Challenges in the diagnosis and treatment of giant fibrovascular polyps of the esophagus: Two case reports

Abstract

BACKGROUND

Fibrovascular polyps (FVPs) are rare benign pedunculated submucosal tumors of the esophagus that may reach considerable size and cause dysphagia or other compressive symptoms. The choice of treatment depends mainly on the size and location of the lesion and may include surgical or endoscopic resection.

CASE SUMMARY

We report two cases of esophageal FVPs treated by endoscopic submucosal dissection (ESD). The first patient presented with progressive dysphagia and significant weight loss. Endoscopy and computed tomography revealed a giant pedunculated esophageal mass. Complete en bloc resection was achieved endoscopically; however, extraction of the specimen was unsuccessful due to its large size. In the second patient, dysphagia led to the detection of a similar pedunculated lesion in the cervical esophagus. Endoscopic resection was successfully performed, and histopathological examination confirmed a FVPs.

CONCLUSION

FVPs are uncommon benign esophageal tumors. Although surgical resection has traditionally been the standard treatment, endoscopic techniques are increasingly preferred due to their minimally invasive nature and favorable recovery profile.

Key Words: Fibrovascular; Polyp; Esophagus; Esophagogastroduodenoscopy; Tumor; Endoscopic resection; Surgery; Case report

Core Tip: Esophageal fibrovascular polyps (FVPs) are uncommon benign tumors that often remain asymptomatic until they grow to a substantial size. When symptomatic, they may cause dysphagia, regurgitation, bleeding, or even life-threatening airway obstruction. We report two cases of esophageal FVPs successfully managed by endoscopic submucosal dissection. These cases demonstrate that, in selected patients, endoscopic treatment can be considered a safe and effective minimally invasive alternative to surgery.

INTRODUCTION

Esophageal fibrovascular polyps (FVPs) are rare benign lesions, accounting for approximately 0.03% of all esophageal tumors[1]. Their exact etiology remains unclear. These tumors are most commonly observed in middle-aged and elderly men, with a male-to-female ratio of about 3:1[2]. FVPs originate from the submucosal layer of the esophagus and are usually covered by normal mucosa. Most frequently, they arise near the cricopharyngeus muscle at the pharyngoesophageal junction, also known as the Laimer-Haeckermann triangle[3]. Histologically, they consist of fibrous tissue, adipose tissue, and vascular components[4]. Clinical symptoms are generally related to the size of the lesion. The most common presentation includes dysphagia, chest discomfort, foreign body sensation, odynophagia, dyspnea, cough, and gastrointestinal bleeding[5]. Surgical resection remains the standard treatment; however, it may be associated with significant morbidity. Endoscopic approaches represent a minimally invasive alternative that can be safe and effective in selected cases. We present two cases of giant esophageal FVPs successfully treated by endoscopic resection.

CASE PRESENTATION

Chief complaints

Case 1: A 53-year-old man presented with dysphagia and weight loss-about 15 kg over half a year.

Case 2: A 59-year-old man with dysphagia.

History of present illness

Case 1: Computed tomography (CT) of the chest was performed at another institution revealing a giant pedunculated tumor mass in the esophagus measuring 160 mm × 40 mm × 50 mm. Subsequently, an esophagogastroduodenoscopy was performed and revealed a polyp of the esophagus located 30 cm from the dental arch with a histology result of a squamous cell papilloma.

Case 2: CT scan performed at another institution revealed a tumor mass measuring 24 mm. Upper endoscopy detected a pedunculated polyp of the esophagus located 18 cm from the dental arch with histology showing an inflamed pseudopolyp of the esophagus.

History of past illness

Case 1 and case 2: There was no past illness.

Personal and family history

Case 1 and case 2: There was no family or personal history of genetic or malignant diseases.

Physical examination

Case 1 and case 2: Physical examination revealed no abnormal findings.

Laboratory examinations

Case 1: Blood tests showed C-reactive protein 32.53 mg/L, hemoglobin 112 g/L, and squamous cell carcinoma antigen 0.9 ng/mL. Other routine tests, including liver and kidney function, electrolytes, and coagulation, were all within normal limits.

Case 2: No abnormalities were found in his laboratory tests.

Imaging examinations

Case 1: Repeated esophagogastroduodenoscopy revealed a pedunculated formation obstructing the lumen of the thoracic esophagus measuring 160 mm × 40 mm × 50 mm, located 20 cm from the dental arch. Endoscopic ultrasound (EUS) demonstrated a hyperechoic, pedunculated mass containing areas with fluid-equivalent echogenicity. The mass contained fibrous, adipose, and vascular tissue, typical for FVPs. There was no compression of the trachea, blood vessels, or other surrounding structures.

