Fibrovascular polyp is a rare benign pedunculated tumor of the esophagus composed of a mixture of fibrous tissue, fat, vascular structures, and submucosal glandular elements. Usually originates from the upper esophagus/cricopharyngeal region (Killian triangle) and may extend as a stalked mass to the distal esophagus — sometimes exceeding 20-25 cm in giant size. More common in males (3:1), typically in ages 60-70. The most serious complication is airway obstruction from regurgitation into the oral cavity with risk of sudden death. Mixed fat + soft tissue densities on CT (heterogeneous — fat: -40 to -100 HU; fibrous: 30-60 HU) and intraluminal pedunculated mass is pathognomonic. T1 hyperintense fat signal and signal loss on T1 fat suppression on MRI confirm fat content.
Age Range
40-80
Peak Age
60
Gender
Male predominant
Prevalence
Rare
Fibrovascular polyp originates from loose submucosal connective tissue in the upper esophagus. Killian triangle (weak area between thyropharyngeus and cricopharyngeus muscles) is an anatomically weak point predisposed to mucosal herniation. Chronic mechanical irritation (swallowing movements, peristaltic pressure) causes submucosal tissue prolapse into the lumen. Peristaltic traction force leads to polyp elongation and pedicle thinning over time. As the polyp grows, it incorporates more fat tissue, fibrous tissue, and vascular structures — suggesting it is a hamartomatous/reactive formation rather than a true neoplasm. The fat content is imaged as fat density (-40 to -100 HU) on CT, T1 hyperintensity and signal loss on fat suppression on MRI. Vascular component appears as enhancing solid areas. Giant polyps (+15 cm) can prolapse into the mouth during swallowing and enter the larynx causing airway obstruction → asphyxia → sudden death — this constitutes emergency surgical indication.
Giant pedunculated intraluminal mass originating from the upper esophagus extending distally, containing both fat (-40 to -100 HU) and soft tissue (30-60 HU) densities, is pathognomonic for fibrovascular polyp. No other esophageal lesion demonstrates this combination.
Heterogeneous density pedunculated mass within the esophageal lumen on CT — fat density areas (-40 to -100 HU), soft tissue density fibrous areas (30-60 HU), and enhancing vascular components together. Mass is usually sausage/cylindrical shaped extending from upper to distal esophagus. Stalk (pedicle) is best evaluated at the upper esophagus. Normal esophageal mucosa is preserved around the polyp.
Report Sentence
A heterogeneous pedunculated mass containing both fat and soft tissue densities within the esophageal lumen originating from the upper esophagus and extending distally is observed, consistent with fibrovascular polyp.
Fat signal in the polyp on T1-weighted images — hyperintense areas isointense with subcutaneous fat. Fibrous component shows intermediate signal on T1, vascular component shows enhancement on contrast-enhanced T1. Marked signal loss in fat areas on fat suppression sequences (STIR or fat-sat T1) — definitively confirms fat content and helps in differential from lipoma/liposarcoma.
Report Sentence
Hyperintense areas isointense with subcutaneous fat within the polyp on T1-weighted images showing signal loss on fat suppression sequences are observed; these findings confirm the diagnosis of fibrovascular polyp.
Heterogeneous signal of the polyp on T2-weighted images — fat component intermediate-high signal, fibrous component low signal, vascular component flow void or variable signal. Vascular structures in the stalk region may be seen as flow voids. Giant polyps may accumulate retention fluid (T2 hyperintense) in the surrounding esophageal lumen.
Report Sentence
Heterogeneous signal structure of the polyp on T2-weighted images is observed, reflecting the mixture of fat, fibrous, and vascular components.
Intraluminal mass containing fat density within the esophageal lumen on non-contrast CT. Fat regions show negative density values between -40 and -100 HU. Fibrous regions are at soft tissue density of 30-60 HU. Calcification is usually absent. Mass is connected to upper esophagus by stalk — stalk is best evaluated on coronal and sagittal reformats.
Report Sentence
An intraluminal pedunculated mass containing fat density within the esophageal lumen on non-contrast CT is observed, strongly supporting the diagnosis of fibrovascular polyp.
