A 63-years-old male presented with a 12-month history of progressive dysphagia and Globus pharyngeus without any comorbidities. Upper endoscopy revealed a hardened elevated lesion in the distal esophagus located between 31 and 40 cm from incisors, covered by intact mucosa (Figure 1). Bite-on-bite conventional biopsies were inconclusive.

The (18)F-FDG-PET/CT showed a solid hypercapturing lesion in the thoracic esophagus, measuring 12.5 cm in the transverse plane (Figure 2). A hypoechoic and homogeneous lesion, inserted in the submucosal layer was seen at EUS. However, the results of fine-needle aspiration were inconclusive. Lastly, macrobiopsy using a diathermy loop was performed. The procedure was followed by self-limited bleeding, controlled by argon plasma coagulation (Figure 3). Histology showed the characteristic formation of atypical and back-to-back arrangement of the lymphoid follicles, composed by small to medium cells proliferation of non-Hodgkin's lymphoma (Figure 4). The immunohistochemistry was positive for Bcl-2, Bcl-6, CD10, CD20, CD23, and Ki-67 (30%) and it was compatible with grade 2 follicular B-cell lymphoma. The patient started treatment with chemotherapy (R-CHOP regimen) with the perspective of additional radiotherapy or surgery.

Esophageal lymphoma is a rare disease and endoscopic biopsy with satisfactory results can be challenging. If methods as standard biopsy or EUS-FNA fail, a macrobiopsy snare can be performed for a conclusive diagnosis.