Esophageal leukoplakia or epidermoid metaplasia: a clinicopathological study of 18 patients

Clinicopathological Study of Lesions of Upper Gastrointestinal Tract

Conditions affecting the upper digestive system are often seen in clinical practice and are associated with a high rate of death and disability. Histopathological confirmation is one of the foundations for good treatment planning and the definite diagnosis of illnesses of the upper gastrointestinal tract. The numerous methods employed in the diagnosis of gastrointestinal lesions have come a long way in the previous 25 years. The identification and diagnosis of gastrointestinal lesions have been substantially aided by the development of endoscopy, endoscopic biopsy, and other surgical techniques. This research aimed to examine the variety of gastrointestinal tract (GI) lesions and to draw connections between the clinical and pathological manifestations of these conditions.

Materials and Methods

A two-year cross-sectional study was conducted in the Department of Pathology, from June 2018 to May 2020, which included surgical specimens of 140 cases from the upper gastrointestinal tract, of which 111 cases were biopsy, and 29 cases were resected surgical specimens. The data were analyzed using SPSS software. Furthermore, P values, sensitivity, specificity, positive predictive value, and negative predictive value were calculated.

Results

This study was a two-year cross-sectional study conducted in the Department of Pathology during the period of June 2018-May 2020.

Esophageal intramural pseudodiverticulosis

Esophageal intramural pseudodiverticulosis (EIPD) is a disease of unknown pathogenesis characterized by usually systemic, cystic dilatation of the excretory ducts of esophageal submucosal glands. In this article, I review the epidemiology, clinical manifestations, endoscopic findings, esophagographic findings, and histopathology of EIPD. I also discuss the etiology and possible pathogenesis of EIPD based on my experiences with this disease and a review of the literature. EIPD usually presents with dysphagia in middle-aged individuals. It is often complicated with secondary infections, most commonly candidiasis. On esophagography, EIPD is delineated as small, multiple, flask-shaped outward projections within the esophageal wall. In recent years, EIPD has been mainly diagnosed by endoscopic findings of multiple, localized, small mucosal depressions. The orifices of the "pseudodiverticula" periodically open and close, and excrete mucus onto the mucosal surface. On histopathological examination, the luminal surface of dilated ducts in EIPD is covered by multilayered, hyperplastic epithelial cells, but myoepithelial cells in the glandular acini are well preserved. Treatment of EIPD is usually symptomatic therapy, and prevention of the infectious complications is important. The etiology and pathogenesis of EIPD are largely unknown, but functional abnormalities of autonomic nerve fibers innervating the esophageal glands likely play an important role, since the structures of the glands are basically preserved in this disease.

Accuracy of narrow‐band imaging for diagnosing malignant transformation of vocal cord leukoplakia: A systematic review and meta‐analysis

Objective

To explore whether narrow-band imaging (NBI) endoscopy is accurate in the diagnosis of malignant transformation of vocal cord leukoplakia.

Methods

The PubMed, Embase, Cochrane Library and Web of Science databases were searched to collect data on studies reporting the use of NBI endoscopy as a diagnostic test for diagnosing vocal cord leukoplakia from January 2015 to December 2021. Study design, analysis method, and extraction results were performed according to the PRISMA guidelines. The sensitivity, specificity, pooled positive likelihood ratio (PLR), negative likelihood ratio (NLR) and area under the curve (AUC) were used to summarize the performance metrics of the meta-analysis. Risk of bias data and the quality of the included studies was evaluated according to the Quality Assessment of Diagnostic Accuracy Studies-2 tool (QUADAS-2).

Results

Nine studies were finally included in the analysis. The results of the meta-analysis showed that the pooled sensitivity and specificity of NBI endoscopy for diagnosing leukoplakia lesions were 0.76 (95% CI: 0.72-0.8) and 0.93 (95% CI: 0.91-0.95), respectively. The PLR and NLR were 10.09 (95% CI: 6.53-15.59) and 0.22 (95% CI: 0.13-0.38), respectively. The comprehensive diagnostic odds ratio (DOR) was 54.96 (95% CI: 24.32-124.17), and the area under the curve was 0.9584. The eight articles had a low risk of bias risk and one article was unclear.

