Teaching Case

Laryngoscopy was normal. Oesophagoscopy revealed a deformation of the posterior wall of the oesophagus but no polyp was described. A biopsy of the "posterior oesophageal wall" was conducted and depicted a normal epithelium intermingled with areas of low grade dysplasia.

Cervical and thoracic CT showed a hypodense mass, confined to the oesophageal lumen, distally surrounded by positive oral contrast and air (Fig. 1). The mass displayed areas of very low attenuation compatible with a predominant fat content. The patient also underwent MRI which showed a mass with spontaneous hyperintensity on T1-weighted images, with substantial signal intensity loss when fat-supression was applied (Fig. 2). The barium swallow study depicted a dilated upper oesophagus containing a long segment-filling defect (Fig. 3).

Since the stalk of the tumour was not individualised in a subsequent endoscopic procedure, removal was not attempted by oral route. The patient underwent a lateral pharyngoesophagotomy and a large submucosal neoplasm was then removed (Fig. 4). The polyp measured 21 cm in length and its distal end was ulcerated.

Pathological examination revealed a huge sub-mucosal polyp covered by stratified squamous epithelium. The tumour was predominantly composed of fibrous tissue, with an admixture of adipose and myxoid tissues intermingled with thin-walled blood vessels.

The patient recovered well after surgical removal and remained asymptomatic 6 months after the procedure.

Benign oesophageal tumours have been classified as intramural and intraluminal, with the latter consisting mostly of fibrovascular polyps [1,2], which, on pathological examination, tend to reveal a predominant fibrous stroma with small vascular component and variable amounts of myxoid and adipose tissues. Depending on the amount of these tissues the polyps have been described as "fibromas", "fibromyxomas", or "lipomas of the oesophagus". Levine et al. [3] consider that histological patterns do not appear to represent clear cut entities and since they all share a common clinical presentation the broader term "fibrovascular polyp" should be adopted.

As in the case reported, most of these polyps arise in the region of the cricoid muscle, are typically long, ranging from 7 cm in length to more than 20 cm [4]. Due to their large size they tend to manifest themselves in dysphagia and globus and approximately half of the patients refer to regurgitation of the polyp into the mouth. Death by regurgitation and obstruction of the upper airways has been reported [2]. Despite their large size and growing potential, malignant transformation is quite rare. More frequently, ulceration of the distal tip of the polyp may lead to acute blood loss, anaemia, or melaena.

Because the mucosa covering the polyp is identical to the remainder of the oesophagus and because of its mobility it is not surprising that even giant polyps can remain undiagnosed on endoscopic studies [2,5]. Imaging findings, both barium swallow and sectional methods, are, in this regard, clearly advantageous over endoscopic procedures. CT and MRI also have the potential to analyse the mass structure using density mesurements or signal intensity evaluation thus enabling prompt recognition of its typical internal fat content.

In general the treatment of these lesions is surgical, using a cervical or transthoracic oesophagotomy approach, depending on the site of attachment of the stalk of the lesion. If a narrow or a short stalk can be demontrated, endoscopic removal can also be considered as a treatment option.