Jpn J Radiol (2016) 34:321–330
DOI 10.1007/s11604-016-0534-6
PICTORIAL ESSAY
The imaging features of protruding esophageal lesions
Hayato Tomita1 · Kunihisa Miyakawa1 · Shinji Wada1 · Satoko Okamoto1 ·
Tsuyoshi Morimoto1 · Keiko Kishimoto1 · Yasuo Nakajima1 
Received: 24 January 2016 / Accepted: 29 February 2016 / Published online: 11 March 2016
© Japan Radiological Society 2016
Abstract  Except for squamous cell carcinoma and ade-
nocarcinoma, lesions that protrude into the esophagus are
rare, and include benign and malignant tumors. The imag-
ing findings of these lesions on esophagography, computed
tomography (CT), and magnetic resonance imaging (MRI)
are often non-specific. However, some of them reveal
characteristic imaging findings. In addition, esophagogra-
phy, CT, and MRI are useful to evaluate location, extent,
invasion, vascularity, lymphadenopathy, and metastasis.
Knowledge of the imaging features of protruding esopha-
geal lesions helps to narrow the differential diagnosis.
We describe the main features of esophageal protruding
lesions.
Keywords  Protruding esophageal lesions · Esophagus
tumors · Esophagography · CT · MRI
Introduction
Protruding esophageal lesions result from a wide spectrum
of esophageal diseases. Patients with esophageal lesions
present with non-specific symptoms, including dysphagia,
odynophagia, or chest pain. These lesions are often discov-
ered by endoscopy, esophagography, and computed tomog-
raphy (CT). Endoscopic biopsy and endoscopic ultrasound-
guided fine-needle aspiration are the gold standard tests
for making the definitive diagnosis of esophageal tumors.
* Hayato Tomita
m04149@yahoo.co.jp
1 esophageal wall that has invaded the submucosa. Although
Department of Radiology, St. Marianna University School
of Medicine, 2‑16‑1 Sugao, Miyamae‑ku, Kawasaki,
Kanagawa 216‑8511, Japan
Esophagography includes single-contrast and double-con-
trast views. Double-contrast esophagography is performed
to evaluate the mucosal contour and thus the extent of
protrusion of esophageal lesions. CT and magnetic reso-
nance imaging (MRI) are useful to characterize tissues
and for staging. The most important diagnostic challenge
is to differentiate esophageal lesions requiring treatment
from those that do not; in particular, asymptomatic benign
esophageal lesions are simply followed closely. These radi-
ological imaging techniques also help to determine whether
a biopsy is necessary for benign esophageal lesions. There-
fore, radiologists are required to be familiar with these clin-
ical and imaging features. The purpose of this article is to
discuss and illustrate the features of protruding esophageal
lesions.
Malignant tumors and potentially malignant
tumors
SCC and adenocarcinoma
Esophageal squamous cell carcinoma (SCC) and adenocar-
cinoma account for 90 % of esophageal malignant tumors
[1]. Esophageal SCC is a malignant epithelial tumor origi-
nating from epidermal keratinocytes. Esophageal adeno-
carcinoma arises from a malignant degeneration of Barrett
epithelium.
Esophagography has a sensitivity of 90 % for identi-
fication of esophageal cancer [1]. On esophagography,
esophageal SCC or adenocarcinomas appear as a bulky and
infiltrating mucosal mass with ulcerations and an irregular
imaging features of esophageal SCC may mimic those of
adenocarcinoma, adenocarcinoma is more likely to arise
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Fig. 1  Esophageal SCC in a 74-year-old man. a Barium esophagog-
raphy shows the bulky and ulcerative mass with the irregular esopha-
geal wall in the middle esophagus. b Contrast-enhanced CT shows
the circumferentially thickened wall of the esophagus. Enlarged
lymph node in the mediastinum is evident (arrow)
in the distal esophagus and invade the stomach. Cross-
sectional CT and MRI are helpful in evaluating staging
issues associated with mediastinal invasion, metastasis, and
lymph node involvement (Figs. 1, 2) [2].
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Jpn J Radiol (2016) 34:321–330
Fig. 2  Esophageal adenocarcinoma in a 47-year-old man. Barium
esophagography shows the intraluminal bulky mass and the irregular
surface of the lower esophagus
Fig. 3  Esophageal carcinosarcoma in a 71-year-old woman. Barium
esophagography shows the intraluminal polypoid filling defect with
the smooth esophageal wall in the middle esophagus
Carcinosarcoma
Carcinosarcoma is a rare malignant tumor composed of
both epithelial and mesenchymal tissues. The invasion
depth in 80 % of esophageal carcinosarcomas is not greater
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Fig. 4  Esophageal melanoma in a 70-year-old man. Barium esoph-

