Introduction: Endoscopic submucosal dissection (ESD) is an endoscopic resection technique being used more in the treatment of Barrett's esophagus. Its role in the treatment of Barrett's esophagus continues to evolve as its advantages continue to be established over other endoscopic techniques. Technical challenges can limit endoscopic therapies in patients with submucosal invasion, scarring, or fibrosis that preclude sufficient mucosal lifting. Here we present such a patient who underwent successful endoscopic resection using ESD for treatment of Barrett's esophagus. Case: 72 year old man was referred after a distal esophageal mass was found through endoscopy for surveillance at an outside facility. History was significant for esophageal adenocarcinoma diagnosed three years earlier and treated with chemoradiotherapy, Barrett's esophagus, and acid reflux. Repeat upper endoscopy with contrast chromoscopy using methylene blue was performed showing a 1cm fungating mass in the distal esophagus. Endoscopic ultrasound showed 4cm in the distal esophagus of diffuse wall thickening in the superficial mucosa. Biopsies of the nodule revealed superficial intramucosal adenocarcinoma in the setting of Barretts esophagus with varying degrees of dysplasia. Upper endoscopy with ESD was performed 3 weeks later. Chromoscopy with indigo carmine was used to mark the borders of the lesion. A mixture of epinephrine with methylene blue was used to raise the lesion. A dual knife and IT nano electrocautery knife was used to dissect the lesion from the underlying deep layers. Significant fibrosis was encountered, but the lesion was dissection in a slow cautious manner. An area of 60mm and approximately 40% circumference of the distal esophagus was successfully resected en bloc. Pathology showed moderately differentiated adenocarcinoma in situ with all margins negative for invasive carcinoma. Discussion: Endoscopic submucosal dissection is becoming a more frequently used modality for treatment of esophageal adenocarcinoma. This case demonstrates its use for treatment of recurrent adenocarcinoma in the setting of Barrett's esophagus after treatment for chemoradiotherapy.Figure: Nodule in the distal esophagus.Figure: completion of ESD.Figure: Specimen dissected en bloc.