Esophageal leiomyomas: Making mole hills out of mole hills?

Clinical study of submucosal tunneling endoscopic resection and endoscopic submucosal dissection in the treatment of submucosal tumor originating from the muscularis propria layer of the esophagus

Herein, we aimed to evaluate the clinical value and safety of transendoscopic submucosal tunnel tumor resection (STER) and endoscopic submucosal dissection (ESD) for the resection of esophageal submucosal intrinsic muscle tumors. We retrospectively analyzed the clinical data of 68 patients with esophageal submucosal intrinsic muscle tumors treated with STER (STER group, n = 38, March 2018 to January 2020) or ESD (ESD group, n = 30, January 2017 to January 2020) at the First People's Hospital of Lianyungang to compare the treatment efficacy, hospitalization time and costs, and postoperative complications between the 2 groups. All 68 cases were of single lesions. The mean operative duration was shorter in the STER group (53.39 ± 11.57 min) than in the ESD group (68.33 ± 18.52 min, P < .05). The postoperative hospital stay duration was significantly shorter in the STER group (5.86 ± 1.01 days; P < .05) than in the ESD group (8.2 ± 3.4 days, P < .05). The mean hospitalization cost was significantly lower in the STER group than in the ESD group (12,468.8 + 4966.8 yuan vs 17,033.3 ± 4547.2 yuan; P < .05). Only 1 case of intraoperative perforation occurred in ESD group. There were no other complications in both groups. The wound healed in both groups, and no residual or recurrent tumors were detected during the follow-up period. Both STER and ESD can be used for the treatment of esophageal intrinsic muscular layer (MP) tumors, and STER is safer and more efficient for lesions with a diameter <3.5 cm.

Esophageal low-grade intraepithelial neoplasia overlying multiple leiomyomas: A case report and review of the literature

BACKGROUND

Esophageal leiomyoma is the most common benign submucosal mesenchymal tumor. Esophageal intraepithelial neoplasia includes low-grade and high-grade intraepithelial neoplasia. The coexistence of epithelial lesions and the subepithelial lesion is rare. We recorded a case of esophageal low-grade intraepithelial neoplasia (LGIN) overlying multiple esophageal leiomyomas and followed with a review of the literature.

CASE PRESENTATION

A 49-year-old female patient came for the treatment of esophageal lesions. The submucosal eminences were observed in the right posterior wall and the left anterior wall of the esophagus by Esophagogastroduodenoscopy (EGD). Additionally, we noticed the mucosa of the right wall with brown background color and the dilated, tortuous vessels by narrow-band imaging (NBI). Then we ensured that the submucosal lesions originated from the esophageal mucosal muscle by endoscopic ultrasonography (EUS) and enhanced CT. Subsequently, the submucosal eminence of the right posterior wall and the overlying mucosal lesion were removed together by endoscopic submucosal dissection (ESD). Postoperative pathological diagnosed esophageal submucosal leiomyoma with focal LGIN. Review EGD showed white scars on the right wall of the upper esophagus three months later, while pathological biopsy showed slight squamous epithelial hyperplasia in the left wall. We decided that the left submucosal lesion can be resected at a selective-time operation, and we continue to follow up as planned.

CONCLUSIONS

The case of intraepithelial neoplasia overlying the submucosal tumor is rare. Either missed diagnosis or overdiagnosis should be avoided through EGD and pathological biopsy.

Large leiomyoma of lower esophagus diagnosed by endoscopic ultrasonography–fine needle aspiration: A case report

BACKGROUND

Benign esophageal tumors are rare accounting for < 1% of esophageal tumors; two-thirds of which are leiomyomas. Esophageal leiomyoma is a benign tumor derived from mesenchymal tissue that is completely muscularly differentiated. Most esophageal leiomyomas are < 5 cm. Esophageal leiomyomas > 5 cm are rare. We describe a case of a large esophageal leiomyoma involving the cardia and diaphragm.

