Ann Thorac Surg 2006;81:393-396
© 2006 The Society of Thoracic Surgeons
Review
Large Pedunculated Polyps Originating in the Esophagus and Hypopharynx
Manuel Caceres, MD
a
,
*
,
Glen Steeb, MD
b
,
Sarah M. Wilks, MS
b
,
H. Edward Garrett, Jr, MD
a
a Department of Cardiothoracic Surgery, University of Tennessee, Memphis, Tennessee
b Department of Surgery, Louisiana State University Medical Center, New Orleans, Louisiana
* Address correspondence to Dr Caceres, 6029 Walnut Grove Road, Suite 401, Memphis, TN 38120 (Email: caceres_manuel{at}hotmail.com).
 |
Abstract
|
|---|
Large pedunculated esophageal and hypopharyngeal polyps are uncommon. Clinical presentation most commonly includes dysphagia and mass regurgitation. If left untreated the patient may develop polyp aspiration complicated by fatal asphyxiation. Diagnosis has depended on endoscopy and barium swallow historically; however, these procedures may fail to provide a diagnosis. In recent years computerized tomographic scan and magnetic resonance imaging have proved reliable methods of diagnosis. These polyps are located predominantly in the upper esophagus and frequently are comprised of a fibrous component. Malignant potential is low. Resection of these lesions is warranted; it may be approached endoscopically if feasible or surgically through a cervical or thoracotomy approach, depending on the location. Recurrence is rare. To our knowledge, this is the largest review of large esophageal polyps, including 110 reported cases in the literature.
|
Introduction
|
|---|
Large pedunculated polyps of the esophagus and hypopharynx are infrequently encountered in clinical practice. The rarity of these lesions was demonstrated by the fact that only two esophageal polyps were identified in 7,459 autopsies performed in the Mayo Clinic, in which 44 benign tumors of the esophagus were found [1]. Both of these patients had been asymptomatic. In spite of this, esophageal polyps attract considerable attention from the medical community due to their remarkable features upon presentation, which include regurgitation of the polyp into the mouth and possible asphyxiation secondary to polyp aspiration.
The majority of information regarding these lesions has been obtained from scattered case reports. Harrington [2] credited Sussius with the first autopsy report of an esophageal polyp in 1559. In 1763, Monroe reported one of the earliest treated cases, which was accomplished by simple transoral ligation [2]. Vinson [3] in 1922 was the first to describe, in the American literature, the successful surgical removal of a large esophageal polyp. It was approached through a left cervical incision. As of 1942, Samson and Zelman [4] had identified a total of 25 treated cases in the world literature; by 1984 Carter and Kulkarni [5] had updated the series to 60 cases.
This report updates the world literature to 110 reported cases of large (> 5 cm) pedunculated polyps originating in the esophagus and hypopharynx, which were identified during the patient's lifetime. The majority of these lesions have been successfully removed.
|
Material and Methods
|
|---|
The MEDLINE and PubMed databases (National Library of Medicine) were searched using two sets of keywords. The first search used the keywords: hypopharynx, esophagus, and esophageal independently. The second search used the keywords polyp, polypoid, lipoma, fibroma, hamartoma and pedunculated independently. Both searches were limited to human studies and cross-combined with each other using the "Boolean" operator "AND". The specific pathologic types: lipoma, fibroma, and hamartoma were used in the search, since these entities have been commonly reported to occur in this setting. There was no preset time frame specified, which generally involves a search back to 1950 as default.
The combined search resulted in 1,190 publications. The articles were addressed and selected for their validity and relevance with regard to the focus of the review. Only pedunculated polyps larger than 5 cm in size, including the stalk, were selected. Additional articles were identified from the references section in each article selected, when deemed applicable to the present study. These additional references corresponded mainly to publications reported prior to 1950.
|
Comment
|
|---|
Analysis of available data demonstrated that hypopharyngeal and esophageal polyps occur with a male to female ratio of 2.2 to 1. Average age at diagnosis was 54 years with a range of 19 months to 88 years. The vast majority of case reports give no information regarding the use of tobacco products or consumption of alcohol. Since both of these are risk factors associated with the development of malignant lesions of the upper gastrointestinal tract, the correlation of tobacco and alcohol use with formation of these large polyps would have been interesting to determine. Race was identified in only 14 case reports. Of these, 11 were Caucasian, 2 were Asian, and 1 was Hispanic.
