Verrucous Carcinoma of the Esophagus: A Potential Diagnostic Dilemma
A 58-year-old female with a past history of squamous cell carcinoma of the larynx, treated with radiation therapy and surgery 13 years earlier, presented with dysphagia and weight loss of approximately 10 pounds; symptoms had started almost 2 months before. At the time of presentation, she was able to tolerate a liquid diet only and was referred to us for further diagnostic workup after two prior gastroscopy studies. Previous evaluation had revealed a large polyp-like mass involving the mid and distal esophagus. However, repeat biopsies from this lesion had been negative for malignancy. On repeat esophagogastroduodenoscopy, a large semi-pedunculated polyp was seen in the distal esophagus (fig. ). The polyp stalk seemed to blend into a background of nodular-appearing mucosa involving the distal esophagus with the gastroesophageal junction. On endoscopic ultrasound, a hypoechoic, irregular mass was found, involving the gastroesophageal junction with associated esophageal thickening, measuring 20 mm in thickness. There was sonographic evidence suggesting invasion into the deep adventitia layer (fig. ). Biopsies using large-capacity forceps demonstrated pseudoepitheliomatous hyperplasia, raising the suspicion of VCE. p16 immunohistochemical staining was positive for HPV.\nInitial positron emission tomography (PET) and computed tomography (CT) evaluation was consistent with an increase in hypermetabolic soft tissue fullness at the gastroesophageal junction. After discussion at the multidisciplinary conference, the decision was made to proceed with chemo-radiation with preoperative carboplatin and Taxol. Repeat PET/CT after 3 months demonstrated significant interval reduction in the size and metabolic activity of the distal esophagus near the gastroesophageal junction, consistent with a positive response to radiation therapy. Clinically, the patient had significant improvement in symptoms after initiation of chemo-radiation therapy. Afterwards, she underwent interval Ivor-Lewis esophagectomy with no residual mass seen on gross specimen. Final histology did not reveal any viable tumor (fig. ).