Diagnosis And Treatment Of Esophageal Leiomyoma

Leiomyoma of esophagus is a orphan disease in clinical, but it isa most common esophageal benign tumor (52%-80%), the report ofthe disease incidence in exterior and interior are disagree. leiomyomaof esophagus are found in male than female (1.9:1). It most happens inintermediate and inferior segment of the esophagus, the size and shapeare very different. The clinical symptom of the esophagus leiomyoma areunspecificity. About 50% patients have absence of symptoms, theother patients have light symptoms, he main manifestation include:â‘  difficulty of food intake;â‘¡poststernum and epigastric zone vaguepain;â‘¢ feel oppressed on chest. The manifestation of gastrointestinal barium meal series areindirect sign and have difficulty to discriminate esophagus leiomyomabetween compression that come from surrounding affection ofesophagus, so the diagnostic accuracy to benign tumor (53.8%) andmaligned tumor (44.4%) of gastrointestinal barium meal series is lowif use it merely. The main manifestation include: 1) intraluminal fillingdefect;2) mucosa alteration, including painting sign and ring sign. Computed tomography have excellent density resolution andtranssection image picture. It can display the density and fringe of thepartial soft tissues, it also can display the relationship between lesionand its surrounding structure than barium meal, it has more value ondiscriminate between esophageal disease and others diseases. Thediagnostic accuracy of CT to esophageal leiomyoma is 42.9%. CTcan't afford more information about leiomyoma itself, and but thebarium meal is more direct-viewing to CT, The diagnostic accuracy tomin esophageal leiomyoma is low because of the volume effectivenessand min esophageal leiomyoma (<1cm) can't be seen on CT. CT is animportant added means to barium meal, especially, when we meet anatypical barium meal result. Through the gastric endoscope, we canget the message about esophageal mucous membrane, also canexclude esophageal carcinoma and other kinds of the esophagealstenosis. But missed diagnosis always happen to non-intracavitarytype The diagnosis of the esophageal leiomyoma by endoscopicbiopsy are questionable, in general condition, endoscopic biopsy arenot command to normal mucosa covered on tumor, unless, it haveanabrosis or inflammation so we cannot exclude the malignant tumor.of the esophageal tumor. So gastric endoscope can be seen as anmeans of exclude. other disease.Endoscopic ultrasonography (EUS) can afford information aboutlesions surface and its vicinity structure, so we can get an integrativeconcept about the lesions. It become another means to diagnosis andtreat the esophageal leiomyoma. In the process of the EUSexamination, we can seen the mucous membrane of esophagus byendoscopy, and the endo-luminal ultrasound can display clearly theesophageal wall thickness and the 5 layers structure, it also display thesize and the location of the tumors. Esophageal leiomyoma locate inlamina muscularis mucosae or muscularis propria, its examinationfeature include: even low or equal echo level echo focus infectionoriginated in lamina muscularis mucosae or muscularis propri;itsmargin was clear, non-network structure;amicula was high-level echoand Integrity;the esophageal leiomyoma originated in muscularismucosae show high-level echo continuous in the tunica submucosa,but originated in muscularis propria show high-level echo break off.Of course, EUS has its shortcoming, for example, it cannot display thedistance lymph node or organ metastatic lesion located at the samesection;the detecting head of EUS cannot pass-through if theesophageal stenosis was severe;the device are expensive. The EUSexamination has its own superiority and can get high coincidencecontrary to other means.Churchill and Sweet performed the enucleation of esophagealleiomyoma in 1954.this operation is most fit for esophagealleiomyoma, and the operation is simple with less complications, soon,it become the standard operation to treat the esophageal leiomyom.Although enucleation of esophageal leiomyoma is an effectivenessoperation, but it is an typical operation that has big incision, patientswho received it always have a long period to reablement., and suffermore pain. The mortality rate are 0-1%.Minimally invasive treatment to esophageal leiomyoma becomean trend, when Pellegrini first use VATS to treat esophagealleiomyoma in 1992 and the endoscopic resection be used to treat thetiny esophageal leiomyoma gradually.It is necessary that the patients with esophageal leiomyomareceived gastric endoscope before VATS operation, because it canoffer information about the position, size, number, shape, et al, of theesophageal leiomyoma to determine which treatment ways is suitable.The lesions locate in superior and middle segment can be removedthrough right chest wall;lesions located in inferior segment the waythat get into the chest wall determined by its locations. But lesionsaccompany with hiatus hernia or supradiaphragmatic diverticulumshould through left chest wall. In addition, if the lesions are bigger andits main body located in left chest wall, under the arcus aortae level,should operate through left chest wall. We can use the gastricendoscope to help locate the position of the lesions that is smaller than2cm, when we are in the processes of the VATS operation. There werereports that aerocyst esophageal dilator was used in the VATSoperation to located the lesions. Esophageal blood supply can beadequate when use these technique. Tearing of esophageal mucosa is anormal complication. Enucleation of esophageal leiomyoma underVATS is one of the most suitable operations to this