Introduction: Esophageal epidermoid metaplasia (EEM) is a rare esophageal disorder characterized by white mucosal plaques mimicking oral leukoplakia. Terms such as EEM and esophageal leukoplakia are often used interchangeably to describe these endoscopic findings. EEM is often associated with alcohol and tobacco abuse. EEM is thought to be a precursor lesion to esophageal squamous cell carcinoma (ESCC) and therefore requires a close follow-up.
Case Description/Methods: A 50-year-old non-Hispanic white man was referred for intermittent dysphagia to solids, heartburn and acid regurgitation for two years. Esophagogastroduodenoscopy (EGD) showed well-demarcated white plaques (20x30mm) in the esophagus 35cm from the incisors (Fig. 1A). The histopathological examination of this lesion showed compact orthokeratosis and a prominent granular layer with keratohyalin granules resembling the epidermis of the skin diagnostic of EEM (Fig. 1B). No dysplasia was noted in biopsies obtained from the esophagus. Due to the premalignant nature of the lesion, it was treated by radiofrequency ablation (RFA) using a HALO-90 ablation catheter with successful eradication after three sessions (Fig. 1C). Subsequent surveillance over 2 years showed no recurrence.
Discussion: EEM is an under-recognized premalignant esophageal disorder commonly presenting as an incidental finding in the mid to distal esophagus. Patients having EEM often present with acid regurgitation and dysphagia. Smoking and alcohol intake are reported risk factors. In white light endoscopy, EEM lesions are visualized as slightly elevated whitish irregular plaques, often translucent or cobblestone-like in appearance. Histopathological examination demonstrates compact superficial orthokeratosis/hyperkeratosis, thickened basal layer, and prominent granular cell layer. EEM is characterized by Lugol's-voiding scaly white plaques with clear distinction. The appearance of Lugol's voiding lesion helps distinguish EEM from other inflammatory conditions like esophageal glycogenic acanthosis and papilloma, both of which stain positive for Lugol's solution. Of note, EEM is considered a precursor to squamous dysplasia and advanced ESCC. Treatment modality further depends on the degree of dysplasia and the presence of concurrent ESCC. Here, we report a case of EEM successfully eradicated by RFA.
Figure: 1A) Upper endoscopy revealing large white plaques with altered texture in the distal esophagus. 1B) High-magnification histopathologic imaging showing orthokeratosis and dense granular layers. 1C) Upper endoscopy showing complete eradication of EEM after RFA treatment.
Prabhat Kumar indicated no relevant financial relationships.
Prashanthi Thota indicated no relevant financial relationships.
Prabhat Kumar, MD, Prashanthi N. Thota, MD. P0345 - Successful Eradication of Esophageal Epidermoid Metaplasia by Radiofrequency Ablation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.