Verrucous Carcinoma of the Esophagus Eluding Multiple Sets of Endoscopic Biopsies and Endoscopic Ultrasound: A Case Report and Review of the Literarure

Abstract

A 56-year-old woman was noted to have a 5 cm to 6 cm long, irregular narrowing of the distal esophagus on an upper gastrointestinal series. Initial endoscopy revealed a polypoid mass in the distal esophagus and concurrent endoscopic ultrasound revealed changes typical of inflammation but no evidence of an obvious neoplastic process. Repeated biopsies revealed only inflammation with no evidence of malignancy. Only after prolonged acid suppression did biopsies reveal verrucous carcinoma of the esophagus. The patient underwent a trans-hiatal esophagectomy and has remained well with no evidence of progression since. Verrucous carcinoma is a rare variant of squamous cell carcinoma, taking on a papillary or warty appearance grossly. Histological diagnosis may be difficult because this tumour typically shows no high-grade dysplasia. Therefore, diagnosis can be challenging, often requiring multiple sets of endoscopic biopsies due to the overlying hyperkeratotic layer. Of the 20 cases that have been reported, this is the second to provide an endosonographic description and the first to describe a change in endoscopic appearance with acid suppression.

Verrucous carcinoma of the tracheobronchial tree: an underdiagnosed entity?

“…Therefore, most definitive diagnoses are based on the examination of resected specimens [5,10]. DEVLIN et al [5] described a verrucous carcinoma of the oesophagus with features very similar to the tumour found in our case. The authors performed multiple biopsies of the tumour, none of which showed signs of malignancy.…”

“…To the Editor: Verrucous carcinomas, first described by ACKERMANN [1] in 1948, are rare, well-differentiated squamous cell carcinomas in the oropharynx [2], larynx [2][3][4] and oesophagus [5], and seem to be associated with Human papilloma virus (HPV) infections [6]. Macroscopically, they have a warty appearance and may easily be mistaken for papillomas [4].…”

“…As verrucous carcinomas mostly only show low-grade dysplasia and focal invasion with an otherwise benign appearance, diagnosis based on biopsies is difficult or even impossible [5,9]. Therefore, most definitive diagnoses are based on the examination of resected specimens [5,10].…”

“…Adjuvant radiotherapy has been reported for the treatment of advanced stages of the tumour [5,12]. As we did not perform tracheal resection, but partly removed the tumour during rigid bronchoscopy and partly destroyed it using Nd:YAG laser and cryotherapy, we referred the patient for adjuvant radiotherapy.…”

Semiquantitative histologic evaluation improves diagnosis of esophageal carcinoma cuniculatum on biopsy

“…It may be impossible to differentiate these entities on endoscopic mucosal biopsies as both entities pose enormous diagnostic difficulties as shown in our current studies as well as in the previous reports. 8,13 As esophageal squamous mucosa can undergo marked reactive changes, we caution that a diagnosis of carcinoma cuniculatum should not be solely based on the histologic assessment, even with the semiquantitative approach described here. Rather, the diagnosis should only be made with a strict clinicopathologic correlation.…”