Pulse granuloma of the gastroesophageal junction mimicking esophageal carcinoma: a case report

Introduction: Pulse granuloma is a foreign body granulomatous reaction to plant-derived food particles, most often legumes, and is classically described in the oral cavity. Esophageal involvement causing symptomatic high-grade stenosis with imaging that mimics malignancy is rare and diagnostically challenging. Case presentation: A man in his seventies presented with an 18-year history of progressive dysphagia and an 18 kg weight loss over the preceding 18 months. Barium swallow, endoscopy with repeated biopsies, endoscopic ultrasound (EUS), computed tomography. Positron emission tomography computed tomography, and MRI all suggested distal esophageal malignancy (cT2–3, cN +/cNX, cM0), yet every histopathological specimen was negative for malignancy. A robot-assisted (da Vinci) Ivor Lewis esophagogastrectomy with two-field lymphadenectomy was performed. The resection specimen showed a stenosis caused by a 48 mm benign spindle cell proliferation at the gastroesophageal junction (GEJ), consistent with a pulse granuloma, with a prominent foreign body giant cell reaction around birefringent plant material. Clinical discussion: Pulse granuloma has been described in the oral cavity and, more rarely, in the intestine, appendix, liver, and peritoneum, with all reported cases occurring after identifiable prior intestinal injury. In this patient, long-standing dysphagia with recurrent bolus impaction provided a mechanism for repeated mucosal breaches and translocation of plant material into the esophageal wall. Intense fluorodeoxyglucose avidity did not distinguish the lesion from carcinoma; preserved wall layering on EUS was atypical for malignancy and, in retrospect, an argument against it. Conclusion: Mass-forming lesions at the GEJ remain diagnostically challenging, and thorough histopathological analysis of the resection specimen is valuable when preoperative tissue sampling repeatedly fails.