Cervical approach for resection of a pedunculated giant atypical lipomatous tumor of the esophagus

Giant esophageal liposarcoma with squamous cell carcinoma resected via the cervical approach: a case report

Background

Liposarcoma is one of the most common soft tissue sarcomas, but is extremely rarely found in the esophagus. There have been no reports of esophageal liposarcoma together with superficial carcinoma of the esophagus. Here, we report a patient who underwent complete resection of esophageal liposarcoma with carcinoma via a cervical approach.

Case presentation

A 66-year-old man was diagnosed with an esophageal tumor 11 years ago, but he left it untreated. He presented to our hospital with progressive dysphagia and appetite loss since the previous year. Esophagogastroduodenoscopy (EGD) showed a large pedunculated submucosal tumor (SMT) originating at the esophageal entrance, extending to the gastroesophageal junction. Additionally, there was a superficial carcinoma on the surface of the SMT, 30 cm from the incisor teeth. Three-dimensional computed tomography (3D-CT) showed a giant elongated intraluminal tumor extending downwards from the cervical esophagus. We diagnosed a giant esophageal polyp accompanied by a superficial carcinoma and performed tumor resection via a cervical approach. The excised specimen consisted of a 23.0 × 8.5 cm polypoid mass. The final diagnosis by histopathological and immunohistochemical examination was well-differentiated liposarcoma and esophageal squamous cell carcinoma. He was discharged on postoperative day 14 with drastic improvement in his swallowing ability.

Conclusion

We reported an extremely rare case of esophageal liposarcoma together with esophageal squamous cell carcinoma that was successfully resected through a small cervical incision.

Esophageal Lipoma and Liposarcoma: A Systematic Review

BACKGROUND

Esophageal lipomatous tumors, also reported as fibrovascular polyp, fibrolipoma, angiolipoma, and liposarcoma, account for less than 1% of all benign mesenchymal submucosal tumors of the esophagus. Clinical presentation and therapy may differ based on location, size, and morphology. A comprehensive and updated systematic review of the literature is lacking.

METHODS

A systematic review of the literature was performed according to PRISMA guidelines. Pubmed, Embase, Cochrane, and Medline databases were consulted using MESH keywords. Non-English written articles and abstracts were excluded. Sex, age, symptoms at presentation, diagnosis, tumor location and size, surgical approach and technique of excision, pathology, and morphology were extracted and recorded in an electronic database.

RESULTS

Sixty-seven studies for a total of 239 patients with esophageal lipoma or liposarcoma were included in the qualitative analysis. Among 176 patients with benign lipoma, the median age was 55. The main symptoms were dysphagia (64.2%), transoral polyp regurgitation (32.4%), and globus sensation (22.7%). The majority of lipomas (85.7%) were intraluminal polyps, with a stalk originating from the upper esophagus. Overall, 165 patients underwent excision of the mass through open surgery (65.5%), endoscopy (27.9%), or laparoscopy/thoracoscopy (3.6%). Only 5 (3%) of patients required esophagectomy. Of the 11 untreated patients with an intraluminal polyp, 7 died from asphyxia. Overall, liposarcoma was diagnosed in 63 patients, and 12 (19%) underwent esophagectomy.

CONCLUSION

Esophageal lipomatous tumors are rare but potentially lethal when are intraluminal and originate from the cervical esophagus. Modern radiological imaging has improved diagnostic accuracy. Minimally invasive transoral and laparoscopic/thoracoscopic techniques represent the therapeutic approach of choice.

Esophageal Lipoma and Liposarcoma: A Systematic Review

Background

Esophageal lipomatous tumors, also reported as fibrovascular polyp, fibrolipoma, angiolipoma, and liposarcoma, account for less than 1% of all benign mesenchymal submucosal tumors of the esophagus. Clinical presentation and therapy may differ based on location, size, and morphology. A comprehensive and updated systematic review of the literature is lacking.

Methods

A systematic review of the literature was performed according to PRISMA guidelines. Pubmed, Embase, Cochrane, and Medline databases were consulted using MESH keywords. Non-English written articles and abstracts were excluded. Sex, age, symptoms at presentation, diagnosis, tumor location and size, surgical approach and technique of excision, pathology, and morphology were extracted and recorded in an electronic database.

Results

Sixty-seven studies for a total of 239 patients with esophageal lipoma or liposarcoma were included in the qualitative analysis. Among 176 patients with benign lipoma, the median age was 55. The main symptoms were dysphagia (64.2%), transoral polyp regurgitation (32.4%), and globus sensation (22.7%). The majority of lipomas (85.7%) were intraluminal polyps, with a stalk originating from the upper esophagus. Overall, 165 patients underwent excision of the mass through open surgery (65.5%), endoscopy (27.9%), or laparoscopy/thoracoscopy (3.6%). Only 5 (3%) of patients required esophagectomy. Of the 11 untreated patients with an intraluminal polyp, 7 died from asphyxia. Overall, liposarcoma was diagnosed in 63 patients, and 12 (19%) underwent esophagectomy.

