Clinicopathological characteristics of esophageal squamous papillomas in Japanese patients--with comparison of findings from Western countries

Detection of Human Papillomavirus in Squamous Papilloma of the Esophagus

Introduction: The etiology of esophageal squamous papilloma (ESP) is largely unknown. Previous studies have shown a variable association with human papillomavirus (HPV) with conflicting data. The aim of this study was to further investigate the possible association of HPV in our ESP series using RNA in-situ hybridization (ISH) and compare study groups from the United States of America and China. Methods: Demographic and clinical data of patients with ESP were retrieved from the University of California Los Angeles (UCLA) (1/2016-3/2019) and Peking Union Medical College Hospital (PUMCH) (9/2014-3/2019) pathology databases. Hematoxylin and eosin slides were reexamined. Confirmed cases were examined by high- and low-risk HPV RNA ISH. Results: For the UCLA cohort, 13 429 upper endoscopies were performed and 78 biopsies from 72 patients were identified as ESP (F:M = 45:27, 66.7% > 45 years). Seventy-four (94.9%) biopsies were designated as polyps or nodules and 46.6% were located in the mid-esophagus. Other abnormal findings included gastroesophageal reflux disease (48.6%), hiatal hernia (38.9%), and esophagitis (36.1%). For the PUMCH cohort, 63 754 upper endoscopies were performed and 73 biopsies from 71 patients were identified as ESP (F:M = 48:23, 71.8% > 45 years). Sixty-four (87.7%) biopsies were designated as polyps or nodules and 57.5% were located in the mid-esophagus. Other abnormal findings included esophagitis (19.7%), and hiatal hernia (8.5%). No features of conventional cytologic dysplasia or viral cytopathic change were found. None of the cases was associated with squamous cell carcinoma, and none showed positive HPV RNA ISH results. Conclusions: No association was found between ESP and active HPV infection in our 2 cohorts. Other etiopathogenetic mechanisms, such as aging, might contribute to the development of these innocent lesions.

Gastrointestinal: Distal esophageal squamous papillomatosis in a healthy 47-year-old man

A 47-year-old man with a background history of gastroesophageal reflux disease (GERD) and seasonal asthma underwent a gastroscopy for further investigation. Endoscopy revealed numerous polypoid lesions diffusely distributed in the lower third of the esophagus, with histology revealing squamous papilloma with occasional intraepithelial lymphocytes. The diagnosis was esophageal squamous papillomatosis (ESP), which is a rare condition characterized by exophytic and circumferential projections with friable mucosa diffusely spread through the esophagus with unclear etiology and malignancy risk.

Esophageal squamous papilloma: Literature review and case-control retrospective study with histopathological exam of human papillomavirus

Background and Aim

Esophageal squamous papilloma (ESP) is a benign growth in the esophagus with unknown malignant potential. The mechanism underlying ESP formation is unknown, but human papillomavirus (HPV) infection has been proposed as a potential etiology. We sought to investigate the clinical characteristic of ESP in our population, review the current literature, and highlight the role of HPV.

Methods

This is a retrospective case-control study conducted at two referral centers. We selected the ESP population by free-text search in the pathology department database and selected controls randomly from the general endoscopy population. Immunostains were used to evaluate ESP tissue for HPV.

Results

Between January 2016 and December 2021, we identified 66 patients with ESP, with a prevalence of 0.72%. ESP patients were younger, with a median age of 52 years (P = 0.021), and more likely African American (34.4 vs 7.5%, P < 0.001) compared to controls. On endoscopy images, the growth was predominantly solitary (92.5%) in the middle of the esophagus (39.4%), with sizes ranging from 0.2 to 2.3 cm. A total of 62 patients had available tissue for HPV immune staining, and none tested positive for HPV. Eighteen patients had a follow-up endoscopy with an average of 504.5 days follow-up period. One patient developed esophageal squamous cell carcinoma during follow-up.

Conclusions

We observed a higher prevalence of ESP compared to previous studies. The formation of ESP is multifactorial and partially explained by HPV infection in selected populations. The malignant potential of ESP is low but not negligible.

Esophageal papillomatosis: an exceedingly rare disease

If esophageal papilloma (EP) is a rare condition, esophageal papillomatosis (EPS) is a distinct rarity. To date, only 53 well documented cases have been described in English literature. However, the number of reports on EPS significantly increased to over 40 cases during the past 20 years. Perhaps, this is due to the broad use of endoscopy and related research achievements. Most of the cases are individual and it seems that there are no associations between them. And up to now no guidelines can be followed. To further understand this exceedingly rare disease, we had a comprehensive review of the epidemiology, etiology, clinical manifestations, pathogenesis, treatment, and clinical course of EPS.

