Lipoma of the Esophagus--Report of a Case and Review of the Literature Seiji AKIYAMA*,Masato KAXAOKA*,Masumasa HORISAWA**,Shoichi INOUE**, Masao SAKAI**, Katsuki ITO*, Tadashi WATANABE* a n d Hiroshi TAKAGI*
ABSTRACT: We report herein, a rare case o f esophageal lipoma and review the J a p a n e s e literature on this subject. Lipoma o f the alimentary tract is relatively u n c o m m o n but that o f the esophagus is extremely rare with only 17 cases having b e e n reported in Japan. T h e majority o f these cases occurred in the cervical esophagus with the most serious symptom being regurgitation o f the pedunculated t u m o r which lead to asphyxia a n d death in one case. Only 2 cases occurred in the thoracic esophagus a n d these tumors were small in size and resected endoscopically. This is the first reported case of an esophageal lipoma being located in the thoracic esophagus which was resected through a thorocotomy. T h e clinical features o f esophageal lipoma are also described herein. KEY WORDS:
lipoma, thoracic esophagus, surgical resection
INTRODUCTION
D e n i g n tumors o f the esophagus are relatively rare a n d most cause no symptoms, often b e i n g f o u n d by chance on barium swallow. However, they must be differentiated from malignant tumors of the esophagus. T h e m a n y kinds of benign tumors occurring in the esophagus include adenoma, fibroma, h e m a n g i o m a , leiomyoma, r h a b d o m y o m a , lipoma, and lymphangioma. Lipoma o f the esophagus, however, is extremely rare a n d very difficult to detect due to the lack o f gymptoms, especially if it occurs in the thoracic or a b d o m i n a l esophagus.
*The Second Department of Surgery, Nagoya University School of Medicine, Nagoya, Japan **The Department of Surgery, Nagoya National Hospital, Nagoya,Japan Reprint requests to: Seiji Akiyama, MD, The Second Department of Surgery, Nagoya University, School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Japan
This case was preoperatively diagnosed as lipoma o f the esophagus by CT scan. CASE REPORT
A 75 year old w o m a n received a medical examination in April, 1985 at which time a b a r i u m swallow r e v e a l e d an esophageal tumor. Subsequent CT scan revealed a low density mass like adipose tissue in the submucosal layer of the thoracic esophagus which was d i a g n o s e d as a n esophageal lipoma a n d followed up for 2 years. The size of the t u m o r r e m a i n e d unchanged, however, she was referred to our hospital for recent mild dysphagia. O n admission, she was well nourished and h a d no other symptoms than the mild disphagia. Barium swallow studies disclosed an intraluminal space occupying mass in the u p p e r half o f the thoracic esophagus (Fig. 1) and CT scan revealed that the tumor extended from the level of the thoracic inlet to the left atrium. Moreover, the t u m o r was not e n h a n c e d by contrast
JAPANESEJOUI~'~ALOFSURGERY,VOL. 20, No. 4 pp. 458-462, 1990
Volume 20 Number 4
Esophageal lipoma
459
Fig. 3. The tumor was enucleated from the mucosa of the e s o p h a g u s and covered with normal mucosa. This figure shows the normal mucosa being dissected from the yellow tumor, after which the tumor was enucleated from the mucosa of the esophagus. Fig. 1. Barium swallow showing the esophageal lipoma. The tumor can be seen extending from the upper part to the middle part of the esophagus.
Fig. 4. Macroscopic findings of the esophageal lipoma. The tumor was yellow like adipose tissue, being 12.0 )< 3.5 X 1.5 cm in size.