disease, and it isthe trend of the future, now, it is the first choice operation in thedeveloped countries. But because it need special equipment and expertskill, and spends more money, it is not universal in our country.In old days, benign tumor under mucosa is a contraindication ofthe excision under the endoscope. But with the improvement of theskill and development of the instrumental, and the appearance of theEUS, the excision under the endoscope becomes possible. With regardto esophageal leiomyoma locate in lamina muscularis mucosaeoesophagi, the enucleation of esophageal leiomyoma may lead totearing of the esophageal mucosa, enhance the probability of theesophagopleural fistula after operation, it is sensible that some patientshave received the excision under the endoscope.We collected clinical data of 25 patients with esophagealleiomyoma from 1992.1 to 2006.5 to analyze its diagnoses andtreatment retrospectively, want to get some inspirations to guide ourclinical works in the future. This group of case includes 18 male, 7female;form 5 to 68 ages, the average age was 38.4. The courses ofdisease are from 1 week to 10 years. The cardinal symptom isdifficulty of food intake (100%), but the symptoms that happened inthe patients were light, and can eat normal food. Some of thesepatients feel poststernum and epigastric zone vague pain (28%). All ofthem accepted gastrointestinal barium meal and fibro gastricendoscope examination, 7 case accepted CT.Only 19 cases can found the lesions in the operation, the othercases are misdiagnosis, include the mediastinal type of lung cancer (1case);the 4th thoracic vertebrae hyperplasy (1 case);mediastinallymphadenectasis (1 case);esophageal wall lip-like thickening (2casese);superior segment esophageal carcinoma (1 case);Thediagnose accordance rate before and after operation is 76%. Here arethe misdiagnoses cause: 1).it have relationships with the location,courser and neighbour tissue or organs, especially the superior-middlesegment esophagus. The impression of aortic arch, thoracic vertebraehyperplasy, lung cancer, mediastinal lymphadenectasis can impressthe esophagus, thus the difficulty of the food intake may be happened.2). case history gathering were not detailed, so that we missed thesymptoms which have distinctive meanings. In this group, there is apatient with the mediastinal type of lung cancer, we missed his casehistory of cough and hemoptysis, because of his dysphagia is obvious.3). we did not emphasize the CT with esophagogram and EUS. In themisdiagnosis group, only 2 cases accepted normal chest CT, none ofthem accepted EUS. 4) The mucous membrane's dimolition of theesophageal carcinoma in earlier period is not obvious;only displaystiffness and thickness of the local esophagus wall. Before operation,the patients' symptoms,the gastrointestinal barium meal results,fibrogastric endoscope examination should be careful analyzed, and the CTwith esophagogram and EUS should be carried out to make sure thisdisease.Because of that: 1) the esophageal leiomyoma and the esophagealstromal tumor is hard to distinct;2) esophageal leiomyoma have theprobability of canceration, it may has relationship with esophagealcancer, so when the clinical diagnosis is clear, we maintain that thepatient should accept operation, unless his physical condition can notfit for it. All patients with esophageal leiomyoma were acceptedenucleation operation(open chest wall 14 cases;under VATS 5cases),4 cases right chest wall, 15 cases left chest wall. The effectiveness ofoperation were satisfy, no surgical death and severe complicationswrer found in all the patients. After enucleation we sew up the openedmuscular layer to avoid pseudodiverticulum.Traditional operation has big incision, the appearance of theVATS have changed this situation. There is no enucleation operationunder VATS in this group, but it should be carrying out in the future ifwe have proper case. With regard to esophageal leiomyoma locate inlamina muscularis mucosae oesophagi, the enucleation of esophagealleiomyoma may lead to tearing of the esophageal mucosa, enhance theprobability of the esophagopleural fistula after operation, it is sensiblethat some patients have received the excision under the endoscope.All specimens were sent to carry out patho-exemination, but onlyroutine morphlolgic diagnoses have been performed, and non-caseaccepted immumohistochemical staining analysis. There have a lot ofliterature reported that there is about 20% esophageal leiomyomawhich was diagnosised by routine morphlolgic analysis porved to beesophageal stromal tumors through immumohistochemical staininganalysis. And esophageal stromal tumors have potential malignantbiological behaviour, so it is very important that the specimen shouldbe accepted immumohistochemical staining analysis after operation.Summary: The first choice of the esophageal leiomyoma includesgastrointestinal barium meal and gastric endoscope, EUS should bethe routine examination of the esophageal leiomyoma because it canimprove diagnose accordance rate. When the clinical diagnosis is notsure and hard to distinct form out-expression of the esophagus, CT canprovide more in formations to help diagnosis. When the clinicaldiagnosis is sure, operation should be perform, the main operation isenucleation through open the chest wall. But some proper casesshould be accepted enucleation under VATS or the excision under theendoscope. Frozen section in the operation should be carrying out inorder to exclude the possibility of the leiomyosar--coma oresophageal carcinoma. The immumohistochemical staining analysis isnecessary in order to exclude the possibility of the esophageal stromaltumors.