Conclusion

NBI likely has good accuracy for diagnosing malignant transformation of vocal cord leukoplakia. However, multicenter studies and large samples are still needed.

Role of Endoscopy in Management of Upper Gastrointestinal Cancers

Upper gastrointestinal (GI) malignancy is a leading cause of cancer-related morbidity and mortality. Upper endoscopy has an established role in diagnosing and staging upper GI cancers, screening for pre-malignant lesions, and providing palliation in cases of advanced malignancy. New advances in endoscopic techniques and technology have improved diagnostic accuracy and increased the therapeutic potential of upper endoscopy. We aim to describe the different types of endoscopic technology used in cancer diagnosis, summarize the current guidelines for endoscopic diagnosis and treatment of malignant and pre-malignant lesions, and explore new potential roles for endoscopy in cancer therapy.

Esophageal epidermoid metaplasia: an unusual condition

A 66-year-old man with a history of tobacco and alcohol consumption was diagnosed with a severe peptic esophagitis. After treatment, an endoscopy showed the resolution of esophagitis, but revealed white multinodular plaques with a diffuse distribution. Histology showed esophageal mucosa with a prominent granular layer and hyperorthokeratotis, in keeping with epidermoid metaplasia. This unusual condition has been linked to esophageal squamous cell carcinoma. Therefore, diagnosis and endoscopic surveillance should be considered.

Esophageal lichen planus: Current knowledge, challenges and future perspectives

Lichen planus (LP) is a frequent, chronic inflammatory disease involving the skin, mucous membranes and/or skin appendages. Esophageal involvement in lichen planus (ELP) is a clinically important albeit underdiagnosed inflammatory condition. This narrative review aims to give an overview of the current knowledge on ELP, its prevalence, pathogenesis, clinical manifestation, diagnostic criteria, and therapeutic options in order to provide support in clinical management. Studies on ELP were collected using PubMed/Medline. Relevant clinical and therapeutical characteristics from published patient cohorts including our own cohort were extracted and summarized. ELP mainly affects middle-aged women. The principal symptom is dysphagia. However, asymptomatic cases despite progressed macroscopic esophageal lesions may occur. The pathogenesis is unknown, however an immune-mediated mechanism is probable. Endoscopically, ELP is characterized by mucosal denudation and tearing, trachealization, and hyperkeratosis. Scarring esophageal stenosis may occur in chronic courses. Histologic findings include mucosal detachment, T-lymphocytic infiltrations, epithelial apoptosis (Civatte bodies), dyskeratosis, and hyperkeratosis. Direct immuno-fluorescence shows fibrinogen deposits along the basement membrane zone. To date, there is no established therapy. However, treatment with topical steroids induces symptomatic and histologic improvement in two thirds of ELP patients in general. More severe cases may require therapy with immunosuppressors. In symptomatic esophageal stenosis, endoscopic dilation may be necessary. ELP may be regarded as a precancerous condition as transition to squamous cell carcinoma has been documented in literature. ELP is an underdiagnosed yet clinically important differential diagnosis for patients with unclear dysphagia or esophagitis. Timely diagnosis and therapy might prevent potential sequelae such as esophageal stenosis or development of invasive squamous cell carcinoma. Further studies are needed to gain more knowledge about the pathogenesis and treatment options.

