SSAT - A RARE CASE OF GIANT ESOPHAGEAL LEIOMYOMA

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A RARE CASE OF GIANT ESOPHAGEAL LEIOMYOMA
Prajjwol D. Bhatta^*¹, Nathan Heller¹, Ahmed Shehadah², Venkat Arutla¹
¹Internal Medicine, Rochester General Hospital, Rochester, NY; ²United Health Services Hospitals Inc, Johnson city, NY

Background
The incidence of benign esophageal tumors ranges from 0.005% to 7.9%. Leiomyoma accounts for 70-80% of all benign esophageal neoplasms. However, the true incidence of leiomyoma remains uncertain due to its asymptomatic nature, with most cases discovered incidentally. Giant esophageal leiomyomas (defined as tumor size is >10cm) are extremely rare. The most common site of leiomyoma is lower two-third of esophagus, while involvement of upper esophagus is uncommon. Approximately 50% of the leiomyomas are asymptomatic. When symptoms are present, particularly in cases of giant tumors, they most commonly manifest as dysphagia, retrosternal burning, and regurgitation.

Clinical presentation
18-year-old male presented to the emergency department with chest pain. The chest pain was located on the left side and was stabbing in character. The patient denied heartburn, regurgitation, dysphagia, nausea, or vomiting. CT abdomen was performed, which showed a dilated esophagus and distal esophageal mass measuring 5.6 x 6.5 cm. Subsequently, a CT chest was conducted to further evaluate the mass, which revealed posterior mediastinum mass measuring 5.7 x 7.2 cm, arising from esophagus. The patient underwent an endoscopy, which showed a large, firm mass extending from 30 cm to 40 cm. Biopsy of the mass revealed nodular submucosal smooth muscle, consistent with leiomyoma.. An endoscopic ultrasound was performed showing heterogenous, avascular, calcified mass arising from muscularis propria. The patient underwent robotic-assisted Ivor Lewis esophagectomy with right VATS, abdominal and mediastinal Lymph node dissection. Gross histopathology examination revealed mass measuring 13.0 x 8.0 x 6.5 cm with tan-white, rubbery lobulated cut surface.

Discussion
Leiomyoma is the most common benign esophageal tumor. Leiomyomas most commonly originates in the middle and distal third of the esophagus. They are common in males than females, with ratio of 1.9:1, and the peak age of presentation is between 30 and 50 years. Most esophageal tumors are asymptomatic and are often discovered incidentally. Symptoms typically appear as the tumor grows in size and begins to compress adjacent structures. Endoscopic ultrasound (EUS) demonstrates high accuracy in diagnosing esophageal leiomyoma. It provides detailed visualization of the esophageal layers, allowing precise determination of the tumor depth and origin.
The management of leiomyoma depends on its size and symptomatology. Asymptomatic small esophageal leiomyoma(<5cm) requires surveillance and regular follow-up. For large symptomatic leiomyomas, enucleation via open thoracotomy or thoracoscopy is the preferred method. The decision to perform esophagectomy or enucleation depends on surgeon�s experience, the size and shape of the mass, and the extent of adhesions between the tumor and esophageal mucosa.

Esophageal Leiomyoma with calcification (Coronal view)

Esophageal leiomyoma after Ivor Lewis Esophagectomy (Mass size 13.0 x 8.0 x 6.5 cm)

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