Ackerman Tumor: A Rare Esophageal Malignancy.

CASE REPORT

A 68-year-old white man with a 75-pack-year smoking history presented to our clinic with a 1-year history of progressive esophageal dysphagia to solids and liquids. Initial physical examination and laboratory evaluation were unremarkable. Esophagogastroduodenoscopy revealed a circumferential, partially obstructing lichenoid lesion in the mid to distal third of the esophagus (Figure 1). Because of concerns for underlying malignancy, an endoscopic ultrasound was performed, which revealed thickening of the mucosa without involvement of other layers. There was no paraesophageal lymphadenopathy. An esophageal stent was placed for symptomatic treatment. The initial biopsies revealed hyperplastic squamous mucosa with hyperparakeratosis without dysplasia. Human papilloma virus stain was negative. Repeat esophageal biopsies were performed; however, histology revealed hyperparakeratosis without dysplasia or carcinoma. Ultimately, an endoscopic mucosal resection was performed using a submucosal saline injection and a hot snare for a deeper specimen. Histology revealed verruciform squamous proliferation with atypia, suspicious for well-differentiated squamous cell carcinoma (Figure 2). The patient was referred to surgical oncology for esophgagectomy; however, the patient was not a surgical candidate because of comorbidities. Ultimately, photodynamic therapy was performed with good response and the patient remained asymptomatic.

Figure 1.

Esophagogastroduodenoscopy revealing a circumferential, partially obstructing lichenoid lesion in the mid to distal third of the esophagus, known as Ackerman tumor.

Figure 2.

Histology of the specimen showing (A) a deep portion of the lesion with pushing borders (arrows) and (B) superficial areas with papillomatosis, parakeratosis, and acanthosis (arrow).

Verrucous carcinoma, also known as Ackerman tumor, is a slow-growing variant of squamous cell carcinoma. Involvement of the esophagus is relatively rare. More often, this tumor involves the upper airway, genitalia, endometrium, anus, or feet. The incidence rate is higher in men and is most closely associated with tobacco and alcohol use.[1] Endoscopically, these lesions usually project into the lumen with a carpet-like distribution and warty appearance. Pathologic diagnosis can be difficult when regular biopsy is performed because of the thick keratin layer. Moreover, histology often reveals only hyperparakeratosis; therefore, adequate tissue is crucial for diagnosis. In previously reported cases, diagnosis is often made when the keratin layer is thin.[2] Sometimes, esophagectomy is required in highly suspicious cases despite nondiagnostic histology. We reported a case of esophageal verrucous carcinoma diagnosed by tissue obtained from the endoscopic mucosal resection.

DISCLOSURES

Author contributions: B. Henderson wrote the manuscript, reviewed the literature, and is the article guarantor. S. Chandan wrote the manuscript, reviewed the literature, and provided the endoscopy image. HC Tsao provided the pathology images with pathologic findings and reviewed the literature. W. Manatsathit revised the manuscript.

Financial disclosure: None to report.

Informed consent was obtained for this case report.