Ann Thorac Surg 2010;90:1017-1019. doi:10.1016/j.athoracsur.2010.02.049
© 2010 The Society of Thoracic Surgeons
Case Reports
Resection of a Giant Esophageal Fibrovascular Polyp
Matthias Peltz, MD*,
Aaron S. Estrera, MD
Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas
Accepted for publication February 15, 2010.
* Address correspondence to Dr Peltz, Department of Cardiovascular and Thoracic Surgery, 5323 Harry Hines Blvd, Dallas TX 75390-8879 (Email: matthias.peltz{at}utsouthwestern.edu).
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Abstract
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Fibrovascular polyps of the esophagus are rare benign neoplasms of the esophagus. They frequently reach giant proportions before patients develop symptoms and a diagnosis is made. Endoscopic or surgical excision is the treatment of choice. We report a case of a giant fibrovascular polyp in a 79-year-old man that was detected incidentally. The mass was resected through a left neck approach. The patient remains symptom- and recurrence-free after a 2-year follow-up.
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Introduction
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Giant fibrovascular polyps, also known as esophageal lipomas, fibromas, fibromyxomas, fibroepithelial tumors, or fibrolipomatous polyps, are rare benign esophageal neoplasms that typically originate from the submucosa of the cervical esophagus near the upper esophageal sphincter [1–6]. These tumors represent approximately 1% to 2% of all benign esophageal neoplasms, and these are the most common benign intraluminal esophageal tumors [1, 2]. Their course is usually indolent, and these tumors tend to reach enormous proportions before patients have symptoms develop.
We report a case of a 79-year-old man who underwent a chest roentgenogram after presenting to his primary care physician with an upper respiratory tract infection. The roentgengram displayed a widened upper mediastinum prompting a computed tomographic scan of the chest. The computed tomographic scan demonstrated a large (4 x 13 cm) intraluminal esophageal mass originating from the anterior aspect of the cervical esophagus. There was no evidence of mediastinal adenopathy or other metastatic disease (Fig 1). The patient was further investigated with an esophagogastroduodenoscopy, which revealed a large, sausage-shaped, smooth, vascular mass emanating from the level of the cricopharyngeus. An endoscopic excision was considered, but this approach was abandoned because of the vascular appearance and size of the mass. The patient was subsequently referred for thoracic surgical evaluation. On further inquiry, the patient did report a 2-year history of slowly progressive, mild dysphagia to solids. He denied any weight loss and stated food usually passed easily with drinking liquids.
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Fig 1. Computed tomographic scan of the chest demonstrates a large, fat density, intraluminal lesion in the esophagus.
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The patient underwent resection through a left neck incision along the anterior border of the sternocleidomastoid muscle. The esophagotomy was made based on the location of the stalk on the preoperative computed tomographic scan. After initial delivery of the distal tumor through the esophagotomy, we were able to identify the stalk in proximity to our incision. The incision was then extended to permit submucosal en bloc resection of the stalk. Despite the tumor's generous size, we were able to deliver the mass through our esophagotomy and complete the excision. The esophagotomy was then closed in two layers. The patient recovered uneventfully and was discharged postoperative day 2. He remains symptom-free and recurrence-free. Pathology revealed a benign, giant (5.5 x 5.5 x 13 cm) fibrovascular polyp (Fig 2).