CASE SUMMARY

A 35-year-old woman presented to the doctor because of a choking sensation after eating. Physical examination showed no positive signs. Gastroscopy indicated an uplifted change in the cardia. Enhanced computed tomography revealed space-occupying lesions in the lower part of the esophagus and cardia, which were likely to be malignant. Positron emission tomography–computed tomography showed increased metabolism of soft tissue masses in the lower esophagus and near the cardia. Malignant lesions were considered, and mesenchymal tumors were not excluded. Endoscopic ultrasonography was performed to examine a hypoechoic mass in the lower esophagus, which was unclear from the esophageal wall. Clinical evaluation suggested diagnosis of esophageal and cardiac stromal tumors. Finally, histological specimens obtained by endoscopic ultrasonography– fine needle aspiration suggested leiomyoma. The patient underwent laparoscopic local resection of the tumor. The postoperative pathological diagnosis was leiomyoma.

CONCLUSION

Endoscopic ultrasonography-fine needle aspiration is necessary for the diagnosis of gastrointestinal leiomyomas. It provides a strong basis for diagnosis of gastrointestinal tumors of unknown nature and origin.

The retrospective comparison between submucosal tunneling endoscopic resection and endoscopic submucosal excavation for managing esophageal submucosal tumors originating from the muscularis propria layer

BACKGROUND

Submucosal tunneling endoscopic resection (STER) and endoscopic submucosal excavation (ESE) were recently introduced to cure submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. This study aimed to compare clinical performance and safety of STER and ESE in treating esophageal SMTs originating from the MP layer.

METHODS

From January 2011 to December 2017, retrospective data collection and follow-up were applied for all STER or ESE cases with esophageal SMTs originating from the MP layer in our endoscopy center, including clinical characteristics, procedure success, efficacy, and adverse events. Subgroup analysis was further done based on tumor size and origin.

RESULTS

90 STER and 77 ESE were enrolled in this study. There were no significant difference for  patient characteristics, procedure performance, and complications for ESE and STER intervention (P > 0.05). STER was faster than ESE (3.90 mm²/min vs 2.82 mm²/min, P < 0.05). For large tumors (≥ 20 mm), both techniques had the similar performance (P > 0.05), while STER led to the shorter hospitalization (4.0d vs 7.0d, P < 0.05) and lower postoperative complication (16.3% vs 45.5%, P < 0.05). For small tumors (< 20 mm), STER achieved faster operation (STER vs ESE, 2.57 mm²/min vs 1.83 mm²/min, P < 0.05). Regardless of tumor origin, there were no significant difference for both techniques, but STER resulted in short hospitalization for SMTs from the deep MP layer (STER vs ESE, 5.0d vs 7.0d, P < 0.05). During the follow-up, 2 residual and 4 recurrence occurred in the STER group, as well as 1 residual and 2 recurrence in the ESE group.

CONCLUSIONS

Both STER and ESE were effective for treating esophageal SMTs originating from the MP layer. STER might be better due to its faster operation, less complications, and shorter hospitalization.

Successful en bloc endoscopic full-thickness resection of a giant cervical esophageal leiomyoma originating from muscularis propria

BACKGROUND

Esophageal leiomyomas, the most common benign primary tumors of the esophagus, are esophageal subepithelial lesions treated by surgery traditionally. In recent years, endoscopic submucosal dissection and related endoscopic treatment techniques are adopted by endoscopists to resect gastrointestinal submucosal tumors. But if a giant esophageal leiomyoma approaches the esophagus entrance and originates from the deep layer of muscularis propria, it will be difficult for both endoscopic resection and surgical treatment. Especially, endoscopic resection has a high risk of huge perforation difficult to be sutured.

CASE PRESENTATION

A 72-year-old man with dysphagia underwent gastroscopy examination which indicated a large submucous eminence lesion, about 18-24 cm from the incisors. Endoscopic ultrasonography revealed the lesion was hypoechoic and originated from the muscularis propria with a clear boundary. The patient refused invasive surgical resection. Then, an en bloc endoscopic full-thickness resection was performed, which perforation was successfully closed with purse-string sutures using a novel endoloop device through standard single-channel endoscopy. Histopathologic examination showed an esophageal leiomyoma.

CONCLUSION

This endoscopic procedure may be an alternative to avoid surgery for the removal of a giant upper esophagus tumor from muscularis propria layer.