| Keywords
Esophagus, leiomyoma, endosonography
Methods for EUS Capture
Olympus GFUM 30 at 7.5 and 12 MHz at radius
of 4-9 cm using water filled balloon
Case/Body
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Case Report History: A 25 year-old male
presented to his physician with an 8-year history of dysphagia.
The patient had lost 40 lbs over this time. Recently he had
been experiencing dyspnea and blackout spells during heavy
physical labor. His physician obtained a chest x-ray, revealed
a large mediastinal mass. The patient was referred for thoracic
surgery. The thoracic surgeon requested an endoscopic ultrasound
(EUS) to further define the lesion prior to surgery. Physical:
The physical examination revealed a somewhat obese, but healthy
appearing male. His lungs were clear to auscultation and his
cardiac exam was unremarkable. No supraclavicular adenopathy
was appreciated. A fine needle aspiration was performed under
EUS guidance using Pentax linear array equipment. There was
no evidence of malignancy with the fine needle aspiration,
but a definitive diagnosis was not made. Surgery: A large
tumor was dissected from the esophageal muscularis. The mucosal
and submucosal esophagus was left intact, with the hope that
the remaining vasculature would support esophageal viability.
Pathologic evaluation: Three specimens of resected tumor were
sent to the pathology laboratory. Two smaller samples were
1.3 x 0.8 x 0.4 cm and 3.5 x 1.5 x 1.4 cm. The largest tumor
specimen was 15 x 11.5 x 7 cm in size and weighed an estimated
800 grams. All consisted of bland swirls of spindle cells
without evidence of mitotoic activity. During the histologic
evaluation, the tumor was found to be S-100 and MSA negative
The final diagnosis was benign leiomyoma. Follow-up: The patient
developed a postoperative leak of the mucosal esophagus into
the thorax. On surgical re-exploration the patient was found
to have necrosis of his intrathoracic esophagus. Diversion
of the esophagus was performed with an external cervical esophagostomy
and a separate gastrostomy. Upon resolution of the inflammation
and infection that had resulted from the leakage of esophageal
contents, the patient underwent esophageal repair. The patient
had a gastric pull up procedure with a cervical esophagogastrostomy
and was discharged on a pureed diet with further recovery
expected.
Discussion/Summary
Statement
Discussion: Esophageal leiomyomas are usually
small submucosal lesions found incidentally at endoscopy.
Biopsy of a suspected leiomyoma does not have to be performed,
and could potentially compromise surgical removal. Less invasive
surgical techniques are the procedure of choice for therapy
(1). The EUS evaluation yields a relatively characteristic
picture, showing a hypoechoic lesion arising from the hypoechoic
musularis propria (2). The case described above is an extremely
unusual presentation in which cardiac outflow appeared to
be compromised, and the vascular integrity of the esophagus
was compromised. Previously, a report of EUS evaluation of
a giant esophageal leiomyoma has been reported (3). In the
case presented by Izumi et al, the tumor bulk was one-sixth
that seen in this case, highlighting the massive size in our
patient. In both cases, EUS evaluation showed some characteristics
of the tumor that were useful in making the diagnosis, including
the fact that the tumor appeared to originate in the muscular
layers. EUS was additionally useful in that our patient had
a biopsy that did not support the diagnosis of a high-grade
malignancy. If biopsy had shown a high-grade malignancy, chemotherapy
with or without radiation therapy would have been the primary
modality of choice. EUS is the preferred modality to be used
in the evaluation of submucosal lesion of the esophagus (2),
and should be employed early in the evaluation of these type
of lesions.
References
1. Bonavina L, Segalin A, Rosati R, Pavanello
M, Peracchia A. Surgical therapy of esophageal leiomyoma
J Am Coll Surg 1995:181(3):257-262.
2. Tio TL, Tygat GN, den Hartog Jager FC. Endoscopic ultrasonography
for the evaluation of smooth muscle tumors in the gastrointestinal
tract: an experience with 42 cases Gastrointest
Endosc 1990;36(4):342-350.
3. Izumi H, Nakahara K, Mikami K, Obata K, Danbara T, Okazaki
S, Masuda S A resected case of esophageal leiomyoma 15
cm in long diameter diagnosed by transesophageal ultrasonic
endoscopy. Kyobu Geka 1994;47(13):1075-1077
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