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A patient presenting with dysphagia and weight loss was found to have a large midesophageal mass. Five biopsies indicated only adenoma but a brush cytology specimen under direct vision was diagnostic of adenocarcinoma. Esophagotomy and resection of tumor, with follow-up radiotherapy were performed; histologic examination confirmed the diagnosis. To date, there has been no recurrence of the tumor. This patient was subsequently found to have a columnar-lined esophagus. Since columnar-lined esophagus may predispose to malignancy, this case illustrates the diagnostic importance of direct-vision cytology in patients with columnar-lined esophagus.