Significant accumulation of KRAS mutations in bronchiolar metaplasia‑associated honeycomb lesions of interstitial pneumonia

Interstitial pneumonia (IP) is a major risk factor for lung adenocarcinoma (LADC). IP-related LADC predominantly develops in the bronchiolar metaplasia lining in honeycomb lesions. Kirsten rat sarcoma virus (KRAS) is the most common oncogene mutated in IP-related LADC. The present study examined the metaplastic epithelia in honeycomb lesions for KRAS mutations using digital droplet polymerase chain reaction (ddPCR), a sensitive method used to detect infrequent mutations. Significantly higher KRAS mutation variant allele frequencies (VAFs) were detected in the metaplastic lung epithelia from 13 patients with IP compared with those in 46 non-lesioned lung samples from patients without IP (G12V, P=0.0004, G12C, P=0.0181, and G12A, P=0.0234; Mann Whitney U test). Multivariate analyses revealed that higher KRAS G12V (logistic regression model; P=0.0133, odds ratio=7.11) and G12C (P=0.0191, odds ratio=5.81) VAFs in patients with IP were independent of confounding variables, such as smoking and age. In patients with IP, metaplastic epithelia exhibited significantly higher KRAS G12V and G12C VAFs compared with the non-lesioned counterparts (paired t-test; G12V, P=0.0158, G12C, P=0.0465). These results suggested that IP could increase KRAS mutations and supported the hypothesis that bronchiolar metaplasia could be a precursor for IP-related LADC.

A Rare Case of Esophageal Leukoplakia in Achalasia

Esophageal leukoplakia refers to a clinical finding of a white patch on the mucous membrane surface that cannot be scraped off. It has been associated with alcohol and tobacco use and chronic acid reflux. An association with squamous cell dysplasia and carcinoma has been reported with potential for malignant transformation warranting endoscopic intervention or surveillance, but no guidelines exist.

We present a case of a 77-year-old female with a history of longstanding achalasia requiring multiple Botox injections. After presenting with weight loss, esophageal dysphagia, and acid reflux the patient underwent an esophagogastroduodenoscopy (EGD) showing a 20 mm white plaque in the middle third of the esophagus and histopathology consistent with esophageal leukoplakia. After repeated Botox injection and treatment with PPI and H2 blocker, no findings of esophageal leukoplakia were noted on repeat EGD.

With this case, we aim to increase awareness of this rare disease pathology, especially in the setting of underlying achalasia. This case also raises the question if maximum anti-reflux therapy could have a potential benefit in avoiding the recurrence of esophageal leukoplakia.

Some Morphology Frontiers of Dysplasia in the Tubular Gastrointestinal Tract: The Rodger C. Haggitt Memorial Lecture

This review, based on the content of the 2020 US Gastrointestinal Pathology Society's Rodger Haggitt Lecture, concerns an array of tubular gastrointestinal tract dysplastic or possible "predysplastic lesions" with an almost purely morphologic focus based on our collaborative efforts over the past few years. These processes include esophageal epidermoid metaplasia, Barrett esophagus-associated dysplasia, polypoid gastric dysplastic lesions, small intestinal dysplasia, and the ability of metastases to mimic it, the controversial "serrated epithelial change" encountered in the setting of long-standing ulcerative and Crohn colitis, and recently described anal columnar human papilloma virus-associated neoplasms.

Development of Epidermoid Metaplasia of the Mucosa in Association with Esophageal Intramural Pseudodiverticulosis and Candidiasis

We report a case of epidermoid metaplasia of the esophageal mucosa that developed in a patient with a long history of esophageal intramural pseudodiverticulosis (EIPD) complicated by candidiasis. The patient, a 69-year-old man, had been treated for about 3 years for EIPD with candidiasis. After candidiasis improved, the development of epidermoid metaplasia of the esophageal mucosa was observed. It comprised longitudinally arranged, multiple, small, whitish flecks with a scaly appearance on the mucosa of the middle to lower esophagus, and pathological examination demonstrated several fine keratohyalin granules in superficial layers of the squamous epithelium. Six months later, candidiasis was almost cured, but these small flecks had slightly increased in size, and pathological examination demonstrated epidermoid metaplasia consisting of a thick, acellular keratin layer and well-developed granular layer beneath it. We considered that chronic candida esophagitis played the principal pathogenetic role in the development of epidermoid metaplasia. EIPD may have provided an environment suitable for the growth of fungi, and mucinous material contaminated by Candida and excreted from the orifices of EIPD may have irritated the mucosa and induced epidermoid metaplasia.