Clinical Presentation
Dysphagia was the most frequently reported presenting symptom, occurring in 62% of the patients, with an average duration of 3.7 years. The dysphagia was usually progressive, starting with solids and then advancing to liquids. Presumably this progression coincided with an increase in polyp size. The second most common symptom was regurgitation of the mass into the mouth, which occurred in 38% of the patients (Fig 1). This was the only symptom in 15% of patients. Some clinicians had a tendency to dismiss this complaint as a figment of the patient's imagination, but regurgitation of the mass can be an ominous sign. There were 7 reported cases of fatal asphyxiation secondary to aspiration of a large polyp [4, 6–11].
View larger version (132K):
[in this window]
[in a new window]
|
Fig 1. Photograph of the patient on admission, with an esophageal polyp protruding through the mouth. (Chitty EC. A case of esophageal polypus accompanied by a tumor of an accessory thyroid gland. Br J Surg 1938;26:195-7 [28]. Copyright British Journal of Surgery Society Limited. Reproduced with Permission. Permission is granted by John Wiley and Sons Ltd on behalf of the BJSS Limited.)
|
|
The sensation of a persistent lump in the throat was reported by 25% of the patients. Weight loss was reported by 19%, with an average loss of 18 lbs. Other reported symptoms included: regurgitation of food (14%), nonexertional chest pain (8%), persistent cough (7%), odynophagia (7%), sore throat (5%), vomiting (2%), abdominal pain (1%), and melena (1%) (Table1).
Diagnostic Evaluation
An appropriate initial evaluation in patients presenting with theses symptoms should include a thorough history and physical examination, followed by a barium swallow and upper endoscopy. Upon review of the case reports it was found that 22% of initial contrast studies and 33% of initial endoscopic examinations failed to identify the presence of these polyps. Proximal dilation of the esophagus was mentioned on 24% of the contrast studies and the free passage of barium into the stomach was universally noted. Care should be taken in dismissing patients who present with similar symptoms and have a nondiagnostic initial workup. These polyps occasionally position themselves against the esophageal wall, giving the impression of a normal barium swallow or endoscopic evaluation. Repeat studies should be obtained and consideration should be given to obtaining a computed tomographic (CT) scan, magnetic resonance imaging (MRI), or endoscopic ultrasonography. When employed, either CT scan (n = 11) or MRI (n = 3) was able to confirm the diagnosis in all patients.
Location
Eighty-four percent of these polyps were found to originate in the esophagus. Of these, 76% had their pedicle attached at or near the upper esophageal sphincter (UES), 15% were attached in the upper esophagus, 3% in the middle esophagus, and 6% in the lower esophagus. Of those originating at the level of the UES, most had their pedicle attached to the posterior wall (Table 2). The remaining 16% had their pedicle based in the hypopharynx, most commonly on the left lateral wall. These lesions probably originate as benign submucosal tumors and, with the propulsive movements of swallowing, are pulled with their thin mucosal lining into the esophagus to become pedunculated polyps. The repetitive forces of esophageal peristalsis cause their stalks to elongate slowly over time ([4, 12).
Surgical Pathology
Grossly, these polyps usually appear pink and smooth. They range in consistency from firm to rubbery. Occasionally they are multilobate and 19% have an ulcer present on their most distal aspect. Ulcer formation is believed to be due to contact with the acidic contents of the stomach. Anemia was reported in 11% of patients, but the presence of an ulcer on the polyp was noted in only one-half of these. Average polyp length was found to be 13.3 cm (range, 5 cm to 28 cm), with an average width of 3.8 cm (2.6 cm to 4.8 cm). The pedicle almost universally represented the narrowest portion of the polyp. Histologic examination revealed a variety of cell types, probably originating as benign submucosal tumors (Table 3), with a fibrous component seen in the majority of cases. Chronic inflammation was noted on 22% of the histologic reports. The overlying mucosa was uniformly found to consist of stratified squamous epithelium identical to that of the normal esophagus. This may explain why approximately one-third of lesions were missed at initial endoscopy.
Malignant Transformation
Malignant degeneration of these large polyps occurs infrequently. There have been only four such reported cases. In two instances, an epidermoid carcinoma originated in the mucosa overlying an esophageal polyp [13, 14]. In one report a pedunculated esophageal lipoma underwent sarcomatous change [15]. Bréhant and colleagues [16] recently reported a case of a giant liposarcoma of the esophagus, arising from the upper esophagus, and extending by a long peduncle into the stomach. After a failed attempt at endoscopic resection, removal of the tumor was approached through a left cervical incision for transection of the pedicle and a laparotomy with a gastrotomy for retrieval of the mass.
