Verrucous Carcinoma of the Esophagus: a Complex Diagnosis

UCTN – Unusual cases and technical notes E137

Verrucous carcinoma of the esophagus: a complex diagnosis

We present the case of a 71-year-old woman with complicated gastroesopha- geal reflux disease with a peptic stricture located 30 cm from the incisors. There was no history of caustic ingestion or alcohol, or use of tobacco. Following four attempts at endoscopic dilation, a self-ex- panding, removable plastic stent had been placed previously. After 4 months of the placement of the stent, the patient experi- enced progressive dysphagia, retrosternal pain, and hematemesis. Esophagogastro- duodenoscopy (EGD) showed clots in the esophageal lumen. After stent removal, an exophytic mass causing partial stenosis Fig. 1 a Endoscopic view of the esophagus showing a whitish, exophytic, wartlike tumor causing par- was identified in the mid-esophagus tial stenosis. b Barium radiography: intraluminal esophageal tumor causing mild dilatation of the prox- (●" Fig. 1). Histological evaluation re- imal esophagus. c Endosonography view: a predominantly hypoechoic, poorly defined wall thickening vealed only inflammatory changes. Endo- in the middle third of the esophagus. scopic ultrasound showed invasion through the muscularis propria, with a nonspecific paraesophageal lymph node. Fig. 2 a Resected specimen with the Fine-needle aspiration cytology was also esophageal tumor in negative for malignancy. Thoracoabdom- the middle third of the inal computed tomography (CT) showed esophagus. b Closeup no distant lesions. view of the whitish, The patient underwent Ivor–Lewis esoph- multilobulated, pseudo- agogastrectomy. The resected specimen pedunculated tumor, consisted of a multilobulated mass 3.9 × 2.5 cm in size. (●" Fig. 2) with an ulcerated surface and signs of severe chronic inflammation. Histologically, the lesion showed papillary projections of well-differentiated kera- tinized squamous epithelium with mild cytologic atypia. Voluminous rete pegs extended into the muscularis propria (●" Fig. 3). Isolated lymph nodes were negative for carcinoma. Histological diagnosis was verrucous squamous cell carcinoma (VSC), pT2 N0 M0. VSC of the esophagus is a rare variant of squamous cell carcinoma, with just over This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. 20 cases reported since its first descrip- tion [1]. It occurs in middle-aged patients with a male–female ratio of about 2 :1, Fig. 3 Histological and mostly affects the lower esophagus. appearance. a Full view of the lobulated pseu- Complications are usually due to local in- dopolypoid lesion par- vasion [2]. Lymph node or distant metas- tially covered by inflam- tasis is exceptional. Most cases of VSC matory granulation have associated chronic esophageal injury tissue. b Invasion of [3]. The human papillomavirus has been the underlying stroma recently implicated [4] but was negative in a pushing fashion by in our case. Dysphagia/odynophagia, the well-differentiated squamous neoplastic weight loss, hematemesis, and coughing epithelium (hematoxy- are the main symptoms. Histologically, lin-eosin stain; magnifi- acanthosis, hyperkeratosis, and parakera- cation × 50). tosis are usually observed. Inflammatory

Macias-Garcia F et al. Verrucous carcinoma of the esophagus … Endoscopy 2010; 42: E137– E138 E138 UCTN – Unusual cases and technical notes

infiltrates around the areas of tumor are Santiago de Compostela, Santiago de report.] Minerva Chir 2005; 60: 61– 65 [Ar- also commonly described. Because these Compostela, Spain ticle in Icelandic] 3 5 Osborn NK, Keate RF, Trastek VF, Nguyen CC. findings are nonspecific, endoscopic mu- Digestive Surgery Department, Univer- Verrucous carcinoma of the esophagus: clin- cosal biopsies rarely help confirm the di- sity Hospital of Santiago de Compostela, icopathophysiologic features and treatment agnosis. Surgery is the only curative treat- Santiago de Compostela, Spain of a rare entity. Dig Dis Sci 2003; 48: 465– ment once the tumor has extended into 4 Pathology Department, University 474 the submucosa [5]. Hospital of Santiago de Compostela, Santiago de Compostela, Spain Bibliography Competing interests: None DOI 10.1055/s-0029-1244049 Endoscopy 2010; 42: E137 –E138 References © Georg Thieme Verlag KG Stuttgart · New York · 1 Ackerman LV. Verrucous carcinoma of the Endoscopy_UCTN_Code_CCL_1AB_2AC_3AB ISSN 0013-726X oral cavity. Surgery 1948; 23: 670– 678

1,2 2 Biemond P, ten Kate FJ, van Blankenstein M. F. Macias-Garcia , L. Martinez-Lesquer- Esophageal verrucous carcinoma: histologi- Corresponding author 3 4 3 eux , B. Fernandez , P. Parada , J. Larino- cally a low-grade malignancy but clinically a F. Macias-Garcia Noia1,2, M. Sobrino-Faya1,2, J. Iglesias- fatal disease. J Clin Gastroenterol 1991; 13: Gastroenterology Department Canle1,2, J. Iglesias-Garcia1,2, J. Forteza4, 102– 107 University Hospital of Santiago de Compostela J. E. Dominguez-Munoz1,2 3 Kavin H, Yaremko L, Valaitis J, Chowdhury L. c/Choupana s/n Chronic esophagitis evolving to verrucous 1 Gastroenterology Department, Uni- 15706-Santiago de Compostela squamous cell carcinoma: possible role of Spain versity Hospital of Santiago de Compos- exogenous chemical carcinogens. Gastroen- Fax: +34-981-951365 terology 1996; 110: 904– 914 tela, Santiago de Compostela, Spain [email protected] 2 Foundation for Research in Digestive 4 Liberale G, De Simone P, Snoeck R et al. [Ver- rucous carcinoma of the esophagus. A case Diseases (FIENAD), University Hospital of This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Macias-Garcia F et al. Verrucous carcinoma of the esophagus … Endoscopy 2010; 42: E137– E138