What are the recommended guidelines for managing esophageal squamous papilloma?

Guidelines for Managing Esophageal Squamous Papilloma

Esophageal squamous papilloma (ESP) should be completely removed via endoscopic resection as the standard management approach. 1

Clinical Features and Diagnosis

• ESP is a rare benign lesion with an estimated prevalence of 0.01-0.45% in patients undergoing upper gastrointestinal endoscopy 2, 3
• Typically presents as:
  • Solitary lesions (most common) 4
  • Small (3-8mm) exophytic growths 1
  • Most frequently located in the middle and upper thoracic esophagus 4, 2
• Usually asymptomatic and found incidentally during endoscopy
• Larger papillomas may rarely cause dysphagia, odynophagia, or bleeding 1

Diagnostic Approach

• Esophagogastroduodenoscopy (EGD) is the primary diagnostic method
• Endoscopic features suggestive of ESP include:
  • Exophytic growth
  • Wart-like projections
  • Surface vessel crossing seen on narrow band imaging 5
• Definitive diagnosis requires histopathological confirmation
• Diagnosis should be made and confirmed by two histopathologists, one with special interest in gastrointestinal disease 6

Management Algorithm

1. Complete endoscopic removal is recommended for all ESPs 1, 5

   • Small lesions (<5mm): Remove using biopsy forceps
   • Larger lesions: Perform endoscopic mucosal resection with diathermic snare

2. Histopathological examination

   • Confirm diagnosis of squamous papilloma
   • Consider HPV testing (though association remains controversial) 4, 3

3. Follow-up surveillance

   • Perform follow-up EGD at 6 months to confirm complete removal and absence of recurrence 1
   • Consider annual surveillance endoscopy thereafter 1

Rationale for Management

• Complete removal is recommended because:
  1. It provides definitive histological diagnosis
  2. It eliminates any potential (though controversial) risk of malignant transformation 5
  3. It has high success rates with minimal complications 1, 2

Important Considerations

• Recurrence is rare after complete endoscopic removal 4, 2
• The malignant potential of ESP remains controversial:
  • Some case reports suggest possible association with squamous cell carcinoma 5
  • Most studies show no direct transformation to carcinoma 4
• Etiology remains unclear:
  • Chronic mucosal irritation theory (GERD/esophagitis) 5
  • Potential HPV association in some cases (detected in 46.2% in one series) 4
  • Not strongly associated with hiatal hernia or reflux esophagitis 2

Pitfalls to Avoid

• Do not confuse ESP with verrucous squamous cell carcinoma, which can have similar appearance 4
• Do not assume ESP is caused by reflux disease, as they typically occur in different locations of the esophagus 4
• Avoid incomplete removal, as this may lead to diagnostic uncertainty
• Do not dismiss these lesions without histological confirmation, even when endoscopically they appear benign

While ESP is generally considered benign, complete endoscopic removal followed by appropriate surveillance represents the most prudent management approach based on current evidence.