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Esophageal Papillomas as an Endoscopic Finding

March 2022
Eurasian Journal of Medicine 54(1):80-81

March 2022
54(1):80-81

DOI:10.5152/eurasianjmed.2022.21056

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Esteban Fuentes-Valenzuela

Hospital Universitario Infanta Elena

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Esophageal papilloma

Bolañosetal.

Dear Editor

We present the clinical case of a 41-year-old woman with a medical history of iron deﬁciency

anemia. The patient came to the consultation for abdominal pain, located in the epigastrium,

and an alteration of the intestinal rhythm of 9 months evolution, referring to tenesmus and

occasional hematochezia. An analysis was carried out (hemogram, coagulation, biochemistry,

and autoimmunity study); low ferritin (4.8 ng/mL) was observed, with the rest of the study

normal. To complete the study, abdominal ultrasound, gastroscopy, and colonoscopy were

requested.

The gastroscopy revealed 2 hairy lesions in the esophagus 20-25 cm from the dental arch:

these lesions were 2-3 mm in diameter each and had an appearance suggestive of papillomas

(Figure 1A). These were excised and sent to pathological anatomy (Figure 1B), corroborating

the diagnosis of esophageal papillomas. In the stomach, pylorus, and ﬁrst and second duodenal

portions, no alterations were observed.

Discussion

Esophageal papilloma is an infrequent entity, with an approximate incidence that ranges

between 0.01% and 0.04% in the population. They are seen more frequently in patients with

tylosis and acanthosis nigricans, and there is an association with Goltz syndrome, a congeni-

tal disorder of focal dermal hypoplasia characterized by hyperpigmentation, sclerodactyly,

Esophageal Papillomas as an Endoscopic Finding

Juan MiguelPachecoBolaños 1, María AndrésCalvo 2, Esteban Fuentes-Valenzuela 3, Pablo CurielMartínez 1,

José PabloMiramontesGonzález 4

Letter to the Editor

Gastroenterology

Letter to the Editor

Eurasian J Med 2022; 54(1): 80-81

Cite this article as: Miguel Pacheco Bolaños J, Andrés

Calvo M, Fuentes-Valenzuela E, Curiel Martínez

P, Pablo Miramontes González J. Esophageal

papillomas as an endoscopic ﬁnding. Eurasian J Med

2022;54(1):80-81.

1Centro de Salud Parque Alameda-Covaresa-

Valladolid, Spain

2Servicio de Anatomía Patológica. H.

Universitario Río Hoterga, Valladolid, Spain

3Servicio de Aparato Digestivo. H. Universitario

Río Hoterga, Valladolid, Spain

4Servicio de M. Interna. H. Universitario Río

Hoterga. IBSAL- Instituto de Investigaciones

Biomédicas de Salamanca. Facultad de Medicina

– Universidad de Valladolid, Spain

Received: 15.02.2021

Accepted: 26.02.2021

Corresponding author: José Pablo Miramontes

González

E-mail: jpmiramontes@hotmail.com

DOI 10.5152/eurasianjmed.2022.21056

Figure1. (A) Endoscopic image of esophageal papillomas at the level of the esophagus. An exophytic

lesion of vegetative appearance, with well-deﬁned borders. (B) Pathological image of the esophageal

papilloma with hematoxylin–eosin stain in which the classic structure of the papilloma can be seen.

Maturestratiﬁed ﬂat epithelium can be seen, with acanthosis and papillomatosis.

Eurasian J Med 2022; 54(1): 80-81 Bolañosetal. Esophageal papilloma • 81

dysplastic changes in teeth and bones, and

papillomas in the perianal, oroesophageal, and

genital regions.1

Pathogenesis is uncertain, although there are

2 proposed theories: the ﬁrst is the inﬂamma-

tory theory. Approximately 70% of papillomas

occur in the distal third of the esophagus and

have been associated with reﬂux, esophagitis,

or irritants of the mucosa.2 The second theory

relates these lesions to HPV infection. Studies

carried out in populations of Italy and Hungary

have documented the existence of HPV in

26-41% of esophageal papillomas.3 However,

other studies in populations of the United

States, Finland, and Poland have identiﬁed HPV

in less than 5% of cases.4 The role of HPV in

pathogenesis is supported by the fact that the

most frequently found serotypes are 6 and

11 (the most frequent in the oropharynx and

human genital tract). The route of acquisition

of this viral infection is most often oral sex, but

it has been considered possible via the inges-

tion of cellular particles from warty lesions

from the hands and genitals.5 The evolution of

these lesions to malignant forms is not frequent,

although in cases with other concomitant risk

factors, this evolution can be seen.

