A 66-year-old man with Barrett’s esophagus presented for evaluation of a 2-cm sporadic duodenal bulb tubulovillous adenoma with high-grade dysplasia (HGD) (Fig. 1). EUS revealed sparing of the muscularis propria and the submucosa. Initial therapy consisted of piecemeal EMR (Duette Kit, Cook Medical, Bloomington, Ind). When residual lesions were found on follow-up examination, EMR was reattempted, but the lesion could not be lifted with submucosal injection, likely because of scar tissue. The patient then underwent more than 2 years of repeated applications of argon plasma coagulation (APC) and radiofrequency ablation (RFA) (HALO, now Barrx, Medtronic, Minneapolis, Minn), but the lesion persisted (Fig. 2) and developed a single minute focus of intramucosal carcinoma.