A Rare Case of Esophageal Leukoplakia: A Potential Precursor to Esophageal Malignancy

Esophageal leukoplakia or epidermoid metaplasia is a rare lesion resembling the commonly found oral leukoplakia. When found, it is typically seen incidentally on endoscopy as a white plaque but rarely it may present as a globus sensation. Histologically, it is seen as epidermal metaplasia with orthokeratosis, closely resembling the skin. Although rare, esophageal leukoplakia is precancerous and may pose a serious threat.

We present a unique case of a 61-year-old male with a history of COPD, tobacco, and alcohol dependence presenting with a six-month history of nausea and emesis resulting in poor oral intake despite having an appetite. The patient also reported weight loss. Considering his risk factors for esophageal carcinoma and alarm symptoms, an upper endoscopy was performed that revealed localized white, plaque-like mucosal changes characterized by altered texture in the lower third of the esophagus at 40cm. Biopsy results showed squamous epithelium with orthokeratosis and a prominent granular cell layer. These findings were consistent with esophageal epidermoid metaplasia. The lesion was ablated using argon plasma coagulation and radiofrequency ablation on subsequent endoscopy. The patient reported continued resolution of symptoms with each treatment session.

Esophageal leukoplakia may increase the risk for squamous cell carcinoma of the esophagus and should be followed closely. Guidelines on surveillance are yet to be established given the rarity of the disease.

White-light endoscopy is insufficient to distinguish between types of esophageal white lesions

OBJECTIVE

Esophageal white lesions (EWL) are commonly observed under upper endoscopy, while their clinical significance remains undetermined. The aim of this study was to identify the endoscopic characteristics of EWL and distinguish between different types of EWL.

METHODS

Consecutive patients with upper gastrointestinal complaints and participants admitted for health check-up who underwent esophagogastroduodenoscopy from October 2018 to August 2019 in a tertiary hospital were prospectively screened. EWL were detected under endoscopy and biopsy was performed for histological analysis. Participants' characteristics, lifestyle, esophageal motility and reflux monitoring variables were analyzed.

RESULTS

Of the 3641 consecutive participants screened, 303 of them aged 56.12 ± 10.95 years were found to have EWL (detection rate of 8.3%). More than one-third of them preferred hot drinks, eating pickled or spicy food, smoking and alcohol consumption and 5.3% had current or former upper gastrointestinal or head and neck cancers. The common endoscopic appearance of the EWL (2.9 mm ± 1.2 mm in diameter) included slightly elevated plaque, translucent white in color, with a clear border, round or oval in shape, and a scaly, rough or smooth surface. Histology showed low-grade intraepithelial dysplasia in 13 cases, leukoplakia in 10 and intestinal metaplasia in one. No significant differences were found between the histological findings and endoscopic manifestations of EWL.

CONCLUSIONS

EWL are not uncommon in daily endoscopic examination, with some of them being precancerous lesions. Conventional white-light endoscopy is insufficient to identify EWL, while histological assessment is important. Further studies using advanced endoscopic techniques with long-term follow-up are needed.

Esophageal Epidermoid Metaplasia: Clinical Characteristics and Risk of Esophageal Squamous Neoplasia

INTRODUCTION

Esophageal epidermoid metaplasia (EEM) is a rare disease.

METHODS

Patients with EEM diagnosed between 2014 and 2020 were reviewed.

RESULTS

Forty EEM cases were identified. EEM occurred in 9 (23%) patients before, concordant, or after esophageal squamous cell carcinoma (ESCC). EEM was associated with previous esophageal lichen planus in 5 patients, Barrett's esophagus 7, and esophageal adenocarcinoma 1. EEM was focal in 28 (70%) or diffuse in 12 (30%) and not detected in 45% on recent previous endoscopy.

DISCUSSION

EEM is a premalignant underrecognized condition associated with multiple conditions. Close follow-up or endoscopic treatment may be warranted because of its ESCC association.

Squamous Neoplasia in the Esophagus

CONTEXT.—

Squamous lesions of the esophagus encompass a spectrum of disorders ranging from reactive changes and benign papilloma to squamous dysplasia and squamous cell carcinoma, which may pose diagnostic challenges especially in superficial biopsies.

