Esophageal papilloma: Flexible endoscopic ablation by radiofrequency

Abstract

Squamous papilloma of the esophagus is a rare benign lesion of the esophagus. Radiofrequency ablation is an established endoscopic technique for the eradication of Barrett esophagus. No cases of endoscopic ablation of esophageal papilloma by radiofrequency ablation (RFA) have been reported. We report a case of esophageal papilloma successfully treated with a single session of radiofrequency ablation. Endoscopic ablation of the lesion was achieved by radiofrequency using a new catheter inserted through the working channel of endoscope. The esophageal ablated tissue was removed by a specifically designed cup. Complete ablation was confirmed at 3 mo by endoscopy with biopsies. This case supports feasibility and safety of as a new potential indication for Barrx^TM RFA in patients with esophageal papilloma.

Key Words: Esophageal papilloma; Endoscopic ablation; Radiofrequency; Minimally invasive; Natural orifice transluminal endoscopic surgery

Core tip: This paper reports for the first time a flexible endoscopic treatment of esophageal papilloma by a new radiofrequency system that goes into the working channel of the endoscope. This allows the endoscopist to see what he is doing along the procedure and to complete the procedure in few minutes. The procedure was performed without particular difficulties and did not required elevated skills.

INTRODUCTION

Esophageal benign lesion is often a major concern due to need of an effective and low risk procedure combined to unmodified physiology[1]. Radiofrequency ablation (RFA) is an established endoscopic technique for the eradication of Barrett esophagus, which has been investigated in a variety of study designs and settings[2-6].

RFA is associated with an acceptable safety profile, high rates of complete eradication of dysplasia and intestinal metaplasia, durability of effect, and a significant relative risk reduction for neoplastic progression, thus it is considered a standard of care for patients with high-grade dysplasia[7].

Squamous papilloma (SP) of the esophagus is a rare benign lesion of the esophagus. The prevalence ranges from 0.01 % to 0.45 %[8]. SP of the esophagus is usually asymptomatic and rarely causes dysphagia. Esophageal squamous papillomatosis is typically reported as a wart-like and fleshy-pink single lesion, most commonly in the middle or distal esophagus; the typical endoscopic appearance is a single, round sessile lesion[9]. The underlying etiology is unclear, but chronic reflux disease, mucosal trauma, and human papillomavirus (HPV) infection have been implicated, although most lesions are found in absence of HPV[10]. The malignant potential of the lesion is unknown, and no guidelines exist regarding follow-up of these lesions[11]. Some authors have recently reported the possibility of an endoscopic removal[12,13]. To the best of our knowledge, no cases of endoscopic ablation of esophageal papilloma by RFA has been reported. We report a case of esophageal papilloma successfully treated with a single session of RFA.

CASE REPORT

This case was conducted according to the Declaration of Helsinki and approved by the local institutional review board. In February 2014, a 52-year-old white asymptomatic woman was referred to our unit in the preoperative assessment of intragastric baloon placement for obesity. Upper gastrointestinal endoscopy (UGIE) revealed the presence of a single whitish wart-like area of about 0.5 cm in diameter which was located 37 cm from the incisors, above the Z-line (Figure 1). Narrow band imaging (NBI) confirmed the presence of an unstained area. Histologic examination showed the presence of micropapilloma of the esophagus surrounded by cilindric epithelium with congestion and flogosis (Figure 2). In April 2014 a session of RFA (Barrx^TM, Covidien, CA, United States) on the dysmorphic esophageal area was performed. Total length of the procedure was 10 min. No complications occurred during the procedure. Postoperative course was uneventful.

Figure 1 Endoscopic view of esophageal papilloma.

Figure 2 Esophageal biopsy showing papillary projections lined with acanthotic squamous epithelium (A: HE 4 ×; B: HE 10 ×).

Endoscopic technique

The patient was positioned in the left lateral decubitus position under monitoring of vital signs. Intravenous sedation was administered. An UGIE allowed identification of the esophageal papilloma. The total length of the area was calculated. Esophageal lumen was pre-treated with N-acetycysteine 1% (Mucomyst^TM). A new designed catheter (Channel RFA Endoscopic Catheter, Barrx™, Covidien) was inserted through the working channel of a standard flexible gastroscope (Figure 3). The electric pad of the catheter was placed under direct visualization so that the entire suspected area was covered. Radiofrequency was applied at 300 W and 12 J/cm². The wound along the ablation zone was cleaned from debris using Barrx™ RFA Cleaning cup mounted on distal end of endoscope. The ablation was repeated using the same procedure (Figure 4). The patient was discharged the same day. An UGIE was repeated after one months, showing a whitish area suggestive of scarring at the site of ablation without macroscopical evidence of residual papilloma. A second UGIE with biopsies, at 3 mo, excluded the presence of recurrent disease.

Figure 3 Radiofrequency catheter inserted into standard flexible gastroscope operative channel (Barrx™, Covidien).

Figure 4 Radiofrequency pad is placed over the lesion under direct visualization (A); Ablation area after the first application of energy (B); Second application of the pad to include all the area of esophageal papilloma (C); Esophageal wound cleaned from debris by cleaning cup (D).

DISCUSSION

RFA has been recently reported to be more effective and less costly than photodynamic therapy in the treatment of Barrett’s related dysplasia[14]. On the other hand, an important advantage of RFA lays on simplicity and safety of the procedure suggesting the treatment can be effective with potential lower complications rates than more invasive techniques such as endoscopic resection. In this case an asymptomatic patient was discovered to have an esophageal papilloma in course of preoperative EGDS before bariatric treatment.

In this case, the efficacy was reached by a single session of RFA, with a minimal discomfort for the patient and a relatively low impact on the endoscopic center. Our initial experience supports the feasibility and safety of a new potential indication for Barrx^TM RFA in patients with esophageal papilloma. Further cases and a longer follow up will be needed to drive a definitive conclusion.

ACKNOWLEDGMENTS

“Considerate la vostra semenza: Fatti non foste a viver come bruti, ma per seguir virtute e canoscenza.” (Consider well the seed that gave you birth: you were not made to live as brutes, but to follow virtue and knowledge). Ulysses in The Divine Comedy. Dante Alighieri, Canto XXVI, 1308-21.

COMMENTS

Case characteristics

A 52-year-old female with esophageal papilloma.

Clinical diagnosis

The tumor was diagnosed during routine gastroscopy for preoperative assessment before placing intragastric baloon.

Differential diagnosis

Esophageal high grade dysplasia, metaplasia, early adenocarcimona or squamous cell carcinoma.

Laboratory diagnosis

All blood test were within normal limits.

Imaging diagnosis

Upper endoscopy showed the lesion, byopsies were taken.

Pathological diagnosis

Histologic examination showed the presence of micropapilloma of the esophagus surrounded by cilindric epithelium with congestion and flogosis.

Treatment

Single treatment of endoscopic ablation by radiofrequency.

Related reports

Endoscopic curative treatment is becoming more popular. This is the first report of squamous esophageal papilome treated by a new catheter radiofrequency technology.

Term explanation

RFA: Radiofrequency ablation is a relatively new technique generally used to treat Barrett’s esophagus related high grade dysplasia. This technology uses bipolar energy associated to impedance to automatically controll the energy output.

Experiences and lessons

The new technical possibility allows a less invasive approach with a reduced risks of potentially serious complication and a faster return to normal life.

Peer-review

The manuscript is very well.