General Fran#{231}ois

Case D. Morin,

ofthe #{149} Patrice

MD

Day’ M. Bret,

MD

#{149} Pierre

1.

Bret,

MD

#{149} Maxj

Palayew,

MD

2a. Figures

1, 2.

(1) Image from a barium swallow shows separation of the barium column into many longitudinal folds between numerous, large lobulations. (2a) Axial CT scan obtained with oral contrast material shows a mass with two to three limbs. (2b) Scan obtained through the middle of the thorax was used to measure the attenuation of the mass, which demonstrates a high fat content.

examination

U FINDINGS The barium swallow study revealed a large elongated filling defect in the esophagus. The mass

was

upper

CT, performed contrast

U HISTORY A 57-year-old She

woman

had

experienced

sausagelike

could

not expel

and

swallow

Index

pendulous

Esophagus,

From

Catherine, C RSNA,

1992;

the

(Fig

1).

Its

and

1992;

the

71.1211

of Radiology,

Department

accepted

Montreal,

A bar-

computed

(Figs Esophagus,

#{149}

sured, tive

with

the

of a fatty

administration that

of the

mass

distinct limbs, depending on the scan was obtained (Fig value of the mass was mea-

.

she

oral

demonstrated

-22

mass

HU result (Fig

being

indica-

2b).

to-

1, 2). neoplasms,

71.311

12:845-847

Departments and

to reswallow.

performed CT,

that

after

material,

had two to three the level at which 2a) Attenuation

dyspha-

of regungi-

mass

examination

RadloGraphics

Montreal, ruary 28,

had

(CT) were

terms:

with

episodes

of a large

ium

1992

presented

tation

mography

July

and

was not well

seen, but it was probably in the area of the T- 1 vertebral body. The upper part of the mass seemed to be pulled down as the patient swallowed.

2b.

gia.

lobulated

limit

Que,

Jewish

ofRadiology, March 20. Address Canada

H3T

General

Hospital

Universit#{233} de Lyon,

reprint

requests

(F.D.M.. Lyon,

to M.J.P..

MJ.P.) France

and

Montreal

(PB.).

From

Department

General the

1991

of Radiology,

Hospital RSNA

Jewish

(P.M.B.),

scientific

General

McGill

assembly.

hospital,

University, Received

3755

Feb-

C#{244}te Ste-

1X2.

1992

Morin

et al

U

RadioGraphics

U

845

I Figure

3-

Photograph

dunculated

polypoid

the cervical

portion

(Scale

of the mass

excised

pe-

arose

from

that

PH

of the esophagus.

is in centimeters.)

DIAGNOSIS:

Fibrovascular

polyp

of the

Fibrovascular polyps originate in the upper third of the esophagus in 90% of the cases; otherwise, they arise in the hypopharynx or

esophagus.

U DISCUSSION Fibrovascular polyp of the esophagus is a rare, benign neoplasm and often is asymptomatic for a long time before it manifests as a lump in the throat. Patients sometimes present with weight loss, retrosternal pain, and nonspecific gastrointestinal symptoms including regurgi-

lower

tation

function

of food,

vomiting,

pain, or bleeding tinal tract caused itself. Progressive velops, and patients regurgitation of a stem. The patients mass,

and

some

pynosis,

from the upper gastrointesby ulceration of the polyp dysphagia to solid food deexperience cumbersome lobulated mass with a broad have to reswallow the

cases

of airway

and asphyxia have been tion is often misdiagnosed disease, or psychosomatic knowledge,

ported. male

about

The adults,

polyps with

abdominal

80

cases

have

more

been

ratio

in of 3:1

(1-12). Eighty

percent

are malignant,

of esophageal

and

neoplasms

20% are benign.

Benign

neoplasms can be divided into intramural and intraluminal. In the intramural group, leiomyomas account for more than 50% of all benign esophageal tumors. Lipomas, hemangiomas, neurofibromas, and cysts occur less frequently. Fibrovascular polyp, although the most frequent intraluminal tumor, represents 0.5% of all benign neoplasms of the esophagus

(2,3,11).

fold

can

gradually

the

whole

gus

then

mass, tion

hamartomas,

U

RadioGrapbic.s

U

Morin

et al

a mixed

septa,

10-20

on de-

due

to disten-

esophageal

is not

lipomas,

large

in length,

pol-

fibrolipomas,

or fibroepithelial adipose tissue,

and

compo-

mesenchymal

vascular

of presentation, cm

by the

histologic

called

bromas, myxomas, They often contain time

of

obstruction

in carcinoma,

been

fills

esopha-

disturbance

Complete

have

elon-

and

in peristalsis,

law).

have

and

of the

pressure

as occurs

The polyps

the

some

decrease

and

down

Dilation

with

of

A mucosal

it distends

to mechanical

(Laplace’s

yps,

until

the degree

swallowing.

intraluminal

obstruction, seen (1,2,6,7).

a high

be forced

occurs,

reflex

below

has

esophagus. due

creased

mucosa

for

by penistalsis

polyps. connective

structures.

they the

fi-

stalk

often

At

measure

is 1-3

cm

in di-

ameter, and the distal end is lobulated and sometimes ulcerated, measuring from 3 to 7 cm (Fig 3). A polyp can weigh as much as 200 g (3,4,6). Diagnosis

notoriously can show pearance

of fibrovascular

polyps

can

be

problematic. Chest radiography a wide upper mediastinum, an apthat can be confused with thyroid

enlargement

or

lesions.

