currently , the most widely used endoscopic therapies for barrett s adenocarcinoma include endoscopic mucosal resection and endoscopic submucosal dissection ( esd ) , which result in complete resection . however , several investigators have reported on the occurrence of metachronous recurrence after the initial endoscopic resection [ 3 - 5 ] . this may occur as multiple lesions at the initial endoscopic examination , and therefore early detection of such lesions is ideal to achieve complete resection and obtain improved survival rates with minimally invasive treatment [ 4 - 6 ] . narrow band imaging ( nbi ) is useful for the detailed examination of adenocarcinoma associated with barrett s esophagus , which includes detection of the irregular microvessels of esophageal and gastric cancer at high magnification [ 4 - 6 ] . however , this technique has limitations , such as the difficulty to brightly view distant lesions in a large luminal organ such as the stomach . recently , a laser endoscopic imaging system ( fujifilm co. , tokyo , japan ) has been developed to facilitate new diagnostic approaches for gastrointestinal lesions . this system allows multiple modalities of endoscopic imaging by using white light laser , flexible spectral imaging color enhancement ( fice ) , blue laser imaging ( bli ) , and linked color imaging even at a distant view . therefore , this system may be useful for the detection of adenocarcinoma associated with barrett s esophagus . we report on a patient with three synchronous lesions followed by one metachronous lesion in a long segment with changes of barrett s esophagus , all diagnosed with this new laser endoscopic imaging system . a 71-year - old woman was referred for further evaluation of an uneven surface mucosa in the esophagus , in a barrett s area on the anterior wall of the distal esophagus where well - differentiated adenocarcinoma was diagnosed with biopsy . the patient has a history of cerebral infarction at age 50 years , from which she recovered , except for moderate left hemiparesis . although she also has a history of chronic heart failure , her cardiac function was improved . her physical examination was normal ; blood and serum chemistry tests including coagulation studies were normal ; and chest and abdominal computed tomography scans showed no metastatic lesions . she has been routinely followed up for the development of malignant lesions in a long segment of barrett s esophagus . according to the prague classification , the circumferential extent ( c ) of barrett s esophagus was 4 cm and the maximum length ( m ) was 7 cm . by using a laser imaging system , we found reddish lesions on the anterior and posterior walls of the distal esophagus in white light laser images ( fig . 1 ) . in addition , another lesion in the middle esophagus was detected as a brownish area , by using fice and bli ( fig . all three lesions were 0-iic early cancers with slight reddish color changes in the laser white light images : two lesions measuring 15 and 10 mm in diameter on the anterior and posterior walls of the distal esophagus , respectively , and another lesion measuring 5 mm in the middle esophagus . fice and bli enhanced all three lesions with high contrast , compared with the surrounding mucosa . magnification bli images revealed an irregular surface pattern on the brown lesion compared with the surrounding mucosa and an irregular vascular pattern in one portion of the tumor . esd was scheduled for the two lesions in the distal esophagus at the first resection and for the lesion in the middle esophagus 3 months later . all lesions were resected completely through esd with sodium hyaluronate solution without difficulties . the en bloc resected mucosa measured 27 mm for the anterior wall lesion in the distal esophagus , 26 mm for the posterior wall lesion , and 25 mm for the middle esophageal lesion . pathological diagnosis of the resected specimens showed well - differentiated adenocarcinoma in all lesions ( figs . all tumors were located within the lamina propria mucosa with tumor - free vertical and horizontal margins . double muscularis mucosae were seen in the area beneath the malignant cells in the resected specimens from the anterior wall of the lower esophagus and the middle esophagus . esophageal glands were found in the submucosa of the posterior wall of the lower esophagus . the patient was followed up with endoscopy with laser imaging every 6 months , and a fourth lesion was detected 2 years after the final esd procedure . this new lesion had a slightly reddish area on white light laser images and an irregular surface pattern on bli bright images ( fig . however , this lesion was not resected because the patient s cardiac function had worsened . this report demonstrates the early detection of three synchronous and one metachronous neoplasms in a patient with a long segment of barrett s esophagus , by using