| Background and ObjectiveWith the popularity of endoscopy,esophageal submucosal tumor(SMT)has been detected more and more frequently in recent years.Endoscopic ultrasonography(EUS)became widely used in the diagnosis and treatment of diseases of the digestive system since the 1980 s.it was able to show clearly the hierarchical structure of the digestive tract wall and echo,currently EUS plays an vital role in the diagnosis of esophageal gastrointestinal submucosal lesions.With the development of endoscopic minimally invasive treatment,EUS plays a guiding role in identifying SMT and selecting endoscopic surgical methods.Many studies have reported the usage of EUS in the diagnosis and treatment of gastrointestinal SMT,but there are relatively few reports on esophageal SMT.With a retrospective analysis,the value of EUS in clinical diagnosis and treatment of esophageal SMT was investigated and discussed.Materials and MethodsA total of 193 patients with esophageal SMT(196 lesions totally),who were diagnosed and treated under EUS,were recruited from the center of digestive endoscopy of the Second Affiliated Hospital of Zhengzhou University from December 2013 to December 2018.According to the EUS results,196 esophageal SMTs with complete data after minimally invasive endoscopic resection,including clinical general information,symptoms and signs,the common endoscopic examination results(size,activity,surface mucous membrane)and endoscopic ultrasonography findings(origin level,size,border,the echo intensity,diagnosis),pathologic results,complications,follow-up,were all retrospectively analyzed.Results(1)General informationAmong the 193 esophageal SMT patients,103(53.36%)were male and 90(46.64%)were female.The average age was 54.73±11.06 years(age range 24 ~ 82 years).3.11%(6/193)patients were under 35 years old,8.29%(16/193)patients between 35 and 45 years old,43.52%(84/193)between 45 and 55 years old,21.76%(42/193)between 55 and 65 years old,and 23.32%(45/193)patients over 65 years old.The main complains of 23.83%(46/193)patients were nausea,vomiting,acid reflux,heartburn;of 12.95%(25/193)was abdominal discomfort;26.94%(52/193)were abdominal pain,abdominal distention,belching;19.69%(38/193)eating choked feelings,difficulty swallowing,hoarse;16.58%(32/196)check-up discoverer.All the patients were not companied with other gastrointestinal and extralimentary diseases.(2)The results of CT & EUSThe detection rates of 193 esophageal SMTs by chest CT were 35.29%(30/85),however,the detection rate of SMT in the upper,middle and lower esophagus by EUS were 36.73%(72/196),34.69%(68/196)and 28.58%(56/196).The proportions of SMT lesions in the anterior wall,posterior wall,left wall,right wall,left anterior wall,left posterior wall and right posterior wall were 34(17.35%),31(15.82%),37(18.88%),24(12.24%),27(13.78%),30(15.30%)and 13(6.63%).Gross observation showed that among 196 cases of SMT,the average diameter was(0.98±0.66)cm.111(56.63%)SMT originated from mucosal muscularis layer,25(12.75%)from submucosa,58(29.60%)from muscularis propria,1 lesion invaded the muscularis mucosa,the submucosa and the muscularis propria,and 1 lesion involved the muscularis mucosa and the submucosa.Multiple esophageal SMT occurred in 3 patients,with a multiple incidence rate of 1.55%(3/193).In 1 patient with 2 SMTs were both originated from the mucosal muscularis and located in the upper segment of esophagus.In 1 patient with 2 SMTs were located in the middle and lower segments of the esophagus respectively,which were originated from the mucosal muscularis layer and the lower layer.In 1 case,2 lesions were located in the upper and middle segments of esophagus,all originated from the mucosal muscular layer.EUS diagnosis data revealed that 172(87.76%)were leiomyoma,111 originated from the mucosal muscularis,6 from the submucosa,and 54 from the muscularis propria.14 esophageal cysts(7.14%)originated in the submucosa.5(2.55%)were stromal tumors,4 originated from the muscularis propria and 1 involved the muscularis mucosa,submucosa and muscularis propria.Two lipomas(1.02%)originated in the submucosa and three hemangiomas(1.53%)originated in the submucosa.