Fig. 2. CT scan of the esophageal lipoma. The tumor has a low density like adipose tissue and the margin of the tumor can be seen clearly in the posterior mediasfilqllm.
enhanced CT (Fig. 2). E n d o s c o p y was performed w h i c h revealed the m u c o s a o f the esophagus to be intact. Right t h o r a c o t o m y was p e r f o r m e d in April, 1987, at which time, the tumor could not be seen, however, a soft mass was r e c o g n i z e d by palpation a l t h o u g h the margin o f the t u m o r was n o t clear. T h e esophagus was incised longitudinally to the
mucosal layer o n its right side a n d the t u m o r p r o t r u d e d to the outside f r o m the e s o p h a geal lumen. T h e t u m o r was soft a n d covered with n o r m a l e s o p h a g e a l m u c o s a . T h e m u c o s a which covered the t u m o r was t h e n incised a n d the t u m o r e n u c l e a t e d (Fig. 3). T h e t u m o r was 12.0 X' 3.5 N 1.5 cm in size, w e i g h e d 24 g a n d was yellowish like adipose tissue (Fig. 4). T h e pathologic diagnosis o f t h e t u m o r was m a t u r e d a d i p o s e t i s s u e divided with connective tissue a n d vessels (Fig. 5). T h e patient's postoperative course was uneventful a n d she was discharged o n the 32nd day after h e r operation.
Jpn. J. Surg. Jul~ 1990
Akiyama et aL
460
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Esophageal lipoma
Fig. 5. Microscopic findings of the esophageal lipoma. The tumor was composed of normal adipose tissue divided with connective tissue. DISCUSSION E s o p h a g e a l l i p o m a is a n u n c o m m o n disease occurring extremely rarely in the thoracic esophagus. Only 17 cases o f esophageal l i p o m a h a v e b e e n r e p o r t e d in Japan, only 2 o f which were located in the thoracic esophagus. Incidentally, 2 o f these 17 cases were originally reported as a pedunculated benign t u m o r and an esophageal polyp, respectively. ',~ Lipomas may occur anywhere in the digestive tract, with the colon b e i n g the most frequent site. T h e y occupy 4.1 p e r cent o f the benign tumors o f the digestive tract a n d the incidence of esophageal lip0ma is only 0.4 per cent according to the Mayo report? Ishihara also reported the incidence of lipomas in the digestive tract to be 4.8 per cent, with that of esophageal lipoma b e i n g 0 p e r cent in 685 necropsy cases in J a p a n ? Concerning the 18 cases, in cluding ours, reported in J a p a n , 12 were m e n a n d 6 women. T h e age at onset ranged f r o m 30 to 75 a n d most padents were in their fifties or sixties. T h e symptoms were mild in general and dysphagia was seen in 8 cases. T h e most severe symptom by far was regurgitation o f the t u m o r into the m o u t h which caused death by asphyxia 5 in one case. There was only one case in the J a p a n e s e literature which required emergency intratracheal intubation because of regurgitation
461
of the tumor. 6 O n e case h a d an ulcer on the surface o f the t u m o r but all the other cases h a d a smooth surface a n d no inflammation. T u m o r biopsy has failed to obtain a pathological diagnosis before surgical intervention and the postoperative pathologic diagnoses were lipoma in 15 cases, fibrolipoma in 2 cases a n d a n g i o f i b r o l i p o m a in 1 c a s e 2 Lipoma o f the esophagus usually originates in the cervical esophagus but very rarely in the thoracic esophagus. Seven other cases were reported as lipoma o f the gastroesophageal junction, 8-1~ however, all 7 cases were lipomas m e a s u r i n g over 10 cm in length a n d all originated in the cervical esophagus. T h e o t h e r lipomas o f the thoracic esophagus were small a n d r e s e c t e d endoscopically. Only 3 cases were tumorous while the others were all pedunculated, which was why regurgitation o f the tumor might easily occur. Hosokawa examined a tumor growth rate and reported that the volume of the tumor h a d increased 2.5 times over a period o f 3 years and 9 months2 W h e n tumors are small in size, it is possible to resect them by endoscopy and surgical intervention is indicated only w h e n endoscopic resection is impossible. Thus, early diagnosis and treatm e n t should be r e c o m m e n d e d for all cases. (Received for publication onJul. 10, 1989) REFERENCES 1. Hosokawa O, Shirasaki I, Sandou N. Endoscopic removal of esophageal lipoma. Gastroenterological Endoscopy i985; 27: 738-743. (in Japanese) 2. Oyamada H, Kishi T, Yoshie S, Kogawa T, Yoshikawa T, Kondo M. A case of esophageal lipoma resected endoscopically. Shindan to Chiryo 1987; 75: 2747-2750. (in Japanese) 3. MayoCW, Pagutalunan PJG, Brown DJ. Lipoma of the alimentary tract. Surgery 1963; 53: 593-603. 4. Ishihara A, Yamagiwa Y, Matsuzaki O. Lipoma of the colon. Gan no Rinsho 1980; 26: 376-381. (in Japanese) 5. Allen MSJr, CharlottesvilleVa, Talbot WH. Sudden death due to regurgitation of a pedunculated esophageal lipoma.J Thoracic and Cardiovascular Surgery 1967; 54: 756-758.