Diagnosis is usually by chance ﬁnding since they

are mostly asymptomatic, but long-standing

lesions can cause dysphagia if they are of con-

siderable size. The macroscopic appearance

on endoscopy is of small, whitish-pink exo-

phytic projections, similar to warts, as seen in

Figure 1A. The biopsy and the pathological study

of the sample are considered essential for the

diagnosis: a ﬁbrovascular nucleus is classically

observed, branching from the lamina propria to

form ﬁnger-shaped projections without invasion

toward the submucosa, completely surrounded

by marked inﬁltration of neutrophils and cov-

ered by an acanthotic squamous epithelium,10 as

seen in the image of the case study described

in Figure 1B.

Peer-review: Externally peer-reviewed.

Author Contributions: Concept – J.P.M.G., J.M.P.B.;

Design – J.P.M.G., J.M.P.B.; Supervision – J.P.M.G.; Data

Collection and/or Processing – J.M.P.B., E.F.V.; Analysis

and/or Interpretation – M.A.C.; Literature Search –

M.A.C., E.F.V.; Writing Manuscript – J.P.M., J.M.P.B.

Conﬂict of Interest: The authors have no conﬂicts of

interest to declare.

Financial Disclosure: The authors declared that this

study has received no ﬁnancial support.

References

1. Brinson RR, Schuman BM, MillsLR, Thigpen S,

Freedman S. Multiple squamous papillomas of

the esophagus associated with Goltz syndrome.

Am J Gastroenterol. 1987;82(11):1177-1179.

2. QuitadamoM, BensonJ. Squamous papilloma of

the esophagus: a case report and review of the

literature. Am J Gastroenterol.

1988;83(2):194-201.

3. SzántóI, SzentirmayZ, BanaiJ, et al. [Squamous

papilloma of the esophagus. Clinical and patho-

logical observations based on 172 papillomas in

155 patients. Orv Hetil. 2005;146(12):547-552.

4. PoljakM, OrlowskaJ, CerarA. Human papillo-

mavirus infection in esophageal squamous cell

papillomas: a study of 29 lesions. Anticancer Res.

1995;15(3):965-969.

5. Serra Valdés MA, Fojo Mallo AW, González

ValeraN, Cardosa Samón M, García TasséM,

Aleaga Hernández YY. Human papillomavirus

infection and esophageal cancer: a case report.

Medwave. 2012;12(9):e5531. [CrossRef]

ResearchGate has not been able to resolve any citations for this publication.

Human papillomavirus infection and esophageal cancer: a case report

Article

Full-text available

Oct 2012

Introduction. Currently over 216 types of human papillomavirus (HPV) have been reported, but only 100 have been fully sequenced. They are able to infect cells of the basal layer of any epithelium. Evidence of HPV oncogenicity has been found. Objective. To describe a case of esophageal HPV infection associated to cancer of the esophagus. Case report. 63 years-old, African and rural origin, single, female housewife with the habit of smoking and frequent ingestion of alcohol. Four months before the diagnosis was established, the patient began to gradually develop dysphagia to solids and weight loss. Upper endoscopy shows a proliferative ulcerated lesion in the middle third of the esophagus. Biopsy is consistent with esophageal squamous cell carcinoma. Cytology is suggestive of papillomavirus infection. Discussion. Prior esophageal papillomatosis and other risk factors contributed to the occurrence of esophageal carcinoma. Histopathology was consistent with the diagnosis of squamous cell carcinoma probably caused by HPV infection. Conclusion. The association between papilloma virus and esophageal cancer is rare but can be diagnosed if it is suspected and other risk factors are present, as well as if there is access to modern diagnostic means.

Squamous papilloma of the esophagus: A case report and review of the literature

Article

Mar 1988

A case of squamous cell papilloma of the esophagus in a 70-yr-old white woman is reported. The literature is reviewed, summarized, and tabulated. This study found that the average age of a person with a squamous cell papilloma of the esophagus was 51.5 yr, with an associated male:female ratio of 1.8:1 (39M:22F). Additionally, most squamous papillomas were single (52) rather than multiple (9), most were located in the distal one-third of the esophagus (41), and symptoms at presentation were diverse, although epigastric pain was the chief complaint in 27 patients.

