acanthosis is a benign condition in which there is accumulation of cytoplasmic glycogen in the squamous epithelial cells lining the esophagus, causing focal, plaque‐like thickening of the mucosa [116, 117]. It is a benign, degenerative condition, occurring primarily in elderly individuals. Glycogenic acanthosis can often be recognized on double‐contrast studies by the presence of multiple small, rounded nodules or plaques in the mid or, less commonly, distal esophagus [118] (Figure 6.59). The major consideration in the differential diagnosis is Candida esophagitis. However, the plaques of candidiasis tend to have a more linear configuration and typically occur in immunocompromised patients with odynophagia, whereas glycogenic acanthosis typically occurs in older individuals who are not immunocompromised and have no esophageal symptoms. Thus, it is usually possible to differentiate these conditions on the basis of the clinical and radiographic findings.
Figure 6.48 Herpes esophagitis in an otherwise healthy patient. Double‐contrast view shows innumerable punctate ulcers clustered together in the mid esophagus below the level of the left main bronchus.
Source: Reproduced from DeGaeta L, Levine MS, Guglielmi GE, et al. Herpes esophagitis in an otherwise healthy patient. AJR Am J Roentgenol1985; 244:1205–1206, with permission.
Leiomyoma
Leiomyomas are by far the most common benign submucosal tumors in the esophagus. Unlike gastrointestinal stromal tumors elsewhere, esophageal leiomyomas almost never undergo sarcomatous degeneration and, unlike gastrointestinal stromal tumors in the stomach, are almost never ulcerated [116]. Patients with esophageal leiomyomas are usually asymptomatic but occasionally may present with dysphagia, depending on the size of the tumor and how much it encroaches on the lumen.
When esophageal leiomyomas grow exophytically into the mediastinum, they can sometimes be recognized on chest radiographs by the presence of a mass in the right superior mediastinum, occasionally containing punctate calcifications [116]. Esophageal leiomyomas are usually manifested on esophagography by a smooth submucosal mass, etched in white, that forms right angles or slightly obtuse angles with the adjacent esophageal wall when viewed in profile [116] (Figure 6.60). These lesions therefore may be indistinguishable on barium studies from other mesenchymal tumors such as granular cell tumors, lipomas, hemangiomas, fibromas, and neurofibromas, except that leiomyomas are more likely on empirical grounds. Occasionally, computed tomography (CT) may be helpful for differentiating submucosal esophageal masses from extrinsic tumors or lymphadenopathy in the mediastinum compressing the esophagus.
Figure 6.49 Cytomegalovirus (CMV) esophagitis in an acquired immunodeficiency syndrome (AIDS) patient. Double‐contrast view shows a giant, flat ulcer (arrows) in the distal esophagus. Note the thin rim of edema abutting the ulcer. Because herpetic ulcers rarely become this large, the presence of one or more giant ulcers should be highly suggestive of CMV esophagitis in the appropriate clinical setting.
Source: Reproduced from Laufer I, Levine MS, eds. Double contrast gastrointestinal radiology, 2nd ed.Philadelphia: WB Saunders; 1992, with permission.
Fibrovascular polyp
Fibrovascular polyps are rare benign mesenchymal tumors characterized by the development of a pedunculated intraluminal mass that can grow to enormous sizes in the esophagus. These lesions consist histologically of varying amounts of fibrovascular and adipose tissue covered by normal squamous epithelium [119]. Fibrovascular polyps are almost always thought to arise near the level of the cricopharyngeus, gradually elongating over a period of years as they are dragged inferiorly by esophageal peristalsis [119]. Some of these polyps can become so large that they cause dysphagia or wheezing as a result of extrinsic compression of the trachea by the polyp. Rarely, these patients have a spectacular clinical presentation with regurgitation of a fleshy mass into the pharynx or mouth, or even asphyxia and sudden death if the regurgitated polyp occludes the larynx [120].
Figure 6.50 Human immunodeficiency virus (HIV) esophagitis in patients with acquired immunodeficiency syndrome (AIDS). (A) Double‐contrast view shows a large diamond‐shaped ulcer (black arrows) with a cluster of small satellite ulcers in the mid esophagus. The rounded filling defect (white arrow) proximally is an air bubble. (B) Double‐contrast view in another patient shows a large, flat ulcer (arrows) in profile in the distal esophagus. HIV ulcers are impossible to differentiate from cytomegalovirus ulcers on the basis of the radiographic findings, so endoscopy is required for a definitive diagnosis before treating these patients.
Source: Reproduced from Levine et al. [95], with permission.
Fibrovascular polyps usually appear on esophagography as smooth, expansile, sausage‐shaped masses that expand the lumen of the upper or mid esophagus [121] (Figure 6.61A). Occasionally, a discrete pedicle can be seen originating near the level of the cricopharyngeus. Fibrovascular polyps that contain a considerable amount of adipose tissue may appear as fat‐density lesions on CT (Figure 6.61B), whereas fibrovascular polyps that contain varying amounts of fibrovascular and adipose tissue may have a heterogeneous appearance with areas of fat juxtaposed with areas of soft tissue density [121]. Thus, fibrovascular polyps may be manifested by a spectrum of findings on CT, depending on their predominant histologic components.
Duplication cyst
Duplication cysts are not true neoplasms, but they may also appear on esophagography as submucosal masses. Esophageal duplications cysts comprise about 20% of all duplication cysts in the gastrointestinal tract [121]. The cysts are development anomalies in which nests of cells are sequestered from the primitive foregut. Duplication cysts contain multiple layers of the bowel, including a mucosa, submucosa, and muscularis propria. Affected individuals are usually asymptomatic, but symptoms occasionally may be caused by bleeding or infection of the cyst. The cysts generally do not communicate with the esophageal lumen (so‐called non‐communicating cysts) and tend to be located in the right lower mediastinum. As a result, they can sometimes be recognized on frontal chest radiographs by the presence of a mass in the right lower mediastinum [116]. The cysts typically appear on barium studies as smooth submucosal masses indistinguishable from esophageal leiomyomas [116]. When duplication cysts do communicate with the esophageal lumen, they occasionally may be recognized as tubular, branching outpouchings from the esophagus that fill with barium [116] (Figure 6.62). These fluid‐filled cysts usually appear as homogeneous low‐attenuation structures on CT and as high‐signal intensity structures on T2‐weighted magnetic resonance imaging (MRI) [122].