Verrucous carcinoma of the esophagus.

A 66-year-old man with chronic dysphagia and chronic cough of 2 years duration was admitted to the Veterans Administration Medical Center. Ann Arbor. MI in October 1983. complaining of progression in dysphagia for both solids and liquids, and 20-lb weight loss during the 2 months before admission. Approximately 27 years before, he sustained extensive battery acid bums to his face, neck, upper part of the thorax, pharynx, and esophagus during a motor vehicle accident. He underwent multiple reconstructive and skin graft operations during the next 4 years. An esophageal stricture resulting from the caustic injury subsequently required frequent dilatations. He continued to be a heavy smoker and alcohol drinker until recently. On physical examination he was a cachectic, dehydrated man in moderate discomfort. There were confluent scars across his face neck and upper chest. Chest examination revealed coarse rales in the right upper lobe and bilateral basilar rhonchi. The remainder of the physical examination was unremarkable. The laboratory studies revealed Hb 13 g/dl, hematocrit 39.6%. white blood cell count 28.600/mm\ and normal serum electrolytes. A chest radiograph revealed cavitating infiltrates in the right upper lobe. A PPD was negative and no acid-fast bacilli were found in the sputum. The sputum cytology showed malignant cells. A barium swallow (Fig. 1) revealed a large polypoid mass in the proximal esophagus almost completely obstructing the lumen. The contrast medium extravasated through an esophageal perforation and filled a mediastinal abscess cavity on the right side. A large diverticulum of the proximal esophagus was also filled with the contrast medium. Computed tomography of the chest (Fig. 2) showed right upper lobe infiltrates with cavity formation and a mediastinal abscess on the right side. Fine needle aspiration of the right upper lobe lesion yielded purulent exudate and budding yeast consistent with aspiration pneumonia. A laryngoscopic examination revealed a paralyzed right vocal cord. Bronchoscopy revealed no intrabronchial mass. Esophagoscopy showed a large cauhflower-like mass occluding the esophageal lumen at 17 cm from the incisors. Biopsy revealed verrucous squamous cell carcinoma of the esophagus (Fig. 3). Initial treatment consisted of antibiotics and nutritional support requiring a feeding gastrostomy tube. Due to combination of severe chronic obstructive pulmonary disease, mediastinal abscess, and marked debilitation, he was considered a poor surgical candidate. The patient refused chemotherapy. His general condition continued to deteriorate and on December 8. 1983 he died due to respiratory arrest. No autopsy was performed.