Causal Link of Human Papillomavirus in Barrett Esophagus and Adenocarcinoma: Are We There Yet?

Esophageal cancer is a relatively common malignancy worldwide with a high mortality (5-year survival of <15%). Despite screening, surveillance, improved imaging and treatment, the exponential rise in OAC continues. The strongest risk factors for OAC are chronic heartburn and metaplastic transformation of the lower third of the esophagus (Barrett's esophagus). The risk profile includes Caucasian race, male gender older age, obesity and smoking. Although the tumor risk in BO has been progressively revised downwards, the exponential rise in OAC remains unchecked. This paradox points to an unidentified missing link. Relatively recently, we provided the world's initial data for a strong association of biologically relevant hr-HPV with BD and OAC. Since then, systematic reviews and meta-analysis have documented HPV DNA prevalence rates in OAC of between 13 to 35%. In this review, we provide some evidence for a probable causal relationship between hr-HPV and OAC. This is challenging given the multifactorial etiology and long latency. Increasingly, high-risk HPV (hr-HPV) is regarded as a risk factor for OAC. This discovery will aid identification of a sub-group of high-risk progressors to esophageal cancer by surveillance and the development of effective preventive strategies including vaccination.

Oesophageal squamous papilloma: a rare finding on oesophago-gastro-duodenoscopy with malignant potential

Oesophageal squamous papillomas (OSPs) are rare epithelial lesions, recognized to be benign but with reported malignant potential. We report a case of a 40-year-old female with chronic vomiting, subsequently found on oesophago-gastro-duodenoscopy to have two mid-oesophageal sessile polyps, the largest of which measured 10 mm. These were endoscopically resected with histopathology confirming an OSP without evidence of dysplasia or malignancy. The case under consideration reports the current literature on OSPs regarding their aetiology, malignant potential and optimal management.

Esophageal Squamous Papilloma in the Pediatric Population

Esophageal squamous papillomas (ESP) are rare benign tumors of the esophagus, which occur mostly in the adult population. Few cases have been reported in children and due to the low incidence, the pathogenesis of ESP is not entirely understood and the management is not standardized. It is thought that mucosal irritation from underlying inflammation, perhaps from GERD, trauma or human papilloma viruses can play a role in the formation of ESP. This report describes 4 cases of pediatric ESP from a single center and discusses the management of these lesions, including the use of antacids and the human papilloma viruses vaccine as treatment modalities. Given the limited data on ESP in the pediatric population, this report aims to describe the management of this condition in 1 center.

Clinicopathological characteristics of patients with oesophageal squamous papilloma in Turkey and comparison with the literature data: The largest case series ever reported from Turkey

AIM

Oesophageal squamous papilloma (ESP) is a rare tumoural lesion of the oesophagus considered to have a benign course. Due to the fact that they are rare lesions, there are not many publications with large case series on ESPs in the literature. In this study, we aimed to investigate the clinical, endoscopic and histopathological characteristics of ESPs.

METHODS

Reports of upper gastrointestinal endoscopies performed in the endoscopy unit within the Division of Gastroenterology of a tertiary care hospital in the Southeastern Anatolia Region of Turkey in the last 8-year period were evaluated retrospectively. Patients who were determined to have oesophageal polypoid lesions during the endoscopic procedure and were then diagnosed with oesophageal squamous cell papilloma in the histopathological examination were included in the study.

RESULTS

Of 11 541 patients who underwent upper gastrointestinal endoscopy, 51 were diagnosed with a total number of 55 ESPs (0.44%). In addition, 26 of these patients (51%) were female, and the mean age of the patients at the time of diagnosis was 42.2 years. The average size of the ESPs was 3.47 mm, and the most frequent location was the middle oesophagus with 51%. No statistically significant relationship was found between the location of ESPs and gender, endoscopy indication, oesophagitis, lower oesophageal sphincter dysfunction, hiatal hernia, gastroesophageal reflux disease (GERD) and Helicobacter pylori positivity.

CONCLUSION

In this study with the largest case series ever reported from Turkey, it was determined that ESPs were seen in younger ages in Turkey and were also smaller in size, which is not in agreement with the literature data. Besides, this study, in which ESPs were most frequently detected in the middle oesophagus, supports the view that GERD may not be the main factor in ESP aetiology.

Esophageal Squamous Papilloma in Children: A Single-center Case Series

OBJECTIVES

Esophageal squamous papilloma (ESP) is a rare epithelial lesion most commonly seen in adults, with an unclear etiology and limited pediatric data available. The aim of this study was to provide an estimated prevalence of this lesion in our pediatric population, as well as to identify any demographic, clinical, or pathologic associations-including human papilloma virus (HPV) infection, which has been linked with ESP in adult literature.

