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

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.

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.

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.

Grim-19 expressed by recombinant adenovirus for esophageal neoplasm target therapy

Esophageal squamous cell carcinoma (ESCC) and esophageal adenocarcinoma (EA) are the two most common types of esophageal cancer, which is the sixth highest cause of cancer‑associated mortality and the eighth most common cancer worldwide. Gene associated with retinoid‑interferon (IFN)‑induced mortality‑19 (Grim‑19) is reported to be a cell death activator that may be used to define mechanisms involved in IFN‑β‑ and retinoic acid‑induced cell death and apoptosis in a number of tumor cell lines. The present study constructed a recombinant adenovirus expressing Grim‑19 (rAd‑Grim‑19) and investigated its therapeutic outcomes in ESCC cells and tumor‑bearing mice. Grim‑19 expression was detected in EC‑109 (ESCC) cells by reverse transcription‑quantitative polymerase chain reaction and western blot analysis. Tumor cell death and apoptosis induced by rAd‑Grim‑19 in EC‑109 cells were analyzed by flow cytometry. The inhibitory effects of rAd‑Grim‑19 on EC‑109 growth were determined by MTT assays. Furthermore, the therapeutic effects of rAd‑Grim‑19 were investigated in EC‑109‑bearing mice. The results demonstrated that Grim‑19 mRNA and protein expression was downregulated in EC‑109 esophageal carcinoma cells compared with Het‑1A normal esophageal epithelial cells. In addition, EC‑109 cells exhibited a significant reduction in tumor cell growth in the rAd‑Grim‑19 group compared with the control groups. Furthermore, rAd‑Grim‑19 increased EC‑109 cell apoptosis compared with the control group. These results indicated that rAd-Grim-19 may regulate tumor cell growth and apoptosis. Additionally, the results demonstrated that rAd‑Grim‑19 led to beneficial outcomes and prolonged the survival of esophageal tumor‑bearing mice. In conclusion, the present study demonstrated that rAd‑Grim‑19 may have potential as an antitumor agent for esophageal neoplasms and may therefore be beneficial for patients with esophageal neoplasms.

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.