Neoplasia
Introduction
Most esophageal tumors are malignant. All esophageal lesions, benign or malignant, typically grow to a fairly large size before causing symptoms. The esophageal lumen usually needs to be significantly decreased (e.g., 20 mm down to 12–13 mm) before a patient complains of dysphagia. Therefore, patients typically present late in the course of their disease. Early detection of malignant or dysplastic lesions would likely result in improved survival. With the advent of unsedated transnasal esophagoscopy, there is a good likelihood that more frequent examination of the esophagus will result in the detection of esophageal neoplasms at an earlier stage. This may ultimately portend a better outcome for patients with esophageal cancer.
Cup biopsy forceps or biopsy brushes can be readily used to sample the vast majority of exophytic or flat intraluminal lesions. Care should be taken in the decision to biopsy submucosal or potentially vascular lesions due to the possibility of uncontrolled bleeding. The key to the evaluation of submucosal lesions is endosonography.
Benign Esophageal Neoplasms
Most benign esophageal tumors, except for fibrovascular polyps, are located in the distal two thirds of the organ. Benign esophageal tumors can be classified clinically into those found within the lumen, whether mucosal or submucosal, and those that are extraluminal. Extraluminal esophageal neoplasms are more common than luminal tumors (1).
Leiomyoma
Leiomyomas are the most common benign esophageal neoplasm (2). They generally occur in men between the second to fifth decade of life. They are found in the distal esophagus, where smooth muscle predominates. The endoscopic appearance is a discrete bulging of the esophageal lumen without disruption of the mucosa. In addition, leiomyomas are mobile and the esophagoscope can be passed readily across the area of luminal narrowing. The diagnosis of leiomyoma is very difficult to make endoscopically and thus is generally made on radiographic examination of the esophagus or during endoscopic ultrasound (3).
Esophageal Cyst
Esophageal cysts are the second most common benign esophageal tumor and can be further classified into the more common inclusion cysts (intramural), or duplication cysts (extramural) (3, 4). Esophageal cysts are typically asymptomatic and are found incidentally during radiographic examination of the esophagus or during endoscopy. The inclusion cysts are usually found in the upper esophagus adjacent to the tracheal bifurcation. They are generally managed without surgery. In contradistinction, duplication cysts primarily occur in the lower third of the esophagus, and their lining may consist of gastric mucosa, thereby producing acid. Acid-producing duplication cysts can cause ulceration; thus excision of these cysts are generally recommended (5). Because they are extraluminal, their endoscopic appearance is characterized by a vague narrowing of the esophageal lumen without disruption of the mucosa.
Fibrovascular Polyp
Fibrovascular polyps are the most common benign intraluminal tumor (6). Generally they are pedunculated, grow slowly, and can become quite long, some > 20 cm (7, 8). Because fibrovascular polyps grow and can cause obstruction or bleeding as necrosis of the tip of the polyp occurs, excision is recommended (9).
Granular Cell Tumor
Granular cell tumors are rare and typically asymptomatic. Over half are found in the distal one-third of the esophagus (3). Clinically they appear as smooth, oval, submucosal polypoid masses that are firm, pale, yellow, and sessile. They are generally <2 cm in diameter (10). Granular cell tumors are rarely malignant (1%–3%) and do not transform into malignancies (11, 12).
Lipoma
Lipomas are rare submucosal tumors that are detected during esophagoscopy as a bulging of the overlying esophageal mucosa. Lipomas typically arise in the upper one third of the esophagus and are soft and pale yellow (Fig. 8.1
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