Recent advances in image-enhanced endoscopy have enabled an early accurate diagnosis of early upper GI neoplasia or precancerous lesions. For the treatment of early esophageal squamous cell neoplasias (ESCNs), endoscopic submucosal dissection (ESD) enables en bloc resection of the neoplasia, and the resected specimen allows for a pathological assessment to evaluate the curability. However, ESD is a complicated procedure that requires a high level of expertise, and a long learning curve. Esophageal stricture is still a serious concern after ESD, especially for those with lesions involving more than 3 quarters of the circumference. Compared to other ablative therapies (APC, Photodynamic), endoscopic radiofrequency ablation (RFA) has advantages of homogenous and controlled depth of ablation. Recent studies have shown its efficacy and safety for eradicating dysplasia in cases of Barrett’s esophagus as well as the early flat-type ESCNs. RFA appears to be less technically demanding compared with ESD, and thus may be more feasible for less experienced endoscopists, and used to overcome the disadvantages of ESD with a much lower risk of stricture. Previously, we demonstrated a good efficacy and safety of RFA for the treatment of ultra-long (>10cm), widespread early ESCNs or even the lesions in patients with well-compensated cirrhosis accompanied by esophageal varices. However, the major concern of RFA is no specimen to evaluate the curability after the treatment. Therefore, an accurate staging and patient selection are critically important. We recently reported the long-term outcome of RFA in treating ESCNs, and found 20% of cases developed local recurrence during a mean follow-up period of 40.1 months. The possible pathogenesis of recurrent ESCN after RFA may be related to the phenomenon of preexisted tumor spread into the ductal system of esophageal gland (ductal involvement). Currently, we suggest that the use of RFA should be conservative and applied only for flat-type pre-cancerous lesions.