(3)Histopathological results196 esophageal SMTs,86.23%(169/196)were leiomyoma,4.59% esophageal cyst,3.06%(6/196 of the inherent submucosal glands hyperplasia with duct expansion),2.04%(4/196)gastrointestinal stromal tumor,1.53%(3/196)angeioma,1.02%(2/196)lipoma,schwannoma 1(0.51%),1 serous glands tumor(0.51%),1 granular cell tumor(0.51%).Among the 196 histopathological diagnoses,49 were spindle cell tumors,which required further immunohistochemical results to confirm the diagnosis.(4)Comparison between EUS diagnosis and final pathological results: diagnosis and misdiagnosisThe sensitivity(SN),specificity(SP),positive predictive value(PPV),negative predictive value(NPV)and diagnostic coincidence rate of EUS in the diagnosis of esophageal SMT were 95.86%,62.96%,94.19%,70.83% and 96.42%.In esophageal cyst were 100%,97.33%,62.28%,100%,97.45%,in esophageal stromal tumor were 50%,98.4%,40%,98.95%,97.45%,in the diagnosis of lipoma,SN of hemangioma,SP,PPV and NPV was 100%,overall diagnostic coincidence rate was 90.82%(178/196).EUS misdiagnosis mainly associated with fibroids.(5)Immunohistochemical results of 49 spindle cell tumors44 cases of leiomyoma in 49 spindle cell tumors.IHC results showed that 97.72%(43/44)were positive for SMA,100%(44/44)for Desmin.100% positive for CD117 and CD34.In 4 cases of gastrointestinal stromal tumor,all negative for SMA.One case with Schwannoma was positive for s-100.Proliferative rate of Ki-67 in 49 lesions was < 1% +.(6)Selection of minimally invasive treatmentThe diagnosis of esophageal SMTs in mucosal muscularis mucosa submucosa,originated in the mucosa lesions to the muscularis propria by EUS were 111,25 and 58,which involving multiple 2.SMTs originated in the mucosa were mainly resected with endoscopic mucosal resection(80.18%,89/111)and with endoscopic mucosal submucosal dissection(19.82%,22/111),SMTs originated from the submucosal layer lesions mainly choose endoscopic mucosal resection(36%,9/25)and endoscopic submucosal dissection(64%,16/25),Endoscopic submucosal tunneling tumor resection(86.21%,50/58)was the most common selection for those originated from the muscularis propria or involving multiple layers of lesions.The maximum diameter of different minimally invasive surgical methods was compared with each other,F=26.38,P<0.05,which was statistically significant.(7)Complications and follow-upThe cure rate was 98.46%(193/196),the incidence of low fever was 23.32%(45/193),the incidence of subcutaneous emphysema was only 1.04%(2/193),and the incidence of delayed bleeding was 0.52%(1/193).The postoperative follow-up time was 1-24 months,and the follow-up success rate was 93.26%(180/193).Only one patient was reexamined for the recurrence of leiomyoma in different parts of the esophagus after a year.Conclusions(1)Esophageal SMT can occur in the whole length and each wall of the esophagus,and patients over 45 years old are the majority,whose pathological type is mainly leiomyoma,and other rare esophageal tumors such as gastrointestinal stromal tumor,granulosa cell tumor and serous cystadenoma.(2)EUS can make a more accurate diagnosis for esophageal SMT than chest CT,the origin of SMT level and size can guide the choice of the ways of esophageal SMT endoscopic minimally invasive surgery,which are safe and effective treatment,and not easy to relapse after complete resection.However,certain limitation for EUS in the differential diagnosis of esophageal stromal tumor and schwannoma has been obsevered,due to the low echo change in esophagus.(3)Histopathology showed esophageal stromal tumor,leiomyoma and schwannoma of spindle cell tumor,which required additional immunohistochemistry such as SMA and Desmin for leiomyoma,and CD117 and CD34 for esophageal stromal tumor. |
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