James Kurtz, Rene Borscheid, Edward Cho, Houssam Osman, Rohan Jeyarajah. Methodist Richardson Medical Center
Introduction: Esophageal leiomyomas are rare, benign tumors that can be adequately treated with limited resection or enucleation. Distinguishing a leiomyoma from a more aggressive entity can present a diagnostic challenge. It has been suggested that positron emission tomography (PET) scanning can help determine the likelihood of an invasive cancer.
Case series: We present a series of two patients with large esophageal leiomyomas that had increased uptake of 18F-fluorodeoxyglucose on PET scan. Both patients underwent transhiatal esophagectomy.
Patient A had a pre-operative endoscopic ultrasound biopsy that showed spindle-cell neoplasm in the esophageal mass. He also had Barrett’s esophagus with high grade dysplasia. Intra-operative frozen section also showed spindle cells and was labeled as probable leiomyoma but cannot rule out sarcoma. After discussion with operative team, pathologist, and radiologist that read the PET/CT scan the decision was made to perform Transhiatal esophagectomy. The final pathology showed an 8.8cm leiomyoma as well as evidence of Barrett’s esophagus with high grade dysplasia. The post-operative course was uneventful and the patient was discharged on post-operative day number nine.
Patient B had a history of achalasia treated with prior thoracic esophagomyotomy who was referred for reflux refractory to balloon dilations and medications. Workup including CT scan, upper GI contrast study, endoscopic ultrasound, PET/CT, and manometry revealed a distal esophageal mass that was PET avid. His endoscopic biopsy showed no malignant cells. Intra-operative frozen section was described as leiomyoma versus gastrointestinal stromal tumor. Final pathology was consistent with 8.5cm leiomyoma that stained positive for smooth muscle and desmin. The post-operative course was uneventful and the patient was discharged home on post-operative day number eight.
Conclusions: The patients in this series had large, symptomatic esophageal leiomyomas with a positive PET scan and underwent an operation fit for an invasive cancer. Only on final pathology could we fully determine that a limited resection would have been acceptable. This underscores the diagnostic uncertainty that comes with large esophageal leiomyomas and also calls into question the utility of PET scan to aid in characterization of tumor aggressiveness. These cases and updated literature review help to expand the awareness of the PET/CT limitations in determining aggressiveness of esophageal submucosal tumors.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95502
Program Number: P513
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster