Hong Kong Society of Upper Gastrointestinal Surgeons CLINICAL MEETING 29 NOV 2012
Esophageal Leiomyoma Introduction Case presentation Operative video Discussion
Esophageal Leiomyoma Benign tumors of the esophagus: uncommon Leiomyomas: 70-80% of all benign esophageal neoplasms 20-50 years old M>F Lower 2/3 Thoracoscopic enucleation of esophageal leiomyoma: a retrospective study on 40 cases. Dis Esophagus 2009, 22:279-283
Ms. WONG F/48 Non-drinker Non-smoker Good past health
Presentation Epigastric pain & hematemesis in April 2011 Hold up sensation after food intake No weight loss/constitutional symptoms Blood tests: unremarkable
Upper endoscopy 1 April 2011 Oesophagus: 2.5 cm whitish submucosal mass at 26 cm from incisor, no evidence of recent hemorrhage Oesophageal mass biopsy: Normal squamous mucosa No tumor
Endoscopic Ultrasound 8 April 2011
Computer Tomography of Thorax 6/2011
Computer Tomography of Thorax 6/2011
Video assisted thoracoscopy + enucleation of oesophageal tumor 31 Jul 2012 Findings: 2.5cm oesophageal submucosal lesion, lobulated and horseshoe shaped Just inferior to the arch of azygos vein No mucosal attachment
Progress Pathology: Leiomyoma of the oesophagus Smooth post-op recovery Follow-up at 3 months: no dysphagia/reflux
Background Most common benign tumor 1% of the esophageal neoplasms M:F (1.9:1.0) Mean age of diagnosis: 44 Distal 1/3: 90% Arise from smooth muscle cells/ precursors in muscularis mucosa/propria Endo/exocentric growth Benign tumors and cysts of the esophagus. In Shackelford's surgery of the Alimentary Tract. Volume 1. 4th edition. Edited by Zuidema GD, Yeo CJ, Orringer MB. Philadelphia: WB Saunders; 1996
Symptoms Symptomatic 50% Dysphagia 50% Retrosternal pain 50% Cough Odynophagia Bleeding Minimally invasive resection of benign esophageal tumors. J Thorac Cardiovasc Surg 2007, 134:176-181.
Investigation CXR: calcification Barium swallow: Smooth crescent shaped defect in contour of oesophageal lumen without a mucosal abnormality Abrupt sharp angle where lesion meets esophageal wall both proximal & distally OGD/EUS: Homogenous & hypoechoic lesion with clear margin Originating from muscularis mucosa/propria, intact mucosa Lymph node involvement
Investigation Contrast CT thorax: Extent of extraluminal involvement Endoscopic biopsy a debating issue Fistula formation/mediastinitis Hamper surgical dissection & enucleation However differentiate leiomyomas from other mesenchymal or epithelial malignancies At least two weeks after biopsy Minimally invasive resection of benign esophageal tumors. J Thorac Cardiovasc Surg 2007, 134:176-181.
Histology Histopathological examination with immunohistochemical staining Differentiate benign or malignant esophageal mesenchymal tumors Firm/round grey yellow unencapsulated mass, composed of spindle shaped smooth muscle cells with cigar shaped elongated nuclei Esophageal leiomyoma: a 40-year experience. Ann Thorac Surg 2005
Treatment Non operative: Indication: Asymptomatic Small size with low risk of malignancy Operative: enucleation Indication: Symptomatic Risk of malignancy Unclear diagnosis Larger size Enucleation of submucosal tumors of the esophagus: minimally invasive versus open approach. Surg Endosc 2004 Thoracoscopic enucleation of leiomyoma of the oesophagus. Br J Surg 1992
Operative management Open thoracotomy/segmental esophagectomy: Indication: Giant esophageal leiomyomas Failed enucleation Transthoracic approach: Upper 2/3: right-sided thoracotomy Lower 1/3: left-sided thoracotomy Transdiaphragmatic approach: Lower 1/3 Extrathoracic cervical approach: Proximal lesions
Operative management Video/Robotic-assisted thoracoscopy: Indication: Any location Any size Upper 2/3: right-sided VATS approach Lower 1/3: left-sided VATS/ laparoscopic approach Intraoperative OGD: Precise localisation of small lesion Checking mucosal integrity Advantages: Avoid morbidity associated with open thoracotomy Safe & effective Short hospital stay Low recurrence rate Disadvantage: Pseudodiverticulum Video-thoracoscopic enucleation of esophageal leiomyoma World Journal of Surgical Oncology 2012, 10:52 doi:10.1186/1477-7819-10-52
Operative management Endoscopic: Indication: <2cm Arise from muscularis mucosa Snare polypectomy Endoscopic aspiration lumpectomy Endoscopic band ligation Endoscopic laser ablation Disadvantage: Incomplete removal of lesion Perforation Endoscopic aspiration lumpectomy of esophageal leiomyomas derived from the muscularis mucosae. The American Journal of Gastroenterology 1995
Our choice Patient factor: Good & fit for GA Good lung function Disease factor: 2.5cm Mid oesophagus Our operation of choice: Video assisted thoracoscopy + enucleation
Reference 1. Postlethwait R, Musser A. Changes in the esophagus in 1,000 autopsy specimens. J Thorac Cardiovasc Surg. 1974;68:953-6. 2. Kramer M, Gibb S, Ellis F. Giant leiomyoma of the esophagus. J Surg Oncol. 1986;33:166-9. 3. Mutrie C, Donahue D, Wain J, et al. Esophageal leiomyoma: a 40-year experience. Ann Thorac Surg. 2005;79:1122-5. 4. Fountain S. Leiomyoma of the esophagus. Thorac Cardiovasc Surg.1986;34:194-5. 5. Bonavina L, Segalin A, Rosati R, et al. Surgical therapy of esophageal leiomyoma. J Amer Coll Surg. 1995;181:257-62. 6. Roviaro G, Maciocco M, Varoli F, et al. Videothoracoscopic treatment of esophageal leiomyoma. Thorax. 1998;53:190-2. 7. Bardini R, Asolati M. Thoracoscopic resection of benign tumors of the esophagus. Int Surg. 1997;82:5-6. 8. von Rahden B, Stein H, Feussner H, Siewert J. Enucleation of submucosal tumors of the esophagus: minimally invasive versus open approach. Surg Endosc. 2004;18:924-30. 9. Wehrman T, Martchenko K, Nakamura M, Riphaus A, Stergiou N. Endoscopic resection of submucosal esophageal tumors: a prospective case series. Endoscopy. 2004;36:802-7.
Thank you
EXTRA
Investigations Endoscopic ultrasonography 8/4/2011: Tumour arising from muscular layer, intact serosa and mucosa, Smooth, slightly lobulated, 2.3cm Hypoechonic, homogenous At the level of azygous vein No lymph node enlargement
Imaging Computer Tomography of Thorax 6/2011: A 2.7cm(W) x 1.3cm(D) x 2.7cm(H) homogenous, mildly enhancing soft tissue mass Right side of mid-esophagus Relations: just inferior to the carina, anterior to the azygous vein and posterior to the right pulmonary artery
Progress Offered thoracoscopic +/- open enucleation Patient agreed due to progressive dysphagia Pre-operative preparation: satisfactory lung function