Endoscopic Resection of Recurrent Esophageal Verrucous Carcinoma

Abstract

Esophageal verrucous carcinoma is a rare type of squamous cell cancer. The diagnosis can be challenging, and consensus treatment recommendations are lacking. We describe the case of a patient diagnosed with esophageal verrucous carcinoma and treated successfully with endoscopic therapy. Case Presentation A 65 year old male presented with dysphagia. EGD showed a 2-cm frond like exophytic tumor in the distal esophagus and a benign peptic stricture at the GE junction (pic 1). Biopsies showed squamous hyperplasia and ulceration. CT showed no nodal or distant metastases. Upper EUS showed no submucosal invasion. Repeat EGD was performed with additional snare biopsies, and histology was similar. Given the recurrent and extensive nature of proliferation, there was suspicion for verrucous carcinoma. The tumor was removed via endoscopic mucosal resection (EMR). Histology confirmed well-differentiated verruciform squamous proliferation (pic 2). Three repeat EGDs at 3, 6 and 7 months later showed a small amount of tumor, treated with further endoscopic therapies (snare, APC, EMR). The fourth EGD after the initial EMR showed no recurrent/residual tumor (pic 3). Discussion Esophageal verrucous carcinoma was first reported in 1967, and less than 50 cases have been reported. It is more common in males, symptoms may include weight loss or dysphagia, and be associated with GERD. Risk factors include cigarette smoking, alcohol, achalasia and esophageal diverticula. Diagnosis is made with characteristic endoscopic appearance of an exophytic, whitish, frond like mass along with histology. Due to the rarity of this disease, there is limited evidence to guide treatment. Work up should include EUS and CT to evaluate for nodal or distant metastasis, both of which are very rare. Previously surgical resection was recommended, however due to the pattern of local proliferation and limited tendency for invasion and metastases, EMR and endoscopic submucosal dissection (ESD) have been successfully performed. Recently, a study described 9 patients treated with local endoscopic therapy. However, only 4 patients were treated with intent to cure requiring up to 48 sessions in one patient. As endoscopic therapies improve, this is likely to be a viable treatment modality for this disease, as seen in our case. Conclusion Verrucous carcinoma is a rare subtype of esophageal carcinoma with limited tendency for metastases, and can be successfully treated endoscopically in appropriate cases.Figure 1Figure 2Figure 3