Recurrence of a giant fibrovascular polyp of the esophagus: What have we learned?

Esophageal fibrovascular polyps are benign tumors with a low prevalence, and a recent search on PubMed identified 109 references. These lesions are large, pedunculated, and require surgical treatment, although endoscopic removal of large polyps is also possible at specialized surgical centers.^1,2 Since most arise in the mucosa of the pharynx and cervical esophagus, cervicotomy is the preferred approach, followed by esophagotomy or pharyngotomy, through which the pedicle is ligated and proper hemostasis can be confirmed.³ The probability of malignant transformation is very low, and recurrence is rare. However, we present a case of recurrence of a giant fibrovascular polyp of the esophagus, along with diagnostic considerations, technical recommendations, and follow-up in order to avoid reoperations that may be associated with greater morbidity.

A 48-year-old male patient underwent surgery in 2015 to remove a 16-cm esophageal fibrovascular polyp via cervicotomy and esophagotomy.³ The patient remained asymptomatic and had no further office visits until he consulted for dysphagia in 2020. Additional examinations were delayed during the pandemic, but an upper gastrointestinal endoscopy, cervical computed tomography (CT), and video-fluoroscopic swallow study were done in 2022. All 3 tests confirmed the presence of a polypoid lesion with a pedicle located on the left lateral wall of the Killian dehiscence.

We operated on the patient, using the previous incision and Ligasure™ to transect the pedicle through a longitudinal pharyngotomy in order to reach its base. The postoperative course was uneventful, and the patient was discharged 72 h later. Histological examination of the surgical specimen, which measured 4.6 × 3 × 2 cm, found that the lesion was composed of richly vascularized fibrocollagenous tissue, containing abundant congestive vessels of various calibers and a central area of ​​adipose tissue composed of adipocytes organized in a lobular architecture, mostly mature in appearance. The presence of lipoblasts was easily identified, as well as fibrous tracts containing somewhat elongated stromal cells with hyperchromatic nuclei and mild to moderate cellular atypia (Fig. 1). Expression of MDM2 and CDK4 was observed (Fig. 2), concluding that the lesion was a well-differentiated liposarcoma.

Fig. 1.

Lipoblasts in the histological section with hematoxylin-eosin stain.

Fig. 2.

Positive immunostaining for MDM2.

Esophageal fibrovascular polyps are large, pedunculated lesions that represent a very small percentage of benign tumors of the esophagus and pharynx. Case series are not useful to establish a causal relationship with toxic habits or race. Sometimes asymptomatic, dysphagia is the most common symptom, although sudden death due to regurgitation or aspiration has been reported.⁴ Diagnosis is sometimes a clinical challenge, but the definitive diagnosis is possible in most cases with CT scan and magnetic resonance imaging combined with upper gastrointestinal endoscopy and barium esophagogram. Malignant degeneration of these polyps is rare, and our search of the literature revealed just 4 cases, all described before 2006.⁵ The recommended treatment of these polyps is removal due to potential complications, including: severe dysphagia, upper gastrointestinal bleeding,³ and asphyxia. The surgical approach, either transoral or transcervical, is determined by the location of the polyp base, width of the pedicle, size of the polyp, and the surgeon’s prior experience. In our case, the dimensions of the polyp prevented endoscopic treatment with ligation or laser, so we opted for a surgical approach, despite the morbidity that could be associated with operating on a previously treated area. Since many of these polyps arise at the level of the Killian dehiscence, we considered it important to make the incision at the pharyngeal wall, extending this proximally to access the polyp base and perform complete excision. Most authors describe mechanical ligation of the polyp base, as we performed in the first procedure. However, as this case was a recurrence, we decided to apply a sealant to achieve hemostasis and a greater local effect.

Recurrence of these polyps is rare and has only been reported on 4 occasions^6–9 after endoscopic and surgical treatment. The interval before onset ranged from 6 to 20 years, and 2 recurrences were reported in 3 patients. Currently, some authors consider these polyps to be liposarcomas, which could explain the cases of recurrence. In fact, in our patient, amplification of the MDM2 gene was obtained by fluorescence in situ hybridization in both the original specimen from 2015 and the current recurrence, confirming the liposarcoma. Thus, Graham et al. recommend conducting this test in all presumed fibrovascular polyps to establish a definitive and differential diagnosis with liposarcomas.¹⁰

In our opinion, annual or biannual endoscopic follow-up studies are advisable, at least for the first 10 years. This is especially true if the histological examination of the specimen confirms liposarcoma, which can degenerate despite the typically benign nature of fibrovascular polyps. Potentially, this would allow for endoscopic treatment of small lesions before they require further surgery due to their large size.

Funding

This research paper has received no specific funding from any public, commercial or non-profit entities.