agography shows the bulky intraluminal filling defect with less irreg-
ular esophageal wall. The shape at the upper edge is obtuse

than the esophageal wall. However, the 5-year survival rate

is not significantly different than that for esophageal SCC
[3].
Most esophageal carcinosarcoma arises in the middle
or lower esophagus. While esophagography demonstrates
a bulky and polypoid intraluminal lesion with an average
diameter of 8 cm, the esophageal wall is smooth because
there is less invasion (Fig. 3). Esophagography may reveal
the cupola sign, a domed shape at the upper edge [2]. The
appearance of carcinosarcoma with predominant sarcoma-
tous components is polypoid due to the presence of few
stroma; in contrast, the appearance with predominant carci-
nomatous components is ulcerative [4]. CT is performed to
evaluate the extent of invasion and metastasis.
Fig. 5  Esophageal GIST in a 67-year-old woman. a Barium esoph-
Melanoma agography shows the extrinsic compression without obstruction at the
lower esophagus. The edge of the bulky mass is obtuse. b Coronal
Primary malignant melanoma of the esophagus (PMME) contrast-enhanced CT shows a heterogeneous mass with a smooth
surface
is also a rare malignant esophageal tumor. PMME can be
diagnosed based on immunohistochemical studies, such as
for HMB45, Melan A, and S-100. on T1-weighted images (T1WI), due to paramagnetic
The location of PMME is in the middle or lower esoph- metal scavenging by melanin, esophageal melanoma rarely
agus due to the high melanocyte content of these cells. exhibits this effect [5].
Esophagography reveals a bulky and lobular tumor with
less irregularity of the esophageal wall, growing radially GIST
and horizontally (Fig. 4). PMME lesions have a smooth
surface and an obtuse shape due to originating from the Gastrointestinal stromal tumor (GIST) is the most com-
submucosa. Although melanoma lesions containing more mon mesenchymal tumor of the gastrointestinal tract.
than 10 % melanin cells appear as hyper-intensity areas GIST, originating from Cajal cells, consists of spindle and

