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Endoscopic submucosal dissection (ESD) is an effective technique to resect neoplasia in Barrett’s esophagus, including for lesions larger than 15mm [1]. Nevertheless, in the area surrounding the Barrett’s neoplasia, buried mucosa with various grades of dysplasia or adenocarcinoma can occur under normal squamous epithelium before or after treatment (0%– 28%) [2,3]. Buried components appear extremely difficult to detect endoscopically, which can result in the lesion size being underestimated [4]. Because of this invisible spread, we should enlarge our resection margins in order to avoid incomplete (R1) resections. We report two cases of adenocarcinoma in Barrett’s esophagus, with no history of previous treatment, which had buried components. Both lesions were carefully examined using white-light endoscopy and virtual chromoendoscopy to evaluate the pit and vascular patterns (●" Fig.1). The edges were delineated with coagulation dots respecting a 10-mm security margin, as previously suggested [5] (●" Fig.2). The two ESD specimens measured 35×25mm and 25×28mm after fixation. The first lesion was a well-differentiated adenocarcinoma invading the submucosa to a depth of 150μm (sm1). The distance between the deepest tumoral gland and the margin was over 500μm. On the lateral oral edge, a 5-mm section of the adenocarcinomawas mostly buried and covered by normal squamous epithelium, but appeared slightly elevated endoscopically (●" Figs.1,2). The lateral resection margin was composed of a normal squamous epithelium on the oral side (●" Fig.3) but showed high grade dysplasia on the anal side despite the 1-cm margin (●" Fig.4). The second lesionwas an adenocarcinoma invading the mucosa (m2) with various buried components composed of intestinal metaplasia (●" Fig.5) but also high grade dysplasia and adenocarcinoma (●" Fig.6). The deep and lateral 1-cm margins were free of dysplasia. To summarize, endoscopists must be aware of the potential of buried extension surrounding Barrett’s neoplasia. This extension, with a normal superficial pattern, is very difficult to detect endoscopically. Therefore this justifies enlarging the security margins to more than 10mm to achieve R0 resections.

Buried adenocarcinoma hidden by normal squamous epithelium in Barrett’s esophagus: should we enlarge the margins for endoscopic resections?