Morehouse School of Medicine Atlanta, GA, United States
Shanli Parnia, MD1, Dharma Sunjaya, MD2, Anand Shah, MD3 1Morehouse School of Medicine, Atlanta, GA; 2Emory University School of Medicine, Atlanta, GA; 3Emory University School of Medicine, Decatur, GA
Introduction: Verrucous squamous cell carcinoma (VSCC) is a rare well-differentiated variant of squamous cell carcinoma. Due to the indolent nature of the tumor, patients often present with chronic dysphagia and recurrent esophageal candidiasis. Diagnosis of esophageal VSCC can be elusive as full-thickness pathologic evaluation is needed to see beneath papillomatous hyperkeratotic and parakeratotic squamous epithelium.
Case Description/Methods: A 73-year-old man with a history of diabetes and hypertension presented to gastroenterology clinic for evaluation of weight loss, chronic dysphagia, and esophageal candidiasis. His upper endoscopy (EGD) showed severe middle and distal esophagitis with diffuse white plaques. Brushing showed atypical cells in background of inflammation and candidiasis. Oral Fluconazole therapy was initiated. Repeat EGD was performed three months later, again, showing persistent severe esophageal candidiasis. Due to concern for drug resistance, Isavuconazonium therapy was started. Three month follow-up EGD again showed persistent candidiasis. Endoluminal functional lumen imaging probe demonstrated absent esophageal contractility. Endoscopic mucosal resection with some submucosal sampling revealed atypical verrucous squamous proliferation but unable to exclude underlying VSCC. Upper endoscopic ultrasound-guided (EUS) was performed showing complete loss of the esophageal muscle layers in middle and distal esophagus with asymmetric thickening of the esophageal wall measure up to 3cm concerning for pT3 disease. Fine needle biopsy of the esophageal mass showed detached dyskeratotic squamous cells. PET-CT scan demonstrated fluorodeoxyglucose avid distal esophageal thickening. Patient was referred to thoracic surgery and underwent an Ivor-Lewis esophagectomy. Surgical pathology confirmed well-differentiated VSCC with focal invasion through the muscularis propria into the adventitia.
Discussion: In patients with dysphagia and refractory esophageal candidiasis, the differential should include evaluation for esophageal dysmotility and malignancy. A delay in diagnosis can occur as endoscopic sampling via mucosal or submucosal resection, and even, EUS guided biopsy may be limited. A full thickness esophageal sampling is often necessary to make the diagnosis of VSCC. Esophagectomy would be diagnostic and curative in the absence of metastatic disease but a strong clinical suspicion is imperative.
Figure: A) Endoscopic appearance: plaque-like erosive lesions superimposed with Candida infection B) Hematoxylin and eosin stain (H&E) Bird’s eye view showing papillary verrucous surface and an invasion by squamous cell carcinoma into the underlying tissue C) Medium power view showing the interface of tumor nests with underlying stromal tissue D) Medium power showing focal areas of the tumor with infiltrating invasion and irregular edge with brisk lymphocytic response. E) High power view of some areas of the tumor with high-grade nuclei, high nuclear to cytoplasm ratio, prominent nucleoli, and increased mitoses. F) High power view showing most of the tumor with bland cytology; low nuclear to cytoplasmic ratio, abundant cytoplasm, and small nucleoli
Shanli Parnia indicated no relevant financial relationships.
Dharma Sunjaya indicated no relevant financial relationships.
Anand Shah indicated no relevant financial relationships.
Shanli Parnia, MD1, Dharma Sunjaya, MD2, Anand Shah, MD3. P1394 - Verrucous Squamous Cell Carcinoma Causing Refractory Esophageal Candidiasis and Dysphagia, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.