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epithelioid cells. Immunohistochemical staining is positive
for CD117 (c-KIT) and CD34 in approximately 95 % and
negative for S-100 in 100 % of cases [6]. Esophageal GIST
is known to have malignant potential.
Esophageal GIST frequently involves the lower third of
the esophagus [2]. Esophagography demonstrates a smooth
intraluminal or ulcerative mass with an exophytic compo-
nent [6]. CT detects a well-circumscribed and heterogenous
mass with cystic or necrotic components (Fig. 5). The solid
component of GIST typically is hypo-intense on T1WI,
similar to muscle, and slightly hyper-intense on T2WI [7].
Hemorrhage within these lesions is seen, depending on the
time course.
Schwannoma
Esophageal schwannoma is an extremely rare submucosal
tumor originating from Schwann cells of the peripheral
nerve sheath. The diagnosis of esophageal schwannoma is
made by positive immunohistochemical staining for S-100
and negative staining for histologic smooth muscle markers
such as desmin, actin, and CD-34 [8].
Esophageal schwannomas usually arise in the upper or
mid-esophagus. Esophagography reveals a smooth pro-
truded filling defect. These appear as a homogenous mass
on contrasted-enhanced CT; this finding is helpful to dif-
ferentiate esophageal schwannoma from other esophageal
submucosal tumors that are heterogenous [8]. Coronal CT
and MRI may demonstrate the fusiform shape formed by
tubular nerves at the upper and lower edges (Fig. 6).
Granular cell tumors
Esophageal granular cell tumors are secondary non-epi-
thelial tumors in the esophagus, consisting of ovoid or
polygonal cells containing eosinophilic cytoplasm granules
that are separated by collagen bundles. In 1–3 % of cases,
malignancy develops, with less than 35 % 5-year survival
[9].
Esophagography shows a submucosal tumor with trap-
ezoidal protrusion in the lower third of the esophagus
(Fig.  7). CT and MRI demonstrate a non-specific tumor
appearance with a thickened esophageal wall, hypo-inten-
sity on T1WI, and slight high-intensity on T2-weighted
images (T2WI).
Benign tumors and conditions
Leiomyoma
Leiomyoma is the most common benign tumor of the
esophagus, accounting for at least 50 % of such tumors [1].
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Jpn J Radiol (2016) 34:321–330
Leiomyoma is a submucosal encapsulated tumor consisting
of intersecting bands of fibrous tissue and muscle [2].
Leiomyoma locates in the middle or the distal third of the
esophagus, and is related to the amount of smooth muscle
present. Esophagography shows smooth and crescent defects
with right or slightly obtuse angles [2]. On CT, larger esopha-
geal leiomyomas may become lobular or horseshoe-shaped,
surrounding the esophagus circumferentially. The characteris-
tic CT finding of this lesion is an area of iso- or hypo-attenua-
tion to muscle, containing areas of calcification (Fig. 8). Cal-
cification also occurs in esophageal GIST and old esophageal
tuberculosis lesions, and hemangioma. MRI usually reveals a
submucosal mass with hypo- to iso-intensity on T2WI.
Hemangioma and blue rubber bleb nevus syndrome
Esophageal hemangioma results from congenital intrinsic
or acquired vascular occlusion. Osler–Weber–Rendu dis-
ease, Klippel–Trenaunay syndrome, or congenital blue rub-
ber bleb nevus syndrome (BRBNS) can give rise to multiple
hemangiomas. BRBNS is a rare congenital disease charac-
terized by multiple venous malformations involving skins,
gastrointestinal tract, and other several organs. Although
most cases of BRBNS are sporadic, autosomal dominant
inheritance has been reported in some families [10].
Esophagography provides information regarding the
size, location, and number, confirmed as lobulated filling
defects. BRBNS based on esophagography may be mis-
diagnosed as polyposis syndrome including Peutz–Jegh-
ers syndrome, Gardner syndrome, and Cronkhite–Canada
syndrome (Fig. 9) [10]. CT is useful to evaluate phleboliths
within the gastrointestinal lesions and the complications, in
particular intussusception and active bleeding. The tumor
demonstrates hyper-intensity on T2WI (Fig. 10). Fluid–
fluid levels and fat can be also identified in hemangiomas.
Dynamic contrast-enhanced CT and MRI reveal a periph-
eral enhancement in the portal venous phase and a homog-
enous enhancement in the late phase [10].
Duplication cyst
Duplication cyst is a congenital anomaly resulting from
abnormal embryological development. The lesion is the
second most common benign lesion of the esophagus,
accounting for 0.5–2.5 % of all esophageal tumors [1].
Approximately 20 % of these lesions communicate with
the esophageal lumen [2].
Duplication cysts are found in the lower half and on the
right aspect of the esophagus because the foregut epithe-
lium undergoes dextrorotation [11]. Esophagography shows
a well-defined extrinsic compression and may demonstrate
communication with the lumen. Although T2WI depicts
common features of cysts such as bright hyper-intensity,
Jpn J Radiol (2016) 34:321–330 325

◂Fig. 6  Esophageal schwannoma in a 52-year-old man. a Barium

esophagography shows the filling defect caused by extrinsic compres-
sion of the upper esophagus. b Coronal contrast-enhanced CT shows
the fusiform mass with heterogeneous enhancements (arrow). c The
mass appears as hyper-intensity on T2WI

CT and T1WI may depict variable attenuation and inten-

sity that depends on the contents, such as hemorrhagic and
mucoid material (Fig. 11).

Fibrovascular polyp

Esophageal fibrovascular polyp is a rare intraluminal tumor

consisting of fibrous, vascular, and adipose tissue. These
lesions represent less than 2 % of all benign esophageal
tumors [2].
The location of esophageal fibrovascular polyp is usu-
ally the cervical esophagus near the cricopharyngeus

Fig. 7  Esophageal granular cell tumor in a 67-year-old man. a Bar-

ium esophagography shows the sessile protrusion with a trapezoid
shape in the middle esophagus (arrow). b Endoscopy reveals the yel-
lowish lesion covered with normal mucosa

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◂Fig. 8  Esophageal leiomyoma in a 31-year-old man. a Barium

esophagography shows the smooth filling defect with an obtuse
angle in the upper to middle esophagus. b CT shows the homogene-
ous low-attenuation mass with calcification in the right esophagus. c
The horseshoe-shaped mass involving the upper to middle esophagus
appears as a hypo-intensity area on coronal T2WI

Fig. 9  Blue rubber bleb nevus syndrome in a 70-year-old woman.

a, b Upper gastrointestinal series show the protruding lesion in the
lower esophagus and smooth filling defect in the greater curvature of
stomach (arrow)

