Esophageal Squamous Papilloma: A Case Series

Abstract

Introduction Esophageal squamous papilloma (ESP) is a rare neoplasm, usually appearing as an incidental finding in 0.01-0.45% of EGDs. The prevalence has increased over the last 10-15 years. ESP arises from a chronic inflammatory reaction related to GERD, smoking, alcohol, food impaction, caustic or mechanical injury, or HPV infection. They are reportedly more common in middle-aged men. We present 2 cases found in women. Case 1 A 61 year old female with no significant medical or surgical history presented with a 6 month history of progressive dysphagia to solids and liquids. She had occasional vomiting and epigastric pain after eating. Review of systems was otherwise negative. The patient was a nonsmoker, without significant alcohol use. Her medications included a multivitamin and lansoprazole. Physical exam was unremarkable. She had a normal barium swallow study. An EGD revealed esophagitis and a single 2 mm polyp in the proximal third of the esophagus. Pathology showed ESP. Case 2 A 19 year old female with history of lupus, Sjogren's syndrome and GERD presented with intermittent dark hematemesis over the past 1 month. She denied abdominal pain, hematochezia or melena. Her medications included mycophenolate, hydroxychloroquine, prednisone, ranitidine, and celecoxib. She had no significant past surgical or family history. Vital signs and physical exam were unremarkable except for heme-positive stool on rectal exam. Labs were notable for severe anemia with hematocrit of 14.9%. An EGD revealed esophageal ulcers and multiple polypoid masses in the distal esophagus, the largest of which was biopsied and found to be squamous papilloma. HPV testing was negative. Discussion ESPs are typically asymptomatic, but can present with an array of clinical manifestations as demonstrated by the cases above. The ESP in case 1 was an incidental finding. Due to its small size, it is unlikely to have contributed to the patient's dysphagia. Conversely, in case 2, the ESP likely developed in response to corrosive reflux. The polypoid area was friable, and likely caused her anemia. Although ESP is benign, there is controversy about its malignant potential. HPV is present in 5-50% of ESPs, and may play a role in malignant transformation of ESP. Because data is lacking on ESP as a premalignant lesion, endoscopic removal is recommended. Long-term follow up of ESP is needed to better understand their potential for progression to malignancy and surveillance after removal.Figure: The 2 mm ESP described in Case 1 is shown in endoscopic view (panel A) and on H&E staining, demonstrating the branched appearance of the papillae underlying the esophageal mucosa (panel B).Figure: This is an endoscopic image from Case 2 depicting an ulcerated multi-polypoid mass which was histologically identified to be a squamous papilloma. The yellow arrows indicate site of biopsy.