A daunting prospect ...

55 yr pt with a Barrett's nodule is referred for an endoscopic resection. I'm surprised to find 4 abnormalities within his 10cm stretch of Barrett's
WHICH OF THESE IS THE MOST LIKELY TO BE ENDOSCOPICALLY RESECTABLE?

a) Lesion A

I agree! Of these 4, A is the only one which isn't ulcerated and therefore is least likely to be invading deeply.

b) Lesion B

Would be my second guess as the ulcerated area seem superficial

c) Lesion C

Don't like the ulceration!

d) Lesion D

Would be my least favourite lesion to attack as the ulceration suggests deeper invasion and poor lift into my cap.

explanation

This may be something of a record, 4 synchronous lesions! Clearly A, B and D are malignant.  At first, ulcer C seem more innocent without an elevated edge but on closer assessment, it also has a slightly elevated rim. 

Of these 4, A is the only one which isn't ulcerated and therefore is least likely to be invading deeply. Of course, they are assessed together as there is no point in EMR'ing one only. Either all are curable endoscopic means or none are ! 

Rather than going ahead with attempting to resect these, I actually bailed out and took samples from each lesion. Biopsies showed invasive, poorly differentiated adenocarcinoma at each location! Clearly, this patient has multifocal 'bad disease' which endoscopy is unlikely to cure in my opinion.  I believe that surgery is a far better option and the patient is currently awaiting his oesophagectomy. 

​If you still are not convinced of the pitfalls in trying to deal with ulcerated Barrett's lesions, have a look at the lesion below. Two rounds of sampling had indicated that the lesion harboured HGD.  However, I failed to remove the lesion and ultimately the patient underwent an 'Ivor-Lewis'.  You can see the histology yourself.  The 4mm surface is literally the tip of the iceberg and below you can see the cancer (red line) invading up to the muscle propria.