Giant fibrovascular polyp of the esophagus: CT and MR findings

A 59-year-old man with a 1 5-year history of intermittent dysphagia for solids presented with fatigue and 9.1 -kg (20-mb) weight loss over a 2-month period. Physical examination was unremarkable. Admission hemoglobin was 6 g/dl. Chest radiography showed a superior mediastinal mass on the right. This had increased in size in comparison with its size on a chest film 2 years earlier. CT revealed a large mass in the posterior mediastinum with both fluid and lipid components (Fig. 1A). The mass produced compression and effacement of the esophageal lumen. The proximal esophagus was dilated to the level of the mass. An esophagram showed a smooth, rounded intraluminalfilling defect measuring 5.4 cm in diameter (Fig. 1 B). MR showed a posterior cylindrical mediastinal mass extending from the thoracic inlet to the esophagogastric junction. The mass contained a central elongated region with high signal intensity on the Ti -weighted images, thought to represent a lipid-containing substance, mucoid secretions, or nonacute blood. A second component of the mass, seen more inferiorly, had a lower signal intensity on the Ti -weighted images similar to that of soft tissue or muscle. Superiorly, a crescent-shaped area of absent signal represented an air-containing structure (Figs. 1C-i E). Endoscopy showed that the esophageal mucosa was normal. The esophagus was dilated and tortuous, without evidence of an intraluminal mass. A long submucosal deformity of the esophagus was apparent that extended along the entire body of the organ and appeared as two thickened folds. The ultrasonic endoscope showed the lesion to be contiguous with the muscular layer of the esophagus on several views. The patient underwent thoracotomy for esophageal exploration. Palpation of the esophagus suggested a mass that could be milked up the lumen. A limited myotomy was performed in the midportion of the esophagus. Contrary to the endoscopic findings, no intramural esophageal masses were seen. A limited esophagotomy was then performed, and a large intraluminal tumor was identified. The tumor originated from a pedicle arising from the posterior wall of the cervical esophagus, just below the cricopharyngeus muscle, and it extended to the gastroesophageal junction. The tumor was removed in two pieces. First, approximately 90% of the tumor was excised from the pedicle and removed through the thoracic esophagotomy. The base of the pedicle was then clipped to obtain hemostasis. A left neck exploration and a limited cervical esophagotomy were then performed. The pedicle of the tumor was excised at its base. The pedicle was 7 cm long, and the intraluminal tumor measured i 8 x 8 x 4 cm. Most of the specimen was covered by normal esophageal mucosa. Gross and microscopic diagnosis was a giant fibrovascular polyp of the esophagus (Fig. i F).