A SURPRISING EVOLUTION OF FOCAL ESOPHAGEAL EOSINOPHIL INFILTRATION

A 83 years-old woman, chronically treated by PPI for gastro-esophageal reflux disease underwent an esophagogastroduodenoscopy (EGD). It showed a 30 mm Paris O-IIa verrucous esophageal lesion on 30% of the circumference at 25 cm from the incisors. The patient was not exposed to alcohol or tobacco. The lesion was lugol negative and atypical pattern with NBI and near focus examination was not in favor of squamous cell carcinoma (SCC). The biopsies revealed a dense eosinophilic infiltration associated to moderate to severe squamous dysplasia, a feature that might be reactional for our pathologist. Human papilloma virus (HPV) was not detected. Biopsies of the upper, medial and lower esophagus were negative for eosinophilic infiltration. Knowing the absence of risk factor for SCC, the atypical aspect of the lesion, the absence of symptoms and the old age of the patient, and after discussion with our pathologist, no endoscopic treatment was proposed and the patient was rescheduled for a follow-up endoscopy at 6 months. The patient came back at 15 months for control EGD. At that time, the lesion involved 30% of the esophageal circumference and its shape changed with a Paris O-Is center. Targeted biopsies revealed SCC. EUS disclosed no lymphadenopathy and was in favor of T1 lesion. Distant metastasis were excluded by thoraco-abdominal CT scan and ¹⁸F-FDG PET/CT. An endoscopic en-bloc resection by endoscopic submucosal dissection (ESD) was then performed. The patient had no symptoms after the resection. Histopathological examination of the specimen showed a moderately differentiated SCC invading the submucosa on 700 µm. Lateral and deep margins were free from malignancy and dysplasia. No lymphovascular infiltration or perineural infiltration was observed, but tumor budding was present (pT1bsm2). Considering the age of the patient endoscopic follow-up was proposed.