Enhancement in vascular components within the polyp in arterial phase. Enhancing areas are usually concentrated in the polyp stalk and central regions — where feeding vessels are located. Fat regions do not enhance. The heterogeneous enhancement pattern reflects the distribution of the polyp's fibrous and vascular structures.
Report Sentence
Enhancing vascular components in the polyp stalk and central regions are observed; identification of the vascular pedicle is important for surgical planning.
Heterogeneous echogenicity intraluminal mass within the esophageal lumen on EUS. Fat component hyperechoic, fibrous component iso-hypoechoic, vascular structures seen as tubular structures showing flow on Doppler. Mucosa is intact forming a smooth covering over the polyp. EUS confirms preserved wall layers and submucosal origin of the mass.
Report Sentence
A heterogeneous pedunculated mass containing hyperechoic fat and iso-hypoechoic fibrous areas within the esophageal lumen showing vascular flow on Doppler on EUS is observed.
Criteria
Size <5 cm, usually asymptomatic or mild dysphagia. Balanced fat and fibrous components. Endoscopic resection may be possible.
Distinct Features
Small intraluminal pedunculated mass on CT, diagnosed by fat content. Low risk of regurgitation and airway obstruction. Endoscopic polypectomy may be appropriate but bleeding risk from vascular pedicle should be evaluated.
Criteria
Size >15 cm (sometimes exceeding 25 cm). Significant dysphagia, history of regurgitation. Risk of airway obstruction and sudden death. Surgical resection mandatory.
Distinct Features
Giant intraluminal mass extending from upper esophagus to stomach on CT. Preoperative CT angiography maps vascular pedicle. Surgical approach: cervical or thoracotomy, pedicle clamping followed by resection. No malignant transformation risk but high surgical urgency due to size.
Criteria
Fat component dominant (>70%). Predominantly fat density on CT. Distinguished from lipoma by presence of vascular component and fibrous areas.
Distinct Features
Predominantly negative density with focal soft tissue and enhancing vascular areas on CT. Pure lipoma has homogeneous fat density without enhancement. Preoperative distinction is not clinically significant but reported differently in surgical pathology.
Distinguishing Feature
Leiomyoma does not contain fat — homogeneous soft tissue density solid submucosal mass; fibrovascular polyp contains fat density (negative HU). Leiomyoma is usually intramural and sessile; fibrovascular polyp is pedunculated and intraluminal.
Distinguishing Feature
GIST does not contain fat and shows heterogeneous enhancement (necrosis + viable tissue); fibrovascular polyp contains fat density. GIST is usually exophytic; fibrovascular polyp is intraluminal pedunculated.
Distinguishing Feature
Squamous cell carcinoma does not contain fat, shows irregular contour, infiltrative growth and LAP; fibrovascular polyp contains fat, smooth mucosal covering, and no LAP.
Distinguishing Feature
Lipoma has homogeneous fat density without fibrous or vascular components; fibrovascular polyp is heterogeneous (fat + fibrous + vascular). Lipoma is usually small and sessile; fibrovascular polyp is usually large and pedunculated.
Urgency
urgentManagement
surgicalBiopsy
Not NeededFollow-up
specialist-referralFibrovascular polyp diagnosis is made by imaging — biopsy is usually not needed (fat + soft tissue mixture is pathognomonic). Surgical resection is urgent in giant polyps (>15 cm) due to airway obstruction and sudden death risk. Endoscopic polypectomy may be considered for small polyps (<5 cm) but bleeding risk from vascular pedicle should be evaluated. Surgical approach: cervical esophagotomy (upper 1/3 pedicle) or thoracotomy (long pedicle). Preoperative CT/MR angiography maps vascular pedicle and guides surgical planning. No malignant transformation risk — benign formation. Recurrence after surgery is rare but reported.
Fibrovascular polyps can regurgitate into the mouth and carry asphyxiation risk. Surgical resection is indicated. Endoscopic resection is possible for small lesions but caution is needed due to bleeding risk. There is no risk of malignant transformation.