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. It is a common finding in oral mucosa, however rare in esophageal mucosa. Etiology of this condition in the esophagus is unclear, thought to be associated with esophageal tobacco and alcohol exposure or possibly an unusual response to chronic acid reflux. In contrast to oral leukoplakia there is a female predominance. Although generally asymptomatic, symptom presentation can include dysphagia. Endoscopic features include slightly elevated whitish surface, which can be translucent or cobblestone-like in appearance. The natural history is unknown though there is concern for an increased risk of squamous cell cancer. Due to paucity of published studies about this condition, we aim to report a case treated with endoscopic submucosal dissection (ESD).
A 64-year-old Caucasian man with a history of tobacco use and stable weight, presented to Gastroenterology clinic due to an 11-month history of solid food esophageal dysphagia. Physical examination was unremarkable. Upper endoscopy demonstrated white plaques at the gastroesophageal junction (Figure 1A and B). Biopsies obtained from this abnormality showed esophageal epidermoid metaplasia consistent with leukoplakia and mild patchy active chronic inflammation. GMS stain for fungal organisms was negative. An ESD procedure was planned, due to lesion size to ensure complete removal. Chromoscopy with methylene blue was used to mark the borders of the lesion and ESD was accomplished without adverse events (Figure 1C). Histologic examination confirmed hyperplastic squamous esophageal mucosa with marked hyperkeratosis without dysplasia and negative margins. During 2 year follow up, patient reported complete resolution of his dysphagia.
The management strategy for esophageal leukoplakia is not well defined though reports suggest that endoscopic resection and surveillance are warranted. Here we represent a case where symptoms resolved and the lesion was completely removed by ESD.