METHODS

ESP cases at University Hospitals Rainbow Babies & Children's Hospital were identified by conducting a retrospective search through all esophagogastroduodenoscopies (EGDs) performed in children under 18 years old, from January 1, 2000 to December 31, 2014. Histopathology reports were analyzed including Fluorescence In Situ Hybridization (FISH) for HPV, and a comprehensive chart review was performed for demographic data.

RESULTS

Of 12,459 children who required an EGD, 10 children were identified with ESP on biopsy, with ages ranging from 2 to 17 years. This provides an estimated prevalence of 0.08% over the entire study period. Seventy percentage of patients underwent endoscopy for abdominal pain, and 40% presented with gastroesophageal reflux. Sixty percentage of lesions were in the proximal esophagus, and 80% of patients had isolated lesions. Notably, none of the lesions tested were positive for HPV on FISH analysis.

CONCLUSIONS

ESP is a rare benign lesion found incidentally in the pediatric population. The prevalence at our institution was 0.08%. All samples tested for HPV via FISH analysis were negative. As a result, regular analysis for HPV may not be necessary in pediatric patients with ESP in the future.

Verrucous esophageal carcinoma is a unique indolent subtype of squamous cell carcinoma: a systematic review and individual patient regression analysis

BACKGROUND AND AIMS

Verrucous esophageal carcinoma (VEC) is a rare malignancy that presents a diagnostic challenge. We aim to characterize the clinical and genomic features, tumor behavior, and treatment outcomes of VEC to guide clinical practice.

METHODS

We performed a systematic review of the literature and identified additional cases from Massachusetts General Hospital records and The Cancer Genome Atlas (TCGA). We obtained individual VEC patient data and analyzed publicly available clinicogenomic data from TCGA. We performed a regression analysis comparing cases of VEC to esophageal squamous cell carcinoma (ESCC) to identify factors influencing survival.

RESULTS

A total of 135 patients were reported in 82 publications, and four unpublished cases from Massachusetts General Hospital (median age 65 years, 69% males, 48% smokers, 33% consumed alcohol). Symptoms were present at diagnosis in 95% of patients, most commonly dysphagia and weight loss. Median symptom onset to diagnosis time was 11.5 months with frequent misdiagnosis as Candida esophagitis. Among VEC cases with pathologic staging, lymph node metastases were rare (5%) compared to ESCC (40%). VEC was genomically characterized by enrichment of SMARCA4 missense mutations and a lack of pathogenic TP53 mutations. Despite its diagnostic elusiveness, in a multivariate regression analysis, VEC was detected at earlier stages (p =  < 0.001) compared to ESCC, and advanced stage was the only significant factor affecting survival (p = 0.013).

CONCLUSIONS

VEC is a rare, clinically and genomically distinct subtype of ESCC. Recognition and diagnosis of this lesion may allow the pursuit of curative and less morbid treatment strategies.

Human papillomavirus infection in esophageal squamous cell carcinoma and esophageal adenocarcinoma: a concise review

The causal link between high-risk human papillomavirus (hr-HPV) infection and cervical, anogenital, and some oropharyngeal malignancies has been established by both molecular and epidemiological data. The association between HPV and esophageal squamous cell carcinoma (ESCC) remains controversial, as is the true prevalence of HPV infection in ESCC. The wide range in reported rates reflects variability in the primary literature, with some larger scale case-control studies suggesting the infection rates range from 0% to 78%. Interactions between HPV and the Barrett's metaplasia-dysplasia-carcinoma sequence have been explored, and these studies have shown some conflicting data. Overall, systematic reviews have reported the prevalence of HPV-positive DNA in esophageal adenocarcinoma patients of between 13% and 35%. Postulated reasons for discrepancies in HPV prevalence rates in esophageal cancer include variations in testing methodology and assay sensitivities; technical issues, including the lack of a gold-standard primer; types of specimens utilized (fresh-frozen versus formalin-fixed tissue); geographical variation; cross-contamination; and small sample sizes. Thus, efforts must be undertaken to (1) standardize HPV testing, ideally in a central laboratory and utilizing tests that detect viral transcriptional activity; (2) avoid cross-contamination; and (3) recruit large numbers of patients to accurately ascertain HPV rates in esophageal malignancy.

