Benign pathologies

Benign pathologies

Benign epithelial lesions include papillomas, fibrovascular polyps, glycogen acanthosis, parakeratosis, lipomas, lymph - angiomas and haemangiomas. They are benign, though parakeratosis is associated with malignancy of the oesophagus and head and neck region. Inlet patches (also referred to as heterotopic gastric mucosa) are common and are most often found within a short distance e 66.40 ). They consist of of the postcricoid region ( Figur

(b) (a) Inlet patch on white light endoscopy at 9–10 o’clock.

embryonic gastric mucosa, though there are conflicting views as to whether they are truly embryonic or acquired in origin. The discovery of inlet patches is usually incidental on endos copy . Biopsies will show corpus- or fundus-type gastric mucosa, sometimes even with parietal cells. Most are incidental and can be observed. An association with globus sensation, c hronic cough and laryngopharyngeal reflux has been suggested. The patches can be ablated with RFA, argon plasma coagulation or multipolar electrocoagulation. Resolution of symptoms, how ever, is unpredictable. Oesophageal duplication cysts are congenital anomalies that arise during early embryonic development. They are located within the oesophageal wall, covered by two muscle lay ers, and contain squamous epithelium or a lining compatible with that found in the embryonic oesophagus. Sometimes heterotopic gastric or pancreatic mucosa can be found. Most duplication cysts do not communicate with the oesophageal lumen, run parallel with the oesophagus and are asymptomatic unless large. Symptomatic duplication cysts can be resected. Granular cell tumours are rare. On endoscopy they are typically sessile, yellowish-white and submucosal. They feel firm when prodded with a biopsy for ceps. On EUS, they are hyperechoic and arise from the submucosal layer. They most likely arise from Schwann cells, suggesting a neural origin. Rarely they undergo malignant transformation. Schwannomas are often found incidentally; if large, surgical removal is indicated ( Figure 66.41 ). Theodor Schwann , 1801–1882, physiologist, Berlin, Germany , later Leuven and Liège, Belgium. Leiomyomas are the most common solid benign tumours of the oesophagus ( Figure 66.42 ). They are mostly found - incidentally as a submucosal mass on endoscopy but may produce compressiv e symptoms when large. EUS shows a hypoechoic mass arising from the muscularis propria or the submucosal layer. They rarely become malignant; however, resection is indicated if enlarging on serial assessment. Small leiomyomas can be enucleated with a thoracoscopic approach, - keeping the mucosa intact. Preoperative biopsy or EUS-guided fine-needle aspiration (FNA) is relatively contraindicated as the consequent scarring will increase the chance of breaching the mucosa during enucleation. Endoscopic resection is possible using submucosal tunnel- ling endoscopic resection (STER); this creates a mucosal open - ing a short distance from the leiomyoma (3–5 /uni00A0 cm proximally), allowing a submucosal tunnel to reach the lesion. The lesion is resected using ESD tec hniques and the specimen retrieved via the mouth. The mucosal opening is closed with clips ( Figure 66.43 ). Because of the av ailability of STER, the threshold of removing smaller leiomyomas is reduced because of its minimal invasiveness. Larger lesions (perhaps larger than 5 /uni00A0 cm) are technically challenging and are better removed thoracoscopically . Leiomyosarcoma is rare and resection o ff ers a chance of cure. Oesophageal gastrointestinal stromal tumours (GISTs) are uncommon and are usually found at the OGJ/proximal stomach. They should be managed along the same principles as GIST in the rest of the gastrointestinal tract.

Figure 66.41 Large tumour of the upper oesophagus showing as an opacity on chest radiograph homogeneous tumour causing tracheal compression (b) . The resected tumour was a Schwannoma. (a) . Computed tomography scan shows a

Figure 66.42 Leiomyoma of the oesophagus. (a) Endoscopic view of a submucosal lesion with intact mucosa. of a hypoechoic lesion arising from the muscularis propria layer (red arrows).