A 64-year-old white man with a history of tobacco use and stable weight presented to the gastroenterology clinic due to an 11-month history of solid-food esophageal dysphagia. On physical examination, patient was alert and in no acute distress. His vital signs were within normal limits. His head and neck examination revealed normal oropharyngeal mucosa. No thyromegaly, lymphadenopathy, or masses in his neck were noted on palpation. Abdominal examination presented normal bowel sounds, without distension or tenderness. Upper endoscopy demonstrated white plaques at the gastroesophageal junction (Figure 1).
Biopsies obtained from this abnormality showed esophageal epidermoid metaplasia consistent with leukoplakia and mild patchy active chronic inflammation. Gomori methenamine–silver nitrate stain for fungal organisms was negative. Given the potential for malignant transformation of leukoplakia, endoscopic resection was suggested for the patient. An endoscopic submucosal dissection was planned, due to the lesion size to ensure compete removal. Chromoscopy with methylene blue was used to mark the borders of the lesion, and endoscopic submucosal dissection was accomplished without adverse events (Figure 2). Histologic examination confirmed hyperplastic squamous esophageal mucosa with marked hyperkeratosis without dysplasia and negative margins. During the 2-year follow-up, the patient reported complete resolution of his dysphagia. An upper endoscopy was ordered for surveillance.
Epidermal metaplasia is a histological correlate to a white patch on the surface of a mucous membrane that cannot be rubbed off, known as leukoplakia.1 It is a common finding in oral mucosa, but rare in esophageal mucosa.1,2 The etiology of this condition in the esophagus is unclear and thought to be associated with esophageal tobacco and alcohol exposure or possibly an unusual response to chronic acid reflux.1,3,4 Although generally asymptomatic, symptom presentation can include dysphagia.3 Endoscopic features include slightly elevated whitish surface, which can be translucent or cobblestone-like in appearance.2,4 The natural history is unknown. As adjacent dysplasia and possible squamous cell carcinoma of the esophagus has been reported, and it is suggested that there is a potential for malignant transformation and therefore strict surveillance or endoscopic resection or ablation is warranted.1,5
Author contributions: PV Hernandez drafted the manuscript. D. Snyder, A. Kahn, KK Wang, DA Katzka, JL Horsley-Silva revised the manuscript. JL Horsley-Silva is the article guarantor.
Financial disclosure: None.
Previous presentation: This case report was presented as a poster at the 2019 ACG Annual Meeting; October 25-30, 2019; San Antonio, TX.
Informed consent was obtained for this case report.
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