LVLs) (OR=6.304; 95% CI, 2.666–14.903; P<0.001), and elevated neutrophil-to-lymphocyte ratio (NLR) (OR=1.441; 95% CI, 1.110–1.869; P=0.006) (IDDF2026-ABS-0221 Table 2, IDDF2026-ABS-0221 Figure 1. ROC curve). A nomogram constructed based on these factors effectively predicted the 3- and 5-year risks of metachronous recurrence (IDDF2026-ABS-0221 Figures 2. Nomogram for predicting the 3 and 5 year risk of metachronous recurrence, IDDF2026-ABS-0221 Figure 3. Calibration curve of the nomogram at 3 years, IDDF2026-ABS-0221 Figure 4. Calibration curve of the nomogram at 5 years).Conclusions This study demonstrates that synchronous multiple lesions, speckled LVLs, and elevated NLR independently predict metachronous recurrence following ESD. The proposed nomogram offers a practical tool for individualized risk estimation, thus informing optimized surveillance protocols and treatment strategies, thereby potentially enhancing patient prognosis.Abstract IDDF2026-ABS-0221 Table 1Baseline characteristics and comparison of features between patients with metachronous recurrence and those with non-recurrenceCharacteristicTotal(N=406)Non-recurrence(N=374)Metachronous recurrence(N=32)p valueAge, years65 (59, 69)65 (59, 69)66 (56,68)0.573Male256 (63.1)235 (62.8)21 (65.6)0.754Family history59 (14.5)55 (14.7)4 (12.5)0.734Hypertension142 (35)135 (36.1)7 (21.9)0.105Diabetes mellitus46 (11.3)40 (10.7)6 (18.8)0.168Coronary heart disease41 (10.1)39 (10.4)2 (6.3)0.452Smoking120 (24.9)108 (28.9)12 (37.5)0.305Drinking101 (24.9)93 (24.9)8 (25)0.987Synchronous multiple lesions41 (10.1)31 (8.3)10 (31.3)<0.001*Tumor location in esophagus0.888 Upper third29 (7.1)26 (7.0)3 (9.4) Middle third240 (59.1)224 (59.9)16 (50.0) Lower third73 (18)66 (17.6)7 (21.9) Upper-middle section16 (3.9)14 (3.7)2 (6.3) Middle-lower section46 (11.3)42 (11.2)4 (12.5) Entire section2 (0.5)2 (0.5)0 (0.0)Tumor circumference0.077 <1/2292 (71.9)274 (73.3)18 (56.3) 1/2~3/468 (16.7)61 (16.3)7 (21.9) >3/446 (11.3)39 (10.4)7 (21.9)Tumor Length, cm0.170<3313 (77.1)292 (78.1)21 (65.6)0.108≥393 (22.9)82 (21.911 (34.4)Macroscopic type0.3330-IS + 0-IIa49 (12.1)44 (11.8)5 (15.6) 0-IIb304 (74.9)278 (74.3)26 (81.3) 0-IIc25 (6.2)25 (6.7)0 (0.00) Polymorphic type28 (6.9)27 (7.2)1 (3.1)JES classification0.536 B1306 (75.4)284 (75.9)22 (68.9) B297 (23.9)87 (23.3)10 (31.3) B33 (0.7)3 (0.8)0 (0.0)Lugol-voiding lesions116 (28.6)93 (24.9)23 (71.9)<0.001*Histoloty0.970 HGIN217 (53.4)200 (53.5)17 (53.1) ESCC189 (46.6)174 (46.5)15 (46.9)Tumor infiltration depth0.009* Intramucosal396 (97.5)367 (98.1)29 (90.6) Submuscosal10 (2.5)7 (1.9)3 (9.4)Laboratory test WBC, 109/L5.34 (4.27, 6.41)5.32 (4.25, 6.43)5.53 (4.42, 6.07)0.931 NEU, 109/L3.00 (2.31, 3.94)2.95 (1.92, 4.35)3.40 (2.28, 4.68)0.244 LYM, 109/L1.58 (1.22, 1.99)1.59 (1.25, 2.00)1.47 (0.96, 1.70)0.017* MO, 109/L0.39 (0.32, 0.52)0.39 (0.32, 0.52)0.30 (0.38, 0.53)0.499 HGB, g/L135 (124, 144)135 (123,144)141 (125, 149)0.218 MCV, fl93.5 (90.7, 96.2)93.4 (90.6, 96.2)93.5 (90.8, 96.2)0.847 RDW, fl42.4 (40.7, 44.6)42.4 (40.7, 44.6)41.1 (44.2, 45.9)0.093 PLT, 109/L198 (167, 238)199 (170, 238)181 (150, 242)0.251 ALB, g/L41.6 (39.0, 44.4)41.6 (38.9, 44.4)42.3 (39.7, 44.7)0.302 AFP, ng/mL2.83 (1.92, 4.35)2.85 (1.91, 4.37)2.79 (1.76, 4.41)0.993 CEA, ng/mL1.35 (2.00, 3.00)2.00 (1.35, 2.95)1.66 (1.33, 3.80)0.754 CA199, U/mL9.15 (6.25, 14.69)9.15 (6.24, 14.55)8.95 (6.57, 15.79)0.978 SII, 109/L364 (262, 566)360 (260, 558)504 (307, 604)0.082 NLR1.87 (1.37, 2.67)1.84 (1.34, 2.64)2.38 (1.79, 3.23)0.007* PLR128.7 (98.1, 160.5)128.2 (97.7, 160.4)144.9 (104.0, 179.1)0.168Abstract IDDF2026-ABS-0221 Table 2Multivariate logistic regression analysis for metachronous recurrenceVariablesHazard ratio95% CIp valueSynchronous multiple lesions2.9411.165~7.4240.022*LVLs6.3042.666~14.903<0.001*NLR1.4411.110~1.8690.006*Abstract IDDF2026-ABS-0221 Figure 1Abstract IDDF2026-ABS-0221 Figure 2Abstract IDDF2026-ABS-0221 Figure 3Abstract IDDF2026-ABS-0221 Figure 4