Oesophageal Squamous Papilloma

Oesophageal squamous papilloma is a benign epithelial polyp made of finger like projections of squamous epithelium around a fibrovascular core. It is usually small, solitary and found incidentally.

Prevalence is 0.01% to 0.45% of upper endoscopies. It occurs at any age, most often in adults aged 30 to 60 years, with similar rates in both sexes.

Causes and associations are chronic mucosal irritation from reflux, and human papillomavirus types 6, 11 and 16 in a minority. Multiple papillomas (papillomatosis) occur in focal dermal hypoplasia, Cowden syndrome and acanthosis nigricans.

Malignant change is very rare, and a link with squamous cell carcinoma is described only in case reports, mainly in papillomatosis.

Pathophysiology.

Epithelial hyperplasia, papillomatosis and acanthosis develop over a vascularised stroma; koilocytes indicate viral effect.

Usually asymptomatic. Large lesions can cause dysphagia, reflux type symptoms or retrosternal discomfort.

Endoscopy shows a sessile or pedunculated white to pink, warty polyp of 2 to 6 mm, most often in the distal third. Biopsy confirms the diagnosis and excludes dysplasia. Human papillomavirus testing is optional.

Differential diagnosis.

• Verrucous carcinoma.
• Granular cell tumour.
• Glycogenic acanthosis.
• Leukoplakia.
• Early squamous carcinoma.

Small, asymptomatic lesions with benign histology need no treatment. Remove symptomatic, larger or histologically uncertain lesions, and lesions with dysplasia, by endoscopic biopsy removal, snare polypectomy or ablation (argon plasma coagulation or radiofrequency).

• Omeprazole: 20 mg orally once daily for 8 weeks when reflux is present; maximum 40 mg daily for this indication; monitor symptoms; reduce to 10 mg daily in severe hepatic impairment.

Monitoring. Repeat endoscopy at 1 year after removal in papillomatosis or atypical histology; no routine surveillance for a single benign papilloma.

Referral and escalation. Gastroenterology when lesions are multiple, dysplastic or recurrent. Genetic review if multiple papillomas appear with skin or mucosal findings.