LAUSR

A 38-year-old male presented with history gradually progressive dysphagia of 2-year duration, intermittent initially which became persistent for the past 3 months. There was associated retrosternal burning sensation which was relieved on taking antacids. There was no history of vomiting, odynophagia, hematemesis, melena, or weight loss. Clinical examination was unremarkable. Lab investigations were normal. Upper gastrointestinal endoscopy revealed a large pedunculated polypoidal lesion with a whitish hue arising from the cervical esophagus, and reaching up to gastroesophageal junction. Biopsy of the lesion was inconclusive. Barium swallow study showed diffusely dilated thoracic esophagus with large filling defect extending up to the gastroesophageal junction (Fig. 1a). There was no hold up of contrast. Motor activity of the esophagus was normal. Computed tomography (CT) scan of the chest with oral and intravenous iodinated contrast medium showed a heterogeneously enhancing polypoidal soft tissue mass within the lumen of the thoracic esophagus (Fig. 1b). A short stalk was seen attached to the wall of cervical esophagus (Fig. 1c). There were fat density areas within the lesion. The outer margin of the esophagus was normal. Subsequently, magnetic resonance imaging (MRI) was done to better characterize the lesion. On MRI, the polypoidal lesion was hypointense on the T2weighted images suggesting its fibrous nature (Fig. 2a). There were hyperintense areas within on the T1-weighted images, which showed suppression of signal on opposedphase images suggesting the presence of fat (Fig. 2b, c). Based on these imaging findings, a provisional diagnosis of giant fibrovascular polyp (FVP) was made. At surgery, a large (25 × 8 × 3 cm) lobulated fibrofatty polyp was seen arising from the posterolateral wall of the cricopharynx reaching up to the gastroesophageal junction. Complete removal of the polyp was done through a l e f t l a t e r a l ph a r yngoe sophago t omy (F i g . 3 ) . Histopathology showed myxoid, fibrofatty, and collagenous areas with scattered spindle and stellate fibroblasts and dilated vessels in the sub-epithelial region of the polyp suggestive of fibrovascular polyp. There were no features of malignancy. The patient is doing well clinically at 18-month follow-up. Fibrovascular polyps of the esophagus are uncommon slow-growing benign tumors arising from the submucosal mesenchymal tissue. Previously, depending on the type of tissue on histology, they have been variably referred to as fibromas, lipomas, or fibrolipomas. They typically arise from the subepithelial region of the cricopharynx or cervical esophagus and protrude into the esophageal lumen. Subsequently, it grows and prolapses into the lumen of the esophagus distally due to the peristaltic activity and movement of the food bolus. Size at presentation is very variable, but frequently large due to their slow growth and mild symptoms. The patients usually present with progressive dysphagia, substernal discomfort, or foreign body sensation in the throat. Large masses may compress the airway and cau s e wheez i ng o r r e sp i r a t o r y d i s t r e s s . Uncommonly, they may prolapse into the oral cavity or larynx and result in asphyxiation. Occasionally, gastrointestinal bleeding may be present due to ulceration of the overlying mucosa. Imaging plays an important role not only in defining the location and extent of the lesion but also in its * Kumble Seetharama Madhusudhan [email protected]