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Benign oesophageal tumours

Section: UGI Sub-section: Oesophagus Curriculum: Curriculum, page 94

Overview

Mucosal Tumours

  • Fibrovascular Polyps
  • Squamous Papillomas

Fibrovascular Polyps

  • Heterogenous group of soft tissue tumours
    • Fibromas, fibrolipomas, myomas, and lipomas
    • Contain a mixture of fibrous, vascular, and adipose tissue covered by squamous epithelium
  • Risk
    • Men 75%
    • 60-70’s
  • Clinical
    • Location
      • Cylindrical or elongated with stalk
      • 85% found cervical oesophagus or by cricopharyngeus
    • Presentation
      • Mostly asymptomatic until very large
      • Giant ones can cause severe dysphagia
      • Can also prolapse into hypopharynx (causing airway obstruction!)
  • Management
    • Most can be resected endoscopically
    • EUS prior to resection ?feeding vessel
    • Endoscopic resection can be technically difficult when the stalk is attached to the proximal esophagus. Surgical resection may be required if a large feeding vessel is present or if the base of the stalk is endoscopically inaccessible.

Oesophageal squamous papillomas

  • Most frequent benign epithelial tumours of the oesophagus
  • Usually associated with some underlying inflammation
  • Distinctive endoscopic appearance
    • Most often middle or lower 1/3
    • Colourless, exophytic lesions
      • Can be sessile or partly pedunculated
    • Well demarcated
    • Usually < 5mm
  • Very rarely become large and symptomatic
  • Excision biopsy warranted to exclude malignancy

Submucosal Tumours

Granular Cell Tumours

  • Found in skin, respiratory tract, GI tract, breast, tongue
  • Distal 1/3 oesophagus most common location
  • Bulging lesion with overlying normal mucosa
    • Standard biopsies may be non-diagnostic
    • Tunnelled biopsy shows eosinophilic granules
    • Stain positive for S100
  • EUS shows regular bordered lesion in 1st or 2nd sonographic layer
  • Mostly benign, 1-2% malignant
  • If symptomatic, atypical EUS, size > 2cm consider resection
  • EMR for biopsy and treatment if feasible

Other Submucosal Tumours

Lipomas

  • Characteristic, homogeneous, hyperechoic, smooth appearance on EUS
  • Symptoms are rare even with large tumours
  • Resection is seldom warranted

Haemangiomas

  • Typically purple or reddish nodule
  • Smooth, hypoechoic, submucosal mass on EUS
  • Most asymptomatic
  • If dysphagia or bleeding – treat endoscopically

Neural tumours

  • Neurofibromas and schwannomas
  • Rare in the oesophagus
  • Majority benign
    • Handful of case reports on malignant oesophageal schwannoma
  • Symptomatic tumours
  • Resected by enucleation
  • Large tumours may require oesophagectomy

Muscularis Propria

Leiomyoma

  • Most common benign Mesenchymal tumours of oesophagus
    • M > F 2:1
    • Typically distal or middle 1/3
  • Arise in muscularis propria
    • Most < 3cm
  • Most asymptomatic
    • If larger can cause dysphagia
  • Form hard white/greyish mass
  • Shows smooth filling defect on barium swallow
  • Similar round, smooth defect with overlying normal mucosa on OGD
  • EUS shows regular bordered, hypoechoic lesions arising from muscularis
  • Can manage small (< 2cm), classically appearing lesions conservatively unless symptomatic
    • Enucleate if uncertain or symptomatic
      • NB: Biopsy = Harder to enucleate!
  • Immunostains for Desmin and Smooth Muscle Actin
    • Differentiates from GIST
      • Stains for KIT and DOG1
  • DDX Leiomyosarcoma, GIST

Duplication Cyst

  • Congenital anomalies, arising in early embryonic development
    • Most commonly small intestine
    • Can be oesophagus, stomach, colon
    • Oesophagus seen in 1:8000 live births
  • 3 criteria
    • Lay in wall of oesophagus
    • Covered by two muscle layers
    • Contain squamous epithelium
      • Or lining compatible with tissue found in oesophagus
  • Up to 1/3 contain heterotrophic gastric mucosa
    • Can also have pancreatic mucosa or mucosa consistent with Peyer’s Patches
  • 80% do not communicate with oesophageal lumen
    • Others run in parallel and do communicate
  • Most commonly on the right lateral portion of oesophagus
  • Frequently cause symptoms (unlike in other parts of the GI tract)
    • Because of this, most diagnosed before the age of 2
    • Symptoms from compression
      • Dysphagia
      • Epigastric or retrosternal pain
      • Respiratory symptoms (cough, stridor, wheeze)
  • Surgically resect symptomatic cysts
  • Malignancy rare but has been reported

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