Next up, we have Peter Dragunov, who's going to talk about refractory barrettes, and if we have time, squamous cell neoplasia and the esophagus. Okay, so I'm actually not going to talk about either. Just, it's an interesting case, though. John, you didn't do your assignment, you know? No, I did, I did, but okay. Okay, I will be much shorter than 20 minutes, so that will catch us up. You have a 31-year-old male, EGD, done for dyspepsia, vague symptoms of some early satiety and fullness, to a point that probably, by guidelines, this patient should not have been scalded, but he did. And this is the lesion that was picked up in the esophagus. Is there a way to turn the front lights off, Marilyn? Because the lesion is fairly subtle, and it is right there. Does it go a little bit more distal as well? Probably. Okay. Right here, but this is the main lesion. I think this is just some pool of fluid. And you can also appreciate the fluid here as well. So this is the left side. And the question is, what do you think of this lesion? Obviously, it's quite flat. I mean, by Paris classification, this will be 2A, slightly elevated. I mean, it has roughly the same color as the rest of the mucosa, to a point that you can easily overlook it. But this was, by the way, a veteran. The procedure was done at the VA. Let's make this interactive. I mean, any thoughts of what this could be? It looks, look, the color is so similar to the esophagus, otherwise, could this be an inlet patch? Inlet patch. Okay. Yeah, I forgot. Where is this located? This is at the 30 centimeters or so. But your point, let's discuss about inlet patch. So those are flat. They're usually completely flat rather than slightly elevated. And they usually tend to be pink, more pink than the rest of the esophagus. And of course, they are in the very upper, maybe typically a centimeter or two below the upper esophageal sphincter. But they certainly bear some similarity with this. So that's certainly in the differential. Most likely not the case in this particular case. You said you weren't going to talk about it, but potentially squamous dysplasia. MSL cancer. Yeah, correct. Okay. That certainly comes into the differential. The kicker is that this guy's 31. And I mean, he's been in the military, so obviously you cannot say that he has not had any alcohol and stuff. I mean, it comes with the territory, but certainly that is to be considered. Epidermoid metaplasia? Epidermoid metaplasia. So that is something that it's so uncommon that we had a discussion yesterday with Vanny. I don't know what to do with it. Actually- I know, neither do I. And lately, we've gotten a couple, multiple referrals for it, so. Interesting. So what do you do with them? The thing about epidermoid metaplasia, usually it has a whiter appearance than the rest of the esophagus. So this is clearly different, clearly raised. Epidermoid metaplasia, so little has been written about it. But this is a different look than you'd expect for it, because it's really, it's white. And this is really almost the same color, just it's a different texture. Exactly. Epidermoid metaplasia, sure. But that wouldn't be the top of my list here. But the top of my list is right now empty, so. Okay. Let me, let me ask the panel, what do you do with epidermal metaplasia, just to kind of dive a little bit deeper into that topic? Well, I guess, obviously, it is a rare entity. And there was one paper out of the Mayo Group, where, you know, they suggested close surveillance unless there's dysplasia, at which point, if it was focal, you could try to either resect or ablate. It's unclear if you have more of a diffuse area, what would be the best treatment for that. But again, you're thinking of this as a pre-pre-cancerous lesion to squamous cell cancer. So I think those are some of the options. Basically, survey, ablate, or resect are the three main options. Obviously, we don't have enough data to support either, just because it's uncommon. But okay, that is something. So actually... Bonnie had one thing. Oh, yeah, sure. I think one of the unique things about the epidermal metaplasia is just the high risk of prevalent cancer. So even if you sample, there's just, especially the bigger, bulkier, whitish, more robust looking ones, there's a, it has a higher risk of prevalent cancer. And I will say that the Japanese seem to be very apprehensive about ablating these, but that might be difference in style. But there is a very strong avoidance for when they talk about that, for epidermoid. I can speak a little bit about that, spending some time in Japan. Japanese are obsessed with pathology. And they are definitely against any type of ablation, just because you don't know exactly what you're dealing, you're burying it under the RFA. So it is something that certainly concurs with their overall approach of basically reject everything. Bonnie, going back to your statement, I am by no means an expert on this, but you said there is a high risk of prevalent cancer. And I didn't think that was necessarily the case unless you found obvious dysplasia. Right, dysplasia or atypia, I think would be, you know, reason, but it's not just, yeah. So I think that if there is, and I think that if you see that, then that's why I think there's erring on the side of resection, just because there is a high chance of the prevalent cancer for the, that if you were to ablate, even if your biopsies just showed dysplasia, you're, you have a chance of having cancer there. So from what I'm hearing, probably resection will be the better choice over ablation, if you decide not to survey. The problem is right now we don't have a diagnosis yet. I mean, I guess you could argue. I'm talking if you have epidermal, epidermal metaplasia, not for this particular reason. Okay, let's move. So I presented here a few potential lesions that may look similar to that. And in full disclosure, I lifted the images from the internet. So this is squamous cell papilloma. And it has somewhat whitish appearance as opposed to the pinkish appearance. And this kind of berry type of appearance, I mean, very similar to the anal papilloma. Certainly precancerous, worth resecting. But again, it's flat plaque in the esophagus. Zontomas can be seen and they can look something similar to that. And they basically look similar to zontomas on the skin that you see in people with hyperlipidemia, a little bit of a yellow tinge to the, yellow discoloration to the lesion. Glycogenic acanthosis, as you can probably appreciate here at the bottom, and that looks very similar to our lesion, doesn't it? And here they have presented a Lugol stain of the same area. And that picks up the