What is the management approach for an esophageal nodule with pathology showing features of benign squamous papilloma?

Management of Esophageal Nodule with Benign Squamous Papilloma

Complete endoscopic resection is the recommended management for esophageal squamous papilloma, with follow-up endoscopy at 6-12 months to confirm complete removal and absence of recurrence. 1, 2

Understanding Esophageal Squamous Papilloma

Esophageal squamous papilloma (ESP) is a rare benign tumor of the esophagus with the following characteristics:

• Typically discovered incidentally during endoscopy
• Prevalence of approximately 0.26-0.45% of upper endoscopies 3, 4
• Usually presents as a solitary, small (few millimeters) lesion
• Most commonly located in the middle and upper portions of the intrathoracic esophagus 3
• Generally asymptomatic, though larger lesions may cause dysphagia, odynophagia, or bleeding 1

Diagnostic Approach

1. Endoscopic appearance:

   • White, pebbly or papillary surface
   • Exophytic, sessile, or pedunculated growth
   • Can appear pink or white depending on keratinization 5

2. Histopathological confirmation:

   • Characterized by papillary pattern with heavy granular layer
   • May show koilocytes (cells with perinuclear halo)
   • Reporting should include assessment of:
     • Dysplasia (typically absent in benign papilloma)
     • Margins of resection
     • Presence of any coexistent pathology 5

Management Algorithm

1. Complete Endoscopic Removal

• Small lesions (≤8mm): Complete removal using biopsy forceps 1, 3
• Larger lesions: Endoscopic mucosal resection (EMR) or removal by diathermic snare 1, 3, 4
• Multiple lesions: All visible lesions should be removed 1

2. Pathological Assessment

• Confirm diagnosis of benign squamous papilloma
• Rule out dysplasia or malignant transformation
• Consider HPV testing (though not mandatory) 3

3. Follow-up Surveillance

• Perform follow-up endoscopy at 6-12 months to confirm complete removal and absence of recurrence 1, 2
• If no recurrence is found at follow-up, further surveillance may be unnecessary due to the benign nature of the lesion 6, 4

Important Considerations

Malignant Potential

• While generally considered benign, some studies suggest a potential association with HPV infection (detected in up to 46% of cases) 3
• The risk of malignant transformation appears to be very low, with no direct transformation observed in large case series 3
• Synchronous squamous cell carcinoma has been reported in rare cases (2 out of 155 patients in one series) 3

Recurrence Risk

• Recurrence after complete removal is extremely rare 1, 3, 4
• One study of 155 patients found recurrence in only one case 3

Etiology Considerations

• Unlike previously thought, ESP does not appear to be strongly associated with gastroesophageal reflux disease or hiatal hernia 3, 4
• HPV infection may play a role in some cases 5, 3

Clinical Pitfalls to Avoid

1. Inadequate removal: Ensure complete excision of the lesion to prevent recurrence
2. Misdiagnosis: ESP must be differentiated from other lesions, particularly verrucous carcinoma 3
3. Overtreatment: Extensive surgical approaches are unnecessary for these benign lesions
4. Inadequate follow-up: While generally benign, a single follow-up endoscopy is prudent to confirm complete removal

In summary, esophageal squamous papilloma should be managed with complete endoscopic resection followed by a single follow-up endoscopy to confirm eradication. The excellent prognosis and extremely low recurrence rate make this approach both effective and appropriate for these benign lesions.