OBJECTIVE.—

To provide a review on the typical features of squamous neoplasia in the esophagus, with an emphasis on the key diagnostic features as well as differential diagnosis from mimicking lesions.

DATA SOURCES.—

Data sources include published peer-reviewed literature and personal experiences of the authors.

CONCLUSIONS.—

Accurate diagnosis of squamous neoplasia requires adherence to established diagnostic criteria, attention to subtle histologic features, and correlation with clinical and imaging findings. In difficult cases, multiple biopsies may be necessary to reach a definitive diagnosis.

Esophagitis in patients without gastroesophageal reflux disease or eosinophilic esophagitis: diagnostic considerations

PURPOSE OF REVIEW

A multitude of inflammatory diseases other than gastroesophageal reflux disease (GERD) and eosinophilic esophagitis can affect the esophagus. Despite the deceptively simple organization of squamous mucosa and its limited number of inflammatory responses, a wide array of histologic patterns can be seen in inflammatory disorders involving the esophagus. Each such histologic pattern is associated with a limited number of underlying conditions, and the clinician can use this information to narrow the differential diagnosis. The purpose of this review is to review and discuss the pathologic diagnosis of esophagitis caused by conditions other than GERD or eosinophilic esophagitis, with an emphasis on recent developments in the field.

RECENT FINDINGS

Recent studies suggest that lymphocytic esophagitis may be a histologic manifestation of esophageal motility disorders. Immunophenotypic features of infiltrating lymphocytes may be helpful in this scenario. immunoglobulin G4-related disease has been implicated as a cause of esophageal inflammation with ulceration, strictures, and mass-forming fibrosis, whereas epidermoid metaplasia has been linked molecularly to the squamous cell neoplasia pathway.

SUMMARY

Improved knowledge and appreciation of the pathology of esophageal inflammation are needed to better understand the pathogenesis of various types of esophagitis, and to inform new approaches to the therapy and management of inflammatory esophageal diseases.

Other Forms of Esophagitis: It Is Not Gastroesophageal Reflux Disease, So Now What Do I Do?

Esophagitis results from diverse causes, including gastroesophageal reflux, immune-mediated or allergic reactions, therapeutic complications, and infections. The appropriate clinical management differs in each of these situations and is often guided by pathologic interpretation of endoscopic mucosal biopsy specimens. This review summarizes the diagnostic features of unusual forms of esophagitis, including eosinophilic esophagitis, lymphocytic esophagitis, esophagitis dissecans superficialis, drug-induced esophageal injury, and bullous disorders. Differential diagnoses and distinguishing features are emphasized.

Targeted next-generation sequencing supports epidermoid metaplasia of the esophagus as a precursor to esophageal squamous neoplasia

Esophageal epidermoid metaplasia is a rare condition that involves the proximal-to-middle third of the esophagus. It is sharply demarcated and defined histologically by epithelial hyperplasia, a prominent granular cell layer, and superficial hyperorthokeratosis. In addition, preliminary studies have suggested an association between esophageal epidermoid metaplasia and esophageal squamous neoplasia (squamous dysplasia and esophageal squamous cell carcinoma). To further characterize esophageal epidermoid metaplasia and better define its relationship to squamous neoplasia of the esophagus, we performed targeted next-generation sequencing on uninvolved esophageal squamous mucosa and matching esophageal epidermoid metaplasia specimens from 18 patients. Further, we evaluated both synchronous and metachronous high-grade squamous dysplasia/esophageal squamous cell carcinoma by next-generation sequencing from 5 of the 18 (28%) patients, and compared these findings to corresponding esophageal epidermoid metaplasia specimens. Targeted next-generation sequencing revealed 12 of 18 (67%) esophageal epidermoid metaplasia specimens' harbored alterations in genes often associated with esophageal squamous cell carcinoma. The most frequently mutated genes consisted of TP53 (n=10), PIK3CA (n=2), EGFR (n=2), MYCN (n=1), HRAS (n=1), and the TERT promoter (n=1). Sequencing of synchronous and metachronous high-grade squamous dysplasia/esophageal squamous cell carcinoma identified shared genetic alterations with corresponding esophageal epidermoid metaplasia specimens that suggests a clonal relationship between these entities. In addition, the presence of a TP53 mutation in esophageal epidermoid metaplasia specimens correlated with concurrent or progression to high-grade squamous dysplasia/esophageal squamous cell carcinoma. No genetic alterations were detected in uninvolved esophageal squamous mucosa. On the basis of these findings, we conclude esophageal epidermoid metaplasia is a precursor to in situ and invasive esophageal squamous neoplasia. Further, the detection of TP53 mutations in esophageal epidermoid metaplasia specimens may serve as an early detection biomarker for high-grade squamous dysplasia/esophageal squamous cell carcinoma.

