Benign oesophageal tumours

Pathophysiology

• Benign tumours more commonly occur in submucosa and muscularis propria than in the mucosa

Mucosal tumours

Granular cell tumours

• • • Found in skin, respiratory tract, GIT, breast, tongue
    • 11% of patients have multiple tumours
    • Derive from Schwann cells (nerve sheath origin)
    • Can also occur in submucosa
    • Distal third of oesophagus is most common location in GIT
      • Sessile or bulging whitish-grey lesions with often normal-appearing mucosa
    • Standard biopsies often non-diagnostic due to overlying epithelium. Tunnelled biopsies reveal eosinophilic granules.
    • 98-99% are benign
    • Indications for excision: atypical features on EUS, size >2cm, presence of symptoms
    • Generally excise endoscopically

Fibrovascular polyps

• • • Mostly found in cervical oesophagus at or near the cricopharyngeus
    • Cylindrical or elongated, with a stalk
    • Symptoms are rare
    • Can resect endoscopically if needed

Squamous papillomas

• • • Most often found in distal oesophagus
    • Usually associated with underlying inflammation, and possibly HPV
    • Colourless, exophytic, wart-like projections
    • Often seen with a crossing vessel on the surface
    • Excise completely to rule out carcinoma

Submucosal tumours

Lipoma

• • • Homogenous, hyperechoic, smooth appearance on EUS
    • Symptoms rare
    • Resection seldom needed

Haemangioma

• • • Purple or reddish nodule
    • EUS - smooth, hypoechoic, submucosal mass
    • Mostly asymptomatic
    • Can cause dysphagia or bleeding
    • If symptomatic, can be treated endoscopically

Neural tumour

• • • Neurofibroma, schwannoma
    • Rare in oesophagus
    • Commonly seen in upper oesophagus
    • Yellow-white-tan rubbery lesions with glistening smooth surface
    • Majority benign, but can transform into malignant schwannoma
    • Symptomatic tumours can be enucleated endoscopically
    • Large tumours may require oesophagectomy

Muscularis propria tumours

Leiomyoma

• • • Most common benign tumour of oesophagus
    • Arises from muscularis propria, although very rarely can arise from muscularis mucosae
    • 2:1 male predominance
    • Usually asymptomatic
    • Usually found in mid to distal oesophagus - more smooth muscle there
    • Round protrusion into the lumen of the oesophagus with smooth, normal mucosa
    • EUS - hypoechoic, regular borders, arise from the fourth endosonographic layer
    • Small asymptomatic suspected leiomyoma can be observed without biopsy
    • Don't biopsy if suspected based on EUS - will complicate attempts to enucleate subsequently, by scarring up the layers
    • Symptomatic lesions can be enucleated
    • Larger lesions can be removed via VATS or endoscopically - endoscopic resection with creation of a submucosal tunnel for leiomyomas up to 5.5cm

Presentation

• Mostly asymptomatic

Investigation

• Barium swallow - smooth defect in the lumen
• Gastroscopy
• CT

Differential diagnosis (see 'oesophageal cancer' topic)

• Leiomyosarcoma
• GIST