Objective There has been an increase in interest in endoscopic therapy (ET) for intramucosal (T1a) or submucosal (T1b) esophageal carcinoma. The objective of the present study was to determine the prevalence of nodal metastases, lymphatic vascular invasion, and multifocal neoplasia in patients with pT1 esophageal carcinoma who underwent esophagectomy without preoperative therapy and assess their potential implication for ET. Methods We retrospectively reviewed the records of all patients who underwent esophagectomy without preoperative therapy for pT1 esophageal cancer. A detailed review of all pathology reports was performed to identify relevant pathologic criteria including depth of invasion (T1a or T1b), cell type (adenocarcinoma/squamous), tumor differentiation (poor vs. well/moderate), extent of Barrett esophagus (short segment [SSBE] and long segment [LSBE]), nodal status, lymphovascular invasion (LVI), and the presence of multifocal neoplasia (MFN) (high-grade dysplasia or invasive carcinoma). Overall survival and disease-specific survival were determined by the Kaplan-Meier method. Results There were 75 consecutive patients (58 men, 17 women) between January 1994 and September 2006. Median age was 68 years. Hospital mortality was 2.6% (2 of 75). Thirty patients had T1a and 45 had T1b. Sixty patients had adenocarcinoma. Nodal metastases were present in 2 of 30 (6%) T1a and 8 of 45 (17.5%) T1b tumors. MFN was present in 30% (9 of 30) of T1a tumors and 29% (13 of 45) of T1b tumors. All 9 patients with LVI had T1b tumors. Collectively, 10 of 30 (33.3%) patients with T1a and 25 of 45 (58%) with T1b had MFN, LVI, or nodal metastases. Forty-nine patients had adenocarcinoma with associated BE (23 SSBE, 26 LSBE). There was no difference between patients with SSBE and those with LSBE in the incidence of nodal disease (2 of 23 vs. 2 of 26) but a significant difference in the incidence of MFN (3 of 23 vs. 13 of 26, P = 0.006). Four patients with squamous carcinoma had nodal metastases and 5 had MFN. Overall 5-year survival was 78% (T1a:90% T1b: 71%, P = 0.07). Five-year disease-specific survival was 86.5% (T1a: 96.7%, T1b: 79.6%, P = 0.06). Conclusion The combined high incidence of MFN, LVI, and occult nodal metastases does not support the use of ET in patients with T1 esophageal cancer regardless of depth of invasion, cell type, differentiation or extent of BE. ET may be of value in patients in whom surgical risk is considered prohibitive.