Causes and Clinical Significance
The development of glycogenic acanthosis is based on focal cell proliferation within the thickness of the stratified squamous epithelium. The main feature of these cells is a marked accumulation of glycogen. This pathology itself is considered an incidental finding that causes no symptoms in the patient and has no negative clinical consequences.
Despite being harmless, glycogenic acanthosis is frequently detected in association with other conditions. Among the most common associations are:
- Gastroesophageal reflux disease (GERD / GORD).
- Celiac disease.
- The rare genetic Cowden syndrome (Cowden syndrome).
Diagnostic radiology
During contrast fluoroscopy of the esophagus, glycogenic acanthosis presents with a characteristic pattern. A key sign that helps the radiologist make the correct diagnosis and avoid tumor overdiagnosis is the multiple nature of the lesions. The foci appear as small, slightly raised nodules above the mucosal surface. Single elements are atypical for this condition.
Differential Diagnosis: Epithelial Tumors
When lesions are detected in the esophagus, glycogenic acanthosis must be differentiated from true benign tumors.
Papillomas (Papillomata) These are rare benign lesions that also consist of hyperplastic squamous epithelium. Unlike multiple acanthosis, a papilloma macroscopically presents as a single sessile polyp (sessile polyp), the size of which rarely exceeds 10 mm. The radiological and endoscopic appearance of papillomas is non-specific. To rule out early-stage adenocarcinoma or squamous cell carcinoma, a biopsy is strictly mandatory in such cases.
Differential Diagnosis: Subepithelial Lesions
Sometimes lesions need to be differentiated from deeper, subepithelial tumors.
Leiomyoma (Leiomyoma) This is the most common benign subepithelial tumor of the esophagus (interestingly, gastrointestinal stromal tumors — GISTs — predominate elsewhere in the gastrointestinal tract).
- On fluoroscopy and endoscopy, it appears as a smooth subepithelial mass.
- Computed tomography (CT) shows a homogeneous soft-tissue density mass with clear margins. Internal punctate calcification is characteristic (occurring as single foci).
- Since visual findings are non-specific, the nature of the tumor is confirmed using endoscopic ultrasonography with fine-needle aspiration biopsy (EUS-FNA / EUS-FNA).
Fibrovascular polyps (Fibrovascular polyps) Extremely rare pedunculated lesions (pedunculated) that typically originate from the upper third of the esophagus. Polyps have a soft consistency, allowing them to grow to giant sizes before the patient experiences dysphagia. CT demonstrates both fat and soft-tissue density components within their structure. A specific and dangerous clinical feature is the risk of regurgitation of such a polyp into the oral cavity, which can lead to sudden death from asphyxia.
Other rare subepithelial lesions include schwannomas (schwannoma), neurofibromas (neurofibromata), and lipomas (lipomata).
Differential Diagnosis: Non-Neoplastic Cysts
A special place in diagnostics belongs to the congenital foregut duplication cyst (Congenital foregut duplication cyst). It is not a neoplasm (not neoplastic). On fluoroscopy or endoscopy, it is identified as a subepithelial lesion, but it is easily differentiated using MRI or endoscopic ultrasonography (EUS), which clearly demonstrate the classic appearance of a simple cyst.
Briefly: answers to topical questions
What rare benign subepithelial esophageal tumors exist?
Rare benign subepithelial esophageal lesions include:
- Fibrovascular polyps (Fibrovascular polyps) — very rare pedunculated subepithelial lesions, usually originating from the upper third of the esophagus. They have a soft consistency and can reach significant sizes before the onset of dysphagia.
- Schwannoma (schwannoma).
- Neurofibroma (neurofibromata).
- Lipoma (lipomata).
Glycogenic acanthosis represents the «freckles» of the esophagus: they are numerous, composed of squamous epithelium, and completely safe.
Class and exam questions
Does esophageal glycogenic acanthosis need to be treated?
No, this condition has no clinical consequences and requires no specific treatment. However, therapy for comorbid conditions, such as GERD, may be needed.
What is the main radiological sign that helps make this diagnosis?
The multiple nature of the lesions detected on fluoroscopy.
Why is a biopsy mandatory for an esophageal papilloma?
Because a papilloma is macroscopically non-specific, and without a biopsy, it cannot be differentiated from an early stage of squamous cell carcinoma or adenocarcinoma.
What else to study on this topic
- Technique of EUS-FNA in esophageal leiomyomas
- Radiological presentation of anastomotic leakage following Ivor Lewis esophagectomy
- Assessment of normal haustral folds in esophagocolonoplasty
- CT diagnosis of fibrovascular polyps: differentiation of fat and soft-tissue components
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