There have been scattered reports in the literature of small pedunculated polyps developing over squamous cell carcinomas and adenocarcinomas of the middle and distal esophagus. However, these are believed to be separate clinical entities.
Treatment
Because of potentially disastrous complications, surgical excision of benign hypopharyngeal and esophageal polyps is strongly recommended. This can be accomplished using a transoral, transcervical, or transthoracic approach, with the strategy dependent on the location and size of the polyp.
Hypopharyngeal polyps have been removed by laryngoscopic or endoscopic ligation (80%) or through a cervical incision (20%). The only reported complication was by Liliequist and Wiberg [17], in 1974, whose patient had a large lipomatous polyp originating in the left hypopharynx. It was removed by undisclosed means and it was reported that the patient died in his sleep on the second postoperative day of unknown causes. The autopsy disclosed a second pedunculated polypoid mass, "the size of a hen's egg," attached to the right aryepiglottic fold.
Those polyps found to originate in the esophagus were removed by means of endoscopic ligation (22%), cervical incision (47%), and thoracotomy (31%) or, in one case, by yttrium aluminum garnet (YAG) laser vaporization [18]. In all but four of these cases the polyp was simply excised.
The remaining four polyps were managed by esophageal resection. Bak and Kim [15] performed a total esophagectomy with colon interposition graft for their patient who had sarcomatous change found in an esophageal lipoma. After an initial anastomotic leak the patient was reportedly doing well seven months postoperatively. McBride [19], Burrell [20], and Venn and colleagues [21] performed esophagectomies through a left thoracotomy for large benign esophageal polyps. McBride's patient died of postoperative hemorrhage due to incomplete excision of the polyp. The other two patients who underwent total esophagectomies recovered uneventfully.
Nonoperative strategies for treating these lesions are of historical interest only and are to be avoided. Hyatt and Kravitz [22] reported using esophageal dilatation to treat a 79-year-old patient with a large fibromyomatous esophageal polyp. Although short-term resolution of symptoms was provided, long-term outcome was not disclosed. Both Moersch and Harrington [1] in 1928 and Mahoney [23] in 1937 used endoscopic placement of radium seeds as the sole treatment for large benign esophageal polyps. The former patient had persistent symptoms and the latter had no report of follow-up.
There were four reported cases of recurrence after polypectomy. Timmons and colleagues [24] reported a fibrovascular polyp originating at the UES, which was removed by endoscopic ligation in 1980. It recurred in the same place in 1986 and 1988, and both times was excised through a cervical incision. Eberlein and colleagues [25] reported a case of a polypoid schwannoma with its base just below the UES, which was originally removed through a left cervical incision in 1969, but recurred in 1983 and 1992. Each time it was removed through a left cervical incision and there have not been any further reports of recurrence since 1992. Gormon [26] in 1962 described an esophageal polyp excised through a left cervical incision that had been previously excised twice by undisclosed means. Som and Wolff [27] in 1952 reported a case of a patient in whom he removed a pedunculated hypopharyngeal lipoma by laryngoscopic ligation. Six years previously that patient had a similar hypopharyngeal polyp removed laryngoscopically. When managing these polyps through an open approach, any redundant esophageal mucosa around the stalk of the polyp should be resected: this may prevent further recurrences caused by the continuous propulsive forces of the esophagus.
The surgical approach to these large polyps should be decided on a case-by-case basis. Endoscopic ligation appears to be a reasonable alternative to operative exploration if it can be accomplished safely in the hands of an experienced endoscopist. Of primary concern is the potential for large polyps to cause airway compromise during endoscopic retrieval, and the need to obtain hemostasis at the transected pedicle, which is frequently well-vascularized. If surgical removal is warranted, a left cervical approach is appropriate if the base of the polyp can be identified with certainty in the hypopharynx or upper esophagus. Otherwise, a thoracotomy may be necessary. The transthoracic approach, using an esophagotomy through the wall opposite to the lesion, allows complete excision and mucosal approximation under direct vision.
Summary
Large pedunculated esophageal and hypopharyngeal polyps are relatively uncommon. They tend to occur in older male patients and their discovery is usually preceded by a history of progressive dysphagia, regurgitation of the mass, or the sensation of having a persistent lump in the throat, Although the regurgitated mass is usually reswallowed, this event has led to fatal asphyxiation on several occasions. The pedicle most frequently originates from the posterior wall of the esophagus at or near the UES. Negative contrast and endoscopic studies should be accepted with caution and repeated if necessary. A CT scan and MRI may also identify the lesion. These lesions are almost always benign and the method of polypectomy (endoscopic versus surgical) is determined on a case-by-case basis. Malignant degeneration is unusual and, following polypectomy, these lesions rarely recur.
|
References
|
|---|
- Moersch JH, Harrington SW. Benign tumor of the esophagus Ann Otol Rhinol Laryngol 1944;53:800-817.