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Comment
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Giant fibrovascular polyps are an uncommon neoplasm of the esophagus. Some authors suggest fibrovascular polyps occur primarily in elderly males. However, the largest review to date reported a mean age at presentation of 56 years with essentially no sex difference [1]. Dysphagia (62% to 87%) is the most common presenting symptom, but this was minor and did not result in weight loss in our patient. Other reported symptoms include regurgitation of food or the mass (13% to 38%), sensation of a lump (25%), weight loss (13%), respiratory symptoms (25%), odynophagia (6% to 7%), and chest pain (8%) [1, 3, 4]. Asphyxiation from laryngeal obstruction after regurgitation of the mass has been described [2]. The diagnosis may be missed by radiographic studies and endoscopy because of the relatively benign features of the lesion. On endoscopy, fibrovascular polyps appear similar to normal mucosa, particularly when the distal end of the mass can not be visualized. This may result in failure to recognize the lesion [1, 3]. Chest roentgenogram abnormalities, most frequently widening of the mediastinum, have been reported in approximately half the patients. A computed tomographic scan demonstrates an esophageal intraluminal soft tissue density lesion. Barium studies typically show a smooth, sausage-shaped, intraluminal mass [1]. Treatment of these masses invariably requires resection for symptom control and to avoid the risk of laryngeal obstruction. Surgical approaches include endoscopic techniques or open excision, usually by a transcervical approach through the left neck [5]. Thoracotomy or even esophagectomy may be required for the largest lesions. Bleeding from the vascularized stalk and asphyxiation are concerns for endoscopic excision [6]. Despite this, small and even some larger lesions (up to 10 cm) have been removed endoscopically.
We agree with Alobid and colleagues [6] and Pham and colleagues [7] that because of the potential for fatal asphyxiation, airway control is important when entertaining endoscopic removal [6, 7]. Most large tumors (>10 cm in size) are removed surgically through a cervical approach and less frequently through a transthoracic approach. Five of 16 patients in the Armed Forces Institute of Pathology review by Levine and colleagues [1] required thoracotomy for excision. Formal esophageal resection may be required when the tumor can not be removed through the esophagotomy or the diagnosis is uncertain. Kanaan and DeMeester [4] reported on such a patient who had a transhiatal esophagectomy with esophagogastric anastomosis performed because of a preoperative biopsy that suggested a potentially malignant spindle cell tumor [4]. On histology, giant fibrovascular polyps appear to originate from the submucosa of the esophagus. These lesions contain varying amounts of fibrous tissue, adipose tissue, and vascular elements, covered by normal squamous epithelium. To our knowledge, only one case of malignant degeneration has been reported in the literature [1]. We performed a submucosal excision of the stalk because of the submucosal origin of these tumors and the potential for recurrence when the stalk is simply transected at its base [8].
In summary, giant fibrovascular polyps are uncommon benign neoplasms of the esophagus. Resection is recommended. Endoscopic excision or open surgical approaches have been used. Resection is usually curative and recurrence is rare.
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References
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- Levine MS, Buck JL, Pantongrag-Brown L, Buetow PC, Hallman JR, Sobin LH. Fibrovascular polyps of the esophagus: clinical, radiographic, and pathologic findings in 16 patients AJR 1996;166:781-787.[Abstract/Free Full Text]
- Sargent RL, Hood IC. Asphyxiation caused by giant fibrovascular polyp of the esophagus Arch Pathol Lab Med 2006;130:725-727.[Medline]
- Lüthen R, Janzik U, Derichs R, Balló, Ramp U. Giant fibrovascular polyp of the esophagus Eur J Gastroenterol Hepatol 2006;18:1005-1009.[Medline]
- Kanaan S, DeMeester TR. Fibrovascular polyp of the esophagus requiring esophagectomy Dis Esophagus 2007;20:453-454.[Medline]
- Lolley D, Razzuk MA, Urschel HC. Giant fibrovascular polyp of the esophagus Ann Thorac Surg 1976;22:383-385.[Abstract/Free Full Text]
- Alobid I, Vilaseca I, Fernandez J, Bordas JM. Giant fibrovascular polyp of the esophagus causing sudden dyspnea: endoscopic treatment Laryngoscope 2007;117:944-945.[Medline]
- Pham AM, Rees CJ, Belafsky PC. Endoscopic removal of a giant fibrovascular polyp of the esophagus Ann Otol Rhinol Laryngol 2008;117:587-590.[Medline]
- Belafsky P, Amedee R, Zimmerman J. Giant fibrovascular polyp of the esophagus South Med J 1999;92:428-431.[Medline]
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Abstract
Introduction
