Verrucous Oesophageal Carcinoma: Single Case Report and Case Series Including 15 Patients - Issues for Consideration of Therapeutic Strategies

Morphological Characteristics of Various Cells in Esophageal Squamous Dysplasia: Extremely Wide Morphological Spectrum

The WHO classification of esophageal tumors divides esophageal squamous intraepithelial dysplasia into high and low grades, but does not specify its morphological spectrum. Here, the morphological characteristics of various cells were investigated in esophageal squamous (high-grade) dysplasia, and a morphological spectrum and terminology for this lesion were proposed to avoid misdiagnosis. The clinicopathological data of 540 patients with esophageal squamous dysplasia were analyzed retrospectively. According to the unique cytomorphological characteristics of the lesions and the predominant cell type, the esophageal squamous dysplasia was divided into the following morphological groups: classic type (34.6%, 187/540), basaloid subtype (10.7%, 58/540), spindle-cell subtype (4.6%, 25/540), differentiated subtype (48.9%, 264/540), and verrucous subtype (1.1%, 6/540). Gender, age, and lesions location did not differ among the subtypes (P > 0.05), while Paris classification and lesions diameter significantly differed among the subtypes (P < 0.01). Classic-type cells showed severe atypia. In the basaloid subtype, the cells were small, and resembled basal cells; most of these lesions were of the 0-IIb type with small lesion diameter. In the spindle-cell subtype, the cells and nuclei were spindle-shaped or long and spindle-shaped and arranged in parallel. Differentiated-subtype showed well-to-moderately differentiated cells, and epithelial basal cells were mature. Verrucous-subtype showed well-differentiated cells, and were characterized by verrucous or papillary structures. Esophageal squamous dysplasia has extremely wide morphological spectrum. Awareness of the spectrum of morphological presentations of this lesion, specifically the basaloid subtype, spindle-cell subtype, differentiated subtype, and verrucous subtype, is important for accurate diagnosis.

Early verrucous cell carcinoma of the esophagus: a case report and endoscopic and histologic features

Background

Verrucous cell carcinoma of the esophagus (VCCE) is an extremely rare tumor and generally detected at advanced stage. Despite of its slow growth and well differentiation, it has very poor prognosis with high mortality. Therefore, early detection is a critical to improve patients’ survival. However, no early cases of VCCE have been reported and the endoscopic features of early VCCE are not well described. We herein report the endoscopic and histologic features of an early VCCE.

Case presentation

A 54-year-old man with a history of excessive alcohol and tobacco use was admitted to our hospital because of chronic persistent swallowing dysfunction for six months. White light endoscopy revealed a flat lesion covered with scattered leukoplakia in the middle esophagus. Magnifying endoscopy with narrow-band imaging showed tiny irregular papillary microsurface structure. The lesion was considered as early esophageal cancer and completely resected with endoscopic submucosal dissection. Histological examination confirmed that the lesion was early VCCE which was limited within the mucosal lamina propria (m2).

Conclusion

VCCE is rare with poor prognosis. This is a report of early VCCE and description of its endoscopic features which will contribute to early detection of these cancers.

Advanced Verrucous Squamous Cell Carcinoma of the Esophagus: Case Report and Literature Review

Verrucous squamous cell carcinoma (VSCC) is a rare esophageal tumor histologically defined as a well-differentiated subtype. We present a rare case that was diagnosed as esophageal VSCC preoperatively. A 62-year-old Japanese man was referred to our hospital for further evaluation, presenting with anorexia and postcibal vomiting. An esophagogastroduodenoscopy examination showed esophageal stricture with white-colored papillary nodules in the lower esophagus. We performed repeated superficial endoscopic biopsies of the lesion, but the histologic findings showed nonspecific changes. With an endoscopic boring biopsy, the lesion showed an endophytic growth pattern, well-differentiated SCC with minimal cellular atypia and rare mitosis, and mature squamous epithelium with extensive keratinization. We preoperatively diagnosed the lesion as esophageal VSCC, and we performed a video-assisted thoracoscopic subtotal esophagectomy and cardiectomy with the patient in the prone position. Histologic findings revealed that the invasive well-differentiated SCC extended into the esophageal adventitia and the stomach wall with a pushing border. Regional lymph node metastasis and vascular invasion were negative. The expression of Ki-67 was distributed mainly in the basal cells rather than parabasal cells. Without a conclusive diagnosis, a certain degree of diagnostic prediction is possible by understanding the clinical manifestations, macroscopic form, and histology around the basal cells. It is helpful to obtain the high accuracy provided by an endoscopic biopsy including the basal layer to avoid the diagnostic dilemma that is often presented by esophageal VSCC.

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.