462
Akiyama et al.
6. Noguchi M, Yoshii M, Mitsuno S. A case of a giant esophageal lipoma vomited after endoscopy. Gastroenterological Endoscopy 1982; 24: 1982. (in Japanese) 7. Tasaka Y, Makimato K, Yamauchi M, Haebara H. Benign pedunculated intraluminal tumor of the esophagus.J of Otolaryngology 1982; 11: 111-115. 8. Hirata S, Sakai K, Hamanaka Y. Lipoma of the gastroesophagealjuncfion: A case report Shokaki
Jpn. J. Surg. Jury 1990
Geka 1985; 8: 633-637. (in Japanese) Nishimura R, Tsuchigame N, Saitou 1~ A lipoma of the gastroesophageal junction. Gastroenterological Endoscopy 1978; 28: 1832. (in Japanese) 10. Kaneko E, Kumagaya J, Nawano M, Hanai H, Honda N, Nakamura S, Kino I. A case of esophageal lipoma resected endoscopically. Gastroenterological Endoscopy 1981; 23: 435-439. (in Japanese)
ABSTRACT: We report herein, a rare case o f esophageal lipoma and review the J a p a n e s e literature on this subject. Lipoma o f the alimentary tract is relatively u n c o m m o n but that o f the esophagus is extremely rare with only 17 cases having b e e n reported in Japan. T h e majority o f these cases occurred in the cervical esophagus with the most serious symptom being regurgitation o f the pedunculated t u m o r which lead to asphyxia a n d death in one case. Only 2 cases occurred in the thoracic esophagus a n d these tumors were small in size and resected endoscopically. This is the first reported case of an esophageal lipoma being located in the thoracic esophagus which was resected through a thorocotomy. T h e clinical features o f esophageal lipoma are also described herein. KEY WORDS:
lipoma, thoracic esophagus, surgical resection
INTRODUCTION
D e n i g n tumors o f the esophagus are relatively rare a n d most cause no symptoms, often b e i n g f o u n d by chance on barium swallow. However, they must be differentiated from malignant tumors of the esophagus. T h e m a n y kinds of benign tumors occurring in the esophagus include adenoma, fibroma, h e m a n g i o m a , leiomyoma, r h a b d o m y o m a , lipoma, and lymphangioma. Lipoma o f the esophagus, however, is extremely rare a n d very difficult to detect due to the lack o f gymptoms, especially if it occurs in the thoracic or a b d o m i n a l esophagus.