iodine avidly. So it stains positively. And finally, something that probably it's more easy to distinguish a granular cell tumor. We get these referrals for EOS quite often. They tend to be a little bit more raised. They tend to be umbilicated, as in this case, and a little bit more white, yellowish. It's more of a nodule rather than a plaque, if you wish. They do, in some cases, can convert into cancer, although in most cases you can watch them. But resection is certainly also always an option. So now going back to our case. So I basically lied to you that I'm not going to talk about squamous cell cancer, because I didn't want to mess up the case. But here is a couple of things more about the history of this patient. So he's 31. It was 2A lesion, biopsy showing squamous high-grade dysplasia elsewhere. It was EMRed, and actually it was HPV positive. So this is squamous cell dysplasia in the face of HPV infection. After six months after the EMR, he had recurrence at the same site, and the biopsy was high-grade dysplasia. And that is the lesion that you saw on the initial image. And at that time, he was referred for us for ESD. Peter, can I ask you a question? So with squamous papilloma, and then you have this lesion with HPV, I've heard from our ENT colleagues that when they remove squamous papilloma from the oral pharynx, they have a lot of precautions because of the concern about the HPV and using cautery, and that you can aerosolize that and spread it to everybody in the room who's doing the procedure. So with cautery. So when I remove squamous papillomas, I just use a cold sneer technique. I don't use cautery. I don't know if there's a concern that was raised with this type of lesion to do an EMR or anything with cautery. Absolutely. I mean, my phone is going ape. I don't know why. Let me mute it. Sorry about this. So absolutely, yes. This is a concern. And actually, years ago, I immunized myself. I took the full three series of HPV vaccine. Funny enough, I had to pay out of pocket because I was too old to fit into the guidelines to be getting HPV vaccine. To add insult to the injury, at that time, I wanted to get a zoster vaccine, and I was too young for that. So I had to pay out of pocket for that as well. So anyway, and I do wear N95 during these cases, and I advise everybody in the room to wear N95. And this is pre-COVID. At that time, those were hard to locate. But there is a concern that when you cut through the lesion, you can aerosolize the HPV and get infected on the personnel side. OK. And say, Peter, again, going back to this case, as soon as you told me it was mitosophagus around 30, I automatically went to squamous cell dysplasia, or SSC. Yeah. For me, that was key, the location. Absolutely. Agree with you. So you're doing the endoscopy. What would you do during that same index endoscopy as a next step? You want to do any chromoendoscopy? That sounds like a good idea. This is virtual chromoendoscopy. In this case, it's a blue light imaging. We are using the Fuji platform, and you can appreciate the lesion better. At least the borders now are kind of coming along to be identified easily. And of course, we did look at the so-called intrapapillary loop pattern, or IPCL. And this is an example of normal intrapapillary loop pattern. And basically, they look like bobby pins of vessels with two arms. And the vessels are slightly curved, but non-dilated. Peter, for time, since we started late, can we try to wrap this up in the next couple of minutes? Okay. I have six more minutes, at least according to my timer. But anyway, yes, we can. I will skip the IPCL pattern. You can look that yourself. And the question is, what would you do next? And Uzma already gave us the answer. I'll go for Lugol's. As opposed to acanthosis, which stains positive for Lugol, this is a negative staining. And ultimately, we did an ESD on this lesion, with the final diagnosis being high-grade squamous dysplasia. Mucosal and deep margins were negative for high-grade dysplasia, and EGD at six months revealed healed scar. Peter, could you go back with Lugol's image? Because it looked like there was other areas there, right? You've got your markings, but right at about seven o'clock and at five o'clock, it looks like there's non-stained areas, too. Absolutely, Gary. I'm glad you're bringing this up. So when you do a Lugol stain, frequently, besides the main lesion, you'll find a small unstained areas. What do you do with that? And we usually leave them alone, but it's not uncommon to have patches of unstained areas. And in this case, what you're referring to, let me point everybody in the right direction, you're talking about this one and this one. And actually, down the esophagus, there are others. As long as it is completely flat and the IPCL pattern is normal, we leave them alone. But this patient certainly will deserve surveillance at his young age and documented HPV, for which, as you are well aware, we don't have any specific therapy. Thanks for bringing that up. And also, so this patient had EMR done as their initial therapy for this lesion, and then they had recurrence. So the question is either, A, did they not resect the entire lesion, or B, in our practice for squamous dysplasia, we usually do ESD up front. Because with squamous cell cancer, as you know, potential for lymphovascular invasion is a little bit higher. So you want to make sure you get a little bit deeper and hopefully negative margin. Absolutely. I cannot agree with you more. We are just finalizing the ESD guidelines, which will be the first ESD guidelines here in the United States. And basically, we are much more forceful about mandating unblock resection for any squamous lesion. I'm talking unblock. So if you have a five millimeter nodule, go with EMR. But the key is unblock, as opposed to, let's say, Barrett's esophagus, where piecemeal certainly can be done in many lesions. In squamous, much more aggressive than Barrett's related neoplasia. And even advanced cancer does not look like fungating mass in many cases. It can be a very subtle plaque that you can easily overlook. So to conclude, squamous cell lesions can be seen in younger people related to HPV. Squamous cell lesions are typically very subtle. Glucose staining can greatly enhance lesion delineation. IPCL pattern can reliably predict the depth of invasion. And unblock resection is highly desirable for these lesions. And I didn't go into that, but of course, we had fibrosis from the EMR. Your first shot is your best shot, as with any other lesions. Thanks. Peter, thank you so much. That was great.

squamous cell dysplasia

EGD

esophagus

inlet patch

epidermoid metaplasia