Updates on World Health Organization classification and staging of esophageal tumors: implications for future clinical practice

The Fifth edition of the World Health Organization classification of digestive system and American Joint Committee on Cancer staging manual contain substantial refinements of information for esophageal tumors. The epithelial tumors of esophagus are classified as benign, dysplasia, and malignant groups. Dysplasia is divided into Barrett dysplasia and squamous dysplasia and graded into either low-grade or high-grade. Malignant esophageal tumors are often adenocarcinoma or squamous cell carcinoma. The main update in cancer staging in esophageal tumors is the subdivision of the prognostic staging into 3 groups; squamous cell carcinoma, adenocarcinoma, and carcinoma after adjuvant therapy. HER-2 amplification is recognized as a molecular target for therapy of esophagogastric adenocarcinoma. The other esophageal tumors are adenoid cystic carcinoma, mucoepidermoid/adenosquamous carcinoma, undifferentiated carcinoma and neuroendocrine neoplasms. Overall, the incorporation of new data and definitions on histopathology, prognostic factors, and genetics are important for personalized management of patients with esophageal tumors.

Histopathological Assessment for Esophageal Squamous Cell Carcinoma

Histological assessment of esophageal squamous malignancies is crucial for management of patients with the cancer as well as working in research on the cancer. The squamous malignancies in the esophagus comprise squamous dysplasia and squamous cell carcinoma. Current classification of squamous dysplasia in the esophagus is to divide it into low grade and high grade. Most of the esophageal squamous cell carcinomas are of conventional type and divided into well, moderately, and poorly differentiated. The variants of esophageal squamous cell carcinoma include basaloid squamous carcinoma, spindle cell carcinoma, and verrucous carcinoma. Preoperative chemoradiation is used commonly in the treatment of esophageal squamous cell carcinoma and induces changes in morphology. Tumor regression grading systems based on the percentage of the remaining carcinoma cells are used to assess the response to the neoadjuvant therapy in the cancer. Additional histological parameters including lymphovascular invasion, perineural invasion, clearance of resection margins, and carcinoma in the nodal and distant metastatic sites provide essential information for the management of the patient with the cancer.

Experience with endoscopic resection of oesophageal verrucous carcinoma and literature review

A 65-year-old male patient with chronic dysphagia was found to have a 2 cm mass at gastro-oesophageal junction on endoscopy. Biopsy showed squamous hyperplasia without malignancy. Controlled radial expansion balloon dilatation and partial resection were performed but the symptoms recurred. He finally underwent endoscopic mucosa resection and histology showed well-differentiated verruciform squamous proliferation limited to the mucosa. Small amounts of tumour remnants were treated during subsequent follow-up endoscopies and the patient has been tumour free since then. Diagnosis of oesophageal verrucous carcinoma can be challenging and could be managed with endoscopic resection. In this report, we review the literature and present our experience with a patient with oesophageal verrucous carcinoma.

Human papillomavirus infection is not involved in esophageal verrucous carcinoma

Verrucous carcinoma of the esophagus (VCE) is a rare variant of squamous cell cancer, with a puzzling clinical, etiological, and molecular profile. The etiological involvement of human papillomavirus (HPV) in the cancer's natural history is controversial. This study considers 9 cases of VCE, focusing on patients' clinical history before surgery, histologic phenotype, immunophenotype (epidermal growth factor receptor [EGFR], E-cadherin, cyclin D1, p16, and p53 expression), HPV infection, and TP53 gene mutational status (exons 5-8). Using 3 different molecular test methods, not one of these cases of VCE featured HPV infection. The only case with synchronous nodal metastasis was characterized by a TP53 missense point mutation in association with high EGFR and low E-cadherin expression levels. In conclusion, HPV infection is probably not involved with VCE, while TP53 gene mutation, EGFR overexpression, and E-cadherin loss might fuel the tumor's proliferation and lend it a metastatic potential.

Verrucous Squamous Cell Cancer in the Esophagus: An Obscure Diagnosis

Verrucous carcinoma is a rare, slow-growing type of squamous cell cancer. Fewer than 50 patients with verrucous carcinoma in the esophagus have been described worldwide. In 2014, two male patients were diagnosed with verrucous carcinoma in the distal part of the esophagus. The endoscopic examinations showed a similar wart-like, white, irregular mucosa in both cases. The diagnosis was difficult to make since all biopsies taken from the affected area showed no malignancy. This cancer type has a relatively good prognosis when the diagnosis is finally obtained. Both our patients presented with dysphagia, weight loss, and an endoscopically malignant tumor, but surgery was not performed until after 9 and 10 months, respectively, and then in order to get a diagnosis. At the last follow-up, both patients were without any recurrence of the disease.