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Endoscopic ultrasound (EUS) is considered to be the most accurate method of locoregional staging of advanced but potentially curable esophageal lesions [1]. This report describes a case of amucinous adenocarcinoma arising in the setting of Barrett’s esophagus with benign endosonographic featuresmimicking a lipoma. A 67-year-old manwas referred for evaluation of Barrett’s esophagus (Prague Criteria C5M5)with foci of high grade dysplasia overlying a subepithelial lesion (●" Fig.1). EUS revealed a hyperechoic subepithelial lesion with well-defined borders originating from the submucosa (●" Fig.2), endosonographic features that aremost consistent with a lipoma. In the presence of this lesion, it was thought that the raised overlying Barrett’s dysplastic mucosa would not be adequately treated by radiofrequency ablation. Thus, endoscopic submucosal dissection (ESD) was performed, keeping the submucosal dissection plane just above the proper muscle layer in an effort to remove the submucosal lesion and overlying Barrett’s mucosa en bloc (●" Fig.3). In contrast to the initial negative mucosal biopsies and benign endosonographic appearance, histology surprisingly revealed a moderately differentiated mucinous adenocarcinoma without lymphovascular invasion, with focal invasion into the submucosa (stage pT1bNx) and negative lateral and deep resectionmargins (R0 resection). The submucosal lesion, thought to be a lipoma based on EUS appearance, consisted of a well-circumscribed tumor Fig.2 Endoscopic ultrasound image showing hyperechoic lesion with well-defined borders (arrows) arising from the third layer of the esophagus.

More than meets the eye: esophageal invasive mucinous adenocarcinoma masquerading as a submucosal lipoma on endoscopic ultrasound