Esophageal Leukoplakia: A Rare Cause of White Patches in Esophagus with Malignant Potential

Abstract

Introduction: A white patch or patches within the oral cavity, termed as oral leukoplakia, is a premalignant condition typically seen in men with a history of alcohol and tobacco intake, and has a well-documented risk for progression to squamous cell carcinoma. An analogous condition found in the esophagus is esophageal leukoplakia. Due to its infrequency, the malignant potential of esophageal leukoplakia is not well established, despite a reported association with adjacent severe squamous dysplasia or squamous cell carcinoma in the few reported cases. On endoscopy, these esophageal lesions are highly characteristic and appear similar to those in the oral cavity, featuring well-demarcated white patches or plaques. Case Report: We report a 75-year-old male presenting with persistent cough and migratory pulmonary infiltrates, who was referred for evaluation of gastroesophageal reflux. He smoked half a pack of cigarettes a day for 10 years and drank 2 cocktails per day. Testing for infectious and autoimmune causes was unrevealing. A 24-hour laryngopharyngeal pH study off acid suppression showed high acid exposure during supine and upright periods. Esophagogastroduodenoscopy showed LA-grade D esophagitis, along with a single well demarcated white plaque in the lower third of esophagus (Figure 1A and 1B). Biopsies showed changes of epithelial hyperplasia, a prominent granular cell layer, and superficial hyperorthokeratosis, features diagnostic for epidermoid metaplasia that is the histologic correlate to esophageal leukoplakia (Figure 1C).Figure 1: (A and B) EGD showing white plaques at the lower third of the esophagus. (C) Biopsies of the plaque show squamous mucosa with a prominent granular layer and hyperorthokeratosis (Hematoxylin and eosin; original magnification 200x.)Discussion: The etiology of esophageal leukoplakia is unknown but is thought to be due to chronic irritation from acid reflux in the setting of alcohol and tobacco use, as was seen in this case. The highly characteristic endoscopic appearance should alert the endoscopist to the diagnosis. Despite the unclear premalignant status of esophageal leukoplakia, its association with squamous dysplasia and invasive squamous carcinoma in some patients in our practice warrants endoscopic surveillance.