Introduction: Development of extensive esophageal papillomas, also known as esophageal squamous papillomatosis (ESP), is extremely rare. Because there is a growing association between ESP and the development of squamous cell carcinoma (SCC), this disease can have significant clinical implications. We describe a case of ESP that develops into SCC.
Case Description/Methods: A 68-year-old man presented to clinic with a one-month history of progressive dysphagia and 10 lb weight loss. He has a history of chronic active Helicobater pylori-associated gastritis, invasive sigmoid colon adenocarcinoma status post resection without recurrence, tobacco use disorder and chronic esophagitis. He was seen two years prior for dysphagia to solids with endoscopy demonstrating numerous lesions (Figure 1, A) and benign inflammatory histology. Several months before his current presentation he had an upper endoscopy which revealed worsening of these lesions (Figure 1, B). Biopsies showed squamous epithelium with acanthosis, superficial hyperkeratosis, parakeratosis (Figure 1, C, yellow arrow) and cores of fibrovascular connective tissue (Figure 1, C, blue arrow) that were negative for Human Papilloma virus (HPV) or malignancy, overall suggestive of ESP. Subsequent upper endoscopy revealed a large, ulcerated esophageal mass (Figure 1, D). Biopsy of the mass demonstrated squamous cell carcinoma.
Discussion: Esophageal squamous papillomatosis is an extremely rare but important endoscopic finding. Grossly, they are described as small, pearly, wart-like projections, and histologically, as finger-like projections of hyperplastic squamous epithelium with a core of fibrovascular connective tissue. Pathogenesis is thought to be due to chronic inflammation from either long-standing acid reflux, pathologies associated with chronic esophagitis, HPV infection, or recurrent exposure to irritants. Surveillance guidelines and management of ESP have not been established due to its rarity, and little is known about the natural history of ESP. There are an increasing number of case reports of its association with the development of SCC as seen in our patient. It is important that providers identify esophageal squamous papillomatosis early and are aware of the risk of malignant transformation to squamous cell carcinoma.
