Subtle mucosal changes...

Patient with Barrett's harbouring HGD has been treated with RFA. He has now returned for the second RFA session when this is found. 
WHAT IS YOUR ENDOSCOPIC DIAGNOSIS?

a) Benign scarring

Doesn't look benign - Looks evil!

b) Local recurrence of non-dysplastic Barrett's

Barrett's are re-emerging in several places. Doesn't look benign!

c) Barrett's adenocarcinoma

Absolutely! Nodules are never allowed in Barrett's!

explanation

Actually, there is a re-emergence of several brown nodules below the squamous mucosa.  Biopsies confirmed this as an invasive adenocarcinoma, re-emerging from below the 'neo-squamous mucosa'.  Clearly, to try RFA again would be a mistake!   The histology showed a 'poorly differentiated' cancer and we are recommending either surgery or chemo-radiotherapy next (CRT).  Even if histology hadn't shown poor differentiation, this 'smells' like bad disease to me which we may well 'undertreat' endoscopically.