Squamous Cell Papilloma of the Esophagus: A Case Series Highlighting Endoscopic and Histologic Features

Esophageal squamous papillomas are rare epithelial lesions typically discovered incidentally during EGD. Their prevalence is estimated to be less than 0.01% in the general population. We present three cases of esophageal squamous papillomas identified histologically. It may be possible to identify these lesions macroscopically. One study provided a positive predictive value of 88% for squamous papilloma utilizing the triad of exophytic growth, wart-like projections, and surface vessel crossing seen on narrow band imaging during endoscopy. The etiology is unclear. Chronic mucosal irritation from GERD or esophagitis is the prevailing theory of pathogenesis, but HPV has been detected in some lesions. The malignant potential of these lesions is considered controversial. There are documented cases demonstrating complications with squamous cell carcinoma, so we recommend removal of all esophageal squamous papillomas; however, the small absolute number of cases documented in the literature makes drawing any associations or conclusions between esophageal squamous papillomas and squamous cell carcinoma difficult. Further research is needed regarding treatment and surveillance. This case series helps contribute to the small but growing literature of this rare finding.

Successful Treatment of Extensive Esophageal Squamous Papillomatosis With Cryotherapy

Esophageal squamous papilloma is a rare endoscopic finding, and esophageal squamous papillomatosis (ESP) is considered exceptionally rare, with only a limited number of cases reported to date. There is a paucity of literature about the management of these lesions, and it remains largely controversial. We report a 61-year-old man who presented for endoscopic treatment of ESP detected during endoscopic evaluation for heartburn. Given the potential risk of malignant transformation, a decision was made to proceed with spray cryoablation, requiring a total of 3 sessions of ablative therapy. The histopathological assessment confirmed the diagnosis, and the specimens tested negative for all low- and high-risk human papillomavirus subtypes. Follow-up endoscopies revealed near-complete resolution. To our knowledge, the present report describes the second successful treatment of ESP using endoscopic spray cryotherapy.

A Case of Esophageal Squamous Cell Carcinoma in situ Arising from Esophageal Squamous Papilloma

Squamous papilloma is a common benign tumor of the esophagus. Patients with papilloma are usually asymptomatic, and they are diagnosed incidentally during esophagogastroduodenoscopy. Most papillomas are small and easily removed by forceps biopsy. Recurrence of papilloma after removal is rare. Human papilloma virus infection is supposed to play a role in the development of esophageal papilloma; however, malignant transformation of papilloma is extremely unusual. Here, we report a case of malignant transformation of esophageal squamous papilloma at the gastroesophageal junction into squamous cell carcinoma in situ, which was treated by endoscopic submucosal dissection.

A case report: Does the ulcer belong to esophageal carcinoma or HIV?

RATIONALE

The deep-rooted pathogenesis of the human papilloma virus (HPV) infection is still uncertain and argumentative. As we know, a lot of cases of esophageal infections, such as esophageal squamous cell carcinoma (ESCC) and esophageal squamous papilloma (ESP), associated with HPV are reported. However, primary esophageal ulcer infection associated with HPV is unusual.

PATIENT CONCERNS

This case is different from the other reports associated with HPV due to the patient's favorable prognosis.

DIAGNOSES

We present a case of a man diagnosed in the Gastroenterology Department of Tianjin Hospital of Integrated Traditional Chinese and Western Medicine, which presented a deep and big esophageal ulcer with irregular borders caused by type 16 HPV infection.

INTERVENTIONS

The esophageal ulcer was treated with vidarabine monophosphate treatment.

OUTCOME

The esophageal ulcer was cured.

LESSONS

We could put forward the diagnostic criteria available for diagnostic guidelines and 2 hypotheses that could possibly prevent esophageal carcinoma from happening.

Detection of human papillomavirus in esophageal papillomas: systematic review and meta-analysis

Since first suggested (in 1982), etiological role for human papillomavirus (HPV) in esophageal papillomas has aroused increasing interest. The objective of this study was to perform systematic review and formal meta-analysis of the literature reporting on HPV detection in esophageal squamous cell papillomas (ESCP). Literature was searched through May 2012. The effect size was calculated as event rates (95% CI), with homogeneity testing using Cochran's Q and I(2) statistics. Meta-regression was used to test the impact of study-level covariates (HPV detection method, geographic origin) on effect size, and potential publication bias was estimated using funnel plot symmetry. Thirty nine studies were eligible, covering 427 ESCPs from different geographic regions. Altogether, 132 (30.9%) cases tested HPV positive; effect size 0.375 (95% CI 0.319-0.434) using the fixed-effects (FE) model and 0.412 (95% CI 0.295-0.540) using the random-effects model. In meta-analysis stratified by (i) HPV detection technique and (ii) geographic study origin, the between-study heterogeneity was not significant (p = 0.071 and p = 0.105, respectively). In meta-regression, HPV detection method (p = 0.260) and geographic origin (p = 0.436) were not significant study-level covariates accounting for the heterogeneity in HPV prevalence. Some evidence for publication bias was found only for PCR-based studies, with a marginal impact on summary effect size estimates. In sensitivity analysis, all meta-analytic results were robust to all one-by-one study removals. In stratified meta-analysis and formal meta-regression, the variability in HPV detection rates in ESCPs is not explained by the HPV detection method or geographic origin of the study.

