Teaching Case

A 50-year-old man with a history of dysphagia, was referred for an episode of regurgitation of a mass which he swallowed.

Barium swallow examination showed significant oesophageal luminal enlargement, with irregular luminal filling by the barium column, apparently caused by a huge endoluminal filling defect whose lower limit was well delineated by the barium contrast on the lower third of the oesophagus. This filling defect was thinner on the upper third of the oesophagus and its upper limit was hard to define.
The patient underwent CT examination, which revealed a huge endoluminal mass attached to the upper oesophagus by a pedicle, near the region of the cricopharyngeus muscle. The lesion had an elongated sausage-shape, with its lower end extending to the lower third of the oesophagus, near the gastro-oesophageal junction, with a longitudinal diameter of approximately 17cm. It was largest in its inferior portion, measuring approximately 5.2 cm in width. The mass was hypodense and with intralesional areas consistent with fat content. There were no signs of infiltration of the surrounding structures.

Benign oesophageal lesions are rare, accounting for 20% of all oesophageal neoplasms [1,2]. Most benign lesions consist of leyomiomas. Fibrovascular polyps are rare, accounting for 0,5-2% of all oesophageal tumours [1, 2]. They are more frequently found in middle aged and elderly men [2], with a male-to-female ratio of 3:1 [1].

Fibrovascular polyps consist of submucosal endoluminal pedunculated lesions, nearly always attached to the cervical portion of the oesophagus, near the region of the cricopharyngeal muscle [2, 3]. Less frequently they can be attached to the hypopharynx. There are also some rare case reports of oropharyngeal fibrovascular polyps [4].
Oesophageal fibrovascular polyps are thought to originate from submucosal evaginations, occurring in areas of decreased resistance of the muscular plane: the Killian´s dehiscence (between the circular and oblique fibres of the cricopharyngeal muscle) and Laimer´s triangle (between the cricopharyngeus and the oesophagus) [2, 4].
On histological analysis fibrovascular polyps are composed of fibrous elements, adipose tissue and vessels, and they are lined by normal squamous epithelium.

Patients with fibrovascular polyps usually complain of dysphagia and foreign body sensation. Very large lesions may be regurgitated into the mouth, a characteristic feature of these lesions. Symptoms are also frequently accompanied by weight loss.

Small fibrovascular polyps, less than 2cm, can be resected endoscopically. However larger lesions, or small lesions with a thick and highly vascularized polyp with risk of haemorrhage, must be surgically removed [4]. Resection of the lesion is curative and recurrence is rare [2].

Diagnosis of fibrovascular polyps can be problematic on endoscopy because they are covered with normal squamous epithelium and so can be misregarded as normal oesophageal mucosa and 25% of fibrovascular polyps are missed at endoscopy [1].
On barium swallows fibrovascular polyps can be demonstrated as a filling defect in an enlarged oesophagus, but their point of attachment to the oesophageal wall can be difficult to visualize.
CT, with its multiplanar capability is the gold standard in the diagnosis of these lesions. CT shows an endoluminal lobulated mass, with a low density that in some cases can be compatible with the presence of fat components. There are no signs of infiltration of the surrounding tissues. The pedicle and site of origin on the upper oesophagus can be demonstrated with the administration of oral contrast and the use of multiplanar reconstructions.