S4282 Recurrent Squamous Cell Carcinoma Presenting as Refractory Esophageal Stricture

Introduction: Esophageal strictures are a recognized complication of surgery and chemoradiation for head and neck malignancies. Although typically benign, resistance to endoscopic dilation should raise suspicion for malignancy. Recurrent or primary squamous cell carcinoma (SCC) may present subtly and elude detection on initial endoscopic biopsy. This case highlights the importance of repeated histologic evaluation in refractory strictures. Case Description/Methods: A 79-year-old man with Stage III (T2N1) supraglottic laryngeal SCC was treated with definitive chemoradiation, including cisplatin, in early 2020. Post-treatment positron emission tomography/computed tomography showed resolution of the primary tumor and regional nodes. He remained stable with persistent hoarseness until July 2024, when progressive dysphagia to solids began. Initial esophagogastroduodenoscopy (EGD) revealed a benign-appearing stricture 21–30 cm from the incisors, with a luminal diameter of 7 mm. Through the scope balloon dilation was performed to 12 mm, with mucosal disruption observed. Biopsy showed reactive squamous epithelium without malignancy or eosinophilia. Four serial EGDs over 8 weeks with through the scope balloon dilations up to 12 mm provided minimal improvement. The diameter remained at 8 mm on his fifth EGD prompting repeat biopsies showing moderately differentiated SCC. The patient opted for palliative management. Discussion: This case highlights the difficulty of distinguishing benign radiation-induced esophageal strictures from recurrent malignancy. Refractory strictures—defined as failure to reach or maintain a luminal diameter ≥14 mm after 5 dilation sessions spaced 2 weeks apart—warrant further investigation. Sampling error is common and diagnostic yield increases significantly when at least 6 samples are taken from 4 quadrants of the stricture. Advanced imaging modalities can improve diagnostic accuracy. Endoscopic ultrasound offers better delineation of mural and periesophageal involvement than computed tomography or positron emission tomography. Newer techniques such as autoantibody panels and volumetric laser endomicroscopy-guided biopsy may enable earlier detection of recurrent SCC in patients. In any patient with esophageal strictures refractory to dilation or a failure to improve >3 mm after 2 EGDs, especially those with prior head and neck cancer, malignancy should be suspected and repeat biopsies should be obtained. Early repeated biopsy is critical for timely diagnosis and management, particularly in high-risk individuals with prior chemoradiation exposure.