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Clin Gastroenterol Hepatol. Author manuscript; available in PMC 2017 July 01. Published in final edited form as: Clin Gastroenterol Hepatol. 2016 July ; 14(7): e71–e72. doi:10.1016/j.cgh.2015.12.026.

A giant esophageal mass in a patient without dysphagia Craig C. Reed, MD1, John T. Woosley, MD, PhD2, and Evan S. Dellon, MD, MPH1 1Center

for Esophageal Disease and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, NC

2Department

of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC

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An 88-year old man with a history of longstanding gastroesophageal reflux disease and Barrett’s esophagus was referred for evaluation of an esophageal mass. He had undergone prior upper endoscopic evaluations for surveillance of long-segment Barrett’s esophagus, but his most recent endoscopy revealed a partially obstructing polypoid mass, raising the concern for progression from Barrett’s to esophageal adenocarcinoma. When he was evaluated at our center, he had no dysphagia or odynophagia symptoms. Physical examination and laboratory results were unremarkable. Repeat endoscopy showed a 20 cm fungating and villous/frond-like mass with some oozing of blood that as first encountered in the proximal esophagus (Figure A). This mass was circumferential with what appeared to be obliteration of the distal third of the esophageal lumen (Figure B–C), but as the distal esophagus was approached, the scope was able to pass without resistance. The mass had a very soft consistency, was friable, and extended across the gastroesophageal junction into the cardia (Figure D). Given the size of this lesion, a hot snare was used to obtain a sizeable sample for pathologic evaluation. The histologic examination at low power (Figure E, 10×) showed a fragmented complex polypoid mass with scattered cystically-dilated glands. No areas of hyperchromasia or dense cellularity were present. High power assessment (Figure F, 40×) showed polyp fronds surfaced by hyperplastic and reactive foveolar epithelium with prominent cystic dilatation of gastric pits. The underlying stroma was markedly edematous. No dysplasia, metaplasia, or neoplasia were identified. These findings were consistent with a gastric hyperplastic polyp.

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Gastric hyperplastic polyps belong to the family of epithelial polypoid lesions. Polypoid lesions include Barrett esophagus-associated polypoid dysplasia, polypoid carcinoma, fundic gland polyps and hyperplastic polyps.1 These masses are rare, often discovered incidentally, and are often asymptomatic as in our patient.2,3 They may arise from the gastroesophageal junction or at sites of healing gastric mucosal ulceration. They can become quite large, and

Corresponding Author: Evan S. Dellon, MD, MPH, CB #7080, Bioinformatics Building, 130 Mason Farm Rd., UNC-CH, Chapel Hill, NC 27599-7080, Phone: (919) 966-2513, Fax: (919) 843-2508, [email protected]. Author contributions (all authors approved this final draft): Reed: data acquisition; drafting of the article; critical revision Woosley: pathologic analysis; critical revision Dellon: project conception and design; data acquisition; supervision; critical revision Disclosures: There are no other potential conflicts of interest for any of the authors pertaining to this study

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when located near the gastric cardia, can herniate upward into the esophagus and present an unclear endoscopic appearance, raising suspicion for esophageal origin. In our patient, while this area was involved, we were not able to definitely determine the origin of this lesion because of its size and extent. Given the known pathogenesis of gastric hyperplastic polyps, it has been postulated that chronic inflammation may drive the development of these polyps as well.2 In addition, gastroesophageal reflux disease-related pathology, including erosive esophagitis and Barrett’s esophagus, has been shown to be present in the majority of patients with hyperplastic polyps of the esophagus or gastroesophageal junction.2

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Because this patient was asymptomatic and the lesion was felt to be benign, no further treatment or surveillance was recommended for him. A limited number of case reports and small case series comprise the literature pertinent to the management of esophageal hyperplastic polyps. Options for treatment include medical, endoscopic and surgical approaches.4–6 As hyperplastic polyps are felt to be a response to esophageal inflammation and injury,2 it is logical that initial treatment should be directed to the underlying etiology. Additional treatment may be warranted when a patient is symptomatic with dysphagia or develops a complication. In these circumstances endoscopic mucosal resection could be performed,5 and with very large tumors, debulking with cryotherapy could be considered. Though there are no specific data to support this latter approach in giant hyperplastic polyps, debulking has been described with other esophageal neoplasia.7

Acknowledgments Funding: There is no funding source for this project

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1. Kinney T, Waxman I. Treatment of benign esophageal tumors by endoscopic techniques. Semin Thorac Cardiovasc Surg. 2003; 15:27–34. [PubMed: 12813686] 2. Abraham SC, Singh VK, Yardley JH, et al. Hyperplastic polyps of the esophagus and esophagogastric junction: histologic and clinicopathologic findings. Am J Surg Pathol. 2001; 25:1180–1187. [PubMed: 11688578] 3. Watson RR, O’Connor TM, Weisel W. Solid benign tumors of the esophagus. Ann Thorac Surg. 1967; 4:80–91. [PubMed: 4292049] 4. Tsai SJ, Lin CC, Chang CW, et al. Benign esophageal lesions: endoscopic and pathologic features. World J Gastroenterol. 2015 Jan 28.21:1091–8. [PubMed: 25632181] 5. De Ceglie A, Lapertosa G, Blanchi S, et al. Endoscopic mucosal resection of large hyperplastic polyps in 3 patients with Barretts esophagus. World J Gastroenterol. 2006; 12:5699–704. [PubMed: 17007025] 6. Zitsman JL, Schullinger JN, Berdon WE. Inflammatory esophagogastric polyps: resolution following antireflux surgery. J Pediatr Surg. 1988; 23:1016–17. [PubMed: 3244075] 7. Cash BD, Johnston LR, Johnston MH. Cryospray ablation (CSA) in the palliative treatment of squamous cell carcinoma of the esophagus. World J Surg Oncol. 2007; 16:34.

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A Giant Esophageal Mass in a Patient Without Dysphagia.

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