*The Second Department of Surgery, Nagoya University School of Medicine, Nagoya, Japan **The Department of Surgery, Nagoya National Hospital, Nagoya,Japan Reprint requests to: Seiji Akiyama, MD, The Second Department of Surgery, Nagoya University, School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya City, Japan
This case was preoperatively diagnosed as lipoma o f the esophagus by CT scan. CASE REPORT
A 75 year old w o m a n received a medical examination in April, 1985 at which time a b a r i u m swallow r e v e a l e d an esophageal tumor. Subsequent CT scan revealed a low density mass like adipose tissue in the submucosal layer of the thoracic esophagus which was d i a g n o s e d as a n esophageal lipoma a n d followed up for 2 years. The size of the t u m o r r e m a i n e d unchanged, however, she was referred to our hospital for recent mild dysphagia. O n admission, she was well nourished and h a d no other symptoms than the mild disphagia. Barium swallow studies disclosed an intraluminal space occupying mass in the u p p e r half o f the thoracic esophagus (Fig. 1) and CT scan revealed that the tumor extended from the level of the thoracic inlet to the left atrium. Moreover, the t u m o r was not e n h a n c e d by contrast
JAPANESEJOUI~'~ALOFSURGERY,VOL. 20, No. 4 pp. 458-462, 1990
Volume 20 Number 4
Esophageal lipoma
459
Fig. 3. The tumor was enucleated from the mucosa of the e s o p h a g u s and covered with normal mucosa. This figure shows the normal mucosa being dissected from the yellow tumor, after which the tumor was enucleated from the mucosa of the esophagus. Fig. 1. Barium swallow showing the esophageal lipoma. The tumor can be seen extending from the upper part to the middle part of the esophagus.
Fig. 4. Macroscopic findings of the esophageal lipoma. The tumor was yellow like adipose tissue, being 12.0 )< 3.5 X 1.5 cm in size.
Fig. 2. CT scan of the esophageal lipoma. The tumor has a low density like adipose tissue and the margin of the tumor can be seen clearly in the posterior mediasfilqllm.
enhanced CT (Fig. 2). E n d o s c o p y was performed w h i c h revealed the m u c o s a o f the esophagus to be intact. Right t h o r a c o t o m y was p e r f o r m e d in April, 1987, at which time, the tumor could not be seen, however, a soft mass was r e c o g n i z e d by palpation a l t h o u g h the margin o f the t u m o r was n o t clear. T h e esophagus was incised longitudinally to the
mucosal layer o n its right side a n d the t u m o r p r o t r u d e d to the outside f r o m the e s o p h a geal lumen. T h e t u m o r was soft a n d covered with n o r m a l e s o p h a g e a l m u c o s a . T h e m u c o s a which covered the t u m o r was t h e n incised a n d the t u m o r e n u c l e a t e d (Fig. 3). T h e t u m o r was 12.0 X' 3.5 N 1.5 cm in size, w e i g h e d 24 g a n d was yellowish like adipose tissue (Fig. 4). T h e pathologic diagnosis o f t h e t u m o r was m a t u r e d a d i p o s e t i s s u e divided with connective tissue a n d vessels (Fig. 5). T h e patient's postoperative course was uneventful a n d she was discharged o n the 32nd day after h e r operation.
Jpn. J. Surg. Jul~ 1990
Akiyama et aL
460
x ~x
X
~
S
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s
" a ' a ~ 3........ s ~ S S ~ ' s 3 oo -~..~
.
