Lessons learned: the importance of timely recognition of verrucous squamous cell carcinoma in the esophagus

Verrucous carcinoma of the esophagus (VCE) is a rare variant of squamous cell carcinoma that poses diagnostic challenges due to nonspecific endoscopic and histologic findings. Its typical Candida overgrowth and hyperkeratotic, non-malignant superficial layer, combined with biopsy results showing fungal hyphae and minimal cytological atypia, are often misleading. Consequently, VCE is frequently diagnosed at advanced stages, limiting curative treatment options and contributing to poor outcomes. Clinicians should consider VCE in patients with persistent verrucous or hyperkeratotic esophageal lesions, especially in the setting of chronic Candida esophagitis. In this commentary, we reflect on seven cases diagnosed at a Dutch tertiary referral center to illustrate diagnostic pitfalls, discuss various treatment options, and offer guidance for improved recognition of VCE. By facilitating earlier diagnosis, curative treatment through endoscopic resection becomes more feasible, ultimately improving patient outcomes.