Lipoma of the oesophagus

Clinical History

Sixty-five year-old man complaining of minimal dysphagia and dyspepsia for many years. The clinical interview disclosed a history of hypertension, diabetes and a surgically removed groin lipoma. Physical examination revealed no abnormalities and laboratory data were normal.

Imaging Findings

Frontal chest radiograph showed a right-sided, lobulated mass in superior mediastinum (figure 1) and lateral radiograph revealed increase in soft-tissue density behind the trachea (figure 2).
A barium swallow of the upper gastrointestinal tract displayed a submucosal lesion at the T3-T8 level. The mass appeared like a filling defect in a dilated oesophagus and it could be falsely interpreted as achalasia with food retention (figure 3).
Contrast-ehanced CT of the chest revealed an oblong-shaped fat-attenuating and submucosal mass which measured 4 x 3 x 11 cm, in upper oesophagus (figure 4). The lesion was encapsulated (surrounding thin rim of contrast). No significant mediastinal or hilar adenopathy, lung or liver metastasis was apparent.
Upper gastrointestinal echo-endoscopy demonstrated an echogenic, smooth, mobile and ovoid lesion was encountered distal to the cricopharyngeus muscle surrounding the oesophagus (figure 5).
Upper gastrointestinal endoscopy showed a submucosal, yellow, space-occupying mass with pliability and smooth surface without ulceration (figure 6).

Discussion

Benign tumours of the oesophagus, especially lipomas, are uncommon. Lipomas have been found in all segments of the digestive tract.
Oesophageal lipomas account for only 0,4% of benign tumours of the gut [1, 2]. They usually originate in the cervical and upper thoracic oesophagus.
Lipomas are well-circumscribed mesenchymal tumours that originate from adipose tissue. These lesions are usually submucosal, slowly-growing and small. Solitary pedunculated large tumours often occur in adults, predominantly men [3].
These lesions can be classified as fibrovascular polyps.
Many cases (>85%) are asymptomatic and are found incidentally, whereas symptoms include dysphagia (the most frequent complaint), epigastric pain, weight loss and bleeding (ulceration). These tumours can be associated with recurrent respiratory infections [1]. Death from asphyxia, related to laryngeal impaction of a regurgitated lesion (some develop a long pedicle and prolapse) has been described [3].
Frontal chest radiography may reveal a right-sided, slightly lobulated, soft-tissue lesion in the superior mediastinum, while lateral film may demonstrate increased retro-tracheal soft-tissue density associated with compression and anterior bowing of the trachea [4].
A barium swallow of the upper gastrointestinal tract shows a mass in relationship to the oesophagus, its smooth surface and the obtuse angle between the lesion and the oesophageal lumen suggest a submucosal mass.
On CT, the finding of a homogeneous mass with Hounsfield units between -80 and -120 is virtually diagnostic of a lipoma [5]. It helps to plan better preoperatively the surgical approach for removal.
MR imaging can also show the extent and confirm the fatty nature of the lesion.
Endoscopic ultrasound may display a homogeneous hyperechogenic mass with smooth outer margins in oesophageal submucosa.
Upper gastrointestinal endoscopy shows a yellow colour oesophageal lesion, pliability and smooth surface.
Imaging is often diagnostic but the definitive diagnosis is made by the pathologist.
Although the literature includes a single case of a pedunculated oesophageal lipoma with squamous cell carcinoma of the overlying mucosa [6], malignant degeneration of these tumours is thought to be extremely rare.
Surgical or endoscopic resection should be recommended for all symptomatic cases [1].
Lipoma of the oesophagus is an extremely rare and benign tumour.
It is typically detected incidentally but it can present with local symptoms and rarely with life-threatening complications.
The diagnosis is established based on the findings of CT or MR, endoscopic ultrasound examination and upper gastrointestinal endoscopy, which evaluate the origin, extent, surface and consistency of oesophageal lipoma.
Management options vary depending on the size and location of the mass.

Differential Diagnosis List

Final Diagnosis

Lipoma of the oesophagus

URL:	https://eurorad.org/case/9517
DOI:	10.1594/EURORAD/CASE.9517
ISSN:	1563-4086