Benign tumors of the esophagus are rare cases encountered by a variety of specialists including gastroenterologists, general surgeons, and thoracic surgeons. The clinical presentation of these lesions may vary from asymptomatic, incidentally discovered tumors (most common) to large lesions resulting in important dysphagia or airway compromise. The development of minimally invasive approaches to esophageal pathology over the last decade has expanded the diagnostic and treatment options for these lesions.
Benign tumors represent less than 1% of all esophageal tumors, and less than 10% of all surgically resected esophageal lesions.1,2 They may be classified based on either histology or location within the esophageal wall (mucosal, submucosal, or extraluminal) (Tables 29-1 and 29-2). The most common lesions include leiomyomas, esophageal cysts, fibrovascular polyps, and granular cell tumors. The development of endoscopic ultrasound (EUS) has improved the preoperative diagnosis of these lesions and is a helpful adjunct for clinical decision-making. Many of these lesions have a characteristic radiological appearance that eliminates the need for biopsy in many cases. Fine-needle aspiration (FNA) is often not required for diagnosis and may not be diagnostic in all lesions (e.g., in differentiating leiomyoma from leiomyosarcoma). Forceps biopsy is appropriate for mucosal lesions, but usually is unhelpful for submucosal or deeper lesions.
Table 29-1Classification of Benign Esophageal Lesions By Cell Type |Favorite Table|Download (.pdf) Table 29-1Classification of Benign Esophageal Lesions By Cell Type
|Epithelial ||Squamous cell papilloma |
|Nonepithelial ||Leiomyoma |
|Heterotopic ||Granular cell tumor |
Table 29-2Classification of Esophageal Lesions By Location |Favorite Table|Download (.pdf) Table 29-2Classification of Esophageal Lesions By Location
|TUMOR TYPE ||ANATOMIC LOCATION ||EUS LAYER |
|Leiomyoma ||Muscularis propria ||4 |
|Esophageal cyst ||Extramural ||4–5 |
|Fibrovascular polyp ||Mucosa ||1–2 |
|Squamous cell papilloma ||Mucosa ||1–2 |
|Granular cell tumor ||Mucosa/submucosal ||1–3 |
|Hemangioma ||Submucosa ||2–3 |
|Lipoma ||Submucosa ||3 |
Benign tumors are generally asymptomatic and are discovered incidentally on imaging studies. Dysphagia is the most common presenting symptom and is more common with intraluminal tumors. Other presenting symptoms vary depending on the lesion, as described below, but may include vomiting, weight loss, gastrointestinal (GI) bleeding, substernal discomfort, cough, or regurgitation of pedunculated cervical lesions. Examples of intraluminal tumors include squamous cell papillomas, fibrovascular polyps, inflammatory pseudopolyps, and fibroneuroid tumors. Fibrovascular polyps are the most common, arise from the cervical esophagus, and generally are seen in men in the sixth or seventh decade of life. Squamous cell papillomas are small, sessile lesions found in the distal esophagus, most commonly seen in elderly patients.