Mid-Esophageal Food Bolus Impaction Associated with Prominent, Segmental Esophageal Papillomatosis and Squamous Cell Carcinoma: 1689

AIM: To describe a case of esophageal food bolus impaction associated with esophageal papillomatosis and a superficial squamous cell carcinoma (SCCa). CASE REPORT: A 62 yo male with a history of hypertension, hyperlipidemia and early stage (F1 disease by biopsy in 2009) type 1a hepatitis C infection, presented to the emergency room with an esophageal food bolus impaction. He sensed mid retrosternal bolus impaction since beginning a meal of pork 3 hours previously. After informed consent was obtained, EGD under moderate sedation revealed a very large pork bolus (2.5X4 cm) which was impacted in the mid esophagus. The food bolus was extracted per os with the use of a friction fit adapter which was attached to a standard video gastroscope. The underlying esophageal mucosa in the mid esophagus was decidedly abnormal (from 28 to 34 cm from the incisors) in a confluent fashion. Over this mid esophageal segment, the lumen was mildly narrowed and there were prominent macroscopic findings consistent with verrucous change (see Figure 1). Biopsies on 2 occasions revealed only esophageal papillomatosis without dysplasia and were negative for HPV. The patient was briefly followed expectantly. Recommendations to masticate food thoroughly, eat slowly and drink plenty of liquids with meals were reinforced. Given the unusual nature of the process, a second opinion was sought at a local tertiary care center. A third EGD was performed and extensive esophageal biopsies were again performed. A small nodular area was noted and biopsies of this region revealed invasive SCCa. Staging PET CT was negative for metastatic spread and it revealed positive uptake in the mid esophagus. Numerous treatment options were considered during multidisciplinary review and in the end, he underwent esophagectomy. The final esophageal resection specimen revealed a 2.0 X 0.5 cm moderately differentiated SCCa (T1a) against a background of papillomatosis.Figure 1CONCLUSION: Histologically, esophageal papillomasare benign tumors composed of fingerlike projections of lamina propria covered by hyperplastic squamous epithelium. Gastroesophageal reflux and HPV have been implicated as possible pathogenic factors. In this case, intense, segmental esophageal papillomatosis caused esophageal lumenal narrowing and led to esophageal food bolus impaction. The finding of a small superficial SCCa was thought to be fortuitous and coincidental.