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Benign oesophageal tumours and thoracic diverticula

The commonest benign oesophageal tumour is leiomyoma — a submucosal mass from the muscle layer diagnosed by EUS and treated, when it causes symptoms or grows, by thoracoscopic enucleation without opening the mucosa; an epiphrenic diverticulum is a "pulsion" diverticulum above the diaphragm that arises from a motility disorder, so it is treated by excision together with myotomy.

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Why it matters in the exam

Leiomyoma accounts for most benign oesophageal tumours, and lies mainly in the lower two thirds. On EUS it appears as a uniform hypoechoic mass arising from the muscle layer (muscularis propria), and on staining it is positive for desmin and SMA and negative for KIT and DOG1 — distinguishing it from GIST, which is rare in the oesophagus and carries malignant potential. When the endosonographic picture is typical and enucleation is planned, biopsy through the mucosa is usually avoided, because scarring makes enucleation harder and increases the risk of mucosal tear. A small asymptomatic leiomyoma suits observation; when there is dysphagia or growth — enucleation by a thoracoscopic (VATS) approach, or laparoscopic for a distal tumour. During surgery mucosal integrity is checked by air insufflation through an endoscope, and if it is breached — the mucosa is sutured and the muscle closed over it.

An epiphrenic diverticulum lies in the lower 10 cm of the oesophagus, and is a "pulsion" diverticulum — a pouch of mucosa and submucosa pushed out by high oesophageal pressure, usually from achalasia or another motility disorder. So manometry is done before surgery, and the operation includes excision of the diverticulum, a long myotomy on the opposite side extending onto the stomach and a partial fundoplication (Dor); excision without myotomy leads to leak and recurrence. A mid-oesophageal diverticulum is usually a "traction" diverticulum from inflamed nodes (tuberculosis, histoplasmosis), usually causes no symptoms and needs no treatment. Zenker diverticulum in the neck is a separate topic.

Other rare benign lesions are a duplication cyst, a giant fibrovascular polyp of the cervical oesophagus, which may regurgitate into the mouth and obstruct the airway, and granular cell tumour.

Key points

• Leiomyoma — the commonest benign tumour.
• EUS diagnoses; VATS enucleation.
• Check mucosal integrity by insufflation.
• Epiphrenic diverticulum — pulsion, motility disorder.
• Excision + myotomy + Dor.

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Sources

• ESGE guideline: Endoscopic management of subepithelial lesions, 2022 — Diagnosis and management
• Shields' General Thoracic Surgery, 8th edition (2019) — Benign esophageal tumors and esophageal diverticula
• Sabiston Textbook of Surgery, 21st edition (2022) — Esophagus

Sources are given for further reading; the text is written afresh and not copied from them.

Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.