Case 2: The patient underwent esophagogastroduodenoscopy, which revealed a pedunculated oval formation of the esophagus measuring 35 mm with a broad, highly vascular stalk located 18-20 cm from the dental arch (Figure 1).

Figure 1 Endoscopic images of a giant fibrovascular polyp in the esophagus. A: Endoscopic view showing the polyp occupying the esophageal lumen with its stalk attached to the mucosa; B: Slightly different angle highlighting the surface morphology and spatial orientation of the polyp within the lumen.

FINAL DIAGNOSIS

Case 1

The histology result was papillomatous squamous stratified epithelium from the esophagus (Figure 2).

Figure 2 Histology results-papillomatous squamous stratified epithelium. Representative area showing the epithelial papillary projections and preserved glandular structures.

Case 2

The histology result showed papillomatous squamous stratified epithelium from the esophagus (Figure 3). Typical pathological features of FVPs, including fibrous tissue, adipose tissue, and vascular structures covered by normal squamous epithelium, were observed. Immunohistochemical studies (e.g., CD34, SMA) were not performed.

Figure 3 Histology results-showing the pathological features of a fibrovascular polyp. A: Overview of the polyp demonstrating fibrovascular stroma with interspersed vascular channels and loose connective tissue; B: Higher-magnification view highlighting the vascular architecture, stromal composition, and interface with the overlying mucosa.

TREATMENT

Case 1

Given that the patient declined surgical intervention, endoscopic submucosal dissection (ESD) was selected as the treatment of choice. The patient was scheduled for ESD, which was performed 1 month later. ESD was performed using a Gold Knife (Goldknife; Micro-Tech, Nanjing, China) and a TT Knife (TTknife nano™; Olympus, Tokyo, Japan). Repeated episodes of bleeding from large submucosal vessels occurred during the procedure and were successfully treated using coagulation forceps (ENSURE Coagulation Forceps; Micro-Tech, Nanjing, China) (Figure 4). A 20-mm clip was applied at the resection bed. After achieving complete en bloc resection, an attempt to extract the resected specimen was made, which was unsuccessful due to its large size. Therefore, the dissected lesion was left in the stomach with the hope of removing it the next day (Figure 5). Since it was not found in the stomach the following day, diagnostic laparoscopy of the abdominal cavity was performed, but the tumor was not found, possibly due to spontaneous digestion in the gastric environment.

Figure 4 Endoscopic images of a post-endoscopic submucosal dissection defect in the esophagus. A: Endoscopic view immediately after endoscopic submucosal dissection (ESD) showing the mucosal defect and surrounding healthy mucosa; B: Closer view of the post-ESD defect showing the treated mucosal area.

Figure 5 Endoscopic images of a giant fibrovascular polyp from esophagus into the gastric lumen. A. Endoscopic view showing the giant fibrovascular polyp extending from the esophagus toward the gastric lumen; B: Close-up view of the polyp’s base and stalk entering the gastric lumen; C: Oblique view of the polyp showing the stalk’s attachment to the esophageal mucosa and spatial orientation within the lumen.

Case 2

Based on the examination findings, the esophageal submucosal tumor was deemed benign, and ESD was performed to remove it in the same session. A Gold Knife (Goldknife; Micro-Tech, Nanjing, China) was again utilized. Dissection of the mucosal and submucosal layers was carried out following injection of a solution of normal saline mixed with methylene blue at the lesion’s base. Recurrent bleeding was encountered during the procedure and was successfully controlled with coagulation forceps. The lesion was resected en bloc, and three clips were applied at the resection bed.

OUTCOME AND FOLLOW-UP

Case 1

Oral feeding was successfully resumed on the third day after surgery, and the patient was discharged on the seventh day without any complications. A three-month follow-up endoscopy demonstrated no recurrence, and he has continued to remain free of recurrence over the past year.

Case 2

The patient resumed oral intake on the second day following the procedure and was released from the hospital on the fifth day. Follow-up esophagogastroduodenoscopy performed 2 months later found no recurrence.

DISCUSSION

FVPs are uncommon benign tumors that most often arise in the cervical esophagus. They are typically elongated and covered with normal mucosa. Although rare, they may reach considerable size, with reported cases up to 25 cm. They account for approximately 0.03% of all esophageal tumors and less than 2% of benign esophageal neoplasms, with fewer than 200 cases reported[6].

