Esophageal squamous papillomas

Esophageal squamous papilloma (ESP) is an uncommon epithelial lesion encountered incidentally during upper gastrointestinal endoscopy. For the endoscopist standing at the trolley, two practical questions follow detection: what should I do with this lesion now, and what should I do with this patient afterwards? The published answers are inconsistent. Series range from reports of benign behavior to case descriptions of malignant transformation, and the lack of a clear clinical pathway leaves trainees and experienced endoscopists alike uncertain whether to biopsy, excise, follow-up, or simply reassure. Drawing on a single-center review of 107 adults with histologically confirmed ESP identified through linked endoscopy and histopathology records spanning October 2007 to December 2025, we offer a practical commentary on the lesion as it presents in real clinical practice. No patient had dysplasia at the index endoscopy, one had a synchronous squamous cell carcinoma, and no metachronous dysplasia or carcinoma was identified during available follow-up. We use this experience to discuss how ESP can be approached pragmatically: when to biopsy versus excise, when to consider follow-up endoscopy, when to look for coexistent disease, how diffuse papillomatosis should be distinguished from a solitary lesion, what our data can and cannot say about human papillomavirus involvement, and how to communicate the diagnosis to patients without alarming them. Our central lesson is that an isolated, non-dysplastic squamous papilloma is, in most cases, a clinically minor finding, but it demands disciplined assessment of the wider mucosa and patient-level risk factors before being dismissed-a conclusion that is limited by a low follow-up rate in our cohort and should be read accordingly. We propose a simple, risk-based clinical framework, illustrated with representative endoscopic and histological images, intended for early-career endoscopists and the wider esophageal community.