Multiple squamous papillomas of the esophagus associated with Goltz syndrome

Article

Dec 1987

A 30-yr-old white female with a history of focal dermal hypoplasia (Goltz syndrome), chronic gastroesophageal reflux, and dysphagia was found to have, by barium esophagram and esophagogastroduodenoscopy, multiple 2- to 3-mm papillary projections in the distal esophagus and an esophageal stricture. Biopsy of these lesions revealed squamous papillomas and a benign stricture. Although chronic irritation from gastroesophageal reflux has been suggested as a possible etiology of acquired esophageal papillomas, the previous association of congenital papillomas of the oral mucosa in Goltz syndrome suggests that the multiple papillomas in this patient are congenital in origin.

Human papillomavirus infection in esophageal squamous cell papillomas: A study of 29 lesions

Article

May 1995

The etiology and pathogenesis of esophageal squamous cell papillomas (ESCP), rare benign tumors of human esophagus, are still controversial. Chronic mucosal irritation and infection with human papillomaviruses (HPV) are two proposed etiologies. To investigate these hypotheses, we screened 29 ESCPs from 28 patients originating from Slovenia and Poland for HPV infection using in situ hybridization (ISH) and polymerase chain reaction (PCR). No evidence of HPV DNA was found using ISH. By PCR, the presence of HPV DNA was detected in only one lesion using two different HPV L1 consensus primer sets. The restriction fragment analyses of PCR product showed patterns unique to HPV type 6. All other ESCPs were successfully amplified only with internal control human beta-globin primers. Our results show that HPV DNA is not frequently detectable in ESCPs, even when highly sensitive methods like PCR are used and that other pathogenetic mechanisms are more important in the etiology of ESCPs.

Squamous papilloma of the esophagus. Clinical and pathological observations based on 172 papillomas in 155 patients

Article

Apr 2005

The papilloma of the oesophagus is a rare disease. The pathogenesis and biological features of the disorder are not clearly known. The purpose of the present paper is to outline the clinical and pathological significance of the papilloma of the oesophagus as detected in the authors' endoscopic laboratory. Endoscopic examinations were carried out with a flexible endoscope. The alterations in the oesophagus were removed by biopsy forceps in order to perform histological investigations, large-sized ones were removed by way of endoscopic mucosectomy. To assess the structure major alterations and their circumstances relative to their environment, endoscopic ultrasonography was performed, as well. Histological examination was done in formalin-fixed slides embedded in paraffin and dyed with hematoxiline eosine. HPV detection was done through polymerase chain reaction (PCR). During the 35 years a total of 59.056 upper panendoscopic examinations were carried out. Planocellular papilloma were detected in 155 patients (0.26% of the total number of patients). 85 of the patients were female, 70 were male. The vast majority of papilloma cases were solitary (142 patients). A minority--13 patients--had multiplex alterations. Most often, the papillomas were sessile changes, most often located in the middle and upper part of the intrathoracic section of the oesophagus. The probability of the papilloma can be established on the basis of the findings of endoscopic morphology, as well. This, however, has to be supported by a histological examination. In the majority of the cases the papillomas of the oesophagus can be removed by endoscopical biopsy forceps, because most often the alterations were only a few millimetres in size. Larger papillomas can be removed by way of endoscopic mucosectomy. Examining the transformation of papillomas into carcinomas, no papilloma was found which directly transformed into a carcinoma. Synchronically occurring planocellular carcinoma was found in the oesophagus of only 2 out of the 155 patients. During the follow-up examination of patients, recurrence of the disease was found only in one patient. The frequency of the human papilloma virus in papilloma of the oesophagus: the authors were able to detect the presence of HPV by way of PCR technique in 12 out of 26 cases (46.2%). With the expectation of 3, they were all viruses with a high risk of cancerous transformation. The squamous papillomas of the oesophagus are begin tumors. Papillomas is not caused by hiatus hernia or reflux oesophagitis. The distinct localization of the two different types of alternations also suggests a non-reflux oesophagus origin of the papilloma. The reason is that papillomas are most often located in the middle and upper part of the intrathoracic section of the esophagus--on the other hand, reflux esophagitis is located in the lower section. It is now generally accepted that papillomas of the mucous membrane covered by multiple planocellular layers are caused by HPV. The identical localization of the papillomas and planocellular cancer in the oesophagus refer to potentially identical etiology (HPV infection), and it may rarely occur that the papillomas wil in fact transform into carcinoma. Papillomas of the esophagus is a rare disorder. Its detection is in part important in order to distinguish it from planocellular carcinoma (especially carcinoma verrucosum), In part it indicated the HPV-infection of the oesophagus, or in HPV-positive cases it may be regarded as a precancerous state. For all this, it is important that the papilloma should be recognised by way of endoscopic examination, removed and a precancerous state should be taken into consideration.