A 65 year old male presented with 1 yr history of dysphagia. An upper endoscopy showed white wart like appearing exudative lesions involving the mid and lower esophagus. The entire esophageal mucosa was friable. The appearance is more extensive in the lower esophagus with luminal narrowing but without any obstruction. Here you can see that the lesion extended through the GE junction into the gastric cardia. The biopsies from this lesion showed foci of hyperkeratosis and parakeratosis with moderate to severe atypia. This was suspicious for verrucous carcinoma.
An endoscopic ultrasound performed using a radial echoendoscope showed thick circumferential hypoechoeic lesion arising from the mucosa and extending to the muscularis propria. Here one can appreciate the thickened submucosa up to 9mm at the lower esophagus. There were several enlarged perigastric and paraesophageal lymph nodes. This lesion demonstrates a T2, N1 esophageal cancer. Since the biopsies are suspicious for verrucous carcinoma, patient underwent esophagectomy. Here you can see the warty appearance of the verricous tumor in the resected specimen. The pathology showed Invasive Well- differentiated squamous cell carcinoma. There are also superficial viral related changes in the tumor but the immunohistochemical stain for p16 and HPV Phenotype were negative. Post operatively the patient recovered without complications. Verrucous carcinoma of the esophagus is a rare variant of squamous cell carcinoma with less than 25 cases reported in the English literature. Mucosal biopsies are usually nondiagnostic and deep biopsies with additional diagnostic modalities such as EUS are helpful. Verrucous carcinoma has low potential for metastasis and resection of the tumor offers the best chance of cure.
Vinay K. Katukuri, MD, Thomas Jefferson University
Robert M Coben, MD, Thomas Jefferson University