Benign tumours of the oesophagus
Benign tumours of the oesophagus are uncommon and are found far more often than they cause trouble. Most are discovered incidentally during an endoscopy or a scan performed for another reason. The clinical task is rarely complex surgery; it is accurate characterisation — establishing what the lesion is, whether it carries any malignant potential, and therefore whether it needs removing at all.
How they form
The oesophageal wall is layered — mucosa, submucosa, muscularis propria — and each layer gives rise to its own tumours. The layer of origin determines both the appearance at endoscopy and the correct treatment.
Leiomyoma
By far the commonest, accounting for the majority of benign oesophageal tumours. It arises from smooth muscle, usually the muscularis propria, most often in the lower two thirds where smooth muscle predominates. It is a slow-growing, well-circumscribed, encapsulated tumour that displaces rather than invades. The overlying mucosa remains intact, which is the key practical point: biopsy at endoscopy is usually unrewarding and, worse, causes scarring between mucosa and tumour that makes later enucleation considerably more difficult. Malignant transformation is essentially not a feature.
Gastrointestinal stromal tumour (GIST)
Arises from the interstitial cells of Cajal, the pacemaker cells of the gut wall, usually through activating mutations in the KIT or PDGFRA genes. Oesophageal GISTs are rare — the stomach and small bowel are far commoner sites — but they matter because, unlike leiomyoma, a GIST is not benign. It is a tumour with a spectrum of malignant potential determined by size and mitotic rate. Distinguishing GIST from leiomyoma is the single most important diagnostic decision in this group, and it requires immunohistochemistry: GIST is typically CD117 (KIT) and DOG1 positive, leiomyoma is desmin and smooth muscle actin positive.
Granular cell tumour
Arises from Schwann cells. Usually small, submucosal, firm and yellowish, and most often in the distal oesophagus. Almost always benign; malignant variants are described but rare, and size above about 4cm or rapid growth raises concern.
Fibrovascular polyp
A pedunculated lesion of fibrous and vascular tissue with a mucosal covering, arising in the cervical oesophagus near the cricopharyngeus and elongating over years as peristalsis drags it downward. It can reach a remarkable size. Its importance is entirely mechanical: a large polyp can be regurgitated into the pharynx and occlude the larynx, causing sudden asphyxiation. This is the one benign oesophageal tumour that can kill, and it is a reason to remove them.
Squamous papilloma
A small wart-like mucosal lesion, associated in some cases with human papillomavirus and in others with chronic reflux irritation. Usually solitary and harmless.
Haemangioma, lipoma, duplication cyst
Vascular, fatty and congenital lesions respectively. Duplication cysts are developmental, arising from incomplete separation of the foregut, and may present in adulthood with dysphagia, chest pain or infection.
Symptoms
Most cause none. When they do, symptoms relate to size and position rather than to the type of tumour:
- dysphagia, typically slowly progressive over years and to solids only — the slow tempo is itself reassuring compared with the weeks-to-months history of cancer
- retrosternal discomfort or a sensation of pressure
- regurgitation
- cough, from a large lesion or from aspiration
- bleeding — unusual, and more typical of ulcerated GIST or haemangioma
- for a large fibrovascular polyp: regurgitation of a fleshy mass into the mouth, and episodes of choking
How the diagnosis is made
- Endoscopy shows a smooth bulge covered by normal mucosa — the appearance of a subepithelial lesion. Normal overlying mucosa is a reassuring sign and distinguishes these from carcinoma, which arises in the mucosa itself and is visibly abnormal.
- Endoscopic ultrasound is the decisive investigation. It identifies the layer of origin, the size, the echo pattern and the margins, which together separate leiomyoma, GIST, granular cell tumour, lipoma and cyst with reasonable confidence. Fine-needle aspiration can be added when a GIST is suspected and the result would change management.
- CT assesses size, relationship to adjacent structures and — where a GIST is possible — the liver and peritoneum.
- Barium swallow demonstrates a smooth, well-defined filling defect with intact mucosa, and remains useful for large lesions and polyps.
Routine mucosal biopsy of a smooth subepithelial bulge is generally avoided. It rarely reaches the lesion and it compromises later enucleation.
When treatment is needed — and when it is not
This is the substance of the consultation, and honest advice here spares many patients an unnecessary operation.
- Small, asymptomatic, typical leiomyoma — observation with interval endoscopic ultrasound is entirely appropriate. Many need nothing ever.
- Symptomatic lesions — removal.
