We are presenting a case of a 45 y/o male underwent an upper endoscopy to evaluate for symptoms of gastroesophageal reflux. A small mucosal lesion was seen in mid esophagus. After careful examination a decision was made to proceed with endoscopic resection. The following video shows the procedure.
Here we can see the mucosal lesion with characteristic verrucous appearance reminiscent of papillomatous wart lesions seen on the skin. A sub mucosal saline injection was performed to lift the lesion to ensure complete resection. After lifting the lesion a electrocautery snare polypectomy with standard settings was done. Here we can see the lesion being resected enbloc. After resection the specimen was retrieved. To destroy the residual tumor along the edges argon plasma coagulation (APC) was performed with the help of a clear tip endoscope cap.
The biopsy shows marked epithelial hyperplasia with a fibrovascular core in its center, consistent with benign squamous papilloma of esophagus.
Review of Literature
On review of literature Esophageal Squamous papilloma is rare; with an estimated prevalence of 0.01 to 0.43. It is mostly reported as an incidental finding on endoscopy. Etiopathogensis is unclear. A number of factors such as chemical, viral and mechanical factor have been implicated. Chronic irritation from reflux esophagitis has been linked to papilloma. Viral infection by human papilloma virus has also been implicated, but the evidence is not strong. Out of the 239 cases analyzed only about 21% of them have been found to be positive for HPV DNA. Direct trauma could be a contributing factor based on the observations of development of esophageal papilloma after bougienage for benign stricture, placement of a self expanding metal stent and variceal sclerotherapy.
Majority of patients with esophageal squamous papilloma are asymptomatic and the lesion is incidentally discovered during workup of gastroesophageal reflux disease.
Esophageal papilloma is seen as a pinkish soft polypoid structure with a smooth or slightly rough surface in the esophagus. Differential diagnosis includes glycogenic acanthosis, verrucoid border of squamous cell carcinoma and verrucous carcinoma. Endoscopic removal can be accomplished as shown in the video either with a snare cautery or biopsy forceps.
The clinical course is quite variable. Majority of squamous papilloma remain asymptomatic. However spontaneous regression has been reported in a few cases. Although malignant transformation has been reported in bovine papillomatous infection, and there is debate about its malignant potential in humans, transformation to esophageal cancer has not been reported in humans. However, HPV DNA has been isolated from esophageal cancer, papilloma is known to be precursor of squamous carcinoma (as in larynx and cervix), and papilloma and occult epidermoid carcinoma of esophagus have been found contiguously in humans. Therefore malignant transformation still remains a concern. Esophageal papilloma is usually described as a case report; the endoscopic series published are small. Moreover most of the cases reported are from Europe; this observation strongly favors an environmental agent as the cause of squamous papilloma. In conclusion squamous cell papilloma is an uncommon benign esophageal tumor which must be removed in all patients because of concern regarding malignant potential.
Sahil Mittal, MD, University of Texas Medical Branch
Rami Hawari, MD, University of Texas Medical Branch
Gottumukkala S. Raju, MD, MD Anderson Cancer Center