Association between oral leukoplakia and risk of upper gastrointestinal cancer death: A follow-up study of the Linxian General Population Trial

Background

This study was conducted to explore the association between oral leukoplakia (OL) and the risk of upper gastrointestinal cancer death in the Linxian General Population Trial Cohort.

Methods

A prospective cohort study of the Linxian General Population Trial Cohort was performed. Participants with OL were treated as an exposed group, and the remainder was selected as a control group. All subjects were followed monthly by village health workers and reviewed quarterly by the Linxian Cancer Registry. Hazard ratios (HRs) and 95% confidence interval (CIs) were evaluated using proportional hazard and proportional subdistribution hazard models, respectively.

Results

Over a median of 27 years of observation, 29 476 subjects were followed‐up. A total of 17 473 deaths occurred, including 2345 esophageal squamous cell carcinoma (ESCC), 1139 gastric cardia carcinoma, and 506 gastric non‐cardia carcinoma deaths. Significant increased ESCC mortality was observed in subjects with OL (exposed 9.66% vs. unexposed 7.39%; P < 0.0001). Furthermore, subjects with OL had a 22% higher risk of death from ESCC (HR 1.22, 95% CI 1.10–1.34; P = 0.0001) after adjusted covariates. In subjects aged ≤52 at the baseline, OL was significantly associated with an elevated risk of ESCC mortality (HR 1.32, 95% CI 1.13–1.54; P = 0.0005). No significant associations were observed for gastric cardia carcinoma and non‐cardia carcinoma mortality.

Conclusions

OL may increase the risk of ESCC mortality, especially in the younger population. These associations should be investigated in further studies.

Prevalence of oesophageal epidermoid metaplasia in 1048 consecutive patients and 58 patients with squamous neoplasms

AIMS

Oesophageal epidermoid metaplasia is defined by a dense granular layer with overlying hyperorthokeratosis, resembling the epidermis of skin. A possible association between epidermoid metaplasia, squamous dysplasia and squamous cell carcinoma has been proposed. The aim of this study was to compare the prevalence of epidermoid metaplasia in patients with oesophageal squamous neoplasms with that in a control cohort.

METHODS AND RESULTS

Medical records and slides from 1048 consecutive oesophageal biopsies and resections for any indication and 58 patients with oesophageal squamous neoplasms were reviewed. Two cases (0.19%) of epidermoid metaplasia were identified in the 1048-patient control group. The prevalence of epidermoid metaplasia was significantly higher (P < 0.05) in the 58 patients with oesophageal squamous neoplasms, two of whom (3.5%) had concurrent epidermoid metaplasia (odds ratio 18.1, 95% confidence interval 2.5-131). One case was associated with a verrucous carcinoma and the other with a well-differentiated, superficial (pT1), exophytic squamous cell carcinoma. No patients had epidermoid metaplasia in a biopsy prior to the diagnosis of squamous neoplasia.

CONCLUSIONS

The increased prevalence of epidermoid metaplasia observed in patients with squamous neoplasms provides some additional support for the proposed association. The hypothesis that epidermoid metaplasia is a precursor to squamous neoplasms remains unproven.