The exact mechanism of development remains uncertain. One hypothesis suggests that weakness at the pharyngoesophageal junction allows progressive elongation of the lesion due to peristalsis and swallowing. Alternatively, cytogenetic studies indicate a possible neoplastic origin related to chromosomal abnormalities and genomic instability[7,8].

The clinical manifestations are related to the tumor’s size. The primary symptoms of an esophageal FVPs include gradually worsening dysphagia and a sensation of a lump in the throat or chest. Additional symptoms may involve retrosternal or upper abdominal discomfort, nausea, unintended weight loss, and respiratory issues such as persistent coughing or breathing difficulties. In extreme cases, particularly with large polyps, there is a risk of severe complications, including asphyxiation[9].

FVPs are uncommon in clinical practice and can present diagnostic challenges. Non-invasive diagnostic options include a barium swallow, which may reveal esophageal dilation and elongated, smooth intraluminal defects. CT and magnetic resonance imaging are considered highly reliable for determining both the origin and characteristics of such masses. Positron emission tomography-CT may be utilized in selected cases where conventional imaging fails to clarify the diagnosis, provided cost allows. Invasive diagnostic approaches involve esophagogastroduodenoscopy and EUS. Endoscopic inspection improves visualization, enabling precise assessment of the lesion’s size, location, and surface features. Doppler-assisted EUS provides real-time ultrasound data about the polyp’s origin, echogenicity, and vascularity. When combined with contrast agents, EUS can reveal microcirculation throughout the polyp head, aiding in bleeding risk evaluation. Additionally, EUS allows for fine-needle aspiration or biopsy under direct ultrasound guidance[10-12].

Histopathological examination is essential for definitive diagnosis, typically showing fibrous, adipose, and vascular tissue covered by squamous epithelium[11]. Surgical removal of these polyps is recommended to relieve symptoms and to prevent potentially severe complications, including bleeding, infection, or airway obstruction. The choice of treatment depends on polyp characteristics, including size and location, and can be carried out via different approaches, such as transoral, transthoracic, transcervical, or endoscopic resection[13,14]. Although surgical excision remains the standard method for polyp removal, it is associated with considerable mortality and morbidity, extended hospitalization, and an increased risk of hospital-acquired infections.

Endoscopic removal provides a less invasive option, yet it can be challenging to perform, especially for larger polyps with pedicles longer than 8 cm, because of the heightened risk of bleeding. While it is relatively less invasive, visualizing the lesion can be difficult, and the potential for uncontrolled hemorrhage is higher in the case of large polyps. Another challenge involves transoral removal of the tumor, which carries a significant risk of impaction within the limited space of the upper esophageal sphincter and oropharynx because of the polyp’s size.

In our first case, the resected polyp could not be retrieved post-ESD. This rare phenomenon may be explained by spontaneous degradation of the lesion in the gastric environment, given its fragile vascular composition. Clinicians performing endoscopic resection of giant FVPs should be aware of this possibility, which may influence post-procedural management and planning for specimen retrieval.

The first documented use of a “hybrid laparo-endoscopic” approach for a giant esophageal FVPs combined ESD with laparoscopic removal was in 2023. This new technique, used for a large, highly vascularized polyp, involved using endoscopy to resect the tumor’s base from the esophagus and laparoscopy to remove the tumor from the stomach through a gastrotomy, offering a less invasive option than traditional open surgery. The procedure showed comparable recurrence rates and a low risk of complications, with follow-up showing no adverse events[15].

From our cases, we observed that FVPs are frequently large, and when planning endoscopic resection, it is essential to anticipate potential challenges, such as the optimal method for polyp extraction, to avoid technically difficult situations during the procedure. Furthermore, the timing of diagnostic laparoscopy is of great importance, as it may help prevent self-digestion or degeneration of the polyp.

CONCLUSION

In summary, giant FVPs are infrequent benign tumors of the esophagus, with recurrences being exceptionally rare. Although surgery remains the primary therapeutic aproach, endoscopic technique has increasingly gained preference over open surgery, because of its multiple advantages, including reduced invasiveness and faster recovery. FVPs are frequently sizable, and when endoscopic resection is selected, it is important to anticipate potential challenges during the procedure. An alternative to conventional treatment is the novel laparo-endoscopic approach, which can provide a safe and effective option for managing giant esophageal FVPs.