Esophageal Squamous Papilloma: A Rare and Ambiguously Benign Lesion

Abstract

Case: A 56-year-old woman with rheumatoid arthritis and COPD was referred for abdominal pain. She was diagnosed and treated for H. pylori after an EGD showed the presence of H. pylori in July 2010. She was retreated with triple therapy for H. pylori positive stool antigen in August 2011 for recurring symptoms. The patient represented a year later with persistent epigastric pain, reflux and early satiety. She also complained of worsening nausea, vomiting and self reported weight loss. Due to persistent abdominal pain and weight loss, she had a repeat EGD. The EGD showed a white, 1 cm nodule in the proximal esophagus. The biopsy identified the specimen as a squamous papilloma, negative for human papilloma virus (HPV). Discussion: Esophageal squamous papillomas (ESPs) are benign, rare tumors of unclear etiology. Some institutions reported that a quarter of EGDs identified esophageal papillomas; although the literature typically ranges from 0.01-0.43%. ESPs are usually less than 5 cm; however, they can range in size. They are usually asymptomatic, but have been reported to cause dysphagia. ESPs may be difficult to identify by gross morphological appearance alone and have been commonly confused with glycogenic acanthosis and verrucous carcinoma. Although the literature is controversial, there are two prevailing thoughts on the etiology of these lesions. The first theory involves an abnormal proliferative response to mechanical or chemical irritation. Gastroesophageal reflux disease (GERD) predisposes the mucosa to chronic irritation and inflammation and may contribute to this reactive response. HPV has recently been elicited as a probable pathogenic factor in the formation of ESPs, although a specific mechanism has not been elucidated. Squamous papillomas of the esophagus are more often negative for HPV, as the case with our patient. Although histologically the lesion is benign, there is debate as to whether the lesion has a predisposition to malignant change. In long term follow-up studies, no significant association has been made regarding esophageal papilloma as a premalignant lesion; although, the rare nature of these lesions makes it difficult to study this process. It is the potential for malignant transformation that some propose that all ESPs should be removed.Figure: No Caption available.