Introduction: Verrucous carcinoma of esophagus (VCE) is a rare variant of squamous cell carcinoma; so far less than 23 cases have been reported in literature. VCE is a well-differentiated carcinoma that is slow growing, irregular and wart like in appearance and has a tendency for local invasion. Verrucous squamous cell carcinoma has been reported in the oral cavity, larynx, urogenital and anorectal regions. We present a case of VCE to highlight that high index of suspicion and evaluation with EUS are crucial steps in making an early diagnosis and management of disease. A 64-year-old man referred to our institution for further evaluation of dysphagia and esophageal mass on EGD. He presented with dysphagia to solids and 60 lb. weight loss over a period of 10 months. There was no history of alcohol or tobacco use or ingestion of caustic substances. He had hypertension, diabetes mellitus, and end stage renal disease requiring hemodialysis. Multiple endoscopic evaluations at outside facilities revealed an esophageal mass with inconclusive pathology; squamous atypia without definitive evidence for malignancy was reported. At our institution, EGD and EUS were performed; conventional upper endoscopy revealed a 9cm long near circumferential obstructing mass with a warty/verrucous appearance. On endosonographic evaluation, diffuse thickening of the mucosa and sub-mucosa was noted with invasion through the muscularis propria, without any invasion of surrounding organs and no pathological lymph nodes were noted. Endoscopically obtained biopsy specimens using a jumbo forceps showed abnormally thick hyperplastic squamous mucosa with marked hyperkeratosis, cellular atypia, focal ulceration with heavy inflammatory cells and exhibiting verrucous growth pattern; suggestive of verrucous carcinoma. CT scan of thorax, abdomen and pelvis showed multiple hepatic lesions and lytic lesions in axial and appendicular skeleton suggestive of metastatic disease. EGD was repeated for new onset hematemesis, previously described long circumferential tumor was visualized; given the sub-optimal surgical candidature for palliation and the advanced metastatic disease, a partially covered self-expanding metallic stent was placed for palliation. Diagnosis of VCE is very elusive as is suggested by the current case as well as those described in the literature. A high index of suspicion on the basis of endoscopic features and EUS findings is helpful. Large biopsy specimens to include the sub-mucosa, such as those can be obtained by use of a jumbo forceps, are important for accurate diagnosis. The role of fine-needle aspiration (FNA) during EUS needs to be evaluated in cases with non-diagnostic pathology even with jumbo biopsy forceps.