Esophageal verrucous carcinoma arising from hyperkeratotic plaques associated with human papilloma virus type 51

Esophageal verrucous carcinoma is a rare variant of esophageal squamous cell carcinoma. We report a case of esophageal verrucous carcinoma associated with human papilloma virus (HPV) type 51. The patient had long-standing dysphagia and odynophagia, and white esophageal plaques showing hyperkeratosis on biopsy. At repeat endoscopy, the esophagus was covered with verrucous white plaques and areas of nodular mucosa with white fronds, with a distal 10-cm smooth mass protruding into the lumen. Biopsies demonstrated an atypical squamoproliferative lesion but no frank malignancy. HPV type 51 DNA was detected in endoscopic biopsy specimens by polymerase chain reaction. Because the size of the lesion favored an underlying verrucous carcinoma, our patient underwent minimally invasive esophagectomy with gastric pull-up and cervical anastomosis. The pathologic diagnosis was a well-differentiated esophageal verrucous carcinoma. One year after esophagectomy, the patient feels well and is free of disease. Although HPV DNA was not detected in the cancer tissue obtained at surgery, our case suggests an association between HPV type 51 and esophageal verrucous carcinoma. The clinical evolution in this case highlights the importance of endoscopic surveillance in patients with exuberant esophageal hyperkeratosis, and of definitive surgical resection when malignancy is suspected even if frank malignancy is not demonstrated on superficial biopsies.

The influence of endocrine disrupting chemicals on the proliferation of ERalpha knockdown-human breast cancer cell line MCF-7; new attempts by RNAi technology

Bisphenol A (BPA) is a monomer use in manufacturing a wide range of chemical products which include epoxy resins and polycarbonate. It has been reported that BPA increases the cell proliferation activity of human breast cancer MCF-7 cells as well as 17-beta estradiol (E2) and diethylstilbestrol (DES). However, BPA induces target genes through ER-dependent and ER-independent manners which are different from the actions induced by E2. Therefore, BPA may be unique in estrogen-dependent cell proliferation compared to other endocrine disrupting chemicals (EDCs). In the present study, to test whether ERalpha is essential to the BPA-induced proliferation on MCF-7 cells, we suppressed the ERalpha expression of MCF-7 cells by RNA interference (RNAi). Proliferation effects in the presence of E2, DES and BPA were not observed in ERalpha-knockdown MCF-7 cells in comparison with control MCF-7. In addition, a marker of proliferative potential, MIB-1 labeling index (LI), showed no change in BPA-treated groups compared with vehicle-treated groups on ERalpha-knockdown MCF-7 cells. In conclusion, we demonstrated that ERalpha has a role in BPA-induced cell proliferation as well as E2 and DES. Moreover, this study indicated that the direct knockdown of ERalpha using RNAi serves as an additional tool to evaluate, in parallel with MCF-7 cell proliferation assay, for potential EDCs.

Values of gastroscopy and endoscopic ultrasonography in diagnosis and treatment of esophageal papilloma

AIM: To explore the value of gastroscopy and endoscopic ultrasonography in diagnosis and treatment of esophageal papilloma.

METHODS: Forty nine cases with esophageal papilloma confirmed by pathological examination underwent gastroscopy and 24 of them underwent endoscopic ultrasonography. Then their manifestations of gastroscopy and endoscopic ultrasonography as well as the relationship between the pathologic and clinical characteristics were analyzed.

RESULTS: On gastroscopy, most lesions of EP cases were located at the middle or distal esophagus (89.8%), assuming feather-like or corpora mammillaria-like bulge, with floccular or fine granular-like surface and grayish-white color, and most of the EP was single with diameter ranging from 0.3-0.6 cm. Of 24 cases undergoing endoscopic ultrasonography, 17 were diagnosed as EP (70.8%), and 6 were diagnosed as inflammatory proliferation or polypus (25%). The classic endosonographic characteristics were even iso-echoic with clear boundary originating from mucosa layer, protruding into the lumen.

CONCLUSION: Esophageal papilloma is well displayed on endoscopic ultrasonography, which could be used to determine indications of endoscopy.