- Harrington SW. Surgical treatment of benign and secondary malignant tumors of the esophagus Arch Surg 1949;58:646-661.[Abstract/Free Full Text]
- Vinson PP. A pedunculated lipoma of the esophagus JAMA 1922;78:801-802.[Abstract/Free Full Text]
- Samson P, Zelman J. Pedunculated tumors of the esophagus Arch Otolaryngol 1942;36:203-211.[Abstract/Free Full Text]
- Carter M, Kulkarni M. Giant fibrovascular polyp of the esophagus Gastrointest Radiol 1984;9:301-303.[Medline]
- Weyrich G. Sudden death due to a pedunculated lipoma of the esophagus Deutsche Ztschr f.d.ges.gerichtl. Med 1933;21:164-167.
- Holt B. Fatty pendulous tumor of the pharynx and larynx Trans Path Soc Lond 1854;5:123-125.
- Penfold JB. Lipoma of the hypopharynx Br Med J 1952;1:1286.[Free Full Text]
- Allen MS, Talbot WH. Sudden death due to regurgitation of a pedunculated esophageal lipoma J Thorac Cardiovasc Surg 1967;54:756-758.[Medline]
- Lejune F. Benign pedunculated esophageal tumors Ann Otol Rhinol Laryngol 1955;64:1261-1269.[Medline]
- Cochet B, Hohl P, Sans M, et al. Asphyxia caused by laryngeal tumor of an esophageal polyp Arch Otolaryngol 1980;106:176-178.[Abstract/Free Full Text]
- Bernatz P, Smith J, Ellis H, et al. Benign, pedunculated, intraluminal impaction of the esophagus J Thoracic Cardiovasc Surg 1958;35:503-512.[Medline]
- Marcial-Rojas R. Epidermoid carcinoma in mucosa overlying a pedunculated lipoma of the esophagus J Thorac Surg 1959;37:427-434.[Medline]
- Stout AP, Lattes R. Tumors of the esophagus Atlas of Tumor Pathology, Fascicle 20. Washington, DC: Armed Forces Institute of Pathology; 1997.
- Bak YT, Kim JH. Liposarcoma arising in a giant lipomatous polyp of the esophagus Korean J Intern Med 1989;4:86-89.[Medline]
- Bréhant O, Pessaux P, Hennekinne-Mucci S, et al. Giant pedunculated liposarcoma of the esophagus J Am Coll Surg 2004;198:320-321.[Medline]
- Liliequist B, Wiberg A. Pedunculated tumor of the esophagustwo cases of lipoma. Acta Radiol Diagn (Stockh) 1974;15:383-392.[Medline]
- Naveau S, Bedossa P. Successful ablation of a large fibrovascular polyp of the esophagus Gastrointest Endosc 1989;35:254-256.[Medline]
- McBride AF. Benign polypoid tumor of the esophagus Cancer 1951;4:708-716.[Medline]
- Burrell M. Fibrovascular polyp of the esophagus Am J Dig Dis 1973;18:714-718.[Medline]
- Venn GE, DaCosta P, Goldstraw P. Giant esophageal hamartoma Thorax 1985;40:684-685.[Free Full Text]
- Hyatt I, Kravitz SC. A benign tumor of the esophagus in an elderly femalecase report. Gastroenterology 1959;37:7748.[Medline]
- Mahoney JJ. Polypoid tumors of the esophagus Laryngoscope 1940;50:1086.
- Timmons B, Sedwitz JL, Oller DW. Benign fibrovascular polyp of the esophagus South Med J 1991;84:1370-1372.[Medline]
- Eberlein T, Hannan R, Josa M, et al. Benign schwannoma of the esophagus presenting as a giant polyp Ann Thor Surg 1992;53:343-345.[Abstract]
- Gormon JB. Esophageal polypcase report. Va Med Mon 1962;89:311-312.[Medline]
- Som M, Wolff L. Lipoma of the hypopharynx producing menacing symptoms AMA Arch Otolaryngol 1952;5:524-531.
- Chitty EC. A case of esophageal polypus accompanied by a tumour of an accessory thyroid gland Br J Surg 1938;26:195-197.
Top
Abstract
Introduction
