the incidence of esophageal adenocarcinoma is rapidly increasing , particularly in europe and north america . this disease has a poor prognosis when detected at an advanced stage 1 , and prevention of death from esophageal adenocarcinoma has therefore focused on its early detection . gastroenterology society guidelines recommend endoscopic surveillance of barrett s esophagus with targeted biopsies of visible lesions and random 4-quadrant biopsies every 2  cm . however , dysplasia and early cancer in patients with barrett s esophagus may present with subtle changes not visible during endoscopic observation . in addition , random biopsies are subject to sampling errors because only a small fraction of the esophagus is biopsied . white globe appearance ( wga ) was recently reported as a novel endoscopic marker for gastric adenocarcinoma 2 . wga represents a small ( <  1  mm ) white globular lesion located underneath the epithelium , which is visualized more clearly with narrow - band imaging ( nbi ) than with white - light imaging . wga is frequently observed in gastric adenocarcinomas and has high specificity for differentiating between early gastric adenocarcinoma and non - cancerous mucosa 3 . we herein report the first two cases of barrett s esophageal cancer with typical wga . an asymptomatic 48-year - old japanese woman with a history of prolactinoma was referred to our hospital for treatment of esophageal adenocarcinoma . esophagogastroduodenoscopy ( egd ) revealed a slightly red , depressed lesion , 10  mm in diameter , in short - segment barrett s esophagus ( fig .  1 ) . magnifying narrow - band imaging ( m - nbi ) revealed no surface structure pattern and a mildly irregular vascular pattern with a clear demarcation line . a small ( <  1  mm ) white globular lesion located under the cancerous barrett s epithelium , typical of wga , was observed close to the demarcation line in m - nbi ( fig .  1 ) . endoscopic submucosal dissection ( esd ) was performed using a ball - tip flush knife ( bt ) ( 1.5  mm , fujifilm medical , tokyo , japan ) , and en bloc resection was achieved with no adverse events . 
 in white light imaging , a slightly red , depressed lesion , 10  mm in diameter , was revealed in short - segment barrett s esophagus . b endoscopic image of white globe appearance ( wga ) in magnifying narrow - band imaging ( yellow arrow ) . histologic examination of the resected specimen revealed a well - differentiated adenocarcinoma , 10  mm in diameter , limited to the superficial muscularis mucosa , without lymphovascular involvement . a dilated neoplastic gland with eosinophilic material and necrotic epithelial fragments , typical of intraglandular necrotic debris ( ind ) , was identified at the site of the wga ( fig .  2 ) . b magnified view of fig .  2  a. an asymptomatic 60-year - old caucasian man was referred to our hospital for treatment of esophageal adenocarcinoma . egd revealed a slightly red , depressed lesion , 5  mm in diameter , in long - segment barrett s esophagus ( fig . the lesion showed no surface structure pattern and a mildly irregular vascular pattern with a clear demarcation line in m - nbi , and a typical wga close to the demarcation line ( fig . esd was performed using a flush knife bt , and en bloc resection was achieved with no adverse events . 
 in white light imaging , a slightly red , depressed lesion , 5  mm in diameter , b endoscopic image of white globe appearance in magnifying narrow - band imaging ( yellow arrow ) . histologic examination of the resected specimen revealed a well - differentiated adenocarcinoma , 5  mm in diameter , limited to the superficial muscularis mucosa , without lymphovascular involvement . the typical finding of ind was identified at the site of the wga ( fig . an asymptomatic 48-year - old japanese woman with a history of prolactinoma was referred to our hospital for treatment of esophageal adenocarcinoma . esophagogastroduodenoscopy ( egd ) revealed a slightly red , depressed lesion , 10  mm in diameter , in short - segment barrett s esophagus ( fig .  1 ) . magnifying narrow - band imaging ( m - nbi ) revealed no surface structure pattern and a mildly irregular vascular pattern with a clear demarcation line . a small ( <  1  mm ) white globular lesion located under the cancerous barrett s epithelium , typical of wga , was observed close to the demarcation line in m - nbi ( fig .  1 ) . endoscopic submucosal dissection ( esd ) was performed using a ball - tip flush knife ( bt ) ( 1.5  mm , fujifilm medical , tokyo , japan ) , and en bloc resection was achieved with no adverse events . 