- Any lesion suspected of being a GIST — removal, because malignant potential exists at any size, though very small gastric-type lesions may be followed in selected cases.
- Lesions growing on surveillance, or with irregular margins, heterogeneity, cystic change or ulceration — removal.
- Fibrovascular polyps — removal, because of the risk of laryngeal obstruction.
- Lesions where the diagnosis cannot be established — removal for diagnosis, which is a legitimate indication.
Treatment
Enucleation
The standard operation for leiomyoma. The muscle over the tumour is split, the tumour shelled out from its capsule with the mucosa left intact, and the muscle layer closed. It is performed thoracoscopically or laparoscopically according to level. Because the mucosa is preserved, the oesophagus is not resected and swallowing is unaffected.
Endoscopic resection
Endoscopic submucosal dissection or submucosal tunnelling endoscopic resection (STER) removes selected subepithelial lesions from within the lumen, through a tunnel created in the submucosa, leaving the mucosal entry point to be closed with clips. This avoids any chest or abdominal incision and is increasingly the treatment of choice for suitable small and medium lesions in experienced hands.
Polypectomy
Fibrovascular polyps are removed endoscopically or through a neck incision depending on size and the calibre of the vascular stalk, which must be secured.
Resection
Oesophagectomy is rarely required — for very large lesions, for those encircling the oesophagus, or for GIST where a margin is needed and enucleation would be inadequate. For GIST, the principles differ from leiomyoma: the aim is complete removal with an intact pseudocapsule, and a tumour that is large or in a difficult position may be treated first with imatinib to shrink it and allow a lesser operation.
Recovery
After enucleation, hospital stay is typically two to four days, often with a contrast study before feeding, and a soft diet for a week or two. After endoscopic resection, patients are frequently home within one to two days. Normal activity returns within two to four weeks for minimally invasive approaches.
Follow-up
None is needed after removal of a confirmed leiomyoma, granular cell tumour, lipoma or papilloma. GIST requires follow-up determined by its risk category — size, mitotic count and site — with adjuvant imatinib for high-risk tumours. Lesions kept under observation are followed with endoscopic ultrasound at intervals, which can be lengthened and eventually stopped once stability is established.
Common questions
I have been told there is a lump in my gullet. Is it cancer?
Most lumps of this kind are not. A smooth swelling covered by completely normal lining is typical of a benign tumour growing in the muscle layer, quite unlike a cancer, which grows from the lining itself and looks abnormal. An ultrasound scan performed through the endoscope usually settles the question.
Why was a biopsy not taken?
Because these lesions sit underneath normal lining, so an ordinary biopsy usually returns only normal tissue. It also creates scarring between the lining and the tumour, which makes it harder to remove the tumour later without opening the gullet. The ultrasound appearance is more informative and safer.
Does it have to be removed?
Often not. A small lesion with typical benign features and no symptoms can safely be watched, with a check scan after an interval. Removal is advised if it causes symptoms, if it grows, if the appearances are not typical, or if it may be a type with some potential to become malignant.
What is the difference between a leiomyoma and a GIST?
Both grow in the wall and look similar from outside. A leiomyoma is a benign muscle tumour that does not turn into cancer. A GIST arises from different cells and does have some potential to behave malignantly, depending on its size and how fast its cells divide. Telling them apart requires laboratory staining of the tissue, which is why removal is sometimes advised to establish the diagnosis.
Will my swallowing be normal afterwards?
Yes, in the great majority. The usual operation shells the tumour out of the muscle without opening or removing any of the gullet, so swallowing is not impaired. Some difficulty in the first week or two while swelling settles is expected.
Can it come back?
A completely removed benign tumour does not usually return. GISTs are followed up afterwards, with the frequency depending on their assessed risk.
I was told I have a polyp in my gullet that could be dangerous. Why?
A particular type, the fibrovascular polyp, grows on a stalk at the top of the gullet and can become long. Occasionally it is brought up into the throat and can block the airway. It is uncommon, but it is the reason this type is removed rather than watched.
Related conditions
Other conditions of the oesophagus covered on this site:
- Gastro-oesophageal reflux disease (GORD) and hiatus hernia
- Paraoesophageal hernia
- Achalasia
- Barrett's oesophagus
- Oesophageal diverticulum (Zenker's and epiphrenic)
- Oesophageal cancer
- Oesophageal perforation and Boerhaave syndrome
This page provides general information and does not replace an individual medical consultation. Assessment and treatment are decided for each patient after review of their history, examination and investigations.