IntroductionDespite the widespread use of upper gastrointestinal endoscopy, the proportion of superficial esophageal squamous-cell carcinomas (SCCs) detected in Western countries is poor [1]. In a European enquiry, 51 such cases were found among 902 207 upper digestive endoscopy procedures. According to the registry in Burgundy, T1 cancer represents 4 % of the total number of esophageal SCCs, and T1 cancer limited to the mucosa only makes up 0.8 % of cases in France. By contrast, the rate of T1 esophageal SCC is five times higher in Japanese reports. The rates of T1 and T1 mucosal cancer reported by the National Cancer Center in Tokyo are 42 % and 18 %, respectively. These differences between Japan and Western countries may be explained by differences in histological interpretation, but it is likely that Japanese authors are more aware of the diagnosis of superficial cancer and pay more attention to it in general, and especially during endoscopy procedures. The failure of endoscopy to provide an early diagnosis of SCC in Western countries, despite a higher incidence of the condition than in Japan, shows that there is insufficient knowledge in the West of the macroscopic patterns of early carcinoma and that there is a tendency to carry out a cursory examination of the esophagus and to use chromoendoscopy to only a very limited extent.Adequate examination of the esophagus involves slow and complete analysis of the mucosa in order to detect any raised areas and ± more importantly ± any abnormalities in color, as alterations in color can reflect differences in the vascular pattern between tumor tissue and normal tissue. The superficial lesions frequently have an erythroplastic appearance if they are flat, or whitish if they are slightly elevated. The examiner also needs to focus on peristalsis transmission along the esophagus; a fixed area may be explained by the presence of a flat but already invasive carcinoma.Chromoendoscopy with vital staining is carried out between the initial precise examination and the taking of biopsies. In Europe, chromoendoscopy is not a widely used procedure, as it is regarded as being of little interest, difficult to perform, and above all, time-consuming and expensive. It must be emphasized that chromoscopy is mandatory in relation to esophageal squamouscell carcinoma; in certain circumstances, not performing it must be regarded as an error.The first expert approach section published in Endoscopy, in 2001, was concerned with Lugol staining [2]. The cases presented in the picture gallery here illustrate the high sensitivity and specificity of this method for diagnosing SCC. Toluidine blue is also capable of revealing occult dysplasia or unsuspected SCC in conventional esophagoscopy, but the technique required is more difficult and prolonged than Lugol staining, and it has a higher rate of false-negative results. Of all the chromoendoscopy methods available, Lugol staining at least should be recommended in Europe.Which patients should undergo Lugol staining? There are several theoretical g...

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