- James C. Chou, MD & Frank G. Gress, MD
Benign Esophageal Tumors
A variety of benign mass lesions can arise from different wall layers in the esophagus (Table 18-6). These tumors are usually asymptomatic and slow growing, noted only as incidental findings during routine radiography or endoscopy. Occasionally, they may be discovered during the evaluation of dysphagia or vague chest discomfort. The most common benign esophageal tumor is the leiomyoma. Because the tumor arises from the muscularis propria, it is covered by an intact submucosa and mucosa, making it difficult to biopsy endoscopically.
Inflammatory polyps and granulomas can arise in the setting of esophagitis and may be confused with malignant lesions from time to time. Endoscopic removal is possible, although usually not indicated. Endoscopic biopsy and regression with therapy for esophagitis clearly distinguish the clinical course of inflammatory polyps and granulomas from cancers.
A. Symptoms and Signs
Although the vast majority of benign esophageal tumors are clinically silent and go undetected, large or strategically located tumors may become symptomatic. Similar to their malignant counterparts, dysphagia is the most common presentation for patients with benign esophageal tumors. Less common presenting symptoms include odynophagia, retrosternal pain or thoracic pressure, food regurgitation, anorexia, and weight loss. Respiratory complaints such as cough, dyspnea, or sore throat may also contribute to the presentation. Occasionally, leiomyomas can outgrow their own blood supply, leading to necrosis and ulceration of the overlying mucosa and resulting in overt GI hemorrhage such as hematemesis or melena.
Endoscopic appearance and biopsy can identify some benign esophageal tumors. However, EUS provides high-resolution images that define the individual esophageal wall layers and can readily identify lesions in the deeper layers (ie, submucosa and muscularis propria) that elude endoscopic biopsy diagnosis.
If necessary, EUS-guided FNA can be performed for diagnostic purposes. Leiomyomas are generally noted as hypoechoic mass lesions within the muscularis propria. Occasionally, the echopattern is more heterogeneous, which may indicate hemorrhage into the tumor. Cystic lesions may appear as anechoic structures within the mucosa and submucosa, whereas inflammatory growths are always superficial and localized to the mucosa.
Small, mucosal-based and submucosal esophageal tumors can be removed endoscopically using EMR techniques or possibly obliterated by endoscopic injection of sclerosants or by APC. Larger mass lesions, especially leiomyomas, are generally removed surgically if they are associated with severe symptoms or other complications, eg, bleeding. In many instances, the resection can now be accomplished by minimally invasive techniques.
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