s ~s
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0
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v
0
0
i' 0
0
z
~.o~
~176 ~,~ 9
~blume 20 Number 4
Esophageal lipoma
Fig. 5. Microscopic findings of the esophageal lipoma. The tumor was composed of normal adipose tissue divided with connective tissue. DISCUSSION E s o p h a g e a l l i p o m a is a n u n c o m m o n disease occurring extremely rarely in the thoracic esophagus. Only 17 cases o f esophageal l i p o m a h a v e b e e n r e p o r t e d in Japan, only 2 o f which were located in the thoracic esophagus. Incidentally, 2 o f these 17 cases were originally reported as a pedunculated benign t u m o r and an esophageal polyp, respectively. ',~ Lipomas may occur anywhere in the digestive tract, with the colon b e i n g the most frequent site. T h e y occupy 4.1 p e r cent o f the benign tumors o f the digestive tract a n d the incidence of esophageal lip0ma is only 0.4 per cent according to the Mayo report? Ishihara also reported the incidence of lipomas in the digestive tract to be 4.8 per cent, with that of esophageal lipoma b e i n g 0 p e r cent in 685 necropsy cases in J a p a n ? Concerning the 18 cases, in cluding ours, reported in J a p a n , 12 were m e n a n d 6 women. T h e age at onset ranged f r o m 30 to 75 a n d most padents were in their fifties or sixties. T h e symptoms were mild in general and dysphagia was seen in 8 cases. T h e most severe symptom by far was regurgitation o f the t u m o r into the m o u t h which caused death by asphyxia 5 in one case. There was only one case in the J a p a n e s e literature which required emergency intratracheal intubation because of regurgitation
461
of the tumor. 6 O n e case h a d an ulcer on the surface o f the t u m o r but all the other cases h a d a smooth surface a n d no inflammation. T u m o r biopsy has failed to obtain a pathological diagnosis before surgical intervention and the postoperative pathologic diagnoses were lipoma in 15 cases, fibrolipoma in 2 cases a n d a n g i o f i b r o l i p o m a in 1 c a s e 2 Lipoma o f the esophagus usually originates in the cervical esophagus but very rarely in the thoracic esophagus. Seven other cases were reported as lipoma o f the gastroesophageal junction, 8-1~ however, all 7 cases were lipomas m e a s u r i n g over 10 cm in length a n d all originated in the cervical esophagus. T h e o t h e r lipomas o f the thoracic esophagus were small a n d r e s e c t e d endoscopically. Only 3 cases were tumorous while the others were all pedunculated, which was why regurgitation o f the tumor might easily occur. Hosokawa examined a tumor growth rate and reported that the volume of the tumor h a d increased 2.5 times over a period o f 3 years and 9 months2 W h e n tumors are small in size, it is possible to resect them by endoscopy and surgical intervention is indicated only w h e n endoscopic resection is impossible. Thus, early diagnosis and treatm e n t should be r e c o m m e n d e d for all cases. (Received for publication onJul. 10, 1989) REFERENCES 1. Hosokawa O, Shirasaki I, Sandou N. Endoscopic removal of esophageal lipoma. Gastroenterological Endoscopy i985; 27: 738-743. (in Japanese) 2. Oyamada H, Kishi T, Yoshie S, Kogawa T, Yoshikawa T, Kondo M. A case of esophageal lipoma resected endoscopically. Shindan to Chiryo 1987; 75: 2747-2750. (in Japanese) 3. MayoCW, Pagutalunan PJG, Brown DJ. Lipoma of the alimentary tract. Surgery 1963; 53: 593-603. 4. Ishihara A, Yamagiwa Y, Matsuzaki O. Lipoma of the colon. Gan no Rinsho 1980; 26: 376-381. (in Japanese) 5. Allen MSJr, CharlottesvilleVa, Talbot WH. Sudden death due to regurgitation of a pedunculated esophageal lipoma.J Thoracic and Cardiovascular Surgery 1967; 54: 756-758.
462
Akiyama et al.
6. Noguchi M, Yoshii M, Mitsuno S. A case of a giant esophageal lipoma vomited after endoscopy. Gastroenterological Endoscopy 1982; 24: 1982. (in Japanese) 7. Tasaka Y, Makimato K, Yamauchi M, Haebara H. Benign pedunculated intraluminal tumor of the esophagus.J of Otolaryngology 1982; 11: 111-115. 8. Hirata S, Sakai K, Hamanaka Y. Lipoma of the gastroesophagealjuncfion: A case report Shokaki
Jpn. J. Surg. Jury 1990
Geka 1985; 8: 633-637. (in Japanese) Nishimura R, Tsuchigame N, Saitou 1~ A lipoma of the gastroesophageal junction. Gastroenterological Endoscopy 1978; 28: 1832. (in Japanese) 10. Kaneko E, Kumagaya J, Nawano M, Hanai H, Honda N, Nakamura S, Kino I. A case of esophageal lipoma resected endoscopically. Gastroenterological Endoscopy 1981; 23: 435-439. (in Japanese)
