verrucous carcinoma of the esophagus ( vce ) is a rare malignant epithelial tumor representing a variant of squamous cell carcinoma . since then , only a small number of cases of this entity have been described in the literature . other sites of verrucous carcinoma include the oropharynx , larynx , genitalia , cervix , urinary bladder , anus and the soles of the feet [ 3 , 4 ] . vce is usually seen in the middle - aged population , affecting mainly the lower esophagus , with higher prevalence in males . symptomatically , it commonly presents with an insidious onset of dysphagia and weight loss , with delayed diagnosis ranging from months to years . grossly , in most cases it is an exophytic slow - growing mass emerging as papillary or warty - like , with extensive superficial growth pattern . under the microscope in addition , hyperkeratosis , nonspecific inflammation and obvious acanthosis can be seen [ 1 , 6 ] . endoscopically , hypoechoic wall thickening is seen from nodular to concentric in appearance , penetrating from the mucosa to the submucosa , with frequent invasion into the muscularis propria layer [ 3 , 4 , 5 , 7 ] . risk factors associated with vce include smoking , alcohol intake , chronic inflammation , achalasia , caustic exposure , and as recently speculated human papillomavirus ( hpv ) infection . the role of hpv in carcinogenesis is contemplated to be secondary to overexpression of p53 , mdm2 , ercb2 and loss of p21 [ 8 , 9 ] . the diagnosis is difficult , often requiring a high clinical suspicion with multiple repeat endoscopic biopsies , preferably with large - capacity spike forceps [ 4 , 6 , 7 ] . due to its rarity , treatment modalities however , surgery is usually preferred in the early stages , as vce has a low potential for metastasis and lymph node involvement [ 6 , 7 ] . a 58-year - old female with a past history of squamous cell carcinoma of the larynx , treated with radiation therapy and surgery 13 years earlier , presented with dysphagia and weight loss of approximately 10 pounds ; symptoms had started almost 2 months before . at the time of presentation , she was able to tolerate a liquid diet only and was referred to us for further diagnostic workup after two prior gastroscopy studies . previous evaluation had revealed a large polyp - like mass involving the mid and distal esophagus . however , repeat biopsies from this lesion had been negative for malignancy . on repeat esophagogastroduodenoscopy , a large 1 ) . the polyp stalk seemed to blend into a background of nodular - appearing mucosa involving the distal esophagus with the gastroesophageal junction . on endoscopic ultrasound , a hypoechoic , irregular mass was found , involving the gastroesophageal junction with associated esophageal thickening , measuring 20 mm in thickness . 2 ) . biopsies using large - capacity forceps demonstrated pseudoepitheliomatous hyperplasia , raising the suspicion of vce . initial positron emission tomography ( pet ) and computed tomography ( ct ) evaluation was consistent with an increase in hypermetabolic soft tissue fullness at the gastroesophageal junction . after discussion at the multidisciplinary conference , the decision was made to proceed with chemo - radiation with preoperative carboplatin and taxol . repeat pet / ct after 3 months demonstrated significant interval reduction in the size and metabolic activity of the distal esophagus near the gastroesophageal junction , consistent with a positive response to radiation therapy . clinically , the patient had significant improvement in symptoms after initiation of chemo - radiation therapy . afterwards , she underwent interval ivor - lewis esophagectomy with no residual mass seen on gross specimen . vce can pose a potential diagnostic dilemma because this tumor typically does not show high - grade dysplasia [ 3 , 10 ] . therefore , multiple sets of endoscopic biopsies may be required due to the overlying hyperkeratotic layer . although commonly described as a wart - like lesion , a polypoid mass - like configuration has also been reported [ 5 , 8 , 9 ] . the proximal end of the lesion in our patient started off as a polypoid mass , being contiguous with the distal esophagus as an infiltrating lesion . . however , the endoscopist 's suspicion for a malignant lesion was high . repeat endoscopic evaluation with concurrent endoscopic ultrasound was suggestive of a malignant process infiltrating through the muscularis propria . furthermore , demonstration of hpv on biopsies and a relevant history of previous squamous cell carcinoma of the larynx was very helpful , raising suspicion for a squamous carcinoma variant involving the esophagus . in a retrospective analysis of 11 patients with vce of the esophagus seen at a tertiary referral center over 5 years , about half the patients reported smoking or consuming alcohol on a regular basis . the median time interval from onset of symptoms to diagnosis of esophageal vce was 2.5 years , with dysphagia being present in all patients . initial pinch biopsies were nondiagnostic in 73% of the patients . in patients treated solely with surgery and who had a preoperative endoscopic ultrasound , the latter tended to overestimate staging of the lesion relative to surgical pathologic staging . in conclusion , a previous history of squamous cell carcinoma , especially with positive hpv staining on biopsies , should raise suspicion of vce . since it is a squamous cell variant , chemo - radiation has excellent response , to be followed by surgical resection .
verrucous carcinoma of the esophagus is a rare variant of squamous cell carcinoma associated with human papillomavirus . 
 we report the case of a 58-year - old female who presented with ongoing symptoms of dysphagia . on previous endoscopies 
 she had been noted to have a large polyp - like mass involving the esophagus , with negative biopsies for malignancy . 
 repeat endoscopy with concurrent endoscopic ultrasound showed a large semi - pedunculated polyp in the distal esophagus and a hypoechoic , irregular mass involving the gastroesophageal junction with esophageal thickening . 
 deep layer biopsies showed pseudoepitheliomatous hyperplasia with immunohistochemical staining positive for human papillomavirus . 
 the patient was subsequently treated with chemo - radiation followed by esophagectomy .