S2336 It Was There All Along

Abstract

Introduction: Esophageal squamous papillomas (ESP) are rare, small, benign epithelial lesions most often found incidentally in asymptomatic patients. Majority of cases occur in the distal esophagus where chronic mucosal injury from the gastric refluxate of gastroesophageal disease can consistently and chemically irritate the mucosa. Diagnosis of ESP often requires biopsy although endoscopy usually demonstrates a , 6mm, solitary lesion with a triad of exophytic growth, verrucous projections, and surface crossing vessels evident on narrow-band imaging (NBI). Here we discuss a rare presentation of dysphagia secondary to a large, partially circumferential esophageal squamous papilloma. Case Description/Methods: A 72-year-old woman was referred to our institution for upper endoscopic ultrasonography (EUS) with possible endoscopic mucosal resection (EMR) for suspected upper GI lesion. Previously, the patient underwent endoscopy for dysphagia and was noted to have an ulcer at 30 cm from incisors. Despite proton-pump inhibitor (PPI) use, the dysphagia did not improve. A repeat esophagogastroduodenoscopy (EGD) was performed which revealed a polypoid lesion in the lower esophagus 34 cm from incisors without an ulcer. The lesion involved 50%-60% of the esophageal lumen extending from 34 cm to 36 cm from incisor, about .5 cm above the gastroesophageal (GE) junction. Part of the lesion was suctioned and a band was deployed. Hot snare polypectomy was performed and band assisted EMR was repeated for the remainder of the lesion. The tissue was sent for histopathological examination which demonstrated squamous papilloma without dysplasia or malignancy (Figure). Discussion: Esophageal squamous papilloma is a rare and often incidental finding on endoscopy in asymptomatic patients. Prevalence of ESPs in the general population is estimated to be less than 0.01%. Practitioners should maintain a high level of suspicion for esophageal squamous papillomas in adult patients who present with symptoms of gastroesophageal reflux disease and dysphagia who are unresponsive to proton pump inhibitors. It is critical to rule out other differentials such as squamous cell carcinoma, papillary leukoplakia, polyps, leiomyoma, malignant melanoma, and ultimately rule out ESP with biopsy of the lesion. First-line treatment has not been solidified, but removal of the lesion is preferred for symptomatic patients and to decrease the potential of malignant transformation.[2335] Figure 1. 1a: Endoscopic narrow-band imaging demonstrating a solitary 2 mm lesion with crossing surface vessels in the distal esophagus Figure 1b: EGD revealing a verrucous, polypoid lesion at 340 mm from incisors Figure 1c: EUS revealing an isoechoic mass in the distal esophagus involving half of the lumen circumference without invasion into the submucosa or muscularis propria.Figure 1d: Band assisted endoscopic mucosal resection of the lesion Figure 1e: Removed verrucous lesion