Barium

characteristically large, smooth

forked

846

The muscle

necessary

gated

tissue

ne-

frequently

a male-to-female

mobility

sition

obstruction

reported. This condias achalasia, peptic problems. To our

occur

esophagus.

cnicopharyngeal

other

common

mediastinal

swallow

studies

wide lobulated

esophagus mass.

column

gin

of the

polyp.

the

distal

bulbous

of barium can

show

a

filled Sometimes,

with

over

the on-

is seen

Up-and-down

part

can

movement

be seen

Volume

a a of

at fluoros-

12

Number

4

copy

during

swallowing.

Tertiary

contractions

may be present. The trachea can pressed anteriorly. Fibrovascular esophagus are often misdiagnosed sia,

but

they

can

be

distinguished

latter condition by the at the gastroesophageal

ageal

tortuosity,

Endoscopic because the

be cornpolyps of the as achala-

and

from

absence junction,

usually

no air-fluid

esophagus

examination

and

endoscopy

should

folds sent

seen the

at barium

narrow

be a clue.

fifing

the

esophagus

tion of the surrounding measurements sometimes

with

nance

imaging

sis easier

does

not seem

4.

mass is reso-

recommended. interventions

July

1992

5.

6.

7.

entity, have

LeBlancJ,

of the

some

occasionally

difficulty

Carrier

Radin DR. esophagus.

GR.

Gi-

Gas-

G, Ferland

Rhinol

S, Boutet

M.

Giant

fibroadipose

J Comput

Tomogr

polyp

of the

1988;

12:226-

229. Houdelette P, Chagnon A, DumothierJ, Marthan E. Polype fibrovasculaire g#{233}ant oesophagien: a propos d’une observation. [Giant esophageal fibrovascular polyp: case report.] Ann Chir 1990; 44: 146-148. Penagini R, Ranzi T, Velio P, et al. Giant fibrovascular polyp of the esophagus: report of Gut

Because

this

of the esophagus.

ofthe esophagus. Ann Otol 1983; 92:344-348.

a case

diagno-

origin is in the upper third ofthe esophagus, an anterior oblique low cervical approach is

M, Avant

polyp

Fibrovascular polyp of the esophagus with computed tomographic and pathological conrelation. J Can Assoc Radiol 1990; 41:87-89.

(4,6,8).

should be used because of the highly vascular content of the polyp and its proximity to the airways. Thoracotomy is indicated if the polyp arises in the middle third to the lower third of the esophagus. Most ofthe time, when the

RW, Martin

troenterology 1984; 87:953-956. Vrabec DP, ColleyAT. Giant intraluminal Laryngol

reprethe

Treatment consists of excision, which should be done quickly once the diagnosis is made to avoid serious complications such as asphyxia or gastrointestinal bleeding. The site of origin of the polyp can help determine the surgical approach. Endoscopic excision can be contemplated if the polyp arises in the hypopharynx and is short. Extreme caution

diagnosing

3.

no infiltra-

to make

Kieffer

ant fibrovascular

tissues. Attenuation allow identification

of fat components. The origin of the sometimes visualized. Use of magnetic

PatelJ,

polyps

Longitudinal

but

is

with no residual motility esophagus (2,3,7).

MM, Kulkarni MV. Giant fibrovascular ofthe esophagus. Gastrointest Radiol 9:301-303.

polyp

at

polyp is recognized when the bulbous end is reached with the fiberscope. Overall, 25% of fibrovascular polyps are missed at endoscopy (3,6,8,10). CT shows a large, intraluminal lobulated mass

Carter 1984;

seen

in a normal-looking mucosa can the edge ofthe polyp. Sometimes

1.

2.

swallow

lumen

curative, of the

gastric surgery, the treatment

REFERENCES

U

level.

findings may be misleading smooth squamous epithelium

wide

usually problems

as laparotomy, Fortunately,

the

of obstruction less esoph-

covering the polyp results in the appearance of a normal esophagus. Discrepancy between the

formed, such or tracheostorny.

and

1989;

effects

on esophageal

function.

30: 1624-1629.

8.

Whitman

9.

cular polyp ofthe esophagus: CT and MR findings. AJR 1989; 152:518-520. Walters NA, Coral A. Fibrovascular polyp of the oesophagus: the appearances on computed tomography. BrJ Radiol 1988; 61:64 1-

GJ, Borkowski

GP.

Giant

fibrovas-

643.

10.

Sheward SE. Case ofthe season: tory fibrous polyps ofesophagus. Roentgenol

1 1.

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Morin

et al

U

RadioGraphics

U

847