Conclusion

Esophageal lipomatous tumors are rare but potentially lethal when are intraluminal and originate from the cervical esophagus. Modern radiological imaging has improved diagnostic accuracy. Minimally invasive transoral and laparoscopic/thoracoscopic techniques represent the therapeutic approach of choice.

Liposarcoma of Hypopharynx and Esophagus: a Unique Entity?

PURPOSE

Liposarcoma is the most common soft tissue sarcoma in adults. It represents approximately 20 % of all mesenchymal malignancies. It most frequently involves retroperitoneum, trunk, and extremities. Hypopharyngeal and esophageal localization of liposarcoma is extremely rare.

METHODS

We performed a systematic review of literature and reported 26 and 33 cases of hypopharyngeal and esophageal liposarcoma. We analyzed natural history, imaging features, histology, treatment, and prognosis, with a specific focus to similarities and differences between tumors of hypopharynx and esophagus.

RESULTS

Hypopharyngeal and esophageal liposarcomas have more similarities than differences. Incidence has a peak at 6th and 7th decades. The diagnostic procedures are barium swallow, endoscopic examination, and CT/MR imaging. Well-differentiated liposarcoma represents the most frequent histological subtype. Surgical excision is the main treatment. Endoscopic resection can be useful for pedunculated tumors of hypopharynx and cervical esophagus. Differences between hypopharyngeal and esophageal liposarcoma are represented by local recurrence rate (greater for hypopharyngeal tumors), number of giant tumors, and time to recurrence (greater for esophageal tumors). Finally, liposarcomas of distal esophagus need more extended approaches.

CONCLUSIONS

Liposarcomas of hypopharynx and cervical esophagus could be considered a unique pathological entity, with similar features and treatment options. Survival rate is dependent on histological type and location. Local recurrence is common, especially for hypopharyngeal liposarcoma, while the risk of lymph node or distant metastasis is very low. Patients should undergo regular examinations to rule out local recurrence, also for a long time, especially for esophageal tumors.

A pedunculated giant esophageal liposarcoma: a case report and literature review

INTRODUCTION

The majority of esophageal tumors arise from the mucosal layer; only 5 % are of mesenchymal origins. Of the latter, barely 0.5 % are liposarcomas. We present a case of an esophageal liposarcoma with a review of the literature.

CASE REPORT

A 64-year-old male was referred with 5 years of progressive dysphagia. Preoperative evaluation initially suggested a leiomyoma. The polypoid lesion was then resected through a cervical esophagotomy, once endoscopic resection proved to be not feasible. The definitive pathologic diagnosis confirmed a well-differentiated liposarcoma.

LITERATURE REVIEW

Esophageal liposarcomas are very rare and only 40 such cases have been reported in the literature. Most patients were male (80 %), the median age was 62 years (range 38-83 years), and the most common symptom was dysphagia (85 %). Only in two cases was a liposarcoma detected on preoperative biopsy. The most common histological subtype was well-differentiated liposarcoma. Overall, 77.5 % of the patients were successfully treated with surgery, 20 % endoscopically, and 2.5 % were ablated with CO2 laser.

CONCLUSION

Esophageal liposarcoma is an extremely rare tumor. The majority of patients are males; dysphagia is the most common initial symptom, and preoperative biopsy is unreliable. Because these tumors are pedunculated, well-circumscribed, and well-differentiated, they can be safely resected locally. All patients need long-term follow-up as this disease can recur many decades after treatment.

Giant hypopharyngeal atypical lipomatous tumor

The so-called "giant fibrovascular polyps" of the esophagus and hypopharynx typically present as sausage-like pedunculated structures that protrude into the lumen and cause obstructive symptoms. Most are cured by local resection but they may recur. Microscopically, they display an admixture of fibrovascular and adipose tissue that is coated by unremarkable squamous mucosa. Here, we report a case that had scattered hyperchromatic cells and lipoblasts within the adipose tissue component. In other anatomic sites similar appearing lesions have been interpreted as pedunculated liposarcomas/atypical lipomatous tumors that are more prone to local recurrences than classic giant fibrovascular polyps. Reports of dedifferentiation and metastases are lacking thus raising the possibility that the cytologic findings in such lesions are degenerative. To confirm our suspicion of liposarcomatous differentiation, we performed immunohistochemistry for MDM2 and p53, 2 markers that are known to be negative in benign lipomatous lesions and positive in well-differentiated liposarcomas/atypical lipomatous tumors. The scattered atypical hyperchromatic cells and the lipoblasts both exhibited strong nuclear staining for both markers and supported the diagnosis of pedunculated giant hypopharyngeal atypical lipomatous tumor.

Primary pedunculated giant esophageal liposarcoma: case report

Liposarcoma is one of the most common soft tissue sarcomas in adults, but the incidence of esophageal liposarcoma is extremely low. To our knowledge there are only 18 cases of esophageal liposarcoma reported in the English-language literature. Here we report a new case of primary esophageal liposarcoma in a 50-year-old male patient who complained of aggravating dysphagia with intermittent vomiting for 6 months. The tumor was located in the upper esophagus. Polypectomy was performed and histologic examination showed a well-differentiated liposarcoma. Diagnostic and therapeutic tools are discussed and the results of a literature review are discussed.