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Fig. 10  Esophageal hemangioma in a 42-year-old man. a–c The

mass in the lower esophagus appears as an area of hypo-intensity on
T1WI, hyper-intensity on fat suppression T2WI, and homogeneous
enhancement on fat-suppression T1WI after administration of gado-
linium-containing MRI contrast agents

muscle. Esophagography reveals a smooth and sausage-like

mass with an unclear proximal pedicle. Fat-attenuation on
CT and hyper-intensity on T1WI can be visualized predom-
inantly when the amount of adipose tissue is larger in quan-
tity than other tissue types (Fig. 12) [2].
Papilloma
Squamous papilloma of the esophagus (SPE) is a rare epi-
thelial tumor characterized by a finger-like growth pattern
covered with fibrovascular cores. The etiology of this tumor
remains unclear, but suggested causes include chronic
Fig. 11  Duplication cyst in a 47-year-old man. a Barium esophago-
graphy shows extrinsic compression at the lower esophagus. b Con-
trast-enhanced CT shows the well-defined mass with low attenuation
at the right of the esophagus (arrow). c T2WI shows the homogene-
ous hyper-intensity mass
irritation from reflux esophagitis or human papilloma virus
(HPV) infection [9, 12]. Whether this is a malignant degen-
eration of SPE is also not sufficiently clear [12].
SPE arises in the lower third of the esophagus, whereas
many lesions associated with HPV are found in a proximal

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Fig. 12  Esophageal fibrovascular polyp in a 55-year-old woman.
a Barium esophagography shows the intraluminal polypoid filling
defect extending to the distal from the proximal esophagus. b Con-
trast-enhanced CT shows the well-circumscribed mass with fat den-
sity (arrow)
location [9]. On esophagography, the cauliflower-like lesion
of SPE is seen (Fig. 13).
Tuberculosis
Esophageal tuberculosis is extremely rare, constituting
approximately 0.2 % of gastrointestinal tuberculosis [13].
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Jpn J Radiol (2016) 34:321–330
Fig. 13  Squamous papilloma in a 47-year-old woman. a Barium
esophagography shows the cauliflower-like lesion in the lower esoph-
agus. b Endoscopy reveals the wart-like reddish protrusion (color fig-
ure online)
Esophageal tuberculosis consists of epithelioid granuloma
with Langhans cells and central necrosis in the submucosa.
Esophageal tuberculosis locates in the middle esopha-
gus. Esophagography reveals an ulceration, pseudotumor
with calcification in the submucosa, and tracheoesopha-
geal fistula (Fig. 14) [1]. CT demonstrates a thickened wall
of the esophagus, a mass with central low attenuation and
peripheral enhancement, and lymphadenopathy.
Candida
Candida albicans is the most common cause of infectious
esophagitis and is found in immunocompromised patients,
such as those with acquired immunodeficiency syndrome,
and following chemotherapy and radiotherapy. Infected
achalasia or scleroderma patients are also described.
Jpn J Radiol (2016) 34:321–330 329

Fig. 14  Old esophageal tuberculosis in a 74-year-old man. Barium Fig. 16  Inlet patch in a 59-year-old man. Barium esophagography
esophagography shows the smooth filling defect with calcification in shows the pair of thin protrusions in the upper esophagus (arrows)
the middle esophagus

advanced stage, irregular or shaggy esophageal walls,

called pseudodiverticulosis, can develop from the mucosa
over weakened muscle layers [14]. CT reveals wall thick-
ening and submucosal edema, which may form the target
signs (Fig. 15).

Inlet patch

Ectopic gastric mucosa in the upper esophagus is a congen-

ital anomaly constituting 10 % of the population who have
undergone endoscopy, called an “inlet patch” [9]. An inlet
patch originates from replacement of squamous epithe-
lium by columnar epithelium during embryonic develop-
ment. Adenocarcinoma in the upper esophagus infrequently
occurs in inlet patch areas.
Inlet patches locate in the upper esophagus, especially
the post-cricoid portion, because squamous epithelium
extends from the middle into the upper and lower esopha-
gus. The characteristic findings of esophagography are the
rim-like protrusion and a pair of indentations (Fig. 16).

Conclusions
Fig. 15  Candida in a 53-year-old man. Barium esophagography
shows the characteristic diffuse plaque-like lesions and intraluminal
Esophageal protruding lesions include a wide spectrum of
pseudodiverticulosis
malignant and benign tumors. The features outlined in this
paper will help radiologists differentiate the various types
Esophagography demonstrates the diffuse plaque-like of lesions that protrude into the esophagus.
filling defects in the early stages of this disease. At a more

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Compliance with ethical standards  7. Amano M, Okuda T, Amano Y, Tajiri T, Kumazaki T. Magnetic
Conflict of interest  No authors have any conflicts of interest to dis-
close.
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