Pyogenic Granuloma of the Esophagus

Abstract

A 59-year-old man had a 1-month history of intermittent dysphagia for solid food. There was no odynophagia, heartburn, regurgitation, or weight loss. Esophagogastroduodenoscopy showed a pedunculated red polyp measuring approximately 15 mm in diameter in the esophagus 25 cm from the incisor teeth and an adherent white deposit on the head (Figure A). Thus, he was referred for management. The physical examination and laboratory testing revealed no remarkable abnormalities. The tumor markers, including carcinoembryonic antigen, carbohydrate antigen 19-9, and alpha fetoprotein, were within normal limits. Endoscopic ultrasonography revealed a homogenous, hyperechoic lesion; the lesion was primarily confined to the mucosal layer and had clear borders (Figure B). A computed tomography scan demonstrated a well-defined, expansive mass in the middle esophagus (Figure C). The lesion was entirely removed without complications by using endoscopic submucosal dissection. Pathologic examination of the resected specimen revealed a surface covered by hyperplastic squamous epithelium and inflamed and edematous stroma containing numerous capillaries with a lobular arrangement (Figure D; hematoxylin-eosin; original magnification, ×40). A diagnosis of pyogenic granuloma (PG) was made. A PG is a lobular capillary hemangioma that presents as a polypoid red mass several millimeters to centimeters in size. PGs commonly occur on the skin and oral mucosa; however, a gastrointestinal PG is extremely rare. Only 21 cases of esophageal PGs have been published since esophageal PG was first described in 1983 by Okumura et al.1Okumura T. Tanoue S. Chiba K. et al.Lobular capillary hemangioma of the esophagus: a case report and review of the literature.Acta Pathol Jpn. 1983; 33: 1303-1308PubMed Google Scholar Nearly one-half of the reported esophageal PGs (10 of 21) have occurred in patients >60 years of age. The symptoms described in these patients included dysphagia, retrosternal pain, weight loss, and bleeding; however, some patients were asymptomatic. On the basis of endoscopy, PG is a pedunculated polyp that is mostly red in color with a white coating and occasional ulcerations, which can mimic esophageal cancer. The rapid growth and metamorphic nature of esophageal PG can serve as diagnostic clues.2Iwamuro M. Okada H. Tanaka T. et al.Morphological changes in a pyogenic granuloma of the esophagus observed over three years.Intern Med. 2015; 54: 1737-1740Crossref PubMed Scopus (2) Google Scholar Endoscopic ultrasonography showed that the lesions are homogeneously hyperechogenic, which reflects the proliferation of blood vessels in lesions like hemangiomas. Because PGs are highly vascular lesions, massive bleeding is expected after biopsy. We should avoid endoscopic biopsy for histologic diagnosis. The differential diagnosis for esophageal PGs includes inflammatory polyps, bacillary angiomatosis, angiosarcomas, reactive angioendotheliomatosis, and angiomatous variants of Kaposi sarcoma. The definitive diagnosis that is based on histopathologic evaluation is characterized by proliferating capillaries surrounded by inflammatory cells in a loose connective tissue stroma. Endoscopic mucosal resection and endoscopic snare polypectomy are the preferred treatment options for esophageal PGs3Seoung H.G. Kim G.H. Song G.A. et al.Esophageal pyogenic granuloma: endosonographic findings and endoscopic treatments.Clin Endosc. 2013; 46: 81-84Crossref PubMed Scopus (6) Google Scholar; however, it should be noted that incomplete excision can result in local recurrence.2Iwamuro M. Okada H. Tanaka T. et al.Morphological changes in a pyogenic granuloma of the esophagus observed over three years.Intern Med. 2015; 54: 1737-1740Crossref PubMed Scopus (2) Google Scholar In the current case, carcinosarcoma was also considered in the differential diagnosis, so endoscopic submucosal dissection was performed to completely remove the lesion. PGs are benign tumors, and no cases of malignant transformation have been reported; however, a case of PG co-occurring with esophageal squamous cell carcinoma has been reported.4Yu J.H. Seo K.J. Cho Y.S. Unusual esophageal mass as a cause of dysphagia.Gastroenterology. 2016; 150: e1-e2Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar In conclusion, PG is a polypoid capillary hemangioma. Because of its unusual appearance, PG can be misdiagnosed and treated as esophageal carcinoma with extensive surgery. Familiarity with this infrequent benign lesion facilitates the diagnosis and proper treatment.