Differentiation of Benign Esophageal Tumors

Leiomyomas

Leiomyomas are the most common benign esophageal masses. They are usually found in the lower third of the esophagus and rarely cause complaints. Most are detected incidentally. They are located in the submucosa.

Lipomas, Fibromas, and Neurinomas

Lipomas, fibromas, and neurinomas are virtually indistinguishable from leiomyomas by their endoscopic appearance. They are very rare mesenchymal tumors.

Hemangiomas

Hemangiomas that are covered by normal mucosa are difficult to distinguish from leiomyomas endoscopically. Some, however, have a bluish tinge suggesting their vascular origin.

Papillomas

Papillomas are wartlike excrescences of squamous epithelium several millimeters in size. They are found predominantly in the distal esophagus. They are very rare.

Fig. 3.63 Differential diagnosis of intramural tumors a Extrinsic indentation by a vessel or bronchus

b Proximal (downhill) varices

Endoscopic diagnostic criteria

- Well-circumscribed round or oval mass

- Overlying mucosa is tense and intact, rarely ulcerated

- Mucosa can be tented with biopsy forceps

► Lipoma, fibroma, neurinoma

- Virtually indistinguishable from leiomyoma by their endoscopic features

► Hemangioma

- Well-circumscribed mass covered by intact mucosa

- Occasionally has bluish tinge

► Papillomas

- Small, several millimeters in size

- Raised, wartlike, hemispherical, sometimes flattened

- Occur predominantly in the distal esophagus

- Single or multiple

► Glycogenic acanthosis (Fig. 3.65)

- Multiple, sometimes myriad, lentiform protuberances

- Grayish-white

- Occur predominantly in the distal esophagus

Differential diagnosis

► Leiomyoma: lipoma, fibroma, hemangioma

► Hemangioma: see above, also varices

► Papilloma: glycogenic acanthosis

Checklist for endoscopic evaluation

► Degree of luminal narrowing

► Circumferential extension

► Mucosal morphology

Fig. 3.64 Leiomyoma a Endoscopic appearance

Fig. 3.64 Leiomyoma a Endoscopic appearance

b Endosonographie appearance

Additional Studies

Biopsy: usually unsatisfactory for submucous tumors, even when several samples are taken at the same site ("dredge biopsy," "buttonhole biopsy").

Caution: Biopsies can compromise a proposed surgical enu-cleation.

Contrast esophagogram

Endosonography: best study for determining the precise location of the lesion within the esophageal wall, differentiating between solid and vascular tumors, and detecting or excluding invasive growth (Fig. 3.64b).

Fig. 3.65 a, b Glycogenic acanthosis

Fig. 3.65 a, b Glycogenic acanthosis

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