 in white light imaging , a slightly red , depressed lesion , 10  mm in diameter , was revealed in short - segment barrett s esophagus . b endoscopic image of white globe appearance ( wga ) in magnifying narrow - band imaging ( yellow arrow ) . histologic examination of the resected specimen revealed a well - differentiated adenocarcinoma , 10  mm in diameter , limited to the superficial muscularis mucosa , without lymphovascular involvement . a dilated neoplastic gland with eosinophilic material and necrotic epithelial fragments , typical of intraglandular necrotic debris ( ind ) , was identified at the site of the wga ( fig .  2 ) . an asymptomatic 60-year - old caucasian man was referred to our hospital for treatment of esophageal adenocarcinoma . egd revealed a slightly red , depressed lesion , 5  mm in diameter , in long - segment barrett s esophagus ( fig . the lesion showed no surface structure pattern and a mildly irregular vascular pattern with a clear demarcation line in m - nbi , and a typical wga close to the demarcation line ( fig . esd was performed using a flush knife bt , and en bloc resection was achieved with no adverse events . 
 in white light imaging , a slightly red , depressed lesion , 5  mm in diameter , b endoscopic image of white globe appearance in magnifying narrow - band imaging ( yellow arrow ) . histologic examination of the resected specimen revealed a well - differentiated adenocarcinoma , 5  mm in diameter , limited to the superficial muscularis mucosa , without lymphovascular involvement . the typical finding of ind was identified at the site of the wga ( fig . we herein report the first japanese and caucasian cases of barrett s esophageal cancer with wga . reported that wga was a good marker for gastric neoplasia , and showed that wga corresponded to ind , defined as eosinophilic material with necrotic epithelial fragments within the lumen of a dilated gland 2 . ind is a histologic marker for high - grade dysplasia or invasive carcinoma of the stomach ; 25 of 58 high - grade dysplasias or invasive carcinomas had ind , and only 1 of 77 other types of lesions had ind 4 . the sensitivity and specificity of ind for high - grade dysplasia or invasive carcinoma were 43.1  % and 98.7  % , respectively 4 . ind has also been identified in adenocarcinomas in other organs , including the esophagus , but is rarely observed in normal mucosa 5 
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 9 , suggesting that it may also act as a marker for barrett s esophageal cancer . the clinical utility of wga was evaluated by yoshida et al . and doyama et al . the sensitivity and specificity of wga for differentiating gastric cancer or high - grade dysplasia from other lesions were 21.4  % and 97.5  % , respectively 3 , and for differentiating gastric cancer or high - grade dysplasia from low - grade adenoma were 21.5  % and 100  % , respectively 2 . the sensitivity of wga was lower than that of ind , probably because ind is located just beneath the gastric epithelium and can therefore be observed by magnifying endoscopy and identified as wga . however , despite its low sensitivity , its high specificity makes wga a valuable endoscopic marker for gastric cancer . although the current cases provide the first reports of wga in esophageal adenocarcinoma , this finding is probably not rare , and the failure to detect wga may be because of a lack of familiarity with this finding . given that we identified wga in 2 consecutive cases of barrett s esophageal cancer in our hospital , it is likely that more cases will be identified in the near future in line with increased awareness of wga . the development of endoscopic modalities such as nbi and magnifying imaging have facilitated the detection and diagnosis of gastrointestinal cancer . however the diagnosis of barrett s esophageal cancer remains challenging , mainly because of concomitant inflammation . gastroenterology society guidelines recommend endoscopic surveillance of barrett s esophagus with targeted biopsies of visible lesions and random 4-quadrant biopsies every 2  cm . however , there are few reliable and accurate endoscopic findings for identifying targeted biopsies , and the results are therefore not satisfactory . although wga requires low- to high - magnification observation , it could offer a reliable endoscopic finding for targeting biopsies if its specificity is as high as in gastric cancer . we herein report 2 cases of barrett s esophageal cancer with wga , 1 in a japanese and the other in a caucasian patient , thus confirming the potential presence of wga in the esophagus as well as the stomach , and in caucasian as well as japanese individuals .
background and study aims : better endoscopic diagnosis in case of barrett s esophagus is still needed . 
 white globe appearance ( wga ) is a novel endoscopic marker for gastric adenocarcinoma , with high sensitivity for differentiating between gastric cancer / high - grade dysplasia and other lesions . 
 we report 2 cases of esophageal adenocarcinoma with wga . in case 1 , 
 esophagogastroduodenoscopy ( egd ) revealed a 10-mm esophageal adenocarcinoma in a 48-year - old japanese woman with short - segment barrett s esophagus . a small ( <  1  mm ) white globular lesion , typical of wga , 
 was observed under the epithelium by magnifying narrow - band imaging . 
 a dilated neoplastic gland with eosinophilic material and necrotic epithelial fragments was identified at the site of the wga by histologic examination . in case 2 , egd revealed a 5-mm esophageal adenocarcinoma in a 60-year - old caucasian man with long - segment barrett s esophagus . 
 a typical wga was observed by magnifying narrow - band imaging and similar histologic findings were identified at the site of the wga . 
 wga could be a reliable endoscopic finding for target biopsy in esophageal adenocarcinoma , if its specificity is as high as in gastric cancer . 
 the clinical implications of wga in patients with barrett s esophagus should be investigated further .