S4239 Diagnostic and Therapeutic Role of Endoscopic Submucosal Dissection in Extensive Esophageal Leukoplakia

Introduction: Esophageal leukoplakia (epidermoid metaplasia) is a rare mucosal disorder characterized by white plaques with a potential risk for malignant transformation. Management guidelines are not standardized, but endoscopic submucosal dissection (ESD) has emerged as an effective tool for definitive treatment and accurate histologic assessment. Case Description/Methods: A 63-year-old woman with a history of coronary artery disease, chronic obstructive pulmonary disease, and chronic gastroesophageal reflux disease presented with dysphagia and significant weight loss. Esophagogastroduodenoscopy revealed circumferential severe mucosal alterations in the lower third of the esophagus (28–34 cm from incisors), characterized by granularity, scalloping, altered texture, and decreased vascular pattern. Enhanced visualization techniques including zoom magnification, white-light endoscopy, narrow-band imaging, and Lugol’s iodine solution 2% was applied into the esophagus, and after 2 minutes, a diffuse circumferential area of no uptake was noted between 28 and 34 cm from the incisors. Pathology demonstrated squamous epithelium with orthokeratosis and hypergranulosis, consistent with epidermoid metaplasia. Due to persistent symptoms and endoscopic suspicion of potential malignancy, the patient underwent ESD for definitive diagnostic and therapeutic purposes. A circumferential lesion measuring 10 × 10 cm was successfully resected en bloc without immediate complications. Pathology results from the ESD specimen are currently pending and will be updated upon availability. Discussion: This case highlights the diagnostic challenge posed by extensive esophageal leukoplakia and emphasizes the role of ESD in managing extensive lesions. The procedure provided a definitive histopathological diagnosis and symptom relief, supporting the consideration of ESD as a primary therapeutic option in extensive or suspicious cases. Furthermore, ESD may uncover deeper invasions or hidden pathology that could be missed on superficial biopsy or other diagnostic modalities. Endoscopic submucosal dissection is an effective and safe modality for managing extensive esophageal leukoplakia, offering both diagnostic accuracy and therapeutic benefit. Further studies and standardized guidelines are necessary to optimize the management of this rare condition.