white light , fice , and bli images produced with a newly introduced laser imaging system . patients with a diagnosis of barrett s esophagus are at a risk of developing high - grade dysplasia or esophageal adenocarcinoma . recurrence and metachronous lesions have been shown to be the major problems with endoscopic resection in patients with early barrett s neoplasia [ 3 - 5 ] . the prevalence of metachronous lesions or disease recurrence increases to 14% within 12 months , and to 21.5% at 5 years . several investigators recommend that even with high - resolution endoscopy , four - quadrant biopsies are necessary after careful evaluation of barrett s mucosa to exclude synchronous neoplastic lesions . the biopsy specimens provide histological information on the mucosa with barrett s changes ; however , only a small fraction of the mucosa can be sampled . the laser imaging system can produce high - resolution images even with white light imaging . before obtaining biopsies , detailed observation by using laser imaging may also be useful for the detection of synchronous neoplasms and may compensate for the disadvantages associated with four - quadrant biopsies . in the current patient , laser endoscopic images are strongly associated with the higher emission intensity of short wavelengths illuminated by using blue laser light rather than xenon light . one of the main advantages is that the higher emission intensity of short wavelengths enables the observation of bright high - resolution images of the mucosal surface at a relatively distant view . another missed lesion was detected as a brownish area , by using fice and bli . bli and fice images reveal malignancies with high contrast compared with the surrounding mucosa . magnifying bli is closely related to short wavelengths and reveals a clearly irregular microstructural pattern ( figs . 2 , 3 ) . however , fice is less related to short wavelengths and can not sufficiently demonstrate the microstructural pattern , which may be a disadvantage . in contrast , images of the microvasculature need higher resolution than those of the microstructural pattern and a nearer view with high magnification for a more precise evaluation , even with the laser imaging system . laser imaging is produced by using longer wavelengths unrelated to absorption by hemoglobin in addition to short wavelengths related to hemoglobin absorption . longer wavelengths responsible for white light images are associated with imaging of the microstructure with low magnification or at a distant view , but not with the microvasculature on the tumor surface . thus , laser imaging with low magnification can show the microstructure but does not sufficiently image the microvessels on the tumor surface . image - enhanced endoscopy with high magnification allows the detailed observation of the microvascular and microstructural patterns of barrett s cancer . several studies with nbi described irregular microvascular and microstructural patterns that were highly associated with high - grade dysplasia / early cancer and showed high sensitivity and specificity of nbi in detecting neoplasia [ 11 - 14 ] . these findings are important in diagnosing barrett s cancer by using image - enhanced endoscopy such as nbi and bli . with the laser imaging system , a recent report revealed that linked color imaging is useful for the early detection of gastric cancer . in the future , linked color imaging should be evaluated for the detection of barrett s adenocarcinoma . in conclusion , laser endoscopic imaging may facilitate the detection of malignancies in patients with early barrett s adenocarcinoma , similar to early gastric cancer . further assessment in a large study is necessary to evaluate the usefulness of endoscopic diagnosis for multiple adenocarcinomas in areas of barrett s esophagus .
barrett s adenocarcinoma may occur in multiple sites , and recurrence and metachronous lesions are the major problems with endoscopic resection . 
 therefore , early detection of such lesions is ideal to achieve complete resection and obtain improved survival rates with minimally invasive treatment . 
 laser imaging systems allow multiple modalities of endoscopic imaging by using white light laser , flexible spectral imaging color enhancement ( fice ) , blue laser imaging ( bli ) , and linked color imaging even at a distant view . 
 however , the usefulness of these modalities has not been sufficiently reported regarding barrett s adenocarcinoma . here 
 , we report on a patient with three synchronous lesions followed by one metachronous lesion in a long segment with changes of barrett s esophagus , all diagnosed with this new laser endoscopic imaging system and enhanced by using fice and/or bli with high contrast compared with the surrounding mucosa . 
 laser endoscopic imaging may facilitate the detection of malignancies in patients with early barrett s adenocarcinoma .