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Gastroenterology 2014;146:618–621 Question: A 45year-old man presented in our surgical department with progressive dysphagia for solids and liquids and weight loss over the last 6 month, he had a long history of tobacco abuse (25 pack-years), but no history of trauma or alcohol use. Physical examination showed his cachexia, but was otherwise unremarkable without palpable lymphadenopathy. He had been treated with long-term bouginage over 4 years for a long segment esophageal stenosis starting 30 cm distal to the dental arch. Repeatedly performed biopsies over that time course had been nondiagnostic, with only chronic inflammation and hyperkeratosis. He presented in our institution owing to shorter bouginage intervals and weight loss. Upper endoscopy showed a thickened, white, contact-vulnerable, exophytic, and lumen-constricting polypoid mass in the esophagus over a distance of 15 cm (Figure A; star 1⁄4 esophageal lumen). Multiple deep biopsies were taken; they revealed keratosis and chronic inflammation but no evidence of malignancy. The subsequent computed tomography with contrast enhancement revealed a long-segment thickening of the thoracic esophagus (Figure B, arrows) without any lymphadenopathy or metastases. What is the most likely diagnosis? Look on page 871 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.