Another odd oesophageal bump ...

An odd lesion in the middle of the oesophagus of a 55 year old woman. 
WHICH OF THESE POSSIBILITIES IS THE MOST LIKELY?

a) Papilloma

Papillomas look more warty and I've never seen them ulcerate

b) Leiomyoma

Statistically the most likely benign lesion probably!

c) GIST

Are very rare in the oesophagus!!!

d) NET

Are also very rare in the oesophagus!

e) SCC

Not likely as the IPCL's are regular and the lesion isn't brownish!

explanation

GIST's are extremely rare in the oesophagus whilst common in the stomach. In contrast, leiomyomas are common in the oesophagus and rare in the stomach. However, this looks odd and the previous biopsies had not been able to get to the bottom of the diagnosis. Are we missing a SCC? However, it looks like something from deeper layers were breaking through the mucosal surface. In contrast an SCC should start growing at the surface and in time invade deeper. The 'intrapapillary capillary loops (IPCL's) dilate up, become irregular and eventually completely disorganised in SCC's. At the same time the oesophageal wall takes on a brownish tint on NBI. 

I decided to remove it and it turned out to be a leiomyoma. I presume that it had got traumatised or perhaps by pressure necrosis ended up with a funny surface. Don't think that I have seen an oesophageal NET as yet. Presumably they are very rare in this location.

By the way, I've uploaded an example of a T2 mid-oesophageal SCC in the clip below.  The lesion looks smallish but is already beyond endoscopic cure and Lugol's shows up a large area of background